Tag: harm reduction

Addiction, Drugs, Guest Contributor, legislature

We Must Support People Who Use Substances, Not Punish Them. Here’s How.

 

Harm reduction includes widely accepted approaches such as needle exchanges and more recent innovations like fentanyl testing strips. Todd Huffman from Phoenix, AZ, CC BY 2.0, via Wikimedia Commons

By Susan E. Collins, PhD

Editor’s note: This Tuesday, the Washington State Legislature will convene in a special session to pass a new drug law, after a 2021 state supreme court decision known as Washington v. Blake effectively decriminalized drug possession. The legislature passed a temporary law re-criminalizing drugs until July 2023, expecting to pass a more comprehensive drug law during the legislative session that just ended; when legislators failed to reach an agreement, Gov. Jay Inslee called a special session to deal with Blake.

After decades of the failed and costly war on drugs, we have collectively learned that we cannot punish and incarcerate people into sobriety and wellness. And in the wake of the 2021 Washington State Supreme Court Blake decision, we have a once-in-a-lifetime opportunity to ensure recovery, not punishment, for people with substance use disorders by using the evidence-based tools of harm reduction.

However, more punitive measures are currently gaining traction, as state legislators and local government officials consider making public use, drug possession, and/or failure to comply with sobriety-based treatment punishable with jail time and fines.

Why? Some argue jail time can serve as a wake-up call. But recent studies have shown incarceration is associated with worsened physical and mental health, including increased drug use. And it can be deadly: Washington state has the fourth highest jail mortality rate in the country. Due to stronger opioids like fentanyl, jail time can also set people up for overdose. That’s why, in Washington state, people who get out of jail have a risk of overdose death that is at least 16 times higher than for everyone else.

We talk about how to be safer and healthier, even if patients continue to use, and we track metrics to show incremental positive changes. Our studies show this approach to be engaging and effective.

Once we learned these old ways were hurting and not helping, my colleagues and I at the Harm Reduction Research and Treatment (HaRRT) Center at the University of Washington started to ask people who use substances how we could do better. They told us to meet them where they are and not require them to get sober to get help. They wanted to learn, step-by-step, how to reduce substance-related harm and improve quality of life for themselves, their families and their communities. This is called harm reduction.

After spending the past 15 years testing such approaches, here’s what our research and clinical group has found.

Our evaluations of law-enforcement assisted diversion showed that diverting people away from jail to harm-reduction case management and legal assistance was associated with 60 percent lower recidivism, reduced legal and criminal justice system use and costs, and greater likelihood of obtaining housing, employment and legitimate income.

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Another successful community-level intervention is providing Housing First, or immediate, permanent, low-barrier housing and supportive services that do not require sobriety to help people meet their basic needs. Contrary to some people’s initial fears, our research has shown that providing Housing First does not “enable” substance use. Studies of Housing First here in Washington State show that it is associated with long-term reductions in alcohol use, alcohol-related harm, and use of jail and publicly funded healthcare. These findings have held in rigorous tests in other parts of the world as well.

Low-barrier shelters, which provide safer-use equipment and spaces, are another effective way to reduce harm. Our evaluation showed this approach did not increase substance use. In fact, people staying in the low-barrier Navigation Center in Seattle were 23 percent less likely to report any alcohol or drug use for each month after their move-in date. Instead, this approach was linked to better general health and a stronger commitment to protecting self and others through safer use.

In another approach, harm-reduction treatment, which can include counseling alone or combined with medication, clinicians set aside a demand for sobriety and instead ask patients, “What do you want to see happen for yourself?” We talk about how to be safer and healthier, even if patients continue to use, and we track metrics to show incremental positive changes.

Our studies show this approach to be engaging and effective. Over 90 percent of those approached have accepted help. We have also seen use and substance-related harm cut in more than half. And even though this harm-reduction treatment approach doesn’t require sobriety, positive urine tests for alcohol decrease as well because some patients decide to get sober after all.

In the case of one client, it took a year and a half to stop using, but even before then, he was reducing his use, recovering from depression, and rebuilding a relationship with his family after 5 years of prison and unsheltered homelessness. He sent me a picture of him and his family at Disneyland, captioning it with “It took a village. But harm reduction worked for me. For the first time in my life, I am truly happy.”

At this watershed moment, let’s remember to support and not punish people for having a substance use disorder. It’s not only the right thing to do, it’s what works.

Dr. Susan Collins codirects the Harm Reduction Research & Treatment Center at the University of Washington School of Medicine. The center receives no funding from the tobacco, vaping or pharmaceutical industries. She also is a professor of psychology at Washington State University. The views expressed in this op-ed are those of the author and not the positions of the University of Washington or Washington State University.

Addiction, Drugs, Health, homelessness, King County

Using Private Funding, King County Provides Alcohol and Cigarettes to Patients at Isolation Sites
Beer, Mug, Refreshment, Beer Mug, Drink, Bavaria
Image via Pixabay.

King County has been providing alcohol, tobacco, and, until two weeks ago, cannabis products to some patients with diagnosed or potential COVID-19 infections who are staying at the county’s isolation/quarantine and assessment/recovery sites, The C is for Crank has learned. These sites serve people who are homeless or who cannot isolate safely at home.

The program, which is not funded through public dollars, is similar to efforts in other cities, including San Francisco, to enable patients who have tested positive for COVID-19 or have been exposed to the virus to remain isolated safely while mitigating or preventing withdrawal symptoms.

