Updated: Oct 24, 2018
Harm reduction exists everywhere in our lives. The government is happy to pass harm reduction laws regarding things like seatbelts, alcohol, motorcycle helmets, booster seats, and the list goes on. The government is less happy to pass harm reduction laws regarding drug addicts. For this to really take hold, the government and, the population in general, will need to stop seeing addiction as a morality issue. With the growing opiate epidemic, more and more people are going to know someone that is addicted or has been addicted to opiates. My hope is that this familiarity with addiction will be a catalyst for acceptance of a full spectrum of harm reduction options to those addicted to, not only opiates, but all drugs.
Safe Injection Facilities
Harm reduction, in regard to drug addiction, has always had a tenuous relationship in the US. We are the country that brought you the prohibition. We love to tell people how to live, morally speaking. Gabor Maté, a Canadian doctor and author who wrote, In the Realm of Hungry Ghosts, talks about the US Government's opposition to harm reduction. At the time his book was printed, he wrote that the US was the only country that would not allow for federal funds to be used for needle exchange programs. In fact, there was much speculation that the Canadian government had canceled a programmed called NAOMI (North American Opiate Maintenance Initiative) due to pressure from the US. This book was written right as the opiate epidemic in the US was really sinking its claws in. Though the federal government still has evangelical views on drug addiction, in 2016 it finally allowed for federal funding to be used for needle exchange programs, a fundamental form of harm reduction that is important for curbing the spread of HIV and other blood born pathogens. At this time, multiple cities and states are working on harm reduction models such as safe injection facilities (SIFs) and even passing out Suboxone on the streets. Currently, the only legal SIF in North America is, Insite, in Vancouver, BC. Insite is under constant scrutiny by people that believe the only way to help addicts is through abstinence-only programs. Most people who have been an addict know that if you are going to do drugs, you will do them regardless of having a safe place to use. Abstinence-only rarely works and we know this.
Insite provides a safe and clean place for addicts to inject drugs and since opening in 2003, there have been zero fatal overdoses. Through creating a relationship with their clientele, treating them like human beings, and helping them find services, some end up finding a place to live, seeking much needed medical care, and even going to drug treatment programs. Above Insite, is Onsite, their on sight detox and transitional housing program that opened in 2007 and has served more than 2,800 people with only 12 beds in the detox program and over 1,200 people in the transitional housing program. Though we don’t know the outcomes of the people helped, the numbers are significant. The Insite/Onsite program is the example that we have to look at in the US while creating our own SIFs. But there is much red tape here. The US Attorney’s Office of Vermont issued a statement in December of 2017 regarding SIFs, stating falsely that SIFs would lead to more overdoses and it would promote heroin use. This slippery slope fallacy is often found in the US Governments “just say no” approach to addiction.
SIFs exist for the most marginalized drug addicts: those that are using on the streets, sharing needles, and possibly using puddle water to shoot up. San Francisco and Philidelphia are in a race to open up the first SIF in the US. In September San Francisco opened a mock SIF to bring awareness to SIFs, what they are, and how they work. San Francisco is not stopping there. They are also piloting a program to pass out buprenorphine (Suboxone) to homeless drug addicts in an effort to get them into treatment. The Mayor of San Francisco, Mark Farrell, quoted in The Fix, “The consequences of standing still on this issue are unacceptable. Drug abuse is rampant on our streets, and the recipe of waiting for addicts to come into a clinic voluntarily is not working. Plain and simple. So we’re going to take a different approach.” This is the innovation that we need to tackle the opiate epidemic. Some people might never stop using drugs left on their own, but when we give them a space to be safe about using and treat them with dignity, they may just take the next step to get into a treatment program.
Harm Reduction and Suboxone
In the 1960s methadone was introduced as a means of harm reduction for opiate addicts. In 1974 a law was passed that created red tape for the regular doctor to treat opiate addicts and the methadone clinic was birthed. It was many years before another medication became available for drug-replacement therapy. In 2000 the Drug Addiction Treatment Act of 2000 act was passed, allowing for physicians that took an 8-hour training to dispense buprenorphine. The caveat is that the physicians are capped at treating only 30 patients the first year and 100 thereafter. At this time physicians that are able to provide care for 100 patients after one year can now apply to increase their patient limit to 250. I have conflicting thoughts about this. On the one hand, this prevents doctors from becoming Suboxone mills the same way doctors became Oxy mills. On the other hand, there are no limits on how many narcotic prescriptions a doctor can give out so why limit the amount of buprenorphine a doctor can give out. It is, after all, a narcotic. I have personally known two people that suffer chronic pain that choose to use buprenorphine over a full agonist opiate because they do not like the way full agonist opiates make them feel.
