ISIH S2 E7 / The Opioid Overdose Crisis: A safe space to use drugs

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Linda Rosenthal: They said you're just enabling, you're just enabling addicts to use by giving them a clean needle. And the answer is they're going to use with a clean needle. They're going to use with a dirty needle.

Celine Gounder: This is Linda Rosenthal. She’s a New York State assembly woman, representing the 67th district in Manhattan, which covers the Upper West Side and parts of Hell’s Kitchen.

Linda Rosenthal: Their addiction compels them to find drugs in any way possible even stealing from their parents. Trading in family heirlooms because the need to use is so great. So we're not enabling them, we're just helping them do it in a more healthful manner.

Celine Gounder: Welcome back to “In Sickness and In Health,” a podcast about health and social justice. I’m your host Dr. Celine Gounder. In this season, we’re tackling the opioid overdose crisis, looking at elements that often aren’t covered in the news, and following each thread of the story to understand the causes, the impact and the challenges of this crisis. In today’s episode, we’re going to look at what some think is a radical solution to the opioid overdose epidemic: supervised consumption sites. The idea is to create a place where users can bring in their own drugs and inject under the supervision of medical staff. The goal is to reduce the health risks of using drugs, to prevent overdoses, and to take drug use out of public places like playgrounds or McDonalds’ restrooms.

Celine Gounder: Although this idea might sound drastic to American ears, these facilities are nothing new. There are nearly 100 supervised consumption sites in 10 countries around the world, including Canada, Australia, Switzerland, Germany and Spain. And in this country, Seattle and Philadelphia recently announced their plans to open supervised consumption sites of their own. But, the idea has been controversial. Isn’t the goal to help get people off drugs? Can giving users a place to inject their drugs safely help cure them of addiction? And, how exactly do these facilities work?

Liz Evans: So the InSite project in Vancouver took a lot of years to open. It was in response to a very significant number of people who were dying every year from injection opiate use. And at that time in the early 90s in Vancouver when I sort of came onto the scene there, there was really only two ways of looking at that problem. There was that people either deserve to die because they were addicted or that they should just get treatment. And it wasn't like there was anything in between. So for all the people that were active users in the community there was an escalating rate of HIV. In fact, we had the highest rate of conversion to HIV in the western world.

Celine Gounder: This is Liz Evans. She’s the co-founder and former director of the Portland Hotel Society in Vancouver, a group that brought support services into single room occupancy hotels, catering to homeless people, giving them a safe place to stay whether or not they were still using drugs.

Liz Evans: ...there was really very few resources for people that were active drug users because of this belief that there's only really two ways of dealing with a problem you either have to get people clean or they die or get locked up, and that was sort of the mentality at the time.

Celine Gounder: In the early 90s, the conversation about drugs and addiction was dominated by the rhetoric of the war on drugs. For many, drug policy was about shutting down all drug use. Abstinence was the end all, be all. And, the notion of giving people a safe place to use drugs didn’t make sense to people at all — wasn’t that defeating the purpose? Back in 1991, the Vancouver neighborhood where Liz worked had a population of sixteen thousand people, six thousand of whom were injection drug users. Imagine that: over a third. People were dying from overdoses, from HIV, from other infections. Something had to be done. In 2003, Vancouver decided to take a bold step. Together with colleagues at the Portland Hotel Society, Liz started InSite. It was the first supervised consumption site in North America.

Liz Evans: A supervised injection site. Conceptually they've been around for a long time and they started the first one started in the 60s, in the 70s in England. They were just places where people who were active drug users could use their drugs without being penalized effectively. And they've used, many terms have been used to apply to them over the years; supervised consumption sites, drug consumption rooms, fixing rooms, safe medically supervised injection sites, and safe and supervised injection facilities.

Celine Gounder: Supervised consumption sites give drug users a clean, safe space to use their drugs without fear of trouble with the law. They’re given sterile equipment. If someone overdoses, nurses are there at the ready with naloxone to revive them. The idea was to put people first, keeping people alive… first.

Liz Evans: No one's ever died. Because that's the purpose of its existence is to make sure people don't die. And to connect them to services. So, they get connected from there into treatment programs, housing, detox and their lives become increasingly stable as a result of having an access point where people can come to get help.

Celine Gounder: So InSite does a lot more than give users a safe place to use. It also provides important medical care, testing for HIV and hepatitis, care for wounds — which are all too common among injection drug users living on the street — drug detox and treatment, mental health care, and social services are there to help them with things like food and shelter.

Liz Evans: The group that come into supervised injection sites tend to be people who feel as though their lives have been given up on and that no one cares about them, that no one gives a shit whether they live or die.

Celine Gounder: These are the most marginalized drug users. Many are homeless. Often, these people have lost their communities or their communities have abandoned them. For Liz, the relationships piece, that’s what turns lives around.