“Limited and controlled quantities of alcohol and nicotine have been provided by the health and behavioral health clinicians on site as part of clinical management of withdrawal symptoms and harm reduction practices to support patients to safely stay in isolation,” Department of Human and Community Services spokeswoman Sherry Hamilton says. “In all cases, this clinical review and approval for a requested item is required.”

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While programs like King County’s have been controversial in other cities, they are based in the principles of harm reduction, a set of strategies at reducing the negative consequences of drug and alcohol use. Other examples of harm reduction include methadone clinics, needle exchanges, and the Downtown Emergency Service Center’s 1811 Eastlake project—not to mention things like nicotine gum and marijuana as an alternative to heroin.

Hamilton did not say how many people had received alcohol, nicotine, and cannabis products, but said that the department’s director, Leo Flor, has been paying for these items out of his own pocket while the county secures “private foundation funding as a more sustainable approach to funding moving forward.” It’s illegal to spend public funds on alcohol, tobacco, or marijuana. Hamilton was not able to immediately provide details about how much these “initial harm reduction supplies” had cost.

Providing people with substances they would otherwise seek out makes it easier to keep people from spreading COVID-19 in the community surrounding the county’s quarantine and isolation sites, and makes it more likely that people will stay at those sites for their entire isolation period instead of leaving against medical advice. In the case of alcohol, it also may be saving lives—for heavy, daily drinkers, withdrawing from alcohol without specialized medical intervention can cause seizures, heart failure, and death.

“For those who cannot do so, or who do not have a home, the County has created isolation and recovery sites,” Hamilton said. “We try to keep guests safe, stable and comfortable so they will stay the entire time, and harm reduction is one strategy that helps to achieve that goal for some of our guests.”

I have asked for more details about funding for this program, including how much DCHS director Flor has spent out of his own pocket, and will update this post when I learn more.

Addiction, Courts, Crime, criminal justice, Mayor Durkan, public safety

New Plan for Dealing With “Prolific Offenders” Substitutes Punishment for Harm Reduction, Advocates Say

Advocates for harm reduction took strong exception to a set of recommendations from a joint city-county “High Barrier Individuals Working Group”, arguing that several of the proposals are just extensions of the existing, punishment-based criminal justice system rather than the kind of programs that make meaningful, lasting change in the lives of people suffering from severe addiction and mental illness.

The four-pronged plan, which Mayor Jenny Durkan, King County Executive Dow Constantine, City Attorney Pete Holmes, and King County Prosecutor Dan Satterberg announced last week, came out of the recommendations of a work group assembled to respond to former city attorney candidate Scott Lindsay’s controversial “System Failure” report last year. That report looked at the records of 100 people with long lists of misdemeanor charges and determined that many of them had failed to comply with conditions imposed by the court, such as mandatory abstinence-based treatment, random drug and alcohol tests, and appearing regularly in court.

“We have too many people who’ve been cycling through the criminal justice system and we have not been able to design the right interventions for that,” Durkan said in announcing the proposals last week. “We had some of the highest-cost interventions that were also the least effective. We knew we needed to come together and bring people across jurisdictions to address this issue.” Satterberg described the proposal’s goals more bluntly: City and county officials needed a way “to manage what we see as obvious social disorder.”

The four pillars of the plan, which would be partly funded through Durkan’s upcoming budget proposal, are:

• Expanded probation. This would include a new “high-barrier caseload” model, in which probation officers (described in the recommendations as “probation counselors”) would meet with parolees outside the probation office and parolees would be required to show up in court more frequently; and a “high-barrier treatment” model, in which offenders would get reduced sentences in exchange for going to inpatient addiction treatment.

According to Durkan, “probation counselors” with “special training in harm reduction…will meet with individuals where they are in the field, have more frequent review hearings with judges, and give people that chance to spend less time in jail only if they agree to certain dependency treatment.”

Harm reduction advocates say adding more obstacles, such as additional mandatory court dates and coercive treatment,  represents a fundamental misunderstanding of the concept, which relies on non-coercive tactics to help people achieve better health, fewer arrests, and a better quality of life. This, in turn, reduces the harm they cause the community. They also argue that sending probation officers out into the field to track down clients and provide “counseling” will cause confusion and could lead to greater harm to people on probation, because probation officers (unlike real counselors) are obligated to tell the judge if a client is violating the terms of their probation.

“It would be incongruous and disingenuous to train probation officers in harm reduction counseling if the judges—to whom the probation officers report—were to use coercion to force people into mandated and abstinence-based treatment and require abstinence in return for reduced sentencing.”

“I’ve found in my clinical practice that clients start to get confused when parole officers start calling themselves ‘probation counselors’ because they start to think, ‘I can tell this person anything, and, I can tell them how I’m really doing,’ but [the probation officers] are still in this adversarial role,” says Susan Collins, co-director of the Harm Reduction Research and Treatment (HaRRT) Center at the University of Washington. For example, if someone on probation told their “probation counselor” that he was struggling to abstain from drugs and alcohol, the officer would have to report that to a judge as a probation violation, which could land the parolee back in jail.

Mandatory treatment is also contrary to harm reduction, because it makes sobriety, rather than improved outcomes, the goal. “Harm reduction doesn’t have to be at odds with serving protecting public safety. In fact, these goals would seem to be very compatible if we weren’t so fixated on abstinence achievement as a proxy for not committing crimes.” Moreover, it isn’t very effective, especially for people with severe drug and alcohol use disorders who are also facing other major challenges such as a criminal record and homelessness.

