If federal law and policy changed to implement the use of harm reduction and safe injection facilities into our treatment of substance abuse disorder, it could save tens of thousands of people from overdose death, infectious disease and arbitrary detention. America does not use this form of harm reduction for the fear or creating a drug using epidemic, however as I will discuss, this is already happening, and people are dying. America’s criminalization of addiction, stigma towards all mental health issues, blatant disregard of human rights, and twenty-year-old drug policies are killing American’s. Harm reduction and safe injection facilities are an integral part of working on a solution to the drug epidemic we are in the midst of. Combatting the drug epidemic by utilizing safe injection facilities, like many other countries have, is proven to save lives, stop the spread of HIV and Hepatitis, and help people learn about recovery from addiction and enter into treatment.
Keywords: Harm Reduction, Addiction, Drug Epidemic
Harm Reduction in America Could Save Lives: The Treatment of Substance Use Disorder Throughout this paper I will be discussing five main topics in relation to harm reduction and the use of safe injection facilities in the United States. I will be discussing history of substance abuse
and harm reduction, how American’s view substance abuse, and the human rights that are affected when we don’t utilize all treatment options possible. I will also be discussing the values and interests that influence our perspective of substance abuse, how many people are affected by substance abuse and how many could be helped by the utilization of safe injection facilities, and how social workers have been responding to this problem. I will be discussing the goals of current drug policy as well as my suggested changes and how these changes would work. Lastly, I will be discussing how these changes will positively affect human rights and work towards reaching the sustainable development goals created by the United Nations in 2012.
Problem Overview: Harm Reduction in the U.S
The main problem is the lack of education about harm reduction in the United States, and our negative outlook on addiction. In the United States we view harm reduction as the use of three FDA approved medications to treat opioid addiction. Methadone, suboxone and the buprenorphine shot are the only harm reduction medications that are currently being prescribed by doctors. However, this leaves a lengthy gap for the people addicted to drugs that are not opioids, such as cocaine or methamphetamines. We also view drug users as criminals. This could be due to the war on drugs that began years and years ago, or it could be because that is what has been perpetrated in many films and books. Whatever the case may be, it is time for American’s to stop criminalizing drug abuse and begin offering real solutions to people who are struggling with addiction.
The perspective has slowly begun to change regarding drug addiction, now that it is hurting people in the suburbs and isn’t just a class or race problem. The more we see prominent people speaking out about drug addiction, the more people begin to change their stance. However, there is a lot of work to do. When you search message boards or scam the comments on viral videos of people overdosing in their car, you can see that American’s still believe these people are “less than” they are, and some even say things like “junkies deserve to die.”
Presently, we don’t use harm reduction and safe injection facilities because we believe that it will make people more addicted to drugs, or more likely to be addicted to drugs. However, we can see in other countries that this is not the case, and that it has helped the number of overdose deaths steadily decrease.
The human rights that we take away from those suffering with drug addiction are the rights to life, freedom and health. We lock people up, call them criminals and we refuse to help these people get healthy and stay well, instead they end up using on the streets and getting diseases by sharing needles. Harm reduction and safe injection facilities could change all of that.
America’s Values and Interests
In the 1930’s America waged the war on drugs by creating the Federal Bureau of Narcotics. It continued heavily with President Nixon, who made the laws stricter and had the presence of drug control agencies doubled. A top Nixon aide, John Ehrlichman, later said in a statement that the Nixon White House had two enemies, one being black people. And part of the war on drugs was to get the public to associate the black people with heroin, and then criminalizing it heavily to disrupt their communities. The goal of America was to arrest black leaders, raid their home, and vilify them night after night on the evening news. And it got worse.
During the Reagan presidency “Just Say No,” came about. This zero-tolerance policy used nationwide set the precedent that we still live with today. Despite the lack of evidence of the effectiveness of zero tolerance, America has barely changed the policy and it has created a negative stigma of people with drug addiction. These values and interests created stigmatized and failing policies, that are also blocking any expansion of syringe access programs and the use of safe sites as harm reduction to reduce the spread of HIV and Hepatitis. (“A Brief History of the Drug War”, 2018)
The group that is interval in any response is the government. Without the federal government changing its 40-year-old policies and values, there is nothing that can be done without nurses, doctors and social workers fearing arrest.
