May 10th, 2016
On a corner of Albany Street, along a strip known in Boston as Methadone Mile, an easy-to-miss sign appears in a window. It simply says: “SPOT.”
This unassuming piece of paper denotes a new program, revolutionary by US standards, called the Supportive Place for Observation and Treatment. Run by Boston Healthcare for the Homeless (BHCHP), SPOT is a sign that the political tide is turning when it comes to dealing with drugs like heroin and the people who use them.
Physically, SPOT is very simple: It’s just a small room encircled by reclining chairs. It’s purpose is equally simple—if, in some circles, controversial. SPOT is a place where people currently under the influence of drugs can go for medical supervision to reduce their risks. The facility is staffed by nurses; people who arrive have their vital signs monitored, and will receive immediate treatment if necessary.
Dr. Jessie Gaeta, chief medical officer at BHCHP (pictured above, before SPOT launched), explains that anyone at all can walk into SPOT. They sign in at the door, but giving a name is optional. Once settled into a chair, their oxygen levels will be monitored, and a finger probe will be used to track their pulse. Their blood pressure will also be taken every five minutes, using an automated blood pressure cuff. Staff frequently reassess participants’ levels of consciousness on a formal scale, says Dr. Gaeta, so they can identify any changes that suggest deepening central nervous system depression.
“An advantage to monitoring a person’s vital signs if they are sedated is that we can often know that someone is deteriorating before respiratory or cardiac arrest occur, and we can respond earlier,” Gaeta explains. The responses to such a situation could include CPR and the use of naloxone, the anti-opioid overdose drug. Emergency services would also be called immediately.
Participants decide when they are ready to leave the space, although staff would wish to ascertain first that they are able to safely walk out.
SPOT “is a long time coming,” Dr. Gaeta says. Granted, the program doesn’t go as far as the supervised injection facilities (SIFs) that Vancouver and other cities around the world have successfully employed for decades. But it’s radical in the context of our abstinence-fixated country, which has yet to implement any legal SIFs despite some encouraging recent campaigns.
SPOT has even garnered the support of Boston mayor Marty Walsh, who himself is abstinent and in recovery—and is a noted opponent of marijuana legalization.
Dr. Gaeta cites a 2013 study that analyzed mortality rates among BHCHP’s patients and found that drug overdose was the leading cause of death for this population. “This data mobilized us to take on addiction as a core part of our program’s identity and to figure out how to integrate addiction services into our primary care model,” she says.
The SPOT space is an extension of work BHCHP is already doing. Dr. Gaeta says they were looking for better ways to manage overdoses, as they see about two to five per week in their main building. “It’s really hard to manage an overdose in the middle of a waiting room, or in a bathroom, or in a dental clinic,” she notes. SPOT allows them to not only respond more effectively when overdoses happen, but also aids relationship-building with clients, she says. “We want people to feel safe coming in intoxicated,” she explains. Once established, these relationships, it’s hoped, will increase the likelihood of clients wishing to access addiction treatment and other health services.
And though SPOT just opened on April 26, the staff is already seeing results. The space hosted about 10 people per day in its first week, and it’s anticipated that will increase as word spreads. “We’re noticing a shift in the way people are talking to us,” says Dr. Gaeta of the early response to SPOT. A person may have come in on Day One and said they were just tired and looking for somewhere to lie down, she explains. Later in the week, they might be telling staff the exact cocktail of medications they’ve consumed.
This information is crucial—and not just because it indicates that SPOT staff are effectively building trust.
“Overdoses are becoming more complicated due to the mixing of drugs,” Dr. Gaeta says. “We’re seeing a lot of people mixing heroin with benzodiazepines and clonidine [a drug commonly prescribed to treat high blood pressure].” Nationwide, the majority of opioid-related fatalities involve combinations of different drugs; knowledge of their presence increases the staff’s chances of better understanding how different drugs interact, and responding effectively to any problem.