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The “success” rate of short-term inpatient treatment, which is what the report recommends for parolees struggling with substance use disorders, is abysmally low already (about 9 out of 10 people with alcohol disorders who enter inpatient treatment, for example, relapse in the first four years), and the “success” rate for people with no support system or place to live when they get out is likely even lower. Although the work group’s report quotes an NIH pamphlet saying that “treatment does not have to be voluntary to be effective,” that pamphlet does not include links to actual research, which shows that although forced treatment can work, it usually doesn’t. The most recent research on the kind of severely addicted, chronically homeless people the probation proposal is supposed to address, Collins points out, actually showed that mandatory 28-day inpatient treatment was the least effective form of treatment.

“In addition to the nonexistent research foundation for coerced or mandated abstinence-based treatment for this population, the proposed approach is troubling philosophically,” Collins says. “It would be incongruous and disingenuous to train probation officers in harm reduction counseling if the judges—to whom the probation officers report—were to use coercion to force people into mandated and abstinence-based treatment and require abstinence in return for reduced sentencing. This is like a bait-and-switch for some of the most vulnerable folks in our community.”

Harm reduction advocates say adding more obstacles, such as additional mandatory court dates and coercive treatment,  represents a fundamental misunderstanding of the concept, which relies on non-coercive tactics to help people achieve better health, fewer arrests, and a better quality of life.

Holmes, speaking last week, said expanded probation, with enforcement mechanisms like “random UAs [drug tests]” and consequences for noncompliance, would be complementary to LEAD’s “softer touch.” “We’re talking about a challenging population that does need the specter of a court intervention or revocation hearing [that] can follow when someone doesn’t comply with the terms of their probation. … We do have to [consider] public safety first, and a probation officer is going to be able to bring noncompliance to our attention so that probation can be revoked and sentencing reimposed as necessary.”

Collins, with the HaRRT Center, says “harm reduction”—like the Downtown Emergency Service Center’s successful program for people with alcohol use disorders at 1811 Eastlake— “doesn’t have to be at odds with serving protecting public safety. In fact, these goals would seem to be very compatible if we weren’t so fixated on abstinence achievement as a proxy for not committing crimes.”

• The expansion of a recently opened shelter in the decommissioned west wing of the King County jail by 60 beds, which Durkan suggested could be reserved for “high-barrier offenders.” Durkan claimed last week that the shelter would be a “comprehensive place-based treatment center” with “on-site treatment for mental health and substance abuse disorders… something that doesn’t exist” yet in the city.

This statement—repeated by the Seattle Times, which described the shelter as a “60-bed treatment center”—is inaccurate.

“It’s going to be a shelter,” says DESC director Daniel Malone. “So, just to be really clear—it’s not going to be licensed as a treatment facility, but we will bring behavioral health treatment resources there. … What we do in a lot of our locations is have a regular, often scheduled, presence of different kinds of behavioral health specialists there to engage with people, form relationships, and help them access services.” (City officials were apparently asked to stop referring to the shelter as a treatment center prior to Durkan’s remarks last week.) Continue reading “New Plan for Dealing With “Prolific Offenders” Substitutes Punishment for Harm Reduction, Advocates Say” →

Drugs, Mayor Durkan, neighborhoods, Uncategorized

Three Years After Opiate Task Force, City Downgrades Safe Consumption Site to Mobile Injection Van

A proposed supervised drug consumption site, first recommended by a county task force and opiate addiction almost three years ago, could be downgraded to what county and city officials euphemistically refer to as a “fixed mobile” site—essentially, a large van where drug users could inject heroin and other drugs under medical supervision. The recommendation, which city and county officials discussed during a meeting of the city council’s housing committee yesterday, comes at a time when drug overdoses, particularly those involving drugs that are frequently smoked or inhaled, like meth and other stimulants, are on the rise.

Jeff Sakuma, an advisor to Mayor Jenny Durkan, told committee yesterday that the city and county have failed so far to find an appropriate site for a permanent safe consumption facility in Seattle, and suggested that buying a large medical van—similar to those used for breast cancer screenings and blood drives—would be a more viable, and affordable, alternative. Sakuma estimated that a van would cost the city around $350,000.

The van proposal would likely preclude safe consumption of drugs by means other than injection—a key recommendation of the county’s opiate addiction task force.

Three years ago, the opiate addiction task force made eight recommendations for addressing the heroin and prescription opiate epidemic in King County. Of those, only one—the opening of two safe consumption sites—has failed for three years to get off the ground, thanks largely to community opposition to (and misconceptions about) the idea of safe injection. Several cities around King County, including Bellevue, have preemptively banned the sites, and as city council member Debora Juarez noted yesterday, Seattle still “can’t find a neighborhood or a district that has their arms and hearts open to some degree” to a safe consumption site. “Are we looking for, like, a unicorn here?” Juarez wondered aloud.

Because it could be easily moved from a neighborhood if problems arose, a van would theoretically address some of the public-safety concerns surrounding drug consumption sites. Users would inject drugs inside the van and access more mainstream services, such as medically assisted treatment, addiction counseling, and wound care, in a fixed location next door.

Patricia Sully, a staff attorney for the Public Defender Association and an advocate with the harm reduction group VOCAL-WA, compares the “fixed mobile” model to portable classrooms outside a brick-and-mortar school—the curriculum may be the same, but it’s hard to get the same quality of education in a rickety, temporary building. “A fixed mobile model is predictable, serving one community. People know where to access it and when. [But] it has inherent space limitations. You can’t just have the same service flow that you can in a brick and mortar site,” Sully says. There’s also something inherently sketchy about a van, which inspires images of quick getaways and dodging the law. A permanent location says: We welcome this solution in our neighborhoods. A mobile van, even one parked next to a community clinic, says: We can move this somewhere else at any moment.

