Safe injection sites and reducing the stigma of addiction

Scott Weiner, MD
Scott Weiner, MD, Contributor

Imagine a chronic medical condition in which the treatment itself has serious side effects. Examples of this are plentiful in medicine. For example, in diabetes, giving too much insulin can cause hypoglycemia (low blood sugar), a dangerous and potentially life-threatening condition. That doesn’t happen very often, but imagine that it was a common complication of treating diabetes because doctors couldn’t really tell how powerful a given dose of insulin actually was. And suppose that doctors and patient safety experts advocated for places where patients with diabetes could be carefully monitored when taking their insulin. Would you be opposed to this idea? Would you blame the patient for developing diabetes, or for needing this carefully supervised medical treatment in order to live? I suspect that the answer is “of course not!”

Now, let’s shift gears and discuss opioid addiction, specifically people who use illicit drugs like heroin and black-market fentanyl. Heroin is the strong opioid substance derived from the poppy seed that has been used for thousands of years. Fentanyl is a synthetic opioid that can be hundreds of times more powerful than morphine or heroin. Increasingly, illicit heroin is adulterated with fentanyl and similar chemicals, which public health experts believe is the reason for the continued rise in opioid-related deaths despite aggressive measures to decrease opioid prescriptions, increase substance use disorder treatment facilities, and widely distribute naloxone, the antidote to opioid overdose.

Saving lives in the face of increased risk for dying of a heroin overdose

People who use heroin are now at significant risk for overdose death, mainly because the opioid content can vary considerably from dose to dose. Previously, a little too much could have caused a decrease in respiratory rate and a high dose could lead to overdose. Now, with the variability of potency from the synthetic opioids, the strength of each dose can be markedly different. Furthermore, the uptake of fentanyl in the brain is so rapid that a fatal overdose can occur much more quickly than with heroin alone.

If we, as a society, are truly serious about saving lives, we have no choice but to allow people who use injectable opioids to do so in safe, monitored locations without fear of negative repercussions (e.g., being arrested). If you had asked me about this several years ago, I never would have believed that I could write the preceding sentence. I would have said, “Why empower junkies to abuse illegal drugs? Why make it easier on them instead of harder? Why should society condone this activity?”

However, I was wrong — dead wrong.

Good reasons for a change of heart

It turns out that addiction (called substance use disorder or, more specifically here, opioid use disorder in medical jargon) is a disease that can affect any one of us, just like diabetes or high blood pressure. It does not discriminate and does not represent a moral failure on the part of the individual who develops it. It is a condition that no one chooses, but when it attacks, it changes the brain of those with the disease. We can actually visualize those changes with tests like functional MRIs. It leads people to make choices that destroy their lives and the lives of others, such as loss of job, isolation and loss of relationships, incarceration, and even death. We also now know that this is a treatable disease, but the window for successful treatment depends on the psychological state of the person. We must be ready to engage them in treatment at that moment when they are ready.

My opinions changed drastically after a visit to a local needle exchange facility. By current law, individuals can’t inject inside the building. They have to take their chances outside and then they can come inside to be monitored after injecting. I initially envisioned the facility to be sterile, dirty, and depressing. Instead, I was surprised to see that it looked like a living room. There were sofas and a television. There was a warm light, and it appeared to be a welcoming place. Across from the sofas were two desks where staff members sat. Their job is to watch for any signs of overdose (a person who is too sleepy or who is breathing too slowly) and then rapidly respond by providing a nasal dose of naloxone to reverse the overdose. More importantly, they are there to help people right when they are open to treatment for substance use disorder. The staff will help connect them to treatment resources, whether it is group therapy or medical treatment like buprenorphine (Suboxone) or methadone.

If that moment of opportunity in which the individual is receptive to treatment passes, the consequences can be deadly.

Furthermore, the facility is all about harm reduction. There are boxes of free supplies: needle kits so that people do not share needles, condoms for safe sex, kits to help treat small skin infections, even little clean cups to freebase injectable drugs. Naloxone kits are also provided free of charge. There is no judgment there. It is only about reducing a person’s risk of serious, life-threatening infections like HIV and hepatitis C, or the risk of death. And it makes sense. If we are going to agree that opioid use disorder is just another medical condition that needs to be treated, then the compassionate thing to do is to remove the stigma associated with it and reduce associated harms while a person is suffering with substance use disorder. Plain and simple: people with this disease are going to use drugs. Is it better for them to use in the shadows, risking transmission of serious infectious diseases, or monitor them when they are using and be there for them to get them treatment at the moment they are ready?

Currently it’s still illegal in the US to allow people to inject in these supervised environments, but the tide is turning. The city of Ithaca, NY is contemplating a safe injection space, as is Seattle. Multiple studies have confirmed that they work. In Vancouver, Canada, where such facilities were implemented in 2003, they concluded: “Vancouver’s safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts.” Massachusetts is also contemplating a similar pilot supervised injection facility program. With the crises of the opioid epidemic now claiming more than 30,000 lives every year in the US, it’s time to change our biases and old ways of thinking — people’s lives depend on it.

