Tough Love Can Be Deadly

In the midst of an unprecedented opioid crisis, the US is neglecting the single most effective way to prevent overdose deaths.

Insite, a supervised-injection site in Vancouver, British Columbia, Canada, July 19, 2008. Wikimedia

Each clean and well-lit booth at Insite comes equipped with a stainless-steel table and a small chair. A large one-way mirror entirely covers one wall, serving two purposes: it helps injection-drug users locate a vein, and it allows medical staff, monitoring clients from the other side, to see if they need additional supplies or are displaying the signs of overdose.

In its fourteen years of operation, Insite, a supervised injection facility (SIF) in Vancouver, British Columbia, has responded to 6,440 overdoses. No one has ever died.

In fact, in nearly thirty years and after millions of doses of heroin, cocaine, and methamphetamine, no safe injection site has ever had an overdose death.

Switzerland set a precedent when it opened the first of these facilities in 1986. Other European countries followed suit, and now more than eighty legal SIFs operate worldwide. Studies conducted over decades and in multiple locations prove that safe consumption sites work.

They not only prevent on-site overdose deaths and reduce rates of HIV and other blood-borne infections; they also help users adopt safer injecting and syringe-disposal practices outside of the facilities. SIFs save money and bring addicts into contact with medical care and social workers, which can motivate users to enter detox or rehabilitation programs. Insite even allows clients to field test their drugs, an increasingly important service as the ultra-lethal opioid fentanyl creeps its way into more and more of the drug supply.

In a landmark decision, the Supreme Court of Canada ruled to keep Insite open, despite the Conservative federal government’s multiple attempts to shut it down. Chief Justice Beverley McLachlin commended SIFs for “reaching a marginalized population with complex mental, physical, and emotional health issues,” populations for whom the “stark choice between abstinence and forgoing health services” is unrealistic and often fatal.

Researchers have repeatedly shown the efficacy of harm-reduction approaches, like SIFs, to addiction. As Dr. Thomas Kerr, Associate Director of the British Columbia Centre on Substance Abuse argues, the scientific evidence surrounding safe injections sites is clear: “There’s no real serious academic debate.”

So why isn’t the United States, currently facing the worst overdose crisis in history, taking the idea of supervised injection seriously?

The Politics of Addiction

Last year, 64,000 Americans died from drug overdoses, a 22 percent increase from 2015. In the United States, death by overdose is now the leading cause of death for people under fifty, killing more people than car accidents or firearm homicides.

Last October, President Trump officially declared the opioid crisis a “public health emergency,” and, a week later, his appointed commission released its report of recommendations.

The document includes some important suggestions, such as removing legal roadblocks to overdose-reversal drugs and expanding access to medication-assisted treatment options. But the commission completely overlooked supervised injection facilities.

Perhaps SIFs weren’t overlooked so much as consciously avoided. For most American policymakers, allowing addicts to use drugs in a legally sanctioned space is unthinkable. George W. Bush’s former drug czar described Insite’s operation as “state-sponsored suicide.”

As hyperbolic as that description may seem, in the US it’s a fairly common way of characterizing harm-reduction strategies for addiction. Even needle-exchange programs (NEPs) — which have unquestionably been shown to lessen the transmission of disease — continue to face resistance.

The most predictable opponents are conservative figures like Mike Pence, who shut down needle exchanges in Indiana on the grounds that drug use is morally wrong — with deadly results. But a less obvious logic is also at work, one that pushes even those most supportive of addicts away from proven harm-reduction practices.

The United States’ dominant understanding of successful addiction treatment is remarkably narrow: addicts need to stop using drugs. The abstinence model, enshrined in twelve-step programs like Alcoholics Anonymous and Narcotics Anonymous, has cornered the rehabilitation market for decades.

In contrast, harm reduction meets addicts as they are by giving them clean needles, or a safe space to use, or medications to assuage withdrawal symptoms — an approach that seems incompatible with the twelve-step movement’s focus on abstinence. Jane Nickels, the Public Relations Manager for Narcotics Anonymous, asserts that an addict combating dependence through medication-assisted treatment is “not clean.”

Conservatives like Pence demand abstinence because they see drug use as an immoral and irresponsible choice that the addict must reject. But organizations like NA, ostensibly built to serve addicts, arrive at the same conclusion: the only route to “true” recovery is complete abstinence.

But abstinence doesn’t work for most addicts, especially when it’s presented as the only option. This is particularly true for long-term opiate addicts and alcoholics, who suffer dangerous withdrawal symptoms when they try to stop using.

Elsewhere in the world, SIFs, needle exchanges, and medication-assisted treatment have become points of transition: ways of caring for vulnerable addicts and possibly opening a path to recovery. When viewed through the lens of total abstinence, however, harm reduction looks quite different. Critics see it as an obstacle to recovery because it enables continued drug use.

The American fixation on abstinence makes effective harm reduction impossible to implement. Anti-drug conservatives and ostensibly pro-addict twelve-steppers might have different reasons for extolling living clean, but the negative consequences for addicts — disease, overdose, and death — are the same.

A Culture of Safety

Some US cities are taking this idea seriously. In January of 2017, Seattle announced that it would be the first city in the United States to open supervised injection facilities, which it refers to as Community Health Engagement Locations.

But before officials could even begin scouting potential locations, they hit a wall: most people don’t want a SIF in their backyard. Seattle-area cities like Auburn, Kent, Federal Way, and Bellevue (all places with high overdose rates) have voted to prohibit such sites from opening, and an initiative to allow local voters to decide whether SIFs should be established, dubbed I-27, qualified for the ballot in August.

Washington State Senator Mark Miloscia made the terms of his opposition perfectly clear: “You’re a bad person unless you get into treatment.” He went on to argue that “we need to stigmatize the people hooked on heroin who refuse to go into treatment, to save their lives.… We need to push people into treatment, with cultural values and cultural pressures.”

But stigmatizing addicts clearly hasn’t worked, and the United States is willfully ignoring what does. Rather than trying futilely to shame people into abstinence programs, harm-reduction advocates urge the adoption of a very different set of values: “a culture of safety and a culture of people not dying.”

Seattle SIF proponents have continued to fight, arguing that public health officials are best equipped to evaluate these facilities. And, in October, the King County Superior Court ruled to remove I-27 from the ballot. This victory, while important, is just one part of a battle that will continue for months, if not years. Meanwhile, the rate of fatal overdoses continues to rise.

“When we say, ‘We’re going to make this easy, we’re going to make this safe,’ we are subtly saying, ‘This is okay,’” one SIF opponent argued. “There is some value in things being horrible.”

The good news for her — and the bad news for addicts and their loved ones — is that they already are.