“A concern with mobile units is whether they can offer the same level of therapeutic benefit and privacy and integrated services as a fixed site model. When you go to the doctor’s office, it’s a dignified experience,” Sully says. “Hopefully you go into a building, there’s a waiting room, you go back to see your service provider. That’s the kind of experience that all of us are hoping to provide to those who use safe consumption sites—giving people access to hope and dignity, where they’re being with respect and being able to build those relationships that can be transformational.”

One of the longstanding issues with siting a safe consumption site—as opposed to a site strictly for safe injection—is that few elected officials seem to understand the difference. “Safe injection” and “safe consumption” are often used interchangeably, but they are different concepts—compared to safe injection sites, safe consumption sites are considered a harm reduction approach, because they give drug users the opportunity to consume drugs by less risky methods than injecting, such as inhalation. By quietly precluding the concept of safe consumption, at least for the first “fixed mobile” safe injection site, the city would be forgoing the opportunity to do something truly groundbreaking—acknowledging the existence of addiction, and the need to help addicts who may not be ready for treatment, by encouraging drug users to adopt less risky consumption methods. A safe injection site, particularly one located in a van, is a start—as Sully notes, “if it’s in an area where most of the public drug use is injection, then maybe for that first pilot site, [allowing] consumption isn’t as vital of an issue”— but a permanent safe consumption site, like the ones the opiate task force unanimously recommended three years ago, would be potentially revolutionary.

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Addiction, Crime, Drugs, Health, homelessness, neighborhoods

Safe Space, Part 4: Safe Consumption in Seattle

This is the fourth and final installment in a series about safe injection and safe consumption spaces, Safe Space, which started in Vancouver, B.C. and concludes back at home in Seattle. Read Parts One, Two, and Three. If you like my coverage of harm reduction in cities, urbanism, transportation, drug policy, homelessness, and many other issues, please consider becoming a sustaining supporter by signing up at Patreon; your contributions are what enables me to keep The C Is for Crank cranking and to occasionally travel to places like Vancouver and Boulder to report on what’s happening in other cities and the lessons they have for Seattle.

consumption1

Safe injection sites have a distinct advantage over many other harm-reduction proposals: They directly address a crisis that is in the forefront of the middle-class American consciousness, the heroin epidemic. Although safe-injection sites like Insite in Vancouver allow clients to use other drugs—in fact, Insite manager Darwin Fisher estimates that heroin makes up only about 40 percent of the drugs injected at the facility—most people think of them as heroin-injection sites, and therefore an answer to an opioid epidemic that claimed nearly 30,000 lives in the US in 2014 alone.

Safe consumption sites are different. At safe-consumption facilities, which are fairly common in Western Europe but nonexistent in North America, drug users (and, sometimes, alcoholics) are allowed to consume drugs by whatever method they prefer, including shooting, snorting, or smoking. This raises all kinds of logistical questions, which I’ll get to in a minute, but the basic premise is that people who shoot drugs aren’t the only ones at risk of overdose or in need of access to treatment and other forms of assistance; moreover, in general, every other method of consuming drugs is safer than shooting up, so moving users from shooting to, say, smoking is an improvement on the harm-reduction continuum.

Another distinction between Insite and what some harm-reduction advocates would like to see in Seattle is that Insite, as its name suggests, consists of a single site—located in a run-down, hardscrabble part of Vancouver that has no Seattle equivalent. Whereas drug use and sales are concentrated heavily in one area of Vancouver, Seattle’s drug use is decentralized and highly distributed, making a single injection site—a central destination for drug users from all corners of the city—less than ideal. (The neighborhoods around methadone clinics tend to be hotbeds of “disorder” and minor nuisance crimes isn’t because drug users concentrate there, but because a huge proportion of the city’s drug users concentrate there; currently, there are only two methadone programs in the city of Seattle, serving an estimated 2,200 clients, according to Evergreen Treatment Services director Molly Carney, with more clinics outside city limits.)

What may work best for Seattle and its drug-using population, in other words, is a network of small facilities spread throughout the city, where clients can consume drugs not only by injecting but by smoking, snorting, or any other method of ingestion. These sites would be indemnified by the government, blessed with the approval of SPD and the city attorney’s office, and staffed with people who can help drug users access services including treatment, housing, and medical care. Radical–yes. Doable–very possibly.

Patricia Sully, a staff attorney at the Public Defender Association and the coordinator for the harm-reduction group VOCAL-WA, says most drug users probably won’t travel across the city to access a safe-consumption site; they need services where they already are, which means small (or, potentially, mobile) sites in Seattle neighborhoods where drug users already congregate. Unlike Vancouver, “We don’t have one centralized area where all the drug use is concentrated; we have very diffuse drug use. And I think to mitigate the impact on neighborhoods, it’s important that there not be just one [safe-consumption facility so that] people are able to access  this kind of service where they already are.” Paradoxically, the diffuse nature of Seattle’s unsafe drug consumption could allay fears that neighborhoods will become drug-use destinations, Sully says: “There’s a lot of fear that if you had this kind of facility, it’s going to draw all these people, but I think it’s actually fairly unlikely that people are going to bus miles and miles and miles to access the service.”