Comments:

  1. Dave

    My views on addiction changed when I became addicted to opiates in 2007. I was fortunate in that my drug addiction only lasted 3 years ending in 2010. I may not be addicted to opiates any more, but I will always be an addict. That said my views on addiction and my judgments of addicts changed with my addiction. Using substances at first may be a choice, but at some point it changes and it becomes a physical and psychological need. Addicts need compassion and understanding non judgment and criticism. I am with Dr. Weiner, 11 years ago I would disagree that SIFs were part of the solution. So far some interventions have helped some people but we still have a long way to go.

  2. Sharma Santamaria

    There is NO comparison between Juvenile Diabetes and Substance Abuse Disorder. As a parent of an 18th month old child diagnosed with Type I Diabetes, is a nightmare at the thought of missing or not adhering strict regimen of 24 hours vigilant monitoring of constant fluctuating blood sugar level and balancing it with the correct dosages, activities, food intake (calorie counts) and illnesses (minor cold, plain diarrhea).
    My child will die or have permanent brain damage if I don’t or miss any strict life sustaining regimen. The permanent damage of the pancreas, his only available option is the INJECTION and poking fingers for blood sugar level (thank GOD for new innovations).
    Substance abuse I get it – TO FEEL GOOD VS to sustaining life.
    How on earth would you compare between the 2 diagnosis.

    • Dave

      Not to start a debate, but that is one of the misconceptions about addiction, that most do it “to feel good”. At first it may, but it doesn’t last long. Then the use is simply a way to not feel sick. I cannot speak for Dr. Weiner, but I do not think he is comparing addiction as a disease to diabetes as a disease, that is apples to oranges. I think more it is about people’s perception of what addiction is and how it is treated/viewed as a society today.

      • Tana Williams

        Great answer David it always needs to be explained in simple terms that anyone can understand two people who have never had an opioid addiction. I was a 30-year cocaine addict in whatever form it came in at the time. So I could tell you what they say in the rooms is correct. First it’s a lot of fun then it’s a little bit of fun and then it’s no fun at all.

  3. brianne fitzgerald

    http://www.publichealthpost.org/viewpoints/we-can-do-better/#.WWzavPWvUEU.email

    Please consider an opposing view from a nurse who has been in the trenches since 1982.
    brianne fitzgerald NP, MPH

    • Scott Weiner, MD

      Thank you for sharing this interesting piece. I’d encourage everyone to read Ms. Fitzgerald’s article as well. Lots of good thoughts/ideas. I think we’re in agreement that we need to be creative and bold if we’re going to save lives.

  4. Grateful

    I was addicted to heroin for 20 years. I never injected it but it still changed my life in many ways. I now have 27 years clean thanks to treatment and AA. I think a SIF is a good idea and methadone patients should be watched too. I was on a minimum methadone dose and it almost killed me twice. Any exposure we can give addicts to treatment options should be implemented. THANK YOU to the Doctors, professionals and recovering ex-addicts who help all the people who need recovery.

  5. Michael

    Very enlightening piece. For some further context on the subject please see my article from September of last year https://healthcareinamerica.us/opioid-crisis-the-u-s-b1796c671427

  6. Zachariah

    Safe Injection Facilities (SIF) and related services are an effective and practical model towards addressing substance use and associated problems. Research indicates that SIFs are credited with a reduction in community problems related to injection drug use such as public drug use and littering of needles , reduction in overdose related mortality, and a reduction in communicable disease transmission. In addition, SIFs have facilitated and improved access to ongoing addiction treatment. SIFs actually reduce drug use and addiction.

  7. Herrnhut

    Great, it is helpful for the addicts. It does not cure them but it has reduced harm. If I may there are currently no sure way to treat any addictions effectively by any government programs, medical treatment, law enforcement and even family counseling. Because one need someone that is higher and greater than the one of the world. I know of at least one preacher who has helped thousands of addicts on TV channels freely and effortlessly. His message is also available on his own website every day and on Youtube. His following are from different countries and his Facebook is almost 4 millions. Main thing is it work for those families.

  8. christopher Hannah

    Hi, i’m christopher hannah from orlando florida. my son grew from taking spice to becoming an addict to “flakka”.he goes insane acting like a zombie. looking possessed.Destroying properties of our neighbors and slamming his body on my husband’s car. seeking to devour or destroy anything that comes his way. we had to lock him inside his room till he tries to get a hold of himself. whenever he feels like taking them he steals from me or sells some of my property.this made him move with bad peers. this got my husband and i worried and disturbed knowing his state of mind. fortunately i came across a testimony of a mother who had similar issue with her husband until he got prayed for by diviner peterson of newgracefoundation. i also contacted him for prayers. now my son is doing fine in less than a week after he got prayed for by diviner peterson. he is totally free from flakka and spice. i’m so glad and urge anyone facing similar or any problem at all to also contact him for prayers via email address:newgracefoundation@gmail.comHola,