Update (11/23/17): Success! Initiative 27, which, sought to ban safe injection sites in Seattle, has been struck down by a King County judge on grounds that it infringes upon the work of public health authorities.
Our country is in the midst of a rather alarming opioid crisis. Over 2.6 million Americans were addicted to opioids in 2015, from which more than 33,000 died from overdose (this figure has quadrupled since 1999). Major pharmaceutical giants like Purdue are largely to blame for facilitating the initial epidemic: the aggressive sale of prescription painkillers such as oxycodone and fentanyl from the early 90’s and onwards has, in a tragic irony, ruined the lives of the companies’ most loyal customers, and has heavily contributed to rising addiction rates throughout the 2000's. However, what has truly caught the nation’s eye is the staggering spike in illicit, street-level opioids, particularly in the case of heroin. The drug has seen a sixfold increase over the past 15 years and is claiming the most victims among those aged 18-25.
The government has long attempted to thwart this problem by
gavel, but to no avail; it has been proven time and again that prosecuting and
jailing drug abusers is a hopeless and counterproductive means of remedying
their situation, and that opioid addiction must be addressed as an issue of
public health. This shift in attitude was only recently reflected in the
federal government with the passage of the Comprehensive Addiction and Recovery Act (CARA) in 2016, although reform on a state and local level has been in the
works for the past decade. A number of innovative solutions have been put on
the table since, but by far the most controversial has been the proposal of
implementing “safe injection sites” in cities with high rates of heroin
addiction.
As the name might suggest, the premise of a safe injection
site is that heroin addicts, mainly among homeless populations, are given a
controlled environment in which they can get their fix under the supervision of
a medical assistant. So far, the only such facility that exists in North
America is Insite, located in a seedy district of Vancouver, BC. Established in
2003 to combat Canada’s rising HIV infections, the site has not had a single
death occur on its grounds, and has contributed to a 35% decrease in overdose
rates within its vicinity. A similar project has been proposed in Seattle,
where it has enjoyed strong local support (including that of the mayor and
numerous King County executives). However, the prospect of introducing a safe
injection site to the US has still been met with pushback, similar to that of
Canadian conservative groups throughout Insite’s tenure.
In May 2017, an initiative was introduced to ban the
implementation of safe injection sites in King County. Backed by figures such
as Bothell mayor Joshua Freed and State Senator Mark Miloscia (R-Federal Way),
Initiative 27 is said to “[protect] taxpayers by prohibiting public financing
of drug consumption sites” and seeks to “[encourage] local governments to offer
treatment instead of continued drug use.” At first glance, this effort seems
reasonable in principle, but I was surprised to see how quickly its proponents’
arguments crumble on contact with contrary evidence.
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| A map of drug overdoses in part of downtown Seattle. (KIRO 7 News) |
Miloscia, the most vocal spokesperson for Initiative 27, is
riding on the common theme among opponents of safe injection sites: that such
facilities encourage continued public drug use. After all, it’s easy to be put
off by the notion that heroin addicts are using near your own neighborhood.
However, this is exactly one of the concerns that safe injection sites would
help solve. Currently, heroin users in the Seattle area commonly use public
restrooms, alleyways, and crowded sidewalks to acquire and consume heroin; in
fact, many addicts choose such locations near popular shopping centers and
restaurants like Nordstrom and McDonald’s, given the commonality of heroin
exchange among homeless shelters nearby. This has proven to be a burdensome
nuisance to many of the companies in question: McDonald’s, for example, stated
to KIRO 7 News that one of its local branches had to hire a private security detail
to ward off heroin users from its property, which imposed “substantial costs”
upon their business. Given such grievances, it seems only rational to
concentrate heroin usage to only one or two locations, in order to avoid the
dispersal of heroin users among public locations that safe injection opponents
themselves probably visit on a regular basis.
Another argument justifying Initiative 27 is that it saves
taxpayer money by barring government funds towards drug consumption. What one
may not realize, however, is that the current rate of overdoses in Seattle is
already taking quite a large toll on taxpayers. The Seattle Fire Department has
had to respond to almost 2,700 overdoses over the past three years, for which
each individual call costs them at least $2,000. This has translated to
millions of dollars of taxpayer money being spent since 2014, to say nothing of
the estimated hundreds of unreported overdoses that Seattle Fire is working to
address. As seen in Vancouver, safe injection sites dramatically reduce
overdose rates, and so implementing them in Seattle would mean less money spent
by the fire department and, consequently, taxpayers.