Liz Evans: When a person feels that their life is utterly worthless, and that they're worthless, it's amazing how the slightest thing can make a massive amount of difference, and having people respect you and treat you well can really make a tremendous amount of difference in how people then start to feel about their own health care, their own value… So it makes people go from feeling like why should they even care if they're HIV positive or not caring enough to possibly get a test, or not caring enough to ever even contemplate what their life might be like without using injection drugs to starting to ask about what it's like to go into a detox program.

Celine Gounder: Liz believes supervised consumption sites keep people alive and help them stabilize. Then, it becomes a lot easier for them to get help for their addiction down the line. And  when users are ready, they can get connected to an on-site detox and to drug treatment services.

Liz Evans: So when I think about supervised injection, I don't think of it as outside of treatment. I sort of see it as treatment. It's the first step into treatment because we know from the site that I was involved in starting in Vancouver that people are twice as likely to get into treatment just because they've walked into the door at that supervised injection site.

Celine Gounder: The stats on InSite are impressive. Within two years after InSite opened, the rate of deaths from drug overdose in the neighborhood dropped by 35%. Between 2003 and 2011, nearly three thousand lives were saved from overdose.

Celine Gounder: And InSite hasn’t just been good for drug users. It’s been good for the community, the city. Vehicle break-ins and thefts actually went down. There were fewer drug users injecting in public, meaning fewer needles and syringes littering the neighborhood. Users were also a lot less likely to share needles and syringes, and so less likely to transmit blood-borne diseases, and that’s been saving the city $6 million on HIV-related costs each year alone.

Celine Gounder: But, despite the evidence, keeping a facility like InSite going wasn’t easy. Although the Canadian government was initially supportive of InSite, the mood changed when conservative Stephen Harper became prime minister. With Harper in charge, the administration rescinded the legal exemption that allowed InSite to operate. And, the words “harm reduction” were taken out of national drug strategy.

Liz Evans: ... in the context of the federal government at the time, who were very conservative and very opposed to the concept of supervised injection ideologically… in order to stay open, we had to go before the courts.

Celine Gounder: InSite took the case all the way to the Supreme Court of Canada. In 2011, the verdict was in. The Court ruled unanimously in favor of InSite.

Celine Gounder: Today, Liz Evans is the executive director of the Washington Heights Corner Project and NY Harm Reduction and Education in New York City. She’s bearing witness to another opioid overdose epidemic — one driven by illicit fentanyl use — and doing what she can to spread the word about the InSite model and other harm reduction approaches. In the United States, there are currently no legally sanctioned supervised consumption sites, but the idea is gaining traction. In 2016, Seattle, like the rest of the country, was seeing a spike in overdoses. Deaths from drug overdose tripled in King County between 2009 and 2014, hitting an all-time high in 2016. 2017 numbers haven’t been tallied yet, but will likely be even higher. On average, someone dies from an overdose in King County every thirty-six hours. King County plans to establish two small pilot sites that already cater to homeless people who use drugs. But even then, the logistics and politics of where to put them is complicated. Especially when supervised consumption sites remain a hard sell for some.

Mark Miloscia: My name is Senator Mark Miloscia from Federal Way, the 30th district in Washington State.

Celine Gounder: Before running for office, Mark did a lot of other things. Mark has been involved with local faith-based efforts to help the homeless since the 1990s. He studied clinical psychology and got an MBA. He was in the Air Force. He worked for the Goodwill. Mark’s district, Federal Way, is a suburban bedroom community between Seattle and Tacoma.

Mark Miloscia: We're a spillover community from Seattle.... I like to tell people when Seattle sneezes, the rest of us get sick.

Celine Gounder: Mark says his district is feeling the effects of Seattle’s rising housing prices.

Mark Miloscia: Right now I think we had 12 months in a row Seattle Housing prices going up highest in the nation. Now if you're not you're lower class or newly entry into the workforce or somebody with a family you virtually can't afford to live in Seattle anymore.  And the spillover down into the suburbs has.. been tremendous. We have seen a rise of homelessness over the last few years.

Celine Gounder: Mark, like many others, sees a link between homelessness and drug use.

Mark Miloscia: I've had a number of bills this last year trying to address that you know link heroin use, you know, long term heroin addiction and homelessness...

Celine Gounder: But Mark thinks that we already have systems for dealing with these problems. We just haven’t invested enough in them, in making them work.

Mark Miloscia: So the whole system of drug courts, of drug diversion programs, of getting people stop trespassing and living under the bridges and the viaducts, getting them into housing has completely fallen apart. So that's why we had this real rise of what’s called the jungles in Seattle where you virtually have these massive encampments, almost like third world shanty towns, living in the shadow of these fantastic new skyscrapers we have. And just because we stop arresting people for poor behavior… And meanwhile we're all distracted… going to this ...new shiny little diamond that everybody think is going to solve everything, the safe consumption site.