Darwin Fisher, the manager of Insite, told me on a recent visit to Vancouver that whether a city builds a single, stand-alone facility, as Vancouver has, or many smaller sites, it should make sure drug users don’t have to travel far, because they won’t. “If I’m in withdrawal, I’m not going to travel 20 blocks to where the site is. That’s just not going to happen,” Fisher says. Montreal is proposing a distributed safe-injection system, and “if you were to take a tour of Europe and go to the 90 sites, I think the only consistent thing would be implied in the title (safe consumption). Everything else is negotiable, depending on what the community wants,” he says.

Sally Bagshaw is one city council member who says she would consider multiple safe-injection sites, but is currently inclined to propose placing them in existing public health clinics, which already have a health-care infrastructure in place. “I don’t think a safe injection site, in and of itself, is the model that I want to pursue. I would like to pursue the public health model where you can come in and have a safe injection site, or safe consumption site, [as well as] other options available when you come in the door,” Bagshaw says—a setup where “if you’re sick and tired of being sick and tired, there are other options that are available to you there, whether it’s a prescription for [buprenorphone, a maintenance drug for opiate addiction] or treatment,  and that we also know that there are beds for people that really want to go into detox.” As I’ve reported, there are only a few dozen detox beds available for people withdrawing from alcohol or other substances in King County, a number that is pathetically smaller than the need. People detoxing from alcohol can die, making medical detox an absolute must for serious alcoholics, but supervised detox can help heroin addicts through the process too, and may be less expensive than building full medical facilities; Insite, for example, has 12 private detox rooms for opiate addicts that are medically supervised but are not full medical detox.

Liz Evans, the founder of Insite, said on a recent visit that she does not support the Bagshaw-approved co-location approach, because “if you embed it into an existing health service, the culture of the health service is the dominant culture at that location, and may not necessarily be as welcoming” as a site run by an independent nonprofit like Insite. (Insite, while its own entity, partners with and gets its funding from Health Canada, the Canadian federal health care service.)

Another hurdle North American advocates for safe consumption spaces face is the very notion of safe consumption, rather than injection; particularly, the idea of crack- and meth-smoking rooms attached to safe-injection sites. But Sully says safe consumption is really “not any more radical than safe injection,” and only raises eyebrows because it’s unfamiliar. “When you’ve got people who are outdoors using drugs, it’s going to be preferable for them to be indoors using drugs both for their own health reasons and for public health and safety of the neighborhoods,” Sully says. “I think that for a lot of people in the neighborhoods who are struggling with people using drugs outdoors, whether those people are injecting drugs or smoking drugs is largely irrelevant.”  

Matt Curtis, the program manager at VOCAL-NY, a New York-based harm-reduction group, adds that “unless you’ve done the world’s worst job of explaining a supervised injection facility, and you’ve explained it so narrowly that people are monofocused on that one little thing, I don’t think it’s that much more of a lift to walk people through why other kinds of safe consumption spaces are a good thing.” And both Sully and Curtis point to the issue of racial justice—limiting safe spaces to heroin users, who tend to be white and have middle-class backgrounds, excludes the crack users who were the victims of the harsh, racially biased drug laws of the ’80s and ’90s, which punished crack users much more harshly than those who used powder cocaine. 

“There’s certainly much more openness to this idea because of the response to the heroin epidemic, and you can’t really separate that from race,” Sully says. “The fact that this is affecting white people and middle America and ‘our sons and daughters’ and all these things —we certainly did not see this response to the crack epidemic.” For that reaosn, if the city chooses to focus exclusively on heroin to the exclusion of drugs used primarily by black people, “we have the potential to really exacerbate our racial disparity,” Sully says.

Building safe smoking rooms would be a minor engineering challenge (the rooms would need to be ventilated properly and segregated from the injection areas), but that seems surmountable. Likewise, the fact that people would be using very different types of drugs—including drugs like meth and crack that can make users aggressive and hyper, along with downers like heroin and fentanyl—hasn’t been a problem at Insite, where more than a dozen drugs are included on the login screen at the front desk, with more being added all the time. When I visited, the room was fairly quiet and mellow, even though there were people in the room shooting heroin, meth, cocaine, and other drugs, often in combination. “You still get people who say, ‘God damn it, it’s the coke users who are taking up so much time because they’re tweaking,’ but that’s just griping that happens. There’s nothing special about that,” Fisher says. 

Will Seattle–famous for processing everything to death, largely ruled at the dictates of neighborhood activists who blame homeless drug addicts for everything from property crime to the presence of discarded couches in neighborhoods–manage to transcend its sometimes-wary attitude toward counterintuitive solutions and embrace safe-consumption sites? Advocates insist there are signs that it may. 

For one thing, we already have Law Enforcement Assisted Diversion (LEAD)–a program that partners SPD and human and social services agencies to divert low-level offenders from jail and into community-based interventions, without expecting them to change everything overnight. Since the program began in Belltown, it has expanded through SPD’s West Precinct and will soon include Capitol Hill.

At a Council District 6 public safety meeting Wednesday night, Public Defender Association director Lisa Daugaard said one thing groups like the PDA, which advocates for harm reduction and criminal justice reform, learned doing LEAD is that advocates can’t merely impose their preferred solutions on neighborhoods; they have to engage communities and show them that they take their concerns seriously. Only then can advocates like Daugaard show communities how programs like LEAD (and, by extension, safe consumption sites) can actually help address the problems they perceive, like property crime, drug addiction, and visible homelessness.

