A few years ago, a Canadian government minister visiting the supervised drug consumption site where I worked in Vancouver asked us, “How many of those people in there would you consider to be a write-off?” His question epitomized an all-too-common attitude toward people who use drugs: Either they’re lost to addiction forever, or redeemed only by total abstinence. But what would happen if we decided that nobody would be written off? If we could meet them where they are, keep them alive and healthy, and be there to help when they are ready to make positive changes? That was in fact the assumption we were working under; and one we must adopt here if we are to address the country’s growing opioid epidemic.
To this effect, the President’s Commission on Combating Drug Addiction and the Opioid Crisis’s July 31 interim report on America’s drug problem did make a number of recommendations that public health experts have in fact been advocating for years: better prescribing practices, more treatment capacity, a significant scale-up of medication-assisted treatment (MAT), increased access to the overdose antidote naloxone, and improvements to Medicaid and insurance coverage. Yet the report failed to make that crucial leap we need: abandoning abstinence-only drug policies and embracing an evidence-based public health approach.
Let’s start with what the report gets right. The commission made a bold recommendation to increase funding for medication-assisted treatment (MAT), which means prescribing heroin substitutes like methadone and buprenorphine. MAT is the gold standard of treatment for opioid dependence, and an effective alternative to the 28-day inpatient rehab model, which is neither effective nor necessary for many of the people currently pushed into it, often by the court system. In the commission’s own words, “MAT has proven to reduce overdose deaths, retain persons in treatment, decrease use of heroin, reduce relapse, and prevent spread of infectious disease.” Unfortunately, many politicians and treatment providers bristle at the concept, suggesting it trades one addiction for another—which is like saying diabetics are addicted to insulin. The commission also recommends the scale-up of specialized inpatient treatment to include these models, making it more effective for the majority of the population it serves. The United States should move quickly to remove barriers to access these life-saving medications—including by preventing judges and other non-medical personnel from dissuading or prohibiting its use.
Likewise, the recommendation to increase access to naloxone—an easy-to-administer medicine that can swiftly reverse opioid overdoses—is a step in the right direction. Legislation allowing “standing order” prescriptions and requiring doctors to co-prescribe naloxone with opioids would help to destigmatize naloxone and to educate patients about overdose. But the report omits the most effective response: giving naloxone directly to drug users. Yes, we should equip police and other potential first responders (including family and friends) with naloxone. But as the World Health Organization notes: “people likely to witness an opioid overdose should have access to naloxone and be instructed in its Administration to enable them to use it for the emergency management of suspected opioid overdose.” The people most likely to witness an opioid overdose are the people taking opioids—so let’s put naloxone in their hands too.
The commission also suggests broadening “good Samaritan” laws that shield individuals from prosecution when they report a drug overdose to first responders or police. Good Samaritan laws are helpful, but it’s naive to expect people not to fear law enforcement involvement, particularly when most jurisdictions still dole out jail time for illegal opioid possession. Legal trouble compounds the problems people struggling with drug dependence face, and the prison system is not an effective place for rehabilitation. In fact, because even a brief jail stay without drug use reduces a person’s tolerance to substance, more opioid users die of overdose after leaving jail (or rehab) than at any other point. While law enforcement has a proactive and positive role to play in responding to the overdose crisis, we need to recognize that laws that criminalize possession discourage them from seeking health care and social support, increase risky behavior, and raise the risk of illness, including HIV infection. We should consider following the lead of countries that have reduced or eliminated criminal punishment for drug possession, like Portugal—where drug use rates have fallen and health outcomes have improved.
Even when possession remains criminalized, harm reduction programs can help. One key solution the report ignores is the creation of supervised consumption sites: places where people can bring illicit drugs and use them under the supervision of trained staff, without fear of arrest. It’s not a new idea—such sites have existed for three decades, and there are now around 100 in Canada, Europe, and Australia.
I have personally witnessed how effective they can be, because for several years I coordinated the activities at Insite, the clinic described above, and Canada’s first legal public supervised injection facility. Insite, a government-funded program, has around 700 to 900 visits per day and has seen over three million injections since it opened in 2003. When overdoses occur, staff is on hand to intervene with oxygen and naloxone. As a result, there hasn’t been a single fatal overdose at Insite—or at any other supervised consumption site. By providing clean injection equipment, these sites also help stop the transmission of HIV and hepatitis C. And because staff are safe and non-judgmental, they are more successful at connecting drug users to health and social services, including treatment or detox programs.
The idea is catching on here: California and Maryland have introduced legislation to establish safe drug consumption services, and Ithaca, New York, and King County in Washington State have recommended the establishment of supervised consumption sites. And in an unnamed American city, some brave people opened an underground safe consumption site—where a team of researchers have found the same beneficial results. If the Administration is serious about saving lives, it should allow states, cities, and counties to permit supervised consumption sites, just as many now permit syringe exchange programs.
Finally, the commission agreed that “the nation needs more options to treat those already addicted.” There is one very effective option they have not considered: prescription heroin. Switzerland has proved it can work. In the early 1990s, the Swiss made a fundamental shift in their approach to heroin addiction. They offered “treatment-on-demand,” including methadone, at conventional health-care clinics. And for some 1,300 people for whom nothing else had worked, they offered stable, clean doses of prescription heroin at special clinics in cities and two prisons. The results were staggering. No one in the program has died from a heroin overdose since the program started, and hepatitis and HIV rates have gone down. The Swiss saved about $38 per day per patient, mostly in lowered costs for court and police time.
Unfortunately, it’s hard to imagine such bold and effective solutions in the United States. While the commission’s report offered a refreshing public health perspective on the overdose crisis, President Trump has made it clear that he intends to return to the days of “just say no,” and his Administration champions enforcement-oriented approaches like building a wall on the Mexican border, expanding the use of mandatory minimum sentencing, and seizing more cash and property from individuals suspected of drug crimes. Most of these policies will be ineffective, wasting precious resources that could save lives. Some will lead to more devastation and death, especially among the communities of color that have borne the brunt of the war on drugs.
We’ve been conditioned to assume that “drug-free” solutions are the only acceptable solutions. While abstinence from drugs can be a goal for some patients who want it, it’s not realistic for everyone, and most drug users in treatment programs will experience relapses. We have to admit that drug use will continue despite our best efforts and intentions, and acknowledge that people who use drugs are still worthy of our concern and support. The evidence overwhelmingly suggests that we have to support drug users in other goals besides abstinence—such as encouraging moderation, permitting safer consumption methods, and above all, saving lives. That’s what a real public health response looks like.