Celine Gounder: In 2017, and again in 2018, Mark introduced bills to ban supervised consumption sites in Washington State. And he’s been a vocal proponent of ballot initiative 27 to ban public funding for such facilities. When Mark talks to his constituents, he hears worries that supervised consumption sites would lead to more drug use and crime.

Mark Miloscia: Well, it'll bring needles and drug dealers, I hear that. They all said this is going to make things worse. This is going to enable and increase drug use, and it’s not going to help people. ... It's a pretend fix.

Celine Gounder: Mark even sees these facilities as a one step away from legalizing heroin.  

Mark Miloscia: Basically it's the movement toward legalization, decriminalization of drugs as a movement toward. And this is even more crucial, is that we're going to move toward the goal of drug treatment is not abstinence or I get off the drug, a cure… the goal is to stay on the on the drug as long as you desire. The patient gets to decide that.

Celine Gounder: Last fall, a King County Superior Court judge ruled that voters couldn’t override the power of the County Board of Health to respond to public health crises, throwing out ballot initiative 27 and allowing King County to proceed with its plans to open supervised consumption sites. But supporters of ballot initiative 27 are appealing the case to the Washington State Supreme Court, and the battle likely won’t end there.

Celine Gounder: In 2017, Mark wrote a letter to Attorney General Jeff Sessions. He called on the U.S. Department of Justice to intervene and block the sites. Jeff Sessions didn’t respond to Mark Miloscia directly, but the Department of Justice issued a statement concerning proposed supervised consumption sites in another state, Vermont. The Department of Justice wrote, ”It is a crime, not only to use illicit narcotics, but to manage and maintain sites on which such drugs are used and distributed.” In other words, Jeff Sessions opposes the establishment of supervised consumption sites and would subject them to federal forfeiture. No supervised consumptions sites have opened yet in this country, so it still remains unclear how this will play out. But Mark doesn’t see any problem with the old model.

Mark Miloscia: Why don't we try to go back to the model we knew that used to work: the criminal justice, drug courts, diversion model. Community pressure, strong families, early intervention strategies, go after drug dealing. … Why don't we go back to what worked?

Celine Gounder: While many see “Just Say No” as a failed relic of the past, Mark believes that shaming addicts is useful. And, that drug users should be shamed until they clean up their act and get into treatment.

Mark Miloscia: ... stigma, shame, guilt are emotions that are are extremely useful in dealing with behavior. ...but there's this movement to say let's get rid of all this stigmatization or guilt or shame or not say anything judgmental about actually a very negative self-destructive behavior, I believe is absolutely crazy.

Celine Gounder: But not everyone sees it that way. Patricia Sully sees things very differently. The problem, Patricia says, isn’t that we need more stigma and shame, it’s that we need less of it.

Patricia Sully: Most people respond better to positive reinforcement. When people feel like their life has meaning and their life has worth, they're more able to treat their life like it has meaning and treat their life like it has worth. People who are living outside, and people who are experiencing this just daily trauma of surviving, experience a tremendous amount of stigma and shame every single day.

Celine Gounder: Patricia is a staff attorney for the Public Defender Association, and she coordinates VOCAL Washington, an organization that advocates for safe consumption sites in Seattle and King County. And like Liz Evans, the co-founder of InSite in Vancouver, Patricia emphasizes the relationship piece, the trust, the feeling there’s someone who cares.

Patricia Sully:  This is a place where people can come in where they are. They can be loved and accepted, and trust that this is going to be an environment where they're not going to encounter stigma and judgment. They can develop those relationships with healthcare professionals, which are really important. ... These are really tailored to serve the population that's using drugs outdoors.   ... We have a lot of people in Seattle who live in very isolated environments where they're living in an encampment, and they may not be in a relationship with any, any service provider. They may have no trusted relationship with any kind of health care worker. So when they do have that moment, it's often in isolation, where there's no place to go with it. So in a supervised consumption space or at CHEL [community health engagement location] where someone is, you know, coming in where they are. When they do have that moment, they're able to be connected immediately to care.

Celine Gounder: And what Patricia means here is that when someone has a moment, when they need help — whether that’s just someone to listen to them or medical care, mental health care, detox services — there’s someone in their life they can reach out to, a place where they can go. And, like Liz Evans, Patricia thinks there’s also something in it for the “law and order” crowd. Supervised consumption sites are a way of sweeping up outdoor drug use, public drug use.

Patricia Sully: It’s one thing we do hear from neighbors and residents is that people are concerned about outdoor drug use, and they are concerned about the number of syringes on the streets, and they don't want those thing happening in their alley or in their bathroom, and supervised consumption spaces are a way to help address those community concerns, and move that activity out of bathrooms, out of parks, and into, you know, a more appropriate location.