Suboxone is polarizing. At times I was pissed that I was given Suboxone by my doctor and at other times, I was happy for it. There are definite benefits and drawbacks to buprenorphine therapy. The benefits of buprenorphine are very easy to spot. Simplistically, people using buprenorphine are no longer engaging in the daily grind of finding money and drugs to feed their habit. This frees up a lot of time, leaving them open to healing themselves and contributing the society again. It is also a powerful drug that causes its own addiction issues. Regardless of whether people end up addicted to buprenorphine, the fact that they do not have to search for it on the streets and that it comes at a fixed cost takes them away from the cycle of finding ways and means to get more drugs and leads them to a healthier lifestyle. This is the same outcome that is hoped for with Methadone and with Heroin-assisted treatment programs.
Just as there are many different anti-depressants, so should there be more than one treatment for opiate addicts. Methadone and Buprenorphine are great options, but they do not necessarily work for everyone. In Switzerland, they have a successful Heroin-assisted treatment program (HAT) for those that have not been successful in using other treatment options—this is what the NAOMI program was like. This program has improved health outcomes for participants and, amongst other things, has decreased the level of crime caused by needing money for drugs. There is also evidence that addicts have found stable housing and employment because they are on a consistent dose of heroin and do not have to seek it out daily. Only about 8% of Switzerland's opiate substitute patients receive prescription heroin. According to an article by Stefanie Knoll, 70% of Switzerland’s heroin addicts are in now substitution therapy. This is huge. When we take away the stigma, and we take away the barriers from addicts so that they can get help, addicts get help.
We can learn from Switzerland just as we can learn from Vancouver, BC. If we are going to make a dent in the current opiate epidemic in the US, we need to stop seeing addiction as a morality issue and stop treating it as an abstinence-only end game. San Francisco is on the right track with their plans for opening a safe injection facility and their Suboxone distribution program. At this time, many other cities are also trying to open SIFs. The biggest roadblock is the US government. At some point, as a nation, we will have to decide what is more important, our puritanical past or the health and wellbeing of our citizens. It is time we meet addiction with love and understanding instead of judgment and shame.
L. (2015, June 22). Apply to Increase Patient Limits. Retrieved from https://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management/increase-patient-limits
First-Ever Suboxone Distribution Program Announced In San Francisco. (n.d.). Retrieved from https://www.thefix.com/first-ever-suboxone-distribution-program-announced-san-francisco
Heroin-assisted treatment in Switzerland: Successfully regulating the supply and use of a high-risk injectable drug. (2017, January 10). Retrieved from https://www.tdpf.org.uk/blog/heroin-assisted-treatment-switzerland-successfully-regulating-supply-and-use-high-risk-0 Holder, S., & CityLab. (2018, October 03).
How to Design a Safe Injection Site. Retrieved from https://www.citylab.com/equity/2018/09/building-a-safe-space-for-san-franciscos-addicts/568942/
Mate, G. (2010). In the Realm of Hungry Ghosts. Berkeley, CA: North Atlantic Books.
Narcotic Addict Treatment Act (1974 - H.R. 12503). (n.d.). Retrieved from https://www.govtrack.us/congress/bills/93/hr12503
Onsite. (n.d.). Retrieved from https://www.phs.ca/project/onsite/
Statement of the U.S. Attorney's Office concerning Proposed Injection Sites. (2017, December 13). Retrieved from https://www.justice.gov/usao-vt/pr/statement-us-attorney-s-office-concerning-proposed-injection-sites
The US can learn a lot from Zurich about how to fight its heroin crisis. (n.d.). Retrieved from https://www.pri.org/stories/2016-02-12/us-can-learn-lot-zurich-about-how-fight-its-heroin-crisis