Scope of the Problem.
Over 70,000 people died last year of drug overdose. This is not only affecting drug users, but their families and there communities are being hurt by these deaths. The first responders that could encounter fentanyl, an opioid stronger than morphine that could kill you by inhaling or touching it accidently at a scene. This problem is affecting employers that are losing employees, that don’t have enough employee’s that can work, or must fire someone for using drugs when they have a zero-tolerance policy. This problem is affecting anyone who pays taxes, because our tax money is being spent putting people into jail instead of treatment, and to pay for the overtime of morgue workers and toxicologists and police officers and EMT’s.
The effects of the problem are wide spread. There is death, homelessness, overcrowded jails, nonviolent drug crimes, and other crimes that can be attributed to addiction such as prostitution.
There are a lot of theories about what is causing the opioid epidemic. Some believe that it is the over prescription of pain killers and big pharma lying about what could happen to someone who takes them long term. Other people believe that you are born addicted and once you have a drink or drug, you will not stop. There are also a lot of theories about why we treat addiction the way we do, one being because it used to be a racial thing, and some even say it is weeding the weak out of our society.
Social work has responded by working with addicts on self-actualization and helping people realize that they can be sober from drugs and alcohol and live a happy life. Some social workers work on policy changes, some work in secret safe injection facilities (there is one in Brooklyn, NY), while others are part of crisis response teams that show up when someone overdoses. Social workers have been working to try to create a solution to the problem we are facing today with the drug epidemic.
The current policy on substance abuse that America follows became law in 1986, and while other policy has been created for prevention and recovery, it is still criminalizing addiction and attempting to battle addiction as a moral issue instead of as a disease that needs treatment and time to heal. In H.R 5484 Subtitle B discusses the drug possession Penalty Act of 1986 and establishes criminal penalties for simple possession of a controlled substance. Giving people with small amounts of drugs, that are obviously for personal use and not distribution, jail time, is part of the bigger problem. Since the 80’s we have believed that drug addiction is criminal. We have seen it as a “low class” problem and even a “lesser race” problem. For the past ten years these problems with the drug policy and the American’s view on addiction has been smacking us in the face. When opioid addiction began affecting white college students from the suburbs suddenly people began to rally, eyes began to open, and more and more have realized that this is a mental illness and can affect anyone, any color, any class, any age. People are dying.
In 2016 we began to make some changes to the treatment of addiction and the prevention of addiction. Bills have been brought into play, some that deal with the prescription of schedule I to II drugs, or naloxone (the anti-overdose drug) being able to be dispensed without prescription, and grants for community treatment and prevention efforts have been suggested to be given out
to states. Since 2016 there have been even more bills regarding substance abuse waiting to be heard and passed, over twenty. However, we are not looking at all the options to help curb overdose and save addicts lives. We are ignoring positive numbers other countries are seeing that use harm reduction and safe injection facilities, due to our negative perception of drug addiction. Instead of helping people we give them the options of jail, death or complete abstinence and treatment. Treatment costs money that not all people have, jail is proven not to help people with addiction, and death is what hurts families and communities most.
There are over 100 safe use sites operating in nine countries around the world, Switzerland opened the first one in 1986 and Germany, the Netherlands, Norway, Luxembourg, Spain, Denmark, Australia and Canada followed suit. The first North American supervised injection site, opened in Vancouver, Canada in 2003. Within two years overdose deaths dropped by 3% according to The Drug Policy Alliance. Vancouver’s InSite program, exempt from federal drug laws, is located in a downtown building where drug users have access to 12 private booths to inject drugs such as heroin or cocaine. In 2016 over 5,000 users were referred to other social/health services. InSite also intervened in over 1,000 overdoses, which could have been fatalities without the site’s services. (Paola,2018)
The policy on harm reduction in the United States is divided. You cannot choose to go to treatment if you die from an overdose. In fact, Seattle, Washington officials approved the nation’s first site back in January 2017 in a unanimous vote of the King County Board of Health. Massachusetts, New York, Maryland, New Hampshire and Vermont are among the other U.S cities exploring this option.
