Morning Crank: A Dramatic Turnaround

1. All Seattle Public Library restrooms will soon be equipped with containers for needle disposal, following a six-month pilot program at the library system’s Ballard, Capitol Hill, University, and downtown branches. The library initiated that pilot after an employee at the Ballard branch was stuck with a needle while removing the trash from the women’s restroom, as I exclusively reported in March.

The decision marks a dramatic turnaround in library policy from just seven months ago, when library spokeswoman Andra Addison said that the library had no plans to install sharps containers for drug users (and diabetics) to dispose of used needles, because “We don’t allow illegal drug use in the library.”  The King County Public Library system preceded the Seattle library in installing sharps containers at branches in Burien, Renton, and Bellevue—branches where library staffers kept finding used needles on the floor, in toilets, and in trash bins.

Addison says it will cost about $2,000 to install the containers—the same ones used in the King County system—in all 60 library restrooms., and about $7,000 to empty and maintain them.  “The Library has ordered the additional sharps containers and we hope to have them installed over the course of November,” Addison says.

According to data provided by the library, the sharps containers at the downtown, Capitol Hill, Ballard, and University branches continue to be the most heavily used. Between the week of April 20 and the week of October 12, 912 sharps were discarded at the Central branch library, 348 on Capitol Hill, 234 in Ballard, and 194 in the University District.

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2. The city of Seattle won on two counts in the lawsuit filed by the owners of the Showbox on Friday, when King County Superior Court judge Mary E. Roberts ruled that legislation expanding the Pike Place Market Historic District to include the music venue did not constitute an illegal land use decision or a taking of private property. However, Roberts did agree to hear claims on two other, arguably more substantive, questions: Did the “Save the Showbox” legislation violate the state appearance of fairness doctrine, which requires officials to keep an open mind on so-called quasi-judicial land use decisions (like zoning changes for a specific property)? And did the city violate the property owners’ constitutional rights by dictating the use of the building as a music venue?

The owner of the building in which the Showbox is located, Roger Forbes, sued the city last month after the city council passed, and Mayor Jenny Durkan signed, “emergency” legislation making the two-story building part of the Pike Place Market Historical District. (The Showbox itself—that is, the venue that rents the building—is owned by the international behemoth Anschutz Entertainment Group).  The law, known as the “Save the Showbox” bill, prevented Forbes from selling the property to a developer, Onni, that had planned to build a 44-story apartment tower on the block. (The city had in fact just upzoned the block, along with the rest of First Avenue, specifically to encourage this type of development).

If the city violated the use of fairness doctrine, it will mean that all the public hearings and rallies and open discussions about the importance of  “Saving the Showbox” as a music venue—of which there have been many—were illegal, because the council should have remained neutral and refrained from holding public hearings. (Not only did the council hold public hearings, its members made signs, staged concerts, and even drafted public comments for private citizens in favor or the proposal.) If the court finds that the city violated Forbes’ rights by dictating the use of the Showbox property it will mean that the legislation thwarting Forbes’ plan to sell and develop the property was unconstitutional, and could open the city up to monetary claims.

The city is arguing that the “Save the Showbox” legislation—whose first section calls the Showbox “a significant cultural resource to Seattle and the region” whose loss “would erode the historical and cultural value of the Pike Place Market neighborhood”—in no way prevents Forbes or any future owner from shutting the Showbox down and using the property for another purpose. Forbes, pointing to the plain text of the legislation and the fact that the law gives the Pike Place Market Historical Commission the right to dictate every aspect of how the building is used, from the tenants down to the font, size, and materials used in its signage, says that’s absurd.

Forbes’ attorney noted that the city has only responded to one of the attorney’s ten public disclosure requests, making it difficult, he argued, to know “all the violations of the appearance of fairness doctrine.” For example, he said, “we just learned by happenstance that the cc staffers were writing public comments”—because of information that I obtained through my own disclosure request and reported on this site.

