In Support of Supervised Injection Sites

“It’s counterintuitive that you would let people do something that is illegal and dangerous in a setting that is safer. But in fact, there’s good scientific and epidemiologic evidence that it saves lives, and we’re in such a terrible epidemic that anything that saves lives, we want to embrace.” ~ Dr. Barbara Herbert, president of the Massachusetts Chapter of the American Society of Addiction Medicine (Source)

I was pleased to finally hear that a hearing called by the Boston City Council for a debate on possibly having Supervised Injection Facilities. I firmly believe in harm reduction as a better means to combating addiction, rather than the harsh rhetoric I am aware of, which seeks to stigmatize people who face addiction by opposition. Unfortunately, and expectedly, some concerns have been raised.

According to the Boston Herald article, “‘Safe’ injection sites rejected for Methadone Mile“:

Some along the city’s Methadone Mile say the opioid crisis has left them feeling under siege.

“We cannot handle one more service down here, we just can’t,” said Susan Sullivan, executive director of the 250-member Newmarket Business Association.

She was one of the dozens who packed a City Council hearing yesterday to debate supervised injection sites. The idea is to allow drug users to inject opioids at a facility where doctors could monitor their use and revive them in case of an overdose.

Several other countries, including Canada, have such sites, but they are illegal under federal and state law in the U.S.

Advocates have been pushing for the creation of safe sites, with the Massachusetts Medical Association calling on the state to open a pilot facility.

State Sen. William Brownsberger (D-Belmont) is also filing legislation that would legalize such sites.

That has councilors and business owners concerned that the Methadone Mile — the South End area that hosts numerous treatment clinics and shelters — would be a likely location for any supervised injection facility.

“I have a hard time thinking it would be helpful there,” said Dorchester Councilor Frank Baker, whose district includes the Mile, adding he was concerned it would just encourage more drug use. “They call it Recovery Road, it doesn’t look like anyone is recovering.”

Doctors for Boston Health Care for the Homeless Program on Albany Street — which already runs a room where opioid addicts can come in and get treatment while high — urged further study of safe sites, saying overdoses are the leading cause of death for their clients because of increasingly potent synthetic opioids like fentanyl.

City resident Aubri Esters — who told councilors she uses drugs and overdosed just last week — said the Methadone Mile area was already a magnet for people shooting up and that a safe site would not change that.

“It already is an injection facility, it’s just not supervised … people are already injecting all over the place, we all know that,” Esters said. “I really don’t understand what the objection is, they’re dying, literally every day. I’m confused on why there would be any limit on keeping people alive.”

But councilors and South End groups said safe injection sites would not address the larger addiction epidemic.

“Getting clean and sober should be the endgame, not providing safe houses and normalizing this activity,” said At-Large Councilor Michael Flaherty, who slammed the concept of safe injection sites.

Mayor Martin J. Walsh has also come out against the idea.

It also comes as a drug used as an elephant sedative — carfentanil, a derivative of fentanyl — has shown up in the Bay State.

The council did not take any vote on the idea of a safe injection site.

Additionally, according to the Boston Herald article, “Ferriabough Bolling: Better options needed along the ‘Methadone Mile’“:

For the life of me — and I realize it’s not my life hanging in the balance — I don’t understand how establishing supervised injection locations near the so-called “Methadone Mile” will help curb the city’s burgeoning opioid crisis in any significant way.

What’s really needed here is a multi-pronged approach that uses mental and public health initiatives to combat the issue up and down the ladder of dependency.

As important as saving drug abusers’ lives may be, these proposed clinics — where users can inject under medical supervision — will only tackle the smallest sliver of the problem. And, in my opinion, no matter how much we upgrade these clinics, they will in essence be upscale shooting galleries.

They will only accomplish what the needle-strewn alleyways and abandoned houses that addicts are currently using have already accomplished: keeping people dependent on the drug.

I also question whether saving a life by encouraging them to keep using drugs safely is the right and most humane approach.

A friend of mine who is a recovering addict shared another concern about the injection sites he refers to as “glorified shooting galleries.”

For him, addiction recovery will always be a one-day-at-a-time affair.

He has had many relapses, has tried every drug you can imagine, and has often traded one addiction for another. And though providing a convenient and safe way for users to administer non-fatal doses will save lives, it will prevent many of them from getting on the road to recovery because it will provide them with a false sense of safety and security — which goes against two of the main reasons people decide to stop in the first place.

He said he wondered, as I do, whether the people overseeing these injection clinics will test the drugs before allowing people to shoot up. Toxic combinations of heroin and the powerful opiate fentanyl, after all, have been blamed for the recent surge of overdose deaths.

Unlike the needle exchange program, which was lauded as a worthwhile tool in combating the spread of AIDS, the addicts taking advantage of that program weren’t exposed to drugs or shown how to use without overdosing. I think the folks proposing these supervised injection sites should go back to the drawing board and come up with solutions that address the many challenges that drive these users to turn to drugs and figure out a better method to help them kick their deadly habit.

So, let’s break down a little to two things:

  • South End cannot handle another service because it will attract outsiders, and;
  • Assertions that it normalizes (enables) illegal drug use, keeping addicts dependent on drugs.