In a statement made this June by the Seattle Human Services Department, “safe-use vans” will be rolling out within the next year. It will cost an estimated 1.8 million dollars to fund the safe-use vans, which will be considered a King County Public Health ran facility. (Kelety, 2018)
The van will park in one spot, daily, and will be a place for people to safely inject drugs. There will be social workers, nurses and other professionals working in the van to help support the substance users by connecting them to treatment and making sure they are safe from HIV and other infections, as well as helping aid in overdose prevention. (Kelety, 2018) (Paola, 2018)
The Justice Department warned all states that the facilities “would violate federal law.” The Justice Department claimed in a statement, “It is a crime, not only to use illicit narcotics, but to manage and maintain sites on which such drugs are used and distributed.” (Paola, 2018)
Tim Lahey, a physician at Dartmouth-Hitchcock Medical Center, and the director of education at the Dartmouth Institute for Health Policy and Clinical Practice, believes that safe injection sites should be open in hospitals. He thinks it would help the addict to be in a hospital setting and would be viewed as more acceptable since it wouldn’t be built in “your backyard.”
In some American cities, they aren’t at all concerned about the federal law and remain concerned with saving the lives of the people using these dangerous drugs.
Massachusetts Senator William Brownsberger proposed a bill for safe sites in Boston that has passed, known as S.2508, which gives the state of Massachusetts authorization to investigate if safe sites would work. The Senator strongly believes that, “Safe injection facilities are one possible tool we have to try to stop the deaths from fentanyl.” (Paola, 2018)
While many people in Boston are against these sites, Dr. Jessica Gaeta, chief medical officer at the Boston Health Care for the Homeless, has been promoting a similar way to aid in the fight against the opiate epidemic. In March 2016, Gaeta started a “safe place.” This facility has chairs where addicts can sit while a nurse monitors vital signs. They can also administer Naloxone in case of an overdose. Gaeta said 400 people had used the facility and about 10% of them have gone directly from the room into treatment. Healthcare for the Homeless has an annual budget of approximately $50 million, about 75% of that comes from third party reimbursements from MassHealth, Medicare and Health Safety Net. At Gaeta’s site, which is legal under federal law by, people are not permitted to use their drugs on site. Instead they are coming directly after use, which does not help the people who overdose in their car before getting to the site. (News, 2018)
In the neighboring state of New York, The New York Daily News reported that the City Council approved $100,000 to study whether to set up safe sites. The $100,000 comes from a $5.6 million budget the city currently has in place to fight against AIDS. According to New York Daily News, the funding was approved by the City Council in September 2016, but nothing has been built yet. (“De Blasio Moves to Bring Safe Injection Sites to New York City”, 2018)
Mayor Bill De Blasio said in a statement that, “After a rigorous review of similar efforts across the world, and after careful consideration of public health and safety expert views, we believe overdose prevention centers will save lives and get more New Yorkers into the treatment they need to beat this deadly addiction.” (“De Blasio Moves to Bring Safe Injection Sites to New York City”, 2018)
In Philadelphia, PA there is an 18-point plan to address the different ways the opioid epidemic is affecting our residents and how to help. Comprehensive User Engagement Sites, known as CUES, are safe injection facilities the city is planning to open. The city said in a statement that CUES are not the only answer, but one option that can help people struggling with substance use disorder stay alive long enough to get into treatment. (Abernathy, Gladstein, Farley & Jones, 2018) (“CUES: the latest effort in the battle against the opioid crisis | Department of Behavioral Health and Intellectual disability Services”, 2018)
Research suggests that safe sites can be an effective public health strategy. Providing clean needles helps prevent infectious diseases like HIV and Hepatitis C from spreading, and nurse supervision prevents death. When combined with a suite of supportive services for homeless or addicted people looking for help, safe injection sites can create a life-saving pipeline between an addicted population and community health professionals such as social workers or treatment center outreach teams.