“Even if it was ineffective, wrong, unconstitutional, and stupid” to lock people up over and over for minor crimes like drug possession, “we weren’t engaging the central dynamic, which is that it was actually problematic for people to engage in those behaviors,” like aggressive panhandling, public urination, and minor property crimes, Daugaard said. “So, some years back, some folks on both sides of these conversations decided to talk about the issue in a different way … and reframe the conversation in terms of what actually works. And it turns out that if that’s the lodestar of your conversation, it leads to completely different policy choices.”

At a city council-sponsored public forum on safe consumption sites earlier this year, one unlikely advocate, Magnolia neighborhood activist Gretchen Taylor, expressed her tentative support for the idea of safe consumption facilities–if they are closely monitored and accompanied by strategies that reduce crime in the neighborhoods. Cindy Pierce, another Magnolia neighborhood activist who, with Taylor and several others, formed a group called the Neighborhood Safety Alliance last year, has also expressed a willingness to discuss safe-consumption sites if they will reduce crime and other visible signs of homelessness and addiction. Both women traveled to San Francisco with Bagshaw earlier this year to visit that city’s Navigation Center, a low-barrier shelter that does not require clients to come in sober.
Taylor, whose son is a heroin addict, told the panel, “I do understand the wisdom behind Insite and I congratulate you for your victories. Vancouver has identified that years of failed policies have failed people and perpetuated … continued suffering. I totally get that.”
Taylor continued: “The frustration [in Seattle] has not only reduced people who are addicted to ‘junkies’ and ‘addicts,’ but they’re also not considered a viable part of our community whatsoever, and the frustration is leading to serious ramifications. When you say ‘harm reduction,’ I get it, but I think the citizens and the neighbors are going to want to hear about harm reduction for the neighborhoods as well–that most notably being safety and crime reduction for all of us.”
Not exactly a ringing endorsement. But, perhaps, a start.
Addiction, homelessness

Author Maia Szalavitz on Harm Reduction, “Aging Out of Addiction,” and Why We Should Consider Prescriptions for Heroin

Maia Szalavitz, the NYC–based drug columnist for VICE and the author of a new book, Unbroken Brain: A Revolutionary New Way of Understanding Addiction, was in Seattle recently to speak at the Downtown Emergency Service Center’s annual dinner. DESC was and is a pioneer in harm  reduction, which involves reducing the negative consequences associated with drug use, and the “housing first” philosophy, which holds that people experiencing homelessness need a place to live first, followed by supportive services and treatment where appropriate.

I got interested in Maia’s work because of a provocative piece she wrote for Scientific American, “Opioid Addiction is a Huge Problem, but Pain Prescriptions Are Not the Cause,” in which she argued that most people who get addicted to opiates start  using them illicitly (say, stealing pills from their parents’ medicine cabinet), not as prescribed, as the popular image of a football star who had everything but became addicted to heroin after taking pills for an injury would have it.

I had a chance to sit down with Maia at Zeitgeist Coffee in Pioneer Square late last month. This is a condensed and edited version of that interview.

The C Is for Crank (ECB): As someone who writes about addiction in the context of homelessness, and as someone in recovery myself, I’m very interested in hearing about your theory of how addiction works.

Maia Szalavitz (MS): I think addiction is a learning disorder that affects the way you make choices, and I think the cause of that is a multifactorial mess. For some people, it’s straightforwardly trauma. For some people, it’s self-medicating for mental illness. For other people, it may be existential despair of various types, sometimes economic. Fifty percent of people with addiction have another diagnosis, and it’s probably more like 60 or 70 percent. Two-thirds have a serious childhood trauma history. They have more trauma than the general population.

Learning is really critical, because you have to learn that it is the drug that fixes you. Because if you didn’t know that, you wouldn’t know what to use, so you couldn’t get addicted. This is why some people get physically dependent on drugs and don’t even realize it. You can be in the hospital after having major surgery, you’ve taken opiates for about a month, you come home,  you’re dopesick, and you do not know it. And because you do not know it, you don’t go to your doctor and ask for heroin or ask or more opiates.

ECB: So you’re drawing a distinction between physical dependence and addiction.

MS: Yes, and that’s a very, very important distinction, because physical dependence is neither necessary nor sufficient to define addiction. It’s not necessary because cocaine and meth have very little physical dependence. You will be very cranky, you will be very filled with cravings, you will be very irritable, but you will not be puking, shaking, or any of the stuff that goes on with heroin or alcohol withdrawal.

I am on Prozac. I probably will stay on Prozac for the rest of my life. Hopefully it will continue working. And when I am not on antidepressants that are working for me, I am depressed. Addiction isn’t the same as physical dependence. Physical dependence isn’t a problem. What addiction is, is compulsive behavior despite negative consequences. The consequences have to be negative. If they’re not negative, it isn’t addiction.

If you take opioids for more than a month, 99 percent of people are going to be physically dependent. People take opioids to the point of physical dependence all the time in cancer treatment without getting addicted. If you screen the patients carefully for past addictions, for mental illness, for trauma and stuff like this, you end up with less than 1 percent getting addicted. When I’m talking about addiction, I mean the compulsive behavior that ruins your life, not physically needing something to function.

I had days at the end of my addiction when I was shooting up dozens of times a day, literally, because I was dealing, so there was always coke. I would wake up every morning and say, “I’m not going to shoot any coke today. I know it’s going to suck. It will be horrible. It will be a bad experience. I will be feeling like I’m going to die. It will not be good.” And—pfft!—I’m doing it.

