Reducing Overdose Deaths with Supervised Heroin Injection
March 26, 2018
by Claire Hughes, current graduate certificate student at The Bioethics Program
By now, the nation’s opioid problem is well known. An explosion in the use of heroin and other injected drugs has fueled a record numberof overdose deaths -- 42,000 in 2016. Since 2010, deaths from heroin alone have quadrupled, with the death toll since 2013 driven by potent synthetic opioids like fentanyl.
Some policymakers have taken impactful steps to address the epidemic. In New York, where I recently covered health care for an Albany newspaper, state officials have increased availability of the overdose antidote naloxone, improved access to treatment with medications like methadone and buprenorphine, and enhanced support for syringe exchange programs.
Yet that hasn’t been enough.
Supervised injection sites, already established in at least eight European countries and a Canadian province, offer another approach. Their purposes include reducing not only overdose deaths and the spread of disease, but also the public nuisance that comes with drug use, like contaminated needles left in parks.
Supervised injection sites adhere to the principles of harm reduction, taking no moral position against drug use nor attempting to make users stop. The harm reduction approach accepts the persistence of drug abuse and seeks to decrease its detrimental effects.
These sites can also connect drug users with medical services. In Vancouver, where a facility called Insite has operated since 2003, withdrawal management and transitional recovery housing are available onsite, and staff refer clients to long-term treatment. According to Keith Brown, director of harm reduction for the Manhattan-based Katal Center for Health, Equity, and Justice, supervised injection sites encourage marginalized clients to develop trust in people who can help them recover. Since Insite opened in 2003, staff have intervened in more than 6,400 drug overdoses, and offered clinical treatment almost eight times as often.
Proposals for supervised injection sites in the United States have met opposition. In Seattle, for instance, a planned three-year pilot program spurred an effort to allow voters to ban the sites. The ballot initiative was struck down in October by a judge who recognized the authority of public health officials to establish them.
That ruling, however, has not ended an intense debate. Critics in Seattle and elsewhere say supervised injection sites discourage personal responsibility and enable dangerous behavior.Law enforcement officials worry the facilities condone illegal activity. Some argue that supervised injection sites make it too easy for addicts to shoot up, removing an incentive for them to quit.
Indeed, the concept is counterintuitive. As the mayor of Ithaca, N.Y., said to the New York Times two years ago, “Heroin is bad, and injecting heroin is bad, so how could supervised heroin injection be a good thing?”
Opponents’ arguments rest in part, however, on the belief that drug abuse is solely a behavioral problem, one that can be solved with a “just say no” approach. But increasingly, experts view addiction as a chronic disease.
Stanley Glick, an addiction medicine specialist who is professor emeritus at Albany Medical College, has described addiction’s effect on brain chemistry this way: early use of a drug is a choice. But once addiction is established, choice recedes -- to the point where addicts behave recklessly and self-destructively.
Dozens of addicts I have interviewed in the last several years attest to this lack of control over heroin or fentanyl once it has, in the words of one, “grabbed” them “by the soul.” They admit to enjoying the initial euphoria of opioids, but then descend into a wretched existence of chasing after drugs to stave off withdrawal. The threat of jail or other punishment is no match for the compulsion fueled by the changes in their brains.
Yet it cannot be ignored that treating addiction involves more than merely correcting a chemical imbalance. However much chemistry is involved, choice must come into play in accepting treatment, which is aimed at changing behavior. Opinions differ over whether treatment is more effective when it is voluntary rather than mandated. Most of the addicts I have interviewed say that both choice and coercion have influenced their quitting, but that coercion has rarely been effective on its own. To get clean, they had to commit to treatment. Supervised injection sites recognize that everyone will not reach that critical point of commitment in the same time and in the same way. They provide safety and a judgment-free zone until an addict gets there.
As for the argument that supervised injection sites facilitate IV drug use, studies have shown they do not result in increased drug injection, trafficking or crime. The fear that they will do so echoes opposition to syringe exchange programs, which recognize that the threat of a life-threatening disease does not keep drug users away from dirty needles. Likewise, the threat of overdose does not limit drug use, as word of potent opioid batches will send some chasing them in hopes of a greater high. Just as syringe exchange programs have proved effective at limiting disease spread, supervised injection sites could cut down on overdose deaths.
Supervised injection sites create discomfort in part because they represent an evolving yet significant shift, rejecting the notion of drug abuse as a crime deserving punishment. But like previous moves to mitigate the harmful effects of drug use, they recognize the realities of addiction, while showing compassion to people who are suffering.