Safe-use sites are an important key to the harm reduction method. It is something that needs to be considered in the U.S when dealing with addiction if we want to see the rising number of overdoses go down during this public health crisis.
When we look at the above miss-matching policies throughout the United States, as well as what the federal government is doing, we can see that substance use and harm reduction has numerous gaps. One of the biggest being that the federal government is fighting against the states and threatening nurses and social workers of being marked as criminals, making the use of safe injection facilities seem like an impossible approach. But why, when Canada saw such dramatic, positive changes?
America is all about money. Harm reduction in the United States would cost the U.s billions of dollars, but suboxone, methadone and buprenorphine don’t, which is why they are the only three FDA approved medications to treat addiction and labeled as harm reduction. All these harm reduction medications must be prescribed by a doctor, usually that specializes in substance abuse which costs someone money they may not have. Then the user must continue to be monitored by a doctor, which costs more money. Then one must buy the prescription each month. This is all assuming that someone has a home, a car to get back and forth from doctor’s offices to pharmacies, and insurance to help aid in the cost. If a drug user is not positive, they even want to stop using the drug, all this likely scares them off.
My suggested changes are unconventional to most but proven to work in multiple other countries around the world. America must get on board, the federal government must stop standing in the way, it is time that we open safe injection facilities in all major cities throughout the United States. We must do this to reduce the number of overdose deaths and help get addicts the treatment they need. We also need to give people the opportunity to realize that treatment is what they want, and respect that addicts are also humans with the same rights as you and I. These people are not criminals, they are suffering from a mental illness. The best way to treat mental illness, is with medication and therapy.
The outcomes I expect with the utilization of safe injection facilities throughout all major U.S cities would be less overdose, less spread of disease due to needle sharing and reuse, and less violent and petty drug related crimes. I believe that if we use the facilities properly and have them staffed with doctors, nurses, social workers and outreach specialists from top recovery centers, we will be able to get more people into treatment centers and off the streets. People that are exposed to recovery and see that the way they are living can change, are more likely to come to the realization themselves that they too can succeed at sobriety. Without the fear of facing death, jail or stigma, we can help change the opioid epidemic.
Of course, with all great things there are some not great things that could potentially happen. One of the things that many people who oppose these sites worry about is that it will enable people and make using drugs become “OK.” The unintended consequence would be that people use these sites to use drugs and addiction and drug use get worse.
When we look at the outcomes in other countries, we can feel assured that this is unlikely to happen, however it is still a valid concern of many.
In social work, we work with people to help them come to their own self-determination, find worth in themselves, and help stigmatized and oppressed populations. All things that harm reduction would bring to the people of the United States that are struggling with substance abuse.
The groups we need to engage most are the people being oppressed by the United States stance on drug abuse, which are the addicts themselves. This would be a difficult population to reach since often they are homeless or unaware of the world around them. To help with understanding how to best serve this community we would need to work with treatment providers, doctors, specialists who have studied addiction, those who are in recovery from addiction, and all harm reduction activists to see what has and has not worked on helping this population. I also think this group would be able to best help in working with communities at large, since addiction is not just a one-person problem, but a family and community problem as well.
The federal government are the biggest obstacle we have, next to the cost. We know in Seattle, New York and Boston the cost of the proposed facilities is up to a million dollars in funding. However, addiction costs us more than that. Addiction costs people their lives. It also is hurting employers find employees, it is overcrowding jail cells and costing tax-payers money, and it hurts communities that don’t have enough space in their county morgues for the number of bodies being dumped for toxicology reports. When we think about a million dollars, and think about what we would gain, I believe it evens itself out.
Policy and Human Rights.