Does opening, and operating, these sort of facilities encourage outsiders to set up shop in Boston?

The short answer is simply ‘No.’ Consider the Massachusetts Repeal of Alcohol Prohibition, Question 2 (1930) Ballot Measure, and the passage of same-sex marriage (2004). Did these occurrences also encourage outsiders to come to Massachusetts in order to partake in these – then revolutionary – changes? 

Guatemala - 0782 - San Francisco El Alto - Chicken Buses

Did buses like these carry alcoholics or drag queens, lesbians, and leather-strapped men to drop off perspective people wanting to set up shop in Boston?

No large amounts of people came to Boston because Massachusetts offered – then exclusive – marriage rights to LGB residents. That didn’t happen. Knowing as such, neither did bus loads of alcoholics show up the Massachusetts doorstep following the repeal of Prohibition in 1930. That, too, just didn’t happen.

These things generally affected only the people that actually live here. Sure, some people moved here and some moved away, but that didn’t have to do with these specific things as there are countless possible reasons someone could move – family, financial, job related, etc. People are not likely to move here, or move away, because a change is made in which they may or may not prefer.

As to why the South End would be the best possible place for such a site, this is clearly due to how it intersects with poverty, as indicated in the above article, “the South End area that hosts numerous treatment clinics and shelters” and many of the addicts already utilize the numerous shelters and sites in the area: Woods-Mullen, Southampton, Healthcare for the Homeless, and AHOPE Needle Exchange. The people are already there to begin with, so adding this facility will not drastically add people unfamiliar with the area. People already familiar with the area are very likely to show up.

According to the CBS Boston article, “Mass. Medical Society: Safe Injection Clinics Necessary To Fight Opioid Crisis“:

The Chairman of the Massachusetts Medical Society’s opioid task force says the group is pushing for safe injection clinics, where drug addicts could shoot up in the presence of medical personnel.

Dr. Dennis Dimitri told WBZ NewsRadio 1030’s Carl Stevens that safe injection clinics could save lives.

“In an ideal world, we would like nobody to be injecting illicit drugs like heroin, but we know that those behaviors go on,” Dr. Dimitri said. “A public health approach to reducing the harm associated with that, such as a safe injection facility, is a reasonable approach.”

He argued that life-saving practices such as needle exchanges and overdose reversal drugs like Narcan or Naltraxone, once controversial, are now part of the weaponry used to fight the opioid crisis on the public health front.

Dimitri said that, for certain marginalized groups that inject intravenous drugs, the facilities can result in fewer overdoses, a reduction in the spread of infectious diseases, and more people going into treatment.

“Often times, individuals who are homeless and otherwise have limited access to services, safe injection facilities have been shown to improve their ability to survive their addiction and get into treatment,” Dr. Dimitri said.

None of these safe injection clinics exist yet in the United States, but Dr. Dimitri said some may open soon in the state of Washington.

“Safe injection sites are one more idea in many that need to be put into place to address the current epidemic of overdose deaths,” Dr. Dimitri said.

Will opening, and operating, these facilities normalize (enable) addicts to continue using, or somehow support making these drugs legalized?

The short answer as well is ‘No.’ The goal of these faculties is specifically to target people already using, so there is not a greater risk of making it normal, because it will be normal at the time for the people who use drugs and go to this facility.

The slippery slope fallacy I have heard many, many times, yet has consistently not really held any water, and none of the arguments I have ever heard using it has turned out in that way in which have projected them. It tends to turn out differently.

Much of this argument puts the focus on the drugs people are using (crack, cocaine, opioids, etc.) rather than the people themselves. It is the people we are trying to reach most – that is where the harm reduction comes in.

But people do not often click a switch in making decisions. It doesn’t happen overnight. To help these individuals, we need to build relationships with them, and that takes time. It’s likely in such circumstances things will not pan out perfectly in conversation, but only real and honest effort will lead to better outcomes overall. I think these facilities will ultimately lead to helping building trust with people who want to actually improve their own lives.

Yet again, consider same-sex marriage happening in Massachusetts using the article according to TFP Student Action, “10 Reasons Why Homosexual “Marriage” is Harmful and Must be Opposed” in the portion on ‘It Validates and Promotes the Homosexual Lifestyle’:

In the name of the “family,” same-sex “marriage” serves to validate not only such unions but the whole homosexual lifestyle in all its bisexual and transgender variants.

Civil laws are structuring principles of man’s life in society. As such, they play a very important and sometimes decisive role in influencing patterns of thought and behavior. They externally shape the life of society, but also profoundly modify everyone’s perception and evaluation of forms of behavior.

Legal recognition of same-sex “marriage” would necessarily obscure certain basic moral values, devalue traditional marriage, and weaken public morality.

Clearly, in Massachusetts, we can reasonably assume that what is being said above is absolutely true. This probably happened, right? I don’t think so either. This slippery slope didn’t happen as no basic moral values, heterosexual marriage, or weakened states of public morality have occurred. With this in mind, opening and operating these facilities will by no means ‘normalize,’ or attempt to legalize dangerous drugs and substances.

