June 29th, 2016
I was rushing to the subway in the South Bronx where I live and work, when I passed by a young man sleeping in a shopping cart. I would sometimes see used syringes on the sidewalk as a reminder of the heroin problem that affected the neighborhood, but not often such a blatant example of public drug use.
I’m a physician and addiction medicine specialist, so I approached him looking for signs of an opioid overdose, like blue lips or shallow breathing. Beneath a mop of black curly hair, I recognized the sun-burned baby face. It was Felix*, a former patient of mine.
Felix was addicted to heroin. I had treated him with buprenorphine—an effective medication for heroin addiction—but it never reduced his craving for heroin. After a few months he stopped coming to the health center for his prescription. Once in a while, I would see him on the street, buy him coffee and ask him to consider more intensive treatment. He would smile brightly and tell me that he’d drop by soon. He wouldn’t show up. Some would say he failed treatment, but seeing him alone and vulnerable in a shopping cart, I couldn’t help but think we failed him.
With addictions, people have to be “ready to change” before they can successfully do so—but in the United States, in the midst of a crisis of opioid-related fatalities, there is so much more we could do for people who aren’t quite there yet.
Right now in Ithaca, officials are pursuing a Supervised Injection Facility (or SIF) to address the overdose problem. Over 60 cities in 10 countries have opened SIFs in order to give people who inject drugs a place to use that is safer and more hygienic than the restrooms, parks, or other public places that may be their only alternative.
SIFs offer sterile syringes, skin-cleansing products, and a brightly lit space; they have medical staff that can respond to an overdose and administer naloxone, which is the antidote to an opioid overdose; they also connect people—if and when they’re ready—with addiction treatment services. SIFs save lives, can prevent the spread of HIV and Hepatitis C, and may be the only connection to the health care system for some people who inject drugs. New York City needs SIFs.
Last month, the New York City Department of Health and Mental Hygiene released a troubling report that drug overdose deaths increased by 10 percent across the city in 2015—a 39 percent increase in the Bronx. The potentially preventable death of 886 New Yorkers is a crisis. Efforts to reduce overprescribing of pain killers had previously reduced deaths in some areas of the city, but fentanyl, an opioid analgesic that is being mixed into bags of heroin, poses a new problem. Because fentanyl is more potent than heroin, even experienced heroin users may unknowingly inject too much and die in an unintended overdose. At SIFs, overdose deaths simply do not happen.
A law professor at Cornell, and critic of Ithaca’s proposal, asked the question, “Does Ithaca really need a government-run heroin shooting gallery?” The comparison to “shooting galleries,” which are often abandoned houses or buildings where people congregate to injection drugs, is relevant, but only because it highlights the fundamental differences between the two places.
At a shooting gallery, people may rent injecting equipment, which could have been used previously by someone who was infected with HIV. There are no medical professionals there to reverse an overdose. In unsanitary conditions, injecting can lead to infections that can spread throughout the body. But also, if someone is tired and wants to stop using drugs, there are no services at a shooting gallery to link them to detoxification or long-term treatment. SIFs are a planned public health response to a crisis, while shooting galleries come out of necessity when there are no safe places to inject.
The debate in the addiction treatment world about harm reduction efforts, like SIFs, usually comes down to a question of “enabling” drug use. The argument goes that by making drug use easier, the person using drugs is shielded from the consequences of their drug use, which prevents them from making necessary changes to stop drug use. A “tough love” mentality insinuates that people need to “hit rock bottom,” whether it’s arrest, loss of possessions, or health problems, before they will change.
But many of my patients, like Felix, have been to prison, lost friends and family members to drug overdoses, become infected with HIV or Hepatitis C, and have already endured an enormous amount of suffering. It’s hard for me to believe that more suffering will lead to anything but more suffering.
In the addiction treatment group that I run, I asked my patients whether having a safe place to inject was enabling. Their first response was a unanimous, “yes.” One patient shared that if he let someone use drugs at his apartment, he was enabling them. “
What happens if you say no to them?” I asked.
“Well, they’ll go someplace else to use,” he responded.
After more discussion, I asked, “Does struggling to find a safe place to use, help people get to that point where they’re ready to stop using drugs?”
Again, the answer was unanimous, but this time it was, “no.” The same patient clarified, “They just go to the stairwell to use where they may overdose.”
Of course, deciding whether or not to allow someone to use drugs in your home would be an impossible choice for any individual to make. Instead, we need to find a solution as a community. It’s natural to have some discomfort with people continuing to do something that we perceive as bad for them, but we need to stop moralizing.
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These same arguments have been made about other harm reduction efforts that have clearly been effective. People argued that distributing sterile syringes to people who inject drugs was enabling. In 1986 up to 50 percent of injection drug users in the Bronx were HIV positive. Syringe exchange was a response to reduce the spread of infectious diseases and it worked. In 2013, there were only 32 new cases of HIV among people who inject drugs in a borough of 1.4 million.
Beginning a little over a year ago, in Scott County, Indiana—an area previously without access to sterile syringes—there was an HIV outbreak with at least 184 cases of HIV in a county of only 23,000. People also argued that distributing naloxone within the community would enable people to use opioids in riskier ways because they would have means to reverse an overdose. A study from Massachusetts demonstrated that communities that implemented naloxone education and distribution had decreases in overdose deaths in comparison to communities that did not. Neither of these effective public health measures, sterile syringe exchange or naloxone distribution, led to the feared increases in injection drug use.
The impact of SIFs in communities that have adopted them is unequivocally positive. Vancouver saw reductions in overdose deaths, reductions in crime in the surrounding community, and more individuals entering addiction treatment. The Netherlands, Germany and Switzerland had dramatic reductions in overdose deaths. None of these communities experienced increases in injection drug use when the SIFs opened. What happened was the communities observed a problem with overdose deaths, brought together politicians, law enforcement, public health officials, and people who use drugs, and came up with a common sense solution that worked.
In order to address the opioid addiction epidemic, we’re going to need a spectrum of services that include medication treatments (like methadone and buprenorphine), residential treatment, mutual help groups (like Narcotics Anonymous), harm reduction measures (like SIFs) and educational efforts—especially about the dangers of mixing multiple drugs. There is no one silver bullet.
As Felix’s doctor, I still want to work with him even if he is not “ready to change.” Behavior change is a process that takes time. I don’t give up on diabetic patients who have trouble adopting a low sugar diet, but I have few options for patients like Felix. It pained me to see him asleep in a shopping cart, but he was sleeping comfortably, and I was in a rush, so I continued on to my train.
In the United States, we’ve decided that people need to be ready for treatment before we can help them, so there was nothing more that I could do.
*Not his real name.
Aaron D. Fox, MD is a doctor and professor at Montefiore Medical Center.