ECB: My understanding of addiction is that drugs or alcohol flood your brain with neurotransmitters like dopamine, and your brain stops producing those chemicals, so that you need a steady and increasing supply of drugs to get high and eventually to just stay level. And withdrawal happens when you don’t have the substancebecause your brain no longer produces the stuff that helps you feel normal, so you feel awful until you have the substance again. What do you think of that theory?

MS: What that perspective leaves out is that the reason that you were using the drugs in the first place is that the drugs helped you do that coping. The people I know that have been addicted, something is going on with them, and if you don’t figure out what that something is, they are going to relapse.

The economic thing—when people are despairing and they have no hope, why wouldn’t you use? I don’t believe addiction is, like, a rational choice, but I do think heavy drug use can be a rational choice in that situation, and then you can certainly end up addicted.

I think this is why, in the ’90s, we saw the black community get hit really hard by crack [when] they had been suffering for years with high unemployment and homelessness. And now we’re seeing that in the white middle class and lower middle class. It is not surprising we are having an opioid epidemic in that population, and if you look at the people who are hardest hit by opioids, they’re only being called middle-class because they’re white, for the most part. It’s not to say that there aren’t plenty of white middle class opioid addicts, as I can speak to myself personally, but if you look at the risk for heroin addiction it’s triple in people making under $20,000 than people making over $50,000. There is an economic piece of this.

With opioids, clearly we had an increase in supply, and at the same time we had a massive increase in use, so it’s not non-correlated. But what we also had at the same time was the collapse of the middle class, and what we also had at the same time was 75 percent of people who misuse opioids are getting them from somebody else’s prescription. These are not pain patients who are directly being prescribed these drugs. Most pain patients are not getting addicted, and those who are getting addicted in their 40s or so are usually people who have had previous addictions.

ECB: Long-term “maintenance” for opioid addiction with drugs like suboxone or methodone is controversial because those drugs are themselves addictive, and because people who use them are physically dependent on them—withdrawal from either drug can be just as bad as coming off heroin. But you’re a firm believer in long-term, even lifelong, maintenance. Why?

MS: What maintenance does, when it leads to recovery, is it replaces addiction with physical dependence, so now you’re basically on an antidepressant. If you look at the data, the only thing that cuts the mortality rate 50 to 70 percent is maintenance with suboxone or with methodone, and possibly with heroin. And the thing with methodone everybody gets all freaked out about it is that they think, “Oh, people are high all the time, and they’re not emotionally available, and they’re not really in recovery.” That’s because they don’t understand tolerance. Opioids create complete tolerance to the intoxicating effect. It’s not like replacing vodka with gin, because you will have impairment when you do that with alcohol. You still get tolerance to alcohol, but you don’t get complete tolerance the way you do with opiates, so that that means if you just take your steady-state dose all the time, you’re not high. You can drive. You can hang out with your kids. You can do what everybody else can do.

Some people will probably need maintenance for life. I certainly believe no one should be pressured to come off of it if it’s working for them. If they’re feeling numb or have bad side effects, like sexual side effects or like whatever other kinds of side effects like you sometimes have from Prozac, that’s a different story, but you shouldn’t want to be coming off because of stigma. You shouldn’t want to be coming off because you’re “not really in recovery.” That’s ridiculous.

ECB: In covering the problems caused by addicted people experiencing homelessness, I’ve heard over and over from people fed up with crime in their neighborhoods that addiction is a choice, and since it’s a choice, people who choose to continue drinking or using drugs don’t deserve any help. This includes everything from help getting housing to portable toilets to needle exchanges. What is your counter to that argument?

MS: In San Francisco, they had pioneered [using] bleach [to sterilize needles], and one of the outreach workers from San Francisco happened to visit a friend of mine in New York when I had started just shooting up, and she taught me to use use bleach. [Without that], I would have God knows what diseases at this point. At that time, half of New York’s active drug users were already HIV positive. God knows about the hepatitis C levels because it wasn’t even discovered, and so nobody was doing anything, and about two years before I finally got in recovery, this woman taught me to use bleach. And I was compulsive about cleaning my needles just as I was compulsive about using my needles.

People said, “oh, they wouldn’t bother to use a clean needle,” or whatever, but you know, it’s always been easier to get people with addiction to use clean needles than it is to get men to use condoms. There are two reasons for this. One is that clean needles make the high better, because with a sharper needle, you’re going to more likely hit the vein than not, which is better. But also, you know, condoms can get in the way of the mood or whatever. But it’s just kind of funny, because people have always thought the irresponsible addicted people are never going to do that and they like sharing. That was my favorite, was that people like sharing needles. And I never was able to get this into print, but I always wanted to say it’s like sharing a tampon. Nobody would want to do that. It’s about money.

It’s like when people say, “They just like living that way. They just want to sleep in the park, passed out. You can’t ever get them into housing. Leaving aside if you think they deserve housing, which I think majority of people don’t think [they do], but people seem to think people want that lifestyle, that it’s a lifestyle choice, and that’s something I have never understood. There are some people who will say that they like that, but I always feel that it’s sort of a bravado. There certainly are people who, once you sink that low, it’s liberating in a weird way. You have to worry about lots of other things but you don’t have to worry about being somewhere at a specific time. You don’t have to worry about them coming after you for the rent or all that kind of other stuff. So I can see why some people might actually say that, and maybe some people actually believe it, but for a lot of people, their reality is that there’s addiction, there’s mental illness, there’s mental illness plus addiction, usually, and about 50 percent of people with addictions also have another mental illness, and the drugs did not cause the mental illness. They were self-medicating with the drugs for the mental illness.

