Part 1 of a two-part series on the recommendations of the Seattle/King County Heroin and Prescription Opiate Addiction Task Force. Part 2, which will focus on the task force’s emphasis on medication-assisted treatment and on whether the heroin epidemic is waning, will run tomorrow.
On Thursday, King County’s Heroin and Prescription Opiate Addiction Task Force released a long-awaited list of recommendations to prevent opiate addiction and reduce harm for people addicted to opiates and heroin.
The headline, of course, is the group’s endorsement of two safe drug consumption sites in King County–one inside and one outside Seattle. The subhead, though, is the task force’s emphasis on “medication assisted treatment” for people addicted to heroin and other opiates, which would make it much easier for people to access maintenance opiate agonists like buprenorphine, which sells under the name suboxone, an opiate that helps reduce cravings for more harmful opiates like heroin, and methadone. (Traditional treatment generally relies on an abstinence-based approach that puts heroin users at a higher risk of relapse, particularly if they lack support systems.) The recommendations also include measures to promote prevention of opiate and heroin use such as education campaigns and drug-abuse screening in schools, and expanded distribution of naloxone, a drug that can reverse the effects of an opiate overdose, to more people, agencies, and institutions.
The proposals, which come with no price tag or timeline, prompted some bold claims on Thursday morning, when task force members gathered at Harborview Medical Center to discuss their impact in a camera-choked conference room. “I think that if we do our job effectively, we should theoretically be able to reduce opiate deaths over time by 80 percent,” said Brad Finegood, head of King County’s behavioral health and recovery division. King County public health officer Jeff Duchin emphasized that addiction is “a medical condition that is treatable and should be treated like other medical conditions,” not a moral failing. And advocates and officials heaped praise on the task force for setting prejudice and stigma aside to come up with nonjudgmental solutions for people with substance use disorders. “What is different and distinct about King County … is always being willing to be oriented toward outcomes of health and safety and following that wherever it goes,” said Lisa Daugaard, head of the Public Defender Association. “It is truly remarkable and unique.”
The political backlash to, say, allowing community clinics to prescribe drugs used mostly by heroin addicts alone could have buried that recommendation, but the task force went even further.
And, by virtually any measure, it is. Any one of these recommendations—wider access to naloxone; increasing the number of physicians and locations authorized to prescribe suboxone; creating a safe-consumption pilot site—could be seen as a radical improvement in itself, especially for a city where heroin addiction is such a visible problem. (According to one estimate, about one in five homeless people in King County suffer from substance use disorder, and the percentage among unsheltered people experiencing homelessness is likely higher). The political backlash to, say, allowing community clinics to prescribe drugs used mostly by heroin addicts alone could have buried that recommendation, but the task force went further and recommended not just wider suboxone distribution, and not just eliminating barriers to getting naloxone, and not just safe injection sites, but all of those things, and more.
It’s an impressively ambitious list of recommendations. But it will remain just that—a wish list—unless the county and its cities, including Seattle, commit firmly to funding all of the proposals on that list, not just the relatively cheap and uncontroversial ones like universal naloxone access and educational pamphlets, and dedicate resources to funding them.
Let’s start with safe consumption sites, which, as I’ve written before, go beyond the safe-injection model pioneered in North America by Insite in Vancouver, to allow supervised consumption of all drugs, including drugs that are consumed by smoking (technically, vaporizing), like meth and crack.
The political challenges facing any kind of supervised drug consumption site are already phenomenal. (In fact, I wrote a four-part series focusing on some of those challenges; part four, which looks at the likely political opposition in Seattle, is here). Opponents will argue that building facilities where law enforcement overlooks consumption of illegal drugs will make Seattle a magnet for drug users, and trash neighborhoods already overwhelmed by needles and crime. (Imagine, for a moment, a proposal to build a safe-injection site in Ballard, where a sober tent encampment proposal was nearly upended by howls of protest from residents, and whose residents turn to Nextdoor and Facebook to condemn addicts as worthless “druggers” and criminals who freely “choose” drug addiction as they rampage lawlessly through neighborhoods filled with upstanding homeowners who got where they are through hard work and willpower.)
Opening just one site could create a situation where the worst-case scenario of concentrated drug use does come true, because every drug user who wants to use the site will flock to a single spot.
Given the inevitable protests, the question will become: Which neighborhood will be the first to accept such a facility? The task force recommends just one safe consumption space as a short-term—three-year—pilot project, instead of multiple sites in the most heavily impacted neighborhoods, which many experts here recommend and which is the standard in Europe. That means putting the site in the neighborhood of least resistance—say, Capitol Hill or the University District—but it also means we won’t get a sense of what the true impact a network of safe consumption spaces would have, and could instead create a situation where the worst-case scenario of concentrated drug use does come true, because every drug user who wants to use the site will flock to a single spot. This could lead the city to declare failure prematurely, before more sites can open.
At Thursday’s press conference, Mayor Ed Murray was quick to point out that “if you look at the heat map of where needles are distributed across Seattle, it’s not restricted to one neighborhood.” He added that his experience with homeless encampments has taught hims that when “certain neighbors tend to go sideways on us, that’s not the whole neighborhood. … Will it be easy? Will there be protests? Will there be another website to go along with Welcome to Murraysville that says I’m putting [safe consumption sites] everywhere? That’s going to happen. But I think we’re going to get there.”
If leaders look to Insite as a model, without understanding the nuances of the term “safe consumption,” they might end up creating a site for needle users only that will do nothing for people who smoke meth and crack, or who smoke other drugs.
Murray said he plans to travel to Vancouver soon to visit Insite, the only safe-injection space in North America. (The comment was apparently inadvertent, and a Saturday press release announcing his trip to Vancouver on September 19 did not indicate whether he still planned to visit Insite.) But he won’t be getting a complete picture of what a safe-consumption site might look like here, and not just because Insite is a single facility, located in a neighborhood where most of the city’s heroin use and crime have long been concentrated. Insite, critical as it is, isn’t a true safe-consumption site, since it only allows injection, and therefore isn’t the model for what safe-consumption advocates want to see here. (For that, you have to look to Norway, Germany, Spain, or Switzerland, along with other European countries where safe consumption is relatively commonplace.)
Harm reduction means meeting people where they’re at and reducing the harm they do to themselves while they’re in active addiction, and smoking, say, heroin instead of injecting it is one kind of harm reduction. But if leaders like Murray (and the other officials arrayed behind him at Thursday’s press conference) look to Insite as a model, without understanding the nuances of the term “safe consumption,” they might end up creating a site for needle users only that will do nothing for people who smoke meth and crack, or who smoke other drugs.
This isn’t just a theoretical concern. For example, media reports on last week’s announcement have consistently referred to CHELs as “safe-injection sites,” the assumption being that they will be for heroin users to inject heroin under supervision. And the report itself hedges on this question. “Every effort is to be made to ensure that the provision of supplies and space for consuming illicit drugs (NOT tobacco-containing products or marijuana) via smoking (more precisely sublimation, meaning without combustion of the drug itself) and nasal inhalation be incorporated into the CHEL program design,” the report says.
I asked Finegood what “every effort” means, and whether true safe consumption might end up falling victim to political compromise. After a long pause, Finegood responded: “I just don’t know.”
“There was just such an emphasis on it through the task force, to be able to provide that kind of resource and understanding—that we don’t want to move downstream inadvertently and say you can’t come here because you’re smoking,” Finegood told me. “Maybe [not emphasizing other means of consumption more] was an oversight on our part.”
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