Even with these obstacles aside, however, there remains the indisputable
fact that safe injection sites still aid in drug consumption. I suspect that
this is the most troublesome detail for critics, who favor direct treatment
instead. This is where one must consider what “drug treatment” entails in order
to be effective, and why forcing addicts into it is not a reliable solution to
their condition. On a neurological level, potent opioids such as heroin bind to
receptors in the limbic system, causing pleasurable sensations to reach the
brain’s reward center. The diminished sensitivity of opioid receptors due to
repeated substance use leads to heightened tolerance and increasingly worse
withdrawal symptoms. There are several theories as to what it takes to reach
the actual “addiction” stage of this process, but the conclusion that is most
relevant to this issue is that the prefrontal cortex, which normally sends
inhibitory signals to the reward center in order to control impulsive behavior,
is compromised by long-term opioid usage, which then amplifies drug craving and
makes it much more difficult to contain. This means that opioid addiction is
less a conscious choice than it is a psychological disorder, and that
therefore, simply “discouraging” drug use (let alone through punishment) cannot
be expected to actually stop it.
The implication for treatment, then, is that substance abuse
disorder cannot be treated instantaneously, and that addicted patients have to
gradually decrease the opioid dosages they take in order to abandon their
habits. The reason nurses are present at injection sites is to ensure that this
process occurs in a safe, controlled manner. Of course, the sites must come
equipped with supplementary drugs that can help with additional problems that
may arise as a result of this type of treatment: for one, if a patient must recover
from his or her drug habit at a faster rate, their average heroin dosage would
have to be reduced to a greater extent; the drug methadone can help mitigate
any withdrawal symptoms that will undoubtedly arise from this approach. More
importantly, nurses will need a consistent supply of naloxone, a drug that is
highly effective in counteracting overdoses. Insite has reported about 1,000
overdoses having occurred at their location since the facility was established,
and the only reason that none have been fatal is because nurses were quick to administer
naloxone.
In the long run, safe injection sites in the US would need a
continuous source of funding in order to sustain themselves. In Canada, Insite
holds a special exemption from the country’s narcotics laws, although this
seems unlikely to happen in the US (not in the least due to Attorney General
Jeff Sessions’ intent on returning to Nixonian prosecution measures against
low-level drug offenders). An op-ed posted in the Brookings Institution
suggested that the government adopt a “tiered-evidence” approach to addressing
the opioid crisis, in which greater sums of grant money are awarded to states
whose treatment programs are both innovative and backed by sufficient evidence
attesting to their efficacy. In the case of Seattle, this would require that an
evaluation program be put in place to track the results of safe injection sites
once implemented. I have suggested elsewhere that safe-use facilities be
integrated into Seattle’s ongoing “LEAD” program, a novel client-centered
therapy system working to redirect homeless heroin users to temporary shelters
and medical care. The program’s effectiveness was analyzed to impressive
results by a team of researchers at the University of Washington, who could
provide similar efforts to assess safe injection services if they are ever put
in place.
Nonetheless, these proposals are all currently contingent on
the defeat of Initiative 27, which will be voted on this November. It needs
47,443 signatures to pass. So far, support for safe injection sites remains
strong among Seattle and King County officials, whereas a political action committee
started on behalf of Initiative 27 has not reported collecting significant sums
of money. This could of course change in the coming months, especially given
the fact that Seattle mayor Ed Murray, a strong supporter of safe injection
sites, is not seeking reelection amidst scandalous allegations surfacing from
his past. Regardless, it is my hope that his proposals see the light of day,
because they could very well pave the road for the solution of America’s worst
drug epidemic.
Thanks for reading!
References
References
- McNeil, D. G. (2011, February 11). An H.I.V. Strategy Invites Addicts In. The New York Times.
- Beekman, D. (2016, April 4). Heroin, cocaine users in Seattle may get country’s first safe-use site. The Seattle Times.
- Young, B. (2017, May 11). Initiative proposed to ban heroin safe-injection sites in King County. The Seattle Times.
- Green, S. J. (2015, April 8). LEAD program for low-level drug criminals sees success. The Seattle Times.
- Wagner, D. (2016, November 7). Seattle heroin overdoses: See maps of where each case happened, 2014-2016. In KIRO 7 News.
- Kosten, T. R., & George, T. P. (2002, July 1). The Neurobiology of Opioid Dependence: Implications for Treatment. NCBI, 13-20.
- Collins, S. E., Lonczak, H. S., & Clifasefi, S. L. (2015, March 27). LEAD Program Evaluation: Recidivism Report. University of Washington.
- Markovich, M. (2017, February 7). Inside the Vancouver, B.C. "safe injection" site Seattle, King County want to use as model. Komo News.