In dismissing the Showbox owners’ takings and land use claims, Roberts said that neither claim was ripe for consideration—in the case of the land use claim, because the owner of the property and the developer, Onni, had not filed a permit to develop the property by the time the legislation passed, and in the case of the takings claim, because the city has not issued any final decision about what kind of development is allowed on the property.

Roberts also rescheduled the remaining counts for early next fall.

Morning Crank: Taxing Uber and Lyft; Stalling Safe Consumption

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Image by PraiseLightMedia via Wikimedia Commons

 When Mayor Jenny Durkan announced in April that her administration would study congestion pricing—a catchall term for strategies that place a price on driving a car into congested parts of the city, such as downtown and South Lake Union, in the hope of achieving some positive goal, such as lower emissions or faster transit service—she said she hoped to implement some kind of pricing scheme by the end of her first term, in 2021. Most people took this to mean that she would introduce a plan for cordon tolling—essentially, drawing an invisible ring around the center city and charging vehicles to enter. Because this strategy would require voter approval, Durkan’s team will need to figure out how to get around the obvious objections—creating a plan that doesn’t disproportionately harm low-income workers who rely on cars, for example, and that makes transit seem like a viable alternative to driving to people who choose to commute by car.

In the meantime, the mayor is considering another option: Charging Uber and Lyft riders a special tax that will increase the cost to use the car-hire platforms by a few bucks a trip—just enough, perhaps, to nudge some commuters onto buses or trains. According to the mayor’s office, half of all Uber and Lyft trips in Seattle include a trip through the center city. In addition, ride-hailing cars often circle around downtown waiting for the signal that someone needs a ride; this contributes to both congestion and pollution, and makes it harder for buses to move quickly through the area. City council member Mike O’Brien, who supports congestion pricing, says, “There seems to be pretty clear evidence that [Uber and Lyft are] causing congestion and that people are converting from transit to a lesser mode, which is riding in these [vehicles].” O’Brien says he has heard reports of companies in South Lake Union giving free Uber and Lyft shared-ride passes to employees, which creates an incentive to use those services instead of less-convenient transit. “There’s an argument, from my perspective at least, that Uber and Lyft are living in an unequitable world to their favor,” O’Brien says.

The Downtown Seattle Association’s annual commute numbers, which do not distinguish between calling an Uber for a ride and carpooling with a group of colleagues, and their annual commute survey does not indicate a major shift from transit to ride-hailing—yet. A University of California-Davis study last year showed that, in general, urban commuters are switching from transit to ride-hailing companies in record numbers. On average, people who live in major American cities use transit 6 percent less after they start using a ride-hailing service, according to the study. Surprisingly, perhaps, ride-hailing service users who also take transit are more likely to own cars, and to own slightly more cars, than people who just commute by transit; and non-transit users who use ride-hailing services are no less likely to own cars than non-transit users who don’t use ride-hailing platforms. According to the study, “The majority of ride-hailing users (91%) have not made any changes with regards to whether or not they own a vehicle.” As for those who have reduced their personal driving, the study concludes, “[They] have substituted those trips with increased ride-hailing use.”

2. Plans to open the nation’s first safe consumption site in Seattle appear to have foundered. According to multiple people familiar with discussions at the city about whether to fund a new safe consumption site, Mayor Jenny Durkan has not committed to fund the project in her upcoming budget proposal.

In 2016, a county task force on heroin and prescription opiate addiction unanimously recommended the creation of at least two safe consumption sites in King County—one in Seattle, the other somewhere else in the county. (Safe consumption sites allow drug users to consume substances by non-injection methods such as inhalation, which is generally safer and allows people who use drugs that are traditionally smoked or snorted to do so under medical supervision). Those plans stalled under political pressure, as city after city (including Auburn, whose mayor Nancy Backus was on the opiate task force) adopted laws preemptively barring safe consumption sites inside their borders. Last year, the Seattle city council appropriated $1.3 million to establish and operate a safe consumption site; in June, however, the council indicated it would opt for a mobile injection-only van, which would likely preclude consumption by means other than injection but would be cheaper and potentially easier than siting a permanent facility. The mayor’s office says the $1.3 million will be in its 2019 budget.