I always hate this idea that, like, people were totally fine and then they started doing drugs and then they have a problem. That is almost never what happens. It is rarely the case that someone with some strong genetic predisposition meets just the right drug and they were perfectly going on with their lives [before]. I have met very, very few such people.

I think that treating people with empathy and compassion and respect is the secret sauce of harm reduction. If you think about it, with homeless people, particularly homeless women, the level of trauma, particularly child sexual abuse and adult sexual abuse after they’ve been out there for a while, is huge. An enormous portion have serious trauma histories. You can’t take away their only coping mechanism before doing something. In some cases, they need to get their coping mechanism in place while they’re still using, before they can move toward recovery.

What harm reduction does is, it opens up a safe place for that to happen. If you’re homeless, why wouldn’t you want to use all day? Is [Housing First] a cure? Hell no. Absolutely not. But will it help? Hell yes. Everybody deserves a decent place to live, and frankly, I don’t understand why people aren’t more selfish and just say, like, “I don’t want to see people lying on the street—why don’t we give them houses?”

ECB: They are that selfish, it’s just that instead of housing, they want to give them one-way tickets out of town.

MS: Right, but they’re still going to be somewhere, and extermination is a horrible thing. If everybody had to pay an extra, like, $5 a month and there would be no homelessness, because you’d have housing for everybody, then why not? I just don’t get that. I always feel guilty, guilty, guilty when I see people that I can’t help, and so I don’t understand. I think that homeless people, and people  with addictions in general, are not hedonists, generally. Sometimes they might take a hedonistic pose out of defiance and some remaining self-respect, but most of the time what’s going on is they are trying to deal with some kind of serious pain.

They’re not getting extra pleasure. It’s not like, “This is so fun lying on the street, I don’t have to show up to the 9 to 5.” This is just not how it works. There is a minority of people with addiction who do have antisocial personality disorder and who are basically the assholes that give everybody else a bad name, but there are assholes in the general population as well.  And it is the case that I don’t think that anybody knows what to do with people with antisocial personality disorder. They’re overrepresented in the homeless population; they’re overrepresented in prison populations.

ECB: We’re having a serious discussion here in Seattle about creating safe injection sites, and possibly safe consumption sites for all drugs. Obviously, if that happens, there’s going to be a huge battle about where they’re located. How do you suggest combating that?

MS: The people who are going to be there—would you like to have them? Not in your sight, most likely, but if they are given a safe space, they will respect that safe space. This is one of the things I’ve seen again and again and again with needle exchanges. They know that this is a fragile thing and everybody hates them, and if they, to put it crudely, shit where they eat, it’s not going to work out so well. So they tend not to. Similarly, methadone programs reduce crime. You cut a methadone program, you get more crime. You add one, you get less crime. That’s the reality of it. People are smart enough to commit their crimes elsewhere.  Once you’re on methadone, you are just much less likely to commit crime. When you give people respect and safe spaces, they will typically give you respect and safe spaces back.

ECB: You talk in your book about people “aging out” of addiction or simply growing out of it with time, which contradicts the more generally accepted belief that once an addict, always an addict. Explain to me what you mean by “aging out.”

Looking at the general population, about 50 percent of people who qualified for alcohol dependence in their 20s and teens, by 30, half of them are no longer qualified. About half of them will have moderated. The problem is that basically none of those people show up in [Alcoholics Anonymous] and never show up in treatment because they managed to stop without it, even though they had every symptom to qualify for severe dependence. They stopped without treatment and we didn’t see them.

I think in some cases, a lot of times, it’s life events, like you fall in love with somebody and because you’re just in love with somebody at that moment, you are able to give it up for them, whereas if you fell in love at another time, it wouldn’t work. Or you just got the job you’e always wanted. Or the structure of your life changes. For a lot of people, you can’t really party the way you did in college 30. And that structurally helps a lot of people to recover, just the fact that in order to earn a living, you have to show up somewhere at 9 or 10 in the morning. And maybe those people have less severe addictions.

ECB: A lot of people believe people have to hit “rock bottom” before they get help, and that sometimes going to jail and being forced to go to meetings is the best way to address addiction.

MS: This is what I think is interesting—because addiction is compulsive behavior despite negative consequences, right? So why do we keep thinking negative consequences can fix it? That’s, like, dumb. And that’s why I really hate the idea of “bottom,” because it’s like, if horrible, cruel things being done to people with addiction fix them, we wouldn’t have addiction. So many horrible things have been done to people in the name of pushing them to bottom, and lots of people have died behind that, and lots of evil, abusive treatment centers have done horrible things to people around that idea, and continue in some places.

Locking people in cages for using certainly doesn’t help anybody. There’s no evidence that criminalizing personal possession helps anybody. People with alcoholism get into recovery all the time without having to go to jail for a few days repeatedly, over and over and over.

We could pay for tons of inpatient treatment if we stopped locking up users. [Ed. note: Szalavitz is not an advocate for widespread inpatient treatment, and believes outpatient treatment is more cost-effective in many cases.] Every cent that we spend arresting people for possession, which is billions of dollars every year, we could have luxury rehab for all. It’s insane the way we do this, and I know there’s a lot of really good people, really well-intentioned people, who genuinely believe in what they’re doing in the field and are absolutely helping people. The unfortunate thing is that if you truly believe in what you do and you don’t realize you can be wrong, you can do an awful lot of harm, and an awful lot of harm has been done, because for so many years there was this notion that you can’t hurt people with addiction—the more you attack them, the closer you’re bringing them to bottom, and that’s all to the good. And a lot of people have been, and continue to be, retraumatized by that.