According to the Harvard Health Publications at Harvard Medical School article, “Safe injection sites and reducing the stigma of addiction“:

Imagine a chronic medical condition in which the treatment itself has serious side effects. Examples of this are plentiful in medicine. For example, in diabetes, giving too much insulin can cause hypoglycemia (low blood sugar), a dangerous and potentially life-threatening condition. That doesn’t happen very often, but imagine that it was a common complication of treating diabetes because doctors couldn’t really tell how powerful a given dose of insulin actually was. And suppose that doctors and patient safety experts advocated for places where patients with diabetes could be carefully monitored when taking their insulin. Would you be opposed to this idea? Would you blame the patient for developing diabetes, or for needing this carefully supervised medical treatment in order to live? I suspect that the answer is “of course not!”

Now, let’s shift gears and discuss opioid addiction, specifically people who use illicit drugs like heroin and black-market fentanyl. Heroin is the strong opioid substance derived from the poppy seed that has been used for thousands of years. Fentanyl is a synthetic opioid that can be hundreds of times more powerful than morphine or heroin. Increasingly, illicit heroin is adulterated with fentanyl and similar chemicals, which public health experts believe is the reason for the continued rise in opioid-related deaths despite aggressive measures to decrease opioid prescriptions, increase substance use disorder treatment facilities, and widely distribute naloxone, the antidote to opioid overdose.

Saving lives in the face of increased risk for dying of a heroin overdose

People who use heroin are now at significant risk for overdose death, mainly because the opioid content can vary considerably from dose to dose. Previously, a little too much could have caused a decrease in respiratory rate and a high dose could lead to overdose. Now, with the variability of potency from the synthetic opioids, the strength of each dose can be markedly different. Furthermore, the uptake of fentanyl in the brain is so rapid that a fatal overdose can occur much more quickly than with heroin alone.

If we, as a society, are truly serious about saving lives, we have no choice but to allow people who use injectable opioids to do so in safe, monitored locations without fear of negative repercussions (e.g., being arrested). If you had asked me about this several years ago, I never would have believed that I could write the preceding sentence. I would have said, “Why empower junkies to abuse illegal drugs? Why make it easier on them instead of harder? Why should society condone this activity?”

However, I was wrong — dead wrong.

Good reasons for a change of heart

It turns out that addiction (called substance use disorder or, more specifically here, opioid use disorder in medical jargon) is a disease that can affect any one of us, just like diabetes or high blood pressure. It does not discriminate and does not represent a moral failure on the part of the individual who develops it. It is a condition that no one chooses, but when it attacks, it changes the brain of those with the disease. We can actually visualize those changes with tests like functional MRIs. It leads people to make choices that destroy their lives and the lives of others, such as loss of job, isolation and loss of relationships, incarceration, and even death. We also now know that this is a treatable disease, but the window for successful treatment depends on the psychological state of the person. We must be ready to engage them in treatment at that moment when they are ready.

My opinions changed drastically after a visit to a local needle exchange facility. By current law, individuals can’t inject inside the building. They have to take their chances outside and then they can come inside to be monitored after injecting. I initially envisioned the facility to be sterile, dirty, and depressing. Instead, I was surprised to see that it looked like a living room. There were sofas and a television. There was a warm light, and it appeared to be a welcoming place. Across from the sofas were two desks where staff members sat. Their job is to watch for any signs of overdose (a person who is too sleepy or who is breathing too slowly) and then rapidly respond by providing a nasal dose of naloxone to reverse the overdose. More importantly, they are there to help people right when they are open to treatment for substance use disorder. The staff will help connect them to treatment resources, whether it is group therapy or medical treatment like buprenorphine (Suboxone) or methadone.

If that moment of opportunity in which the individual is receptive to treatment passes, the consequences can be deadly.

Furthermore, the facility is all about harm reduction. There are boxes of free supplies: needle kits so that people do not share needles, condoms for safe sex, kits to help treat small skin infections, even little clean cups to freebase injectable drugs. Naloxone kits are also provided free of charge. There is no judgment there. It is only about reducing a person’s risk of serious, life-threatening infections like HIV and hepatitis C, or the risk of death. And it makes sense. If we are going to agree that opioid use disorder is just another medical condition that needs to be treated, then the compassionate thing to do is to remove the stigma associated with it and reduce associated harms while a person is suffering with substance use disorder. Plain and simple: people with this disease are going to use drugs. Is it better for them to use in the shadows, risking transmission of serious infectious diseases, or monitor them when they are using and be there for them to get them treatment at the moment they are ready?

Currently it’s still illegal in the US to allow people to inject in these supervised environments, but the tide is turning. The city of Ithaca, NY is contemplating a safe injection space, as is Seattle. Multiple studies have confirmed that they work. In Vancouver, Canada, where such facilities were implemented in 2003, they concluded: “Vancouver’s safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts.” Massachusetts is also contemplating a similar pilot supervised injection facility program. With the crises of the opioid epidemic now claiming more than 30,000 lives every year in the US, it’s time to change our biases and old ways of thinking — people’s lives depend on it.

It’s time for a change, Massachusetts, and it won’t hurt us. It may, on the other hand, help people out who really need it.

 

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