Celine Gounder: The way Patricia sees it, supervised consumption sites are a win-win for drug users, for communities, for public health officials, for law enforcement.

Patricia Sully: ... at the end of the day, supervised consumption spaces make sense. … Right now, people are using drugs. They're using drugs outside. They're using drugs in bathrooms. They're using drugs in parks, when people are afraid… afraid of the consequences of that drug use that they might encounter a law enforcement officer. They might be arrested, or they might just be seen by the general public, and they're embarrassed and ashamed and don't want… their behavior on display. They rush. That leads to problems. They're in dirty locations. That leads to problems, and they're at risk for a fatal overdose, which of course is tragic. It's the end of the story. Someone who dies never gets the chance to recover.

Celine Gounder: A lot of other cities across the U. S. are considering supervised consumption sites of their own. New York, Ithaca, Baltimore, San Francisco, Denver — a dozen or so cities across the country are exploring the possibility. Linda Rosenthal, who we heard from at the beginning of this episode, is on the frontlines of the debate in New York City. The way Linda sees it, many people don’t understand how relentless addiction can be.

Linda Rosenthal: People who are gripped by addiction have to use in order to feel OK, you know, they don't get up and say I'm going to go get high today. They… they are compelled to find their drug and and use it.

Celine Gounder: Linda told me about a family she’s gotten to know in upstate New York that really crystallized things for her.

Linda Rosenthal: I had dinner with the mother of someone who is very active user in Albany, and she worked for the state government, you know, very professional family, and somehow her son who's now 20-something got ensnared into the addiction world. And she and her husband are retired now, and they have moved to Florida, and they have said, “We've done everything we can for our son. We've had the police arrest him. We've paid to put him in a treatment center, and there's nothing we can do any more for him.” And, I mean, she's a very nice person, very wonderful person, and she is saying she's basically giving up on her own flesh and blood.

Celine Gounder: For many people, it can take years and numerous attempts to kick an addiction before they’re successful in quitting. And in the meantime, they could overdose, they could get HIV or hepatitis or an infection of the heart or bone. They could die. It can be hard not to give to give up on someone — even family — when it’s such an uphill battle. But maybe when we frame it as quitting or not, we’re setting ourselves up with an impossible goal. It feels hopeless, so we give up. Just maybe the goal might be keeping people alive now, and helping them quit comes later.

Linda Rosenthal: It works. It saves lives. But it's also a challenge because people's knee-jerk reaction — and I've gotten this, you know when I talk to constituents and others — they’re like, "oh, so are you going to put an injection site on Broadway?" Like no, that's not, that’s not how it works. And I explain to them about how syringe exchange, nobody knows where where those facilities are located. Yet they're all over the place, and it's the same model. When it was proposed, you know, maybe 20 years ago, people said you are enabling people to use drugs and, you know, you have to explain. ... People will use drugs whether the needle is clean, whether they're in a public park, whether they're in a McDonald's. It's, it’s a necessary act for people who are in the grips of substance use disorder.

Celine Gounder: But Linda’s hopeful that the data that’s been gathered from all around the world — from Vancouver to Sydney, Australia to a number of cities in Western Europe — will ultimately convince people this is the right thing to do.

Linda Rosenthal: ... we should we should take a lesson from our sister countries around the world where they have provided safe injection facilities spaces for their population. People don't die. People get on the road to recovery, and it's one of the tools that we need to deal with this heroin and opioid crisis in the world.

Celine Gounder: Despite all the legal challenges, it’s likely that at least some supervised consumption sites will open in the U.S. We’ll get to test it out ourselves, to see if they do save lives and help drug users on the path to recovery. We’ll have a chance to see what impact they have on public order and safety: if there are fewer discarded needles and syringes littering the streets, if we see less public injecting, and if crime stats go up or down. Because ultimately, even if we can’t all agree on how to get there, isn’t the goal to save lives and to make our communities better, safer and healthier?

Celine Gounder: Our next episode takes us back to Vancouver and on a trip overseas. We’ll hear how medications can play an important role in helping people recover from addiction and how sometimes those medications can be the very drug they’re trying to quit.

Celine Gounder: Today’s episode of “In Sickness and in Health” was produced by Nora Ritchie and me. Our theme music is by Allan Vest. You can learn more about this podcast and how to engage with us on social media at insicknessandinhealthpodcast.com, that’s insicknessandinhealthpodcast.com.

Celine Gounder: If you or a loved one needs help, you can reach out anonymously and confidentially to SAMHSA’s National Helpline at 1-800-662-HELP, that’s 800-662-4357. SAMHSA stands for Substance Abuse and Mental Health Services Administration. You can also find information online at www.findtreatment.samhsa.gov, that’s www.findtreatment.samhsa.gov.

Celine Gounder: I’m Dr. Celine Gounder. This is “In Sickness and in Health.”