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Running a safe consumption site would require a new financial commitment of about $2 million a year. Durkan has already asked city departments to come up with budget cuts of between 2 and 5 percent in anticipation of a funding shortfall for 2019. In addition, the city budget office and council have to come up with around $10 million a year to pay for programs related to homelessness that Durkan paid for this year with one-time funding. In that climate, it’s hardly surprising that Durkan—who did not make safe consumption or reducing overdoses a campaign issue and has not made the proposal one of her legislative priorities—would be inclined to let it fall through the cracks, at least for now. On August 27, three days before Seattle advocates commemorated International Overdose Awareness Day with balloons and overdose prevention trainings in Westlake Park, deputy US attorney general Rod Rosenstein wrote an op/ed for the New York Times railing against safe injection sites, and specifically calling out Seattle’s plans to build a mobile injection van. “Injection sites destroy the surrounding community, creating “war zone[s]” with “drug-addled, glassy-eyed people strewn about.”

Seventeen years ago, a county task force on heroin and opiate addiction recommended many of the same measures the city and county are discussing today, including overdose response training, greater access to syringes, and other harm reduction methods, including (potentially) safe injection sites and encouraging drug users to use safer consumption methods. The report, and its recommendations, sat on a shelf for 14 years, with predictable consequences. The consequences of ignoring the recommendations of the 2016 task force will be equally predictable.

3.  It’s been  nine months since Scott Kubly, the former director of the Seattle Department of Transportation, resigned and was replaced on an interim basis by his deputy, Geron Sparrman. It’s been more than two weeks since Sparrman left to take a job at HNTB, a consulting firm that had numerous open contracts with the city of Seattle when Sparrman agreed to take the position, and Durkan announced that former Alaskan Way tunnel project director Linea Laird would take over as his replacement, also on an interim basis. And it’s been one week since the city finally posted the SDOT director position on the city’s official job bulletin, along with a brief description of the position and desired qualifications. According to the notice, interested candidates should contact Reffett Associates, an executive search firm with offices in Bellevue, Dallas, and Washington, D.C.

After Needle Incident at Ballard Library, Library System Will Install a Handful of Sharps Containers on a Pilot Basis

UPDATE: On Friday, the Seattle Public Library said it now plans to install sharps containers in all restrooms at the downtown, Ballard, University District, and Capitol Hill branches on a six-month pilot basis. In an email, library spokeswoman Andra Addison said the pilot is intended to help library staff “better understand the performance and durability of the containers we have selected, as well as any physical impacts to the restrooms.” The sharps containers will stay in the restrooms after the six-month pilot period ends, unless there is a compelling reason” to remove them.
“In addition to monitoring use of the containers, the Library will also be tracking whether or not the containers reduce the number of needles found inside or outside the libraries,” Addison said.

This story originally appeared on Seattle Magazine’s website.

 

In the wake of an incident in which a custodian was pricked with a hypodermic needle at the Ballard library last month, the Seattle Public Library system will install sharps containers on a pilot basis at several of its branches, potentially including Ballard. The custodian was taking out the trash in the women’s restroom when he was stuck with a needle tucked inside the package for a sanitary pad and was taken to the hospital, where he was released without incident.

Earlier this month, library spokeswoman Andra Addison said SPL had no plans to install sharps containers in any of its branches, despite the recent dramatic uptick in public use of injection drugs, including heroin and fentanyl. “We don’t allow illegal drug use in the library. It’s against our rules of conduct,” Addison said. Addison claimed the incident in Ballard was the first of its kind in the library system, and said “we don’t really have a need for” containers for drug users (and insulin-dependent diabetics, for that matter) to dispose of used needles.