The rights reflected in my proposed policy are a standard of living and health that human beings living with addiction are not given. When someone is using drugs, it does not mean their human rights are forfeited, however that is how we have been dealing with addiction in the United States the past twenty-plus years. Not giving people easy access to drugs that can save lives, such as naloxone, locking up people who have an addiction instead of helping them, dirty needles being an only option for some, have all been ignored leaving these people with a lower standard of life than you or I. Addiction is a disease, and we need to treat it as one. The use of safe injection facilities will help countless people have access to nurses and social workers, clean needles, overdose reversal drugs, and keep them off the streets and out of jail cells. They will be less likely to contract preventable diseases and death. Harm reduction is really about someone’s health and wellbeing and allowing them the freedom to make their own choices without negative consequence.
When I think about addiction, I think of the two options we have been giving people: get 100% sober or use drugs and die. There are so many positive places between these two, such as using less dangerously, using less over time, entering treatment and attempting to gain control of one’s life, the list goes on and on. However, we do not give people the opportunity to make this choice for themselves, instead we attempt to make it for them, giving them no respect, dignity or compassion. In harm reduction, we are giving them all of those things, we are handing them the wheel and letting them drive their bus.
Sustainable development goals were created by the United Nations in a 2012 conference, intended to be met by 2030 throughout the entire world. The safe injection facilities would help meet these goals by reducing the inequality and oppression of people with substance use disorder, it would help them get out of poverty and stop them from being labeled as criminals. Another goal it would help meet is for good health and wellbeing, which we would be improving the health of many people who previously shared needles, and the wellbeing of people whom could have died on the streets using drugs.
In conclusion safe injection facilities in the United States would save the lives of thousands of people each year as well as help stop the spread of infectious disease. If American’s want to end the drug epidemic, they must consider all possible courses of action, this form of harm reduction being one of them. Addiction is a disease, not a moral failing, its time we start treating it like one.
A Brief History of the Drug War. (2018). Retrieved from http://www.drugpolicy.org/issues/brief history-drug-war
Abernathy, B., Gladstein, E., Farley, S., & Jones, D. (2018). Retrieved from https://generocity.org/philly/wp-content/uploads/sites/2/2018/01/OTF_Comprehensive User-Engagement-Site-Report-clean_jg.pdf
CUES: the latest effort in the battle against the opioid crisis | Department of Behavioral Health and Intellectual disability Services. (2018). Retrieved from https://www.phila.gov/2018- 01-24-cues-the-latest-effort-in-the-battle-against-the-opioid-crisis/
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De Blasio Moves to Bring Safe Injection Sites to New York City. (2018). Retrieved from https://www.nytimes.com/2018/05/03/nyregion/nyc-safe-injection-sites-heroin.html
H.R.5210 – 100th Congress (1987-1988): Anti-Drug Abuse Act of 1988. (2018). Retrieved from https://www.congress.gov/bill/100th-congress/house
H.R.5484 – 99th Congress (1985-1986): Anti-Drug Abuse Act of 1986. (2018). Retrieved from https://www.congress.gov/bill/99th-congress/house
H.R.993 – 115th Congress (2017-2018): Opioid Abuse Prevention and Treatment Act of 2017. (2018). Retrieved from https://www.congress.gov/bill/115th-congress/house bill/993?q=%7B%22search%22%3A%5B%22drug+abuse%22%5D%7D&s=1&r=5
Kelety, J. (2018). Seattle and King County Officials Want a Safe Injection Van | Seattle Weekly. Retrieved from http://www.seattleweekly.com/news/seattle-and-king-county-officials-want-a safe-injection-van/
News, K. (2018). Boston Brings Safe Spaces for Drug Users to America. Retrieved from http://www.governing.com/topics/health-human-services/khn-boston-heroin-safe safe.html
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Office of National Drug Control Policy. (2018). Retrieved from
Paola, I. (2018). Safe Injection Sites | Amatus Recovery Centers. Retrieved from https://www.amatusrecoverycenters.com/from-the-frontlines/safe-what-sites/
S.524 – 114th Congress (2015-2016): Comprehensive Addiction and Recovery Act of 2016. (2018). Retrieved from https://www.congress.gov/bill/114th-congress/senate bill/524?q=%7B%22search%22%3A%5B%22drug+abuse+prevention%22%5D%7D&s= 7&r=27