When designing the program, Dr. Gaeta believed it was crucial that the people who would be using the space had their voices heard. Her organization surveyed people using the local needle exchange and asked them what barriers to utilizing SPOT might be—out of that consultation, for example, came the practice that anyone can use the space, without being required to provide their name or ID. BHCHP’s Consumer Advisory Board, made up of formerly homeless people, also had input in determining that the space was needed and that people would use it. Members of that board have also served as peer support in SPOT itself—they are often people in long-term recovery themselves, who can facilitate with the relationship-building work.
Speaking with someone who uses SPOT proved a difficult task at this early stage. The participants are mostly homeless and transient, and without being required to provide a name, there is no record of who has used the room. The space is closed to visitors, and by nature of the room’s use, many of the people entering or exiting are either not in the mood to talk with a journalist, or unable to do so consensually. But the fact that their numbers are already growing is a pretty good indication of its immediate value.
Reception from Boston’s large recovery community, where some might feel challenged by SPOT’s non-abstinence focus, has also been mostly positive. “The reality is people are going to continue to use,” says Marisol, a local woman in long-term recovery. “We cannot force them into treatment and we cannot arrest them out of addiction. Just because people are active in their addiction doesn’t mean that they deserve to be thrown to the outcasts of society.” She adds that she wishes a place like SPOT had existed when she was still using. “If I was still active and I was injecting by myself in the bathroom, the chances of me overdosing and nobody finding me would be much higher.”
The space is not without its detractors, however. Dave Mitchell, another Boston resident in recovery, has mixed feelings about SPOT. “One side says it’s a great idea, and maybe there won’t be so many fatal overdoses. But on the other hand, I feel like any funding going towards this project could be used in a more beneficial, recovery-based solution… like treatment beds or sober houses.” He also worries that the space is “enabling active addicts.”
But the evidence from programs that go further still than SPOT is hard to argue with. In the eight countries that allow supervised injection facilities, the results have been clear. These sites have reduced the number of drug-related deaths, increased numbers of people seeking both drug treatment and medical care for other conditions, and decreased numbers of discarded syringes in public areas. Such unequivocal evidence of positive outcomes has to outweigh any instinctive concerns about “enabling.”
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So why doesn’t Boston go further? Dr. Gaeta notes that providing a space for people to safely inject their drugs would violate both state and federal laws. A recent op-ed in the Boston Globe addressed the “daunting legal hurdles” that would have to be navigated if Massachusetts hoped to follow in Vancouver’s footsteps, but ultimately argued that SPOT doesn’t go far enough and that a supervised injection facility is badly needed.
Few US politicians have caught up. In an interview with Rolling Stone, US “Drug Czar” Michael Botticelli indicated that SIFs are being researched and have not been ruled out as a possibility: “”Taking a close look at these programs becomes very important for us – not only in terms of reducing overdose and infectious disease, but also how these programs might or might not [be] an entryway into treatment.”
SPOT is not the only harm reduction method the city of Boston is utilizing. The needle exchange AHOPE—which is located next door to SPOT—provided over 150,000 clean needles last year, reducing people’s risks of HIV and hepatitis C transmissions. And the Boston Public Health Commission has made needle disposal kiosks available for a range of organizations and service providers.
The most recent kiosk was installed at the Dimock Center, a community health provider. It’s an outdoor model available to anyone in the community; you don’t even have to come inside to access it. Dimock staff hopes this low barrier to use will promote further treatment when the person is ready. “The needle kiosk provides a safe, secure and nonjudgmental method for reducing risks,” says Rachel Maloney, nurse medical manager for HIV Services at Dimock.
Time will tell how much of an impact SPOT can have, or how soon it may be superseded by an SIF. But for now, it’s doing its best to provide a desperately needed service. Dr. Gaeta doesn’t see SPOT as new or innovative, because managing overdoses is something that many providers do already—people aren’t kicked out of the building due to intoxication. But explicitly naming a safe space where people can go when they’re under the influence is new, and could potentially be a model for the rest of the country to follow.
“People are worried about [SPOT] making it easy to use and that it will promote use. But there is no evidence for that,” Dr. Gaeta notes. On the other hand, “There is no recovery in death.”
Britni de la Cretaz is a freelance writer, feminist momma and recovered alcoholic living in Boston. You can follow her on Twitter: @britnidlc.