It’s time to legalize Supervised Injection Facilities (opinion)
Mental Health Matters
Here’s the story: Dr. Gabor Mate, his first day on the job, accompanied by his nurse, is making a home visit (“Mate, Gabor, In the Realm of Hungry Ghosts,” 2010). Claude, his patient, is kneeling by the bedside peering into a mirror while attempting to locate and inject a vein in his neck.
Claude is a heroin addict. Dr. Mate, alarmed at his choice of an injection site, says, “You’re asking for a brain abscess.” Dr. Mate then produces a tourniquet, wraps it around Claude’s arm, has Claude pump his hand, and instruct’s Claude to insert the syringe filled needle in a bulging vein.
Dr. Mate’s nurse removes the tourniquet, Claude injects himself, and the illicit drug concoction, whatever it is, works its way to Claude’s brain.
Says Dr. Mate, “Under the circumstances … it was the best I could do. Without that help, Claude would have persisted in his attempts to inject a neck vein, a procedure with a high risk ratio. I had no realistic hope of dissuading him from self-injection, let alone curing his long-established drug habit.”
Dr. Mate was never accused of any crime, nor was his heroin-using patient. The year was 2002 in Vancouver, Canada, where Insite — North America’s first and still only medically Supervised Injection Facility (SIF) for addicts — was just getting started.
A number of similar programs exist around the world. There are now some 74 facilities in six European countries. There are no facilities in the United States where heroin possession is a criminal offense and opening a SIF is a federal crime.
Supervised Injection Facilities utilize harm reduction, a public health strategy whose central purpose is to reduce the harm associated with chronic illegal drug use. They are medically supervised facilities where addicts inject their own drugs or heroin provided by the program. Other available services include overdose treatment, needle-exchange or provision, detoxification and rehabilitation options.
In medicine, the primary goal is always how best to help your patient. For certain patients, a small but critical subset of the drug using population, drug abstinence is not an achievable goal. This group consumes a disproportionate amount of medical and criminal justice resources in the form of arrest, incarceration, recidivism, parole, probation, AIDS/HIV and Hepatitis C treatment.
Policy promotors and politicians may not accept it, but there are some people who will continue to use drugs, no matter the pain or penalty.
Harm reduction strategies for chronic drug users include substituting a legal (but addicting) drug for an illegal, addicting drug. Methadone, one such legal drug, diminishes heroin use, drug cravings and drug withdrawal. Similar benefits accrue from office based buprenorphine treatment.
Needle exchange is another harm-reduction tactic, one in which users are provided clean syringes and needles in exchange for dirty ones, thus limiting disease transmission, skin infections, and abscesses. Remarkably, this simple and effective harm reduction tool is still resisted in many jurisdictions.
Which brings us back to SIFs and the horrific wave of drug overdose deaths in the United States.
The federal drug war budget was $26 billion in 2015, almost none of it used for drug harm reduction programs. In 2014, almost 1 million Americans used heroin, triple the rate of 2007, according to the United Nations Office on drugs and crime. Heroin remains the world’s deadliest drug. Deaths due to heroin have increased five-fold since 2000, escalating to 125 per day, according to the New York Times.
It’s time to stop pontificating about lax morals while drug overdose deaths continue and continue to escalate.
SIFs have a proven record of reducing the harm that drugs cause including reducing overdose deaths, reducing needle sharing, reducing the likelihood of transmissible disease, reducing drug sales and crime in surrounding neighborhoods, and increasing the likelihood that addicts will enter a detoxification and treatment program.
Such facilities do not encourage drug use, as some contend. They are available only to chronic addicts who have failed all treatment approaches on multiple occasions.
For example, at the Insite program in Vancouver, where this column started, the average patient injected drugs for 15 years before starting the program. By then most had the hepatitis C virus, 17% the HIV virus, 20% were homeless, 80% had a history of incarceration and 40% were sex workers.
To save lives, its high time that SIFs are legalized and utilized as one more form of care for the small group of addicts who require it.
Incline Village resident Andrew Whyman, MD, is a clinical and forensic psychiatrist. He can be reached for comment at firstname.lastname@example.org.