Since that story ran, however, the library has told staffers that it now plans to install sharps containers on a pilot basis in collaboration with Seattle Public Utilities, which already has installed sharps containers at a handful of locations (including three park restrooms) around the city. Earlier this week, SPL chief librarian Marcellus Turner told a citizen inquiring about sharps containers that the library “recognize[s]we need to enhance our practices and are moving in that direction.

“We also are conducting additional research with other library systems and have contacted Seattle Public Utilities to understand how the Library might participate in or be served through its Sharps disposal project,” Turner added.

According to library spokeswoman Caroline Ullmann, the library is “moving forward with a project that pilots two approaches 1) a container placed outside of a branch on Library property and 2) a container placed inside a branch. We are doing this at several locations at one time with the goal being to find out if one type of device or treatment is preferable to another. We are in the process of determining the locations for the project and confirming a timeline,”

The King County Public Library system, which operates outside Seattle, has sharps containers branches in Burien, Renton, and Bellevue, locations where library staffers reported finding needles on bathroom floors and flushed down toilets.

According to library spokeswoman Caroline Ullmann, the library is “in the process of determining the locations for the project and confirming a timeline.” Asked whether the plan is to locate the inside sharps container in a restroom—and, if so, whether it will be in the men’s or women’s restroom—Ullmann responded, “I have not heard if we’ve decided precisely where in the branch to locate the container.”

The five library branches with the highest number of drug-related incidents are Capitol Hill, the University District, Ballard, Lake City, and South Park.

Families of Opiate Epidemic Victims Reach Different Conclusions on Safe Consumption Sites

This story appeared in Seattle Magazine.

For months, there had been red flags. In the past, 19-year-old Amber Roberts had always made plans with her father, Michael Roberts, for his birthday. But this year, she canceled at the last minute without explanation.

A few weeks earlier, the former Lake Washington High School student had broken things off with her longtime boyfriend, who lived in Oregon, claiming he was “smothering” her. And friends who partied with her had noticed changes, too. Earlier that month, one of them had texted Amber’s mom telling her that Amber—the girl who still hated needles so much that she took her dad with her when she had to get a shot—had been doing heroin for the past several months. Alarmed, Amber’s mom contacted Roberts, and they made a plan to get their daughter into treatment as soon as Amber returned from Paradiso, a two-day music festival held every year at the Gorge.

But Amber had a friend drive her home from Paradiso early, complaining that she was sick. (Roberts believes she was in heroin withdrawal.) She left her mom’s house for a while, then came back and went upstairs, telling her mom and stepdad she was feeling fine. Roberts still remembers the last text he got from his daughter. “She texted me at around midnight to say she was fine,” he recalls. “And she probably died right after that.”

Heroin can kill slowly or quickly. Many people live through overdose after overdose—saved, in many cases, by the overdose reversal drug naloxone—and experience periods of recovery interspersed with periodic relapses. Others, like Amber, use the drug for just a short time—in Amber’s case, about four months—before taking a last, fatal dose. Sometimes, Roberts says, he feels lucky compared to parents who watch their kids struggle with addiction for years and years. Then he remembers his daughter’s loyalty, her “indescribable laugh” and her love for her family, and he says, “We would take that [struggle] over anything, because at least there would be a chance to save her.”

Since Amber’s death, Roberts, who lives in Kirkland, and Amber’s mother, Kristen Bretthauer, have started Amber’s HOPE (Heroin, Opiate Prevention and Education), a group that works to raise awareness of opiate addiction among teenagers. He’s also become an outspoken advocate for supervised consumption sites—places where users can inject or smoke their drug of choice under medical supervision, with access to wound care, detox and treatment referrals, and overdose reversal and prevention. The goal of supervised consumption isn’t to “cure” addicts. But, as Roberts says, it “can save people’s lives. That’s the bottom line for me. Once you’ve gone through what I went through, you will do anything for other parents not to have that experience.”

So far, there’s only one supervised injection site in North America: Insite, in Vancouver, British Columbia, which has an average of 514 injection-room visits every day, according to program founder Liz Evans. (Insite’s facility only caters to injection drug users; most safe consumption sites also allow people to smoke drugs as well as inject them.) But the sites are common across Europe and they could soon be coming to King County. Last year, the 27-member King County Heroin and Prescription Opiate Addiction Task Force, which includes political leaders, medical experts, drug-policy reform advocates and the mayors of several suburban cities, recommended that the county open two supervised consumption sites as a three-year pilot project, including one in Seattle.

King County Executive Dow Constantine and Seattle Mayor Ed Murray convened the task force last year in response to sharp increases in both opioid addiction and overdose deaths. In 2015, the last year for which finalized data is available, 132 people died of heroin overdoses in King County, up from 99 just two years earlier. Meanwhile, since 2015, heroin, rather than alcohol, is the primary reason people enter detox programs in King County. The recommendation for supervised consumption sites was just one of the task force’s eight proposals, which also included increased access to medication-assisted treatment with buprenorphine, a drug that reduces opioid cravings; widespread distribution of naloxone, a nasal spray that can reverse overdoses; and increased spending on prevention programs. But of all the recommendations, safe consumption has been by far the most controversial.

Opponents, such as state Senator Mark Miloscia, who represents Federal Way, argue that safe consumption sites enable users and normalize drug use; he believes drug users need to “hit rock bottom, where they’re looking death in the eye…that’s how you change behavior.” Miloscia, a conservative Republican who has sponsored legislation that would ban safe consumption sites as well as a bill banning all homeless encampments in Seattle, argues that shame, not acceptance, is what keeps people from using drugs. Proponents counter that safe injection sites keep drug users alive—by offering medical care, teaching safer injection practices and monitoring users for overdoses—and provide them with tools and services that help them reintegrate into society, even if they aren’t ready to quit.

“These spaces are not just about drug use—they’re about really connecting folks to community and not just kicking them back out onto the street,” says Patricia Sully, an attorney with the Seattle Public Defender Association (PDA) and the coordinator for Voices of Community Activists and Leaders (VOCAL-WA). VOCAL-WA, which operates under the umbrella of the PDA, is a grassroots group of low-income people, drug users and community advocates who work to promote harm reduction. “Drug treatment itself might not be the only thing people need. Many people need connections to mental health services. Many, many people need connections to housing. And we know that all of those things really make a huge impact in someone’s quality of life,” Sully says.

Harley Lever is a neighborhood activist who ran for mayor in this year’s race and  founded the group Safe Seattle, which advocates against safe consumption sites. HeImage result for harley lever seattlesays the problem with that point of view is that the sites “could never scale to the enormity of the problem,” which is only growing as drugs like fentanyl make street heroin more unpredictable and lethal. “If you said, ‘What’s going to save more lives?’ I think the science will back me up and say widespread distribution of naloxone is going to save far more lives” than safe consumption sites, Lever says.

Safe Seattle advocates for naloxone distribution, but their main contribution to the debate over safe consumption sites has been advocating Initiative 27, which would ban safe consumption sites throughout King County. Editor’s note: Opponents of the initiative won a court ruling that could keep the initiative off the ballot, but proponents are expected to file an appeal. In the meantime, the King County Council has passed an alternative ballot measure to replace I-27 if proponents win on appeal; that measure would ask voters whether they support voting on supervised consumption sites at all, and, if they say yes, whether they support or oppose the sites.

Lever, like Roberts, came by his views on addiction the hard way. Two of his brothers, along with countless friends and relatives back in his hometown of Boston, have been addicted to heroin, and several have wound up in jail or died. One of Lever’s brothers has been clean for years; the other, an Army veteran who has spent years in and out of Veterans Administration (VA) rehabs, is now homeless and living, Lever says, on “borrowed time.”

“[My brother] has OD’ed four times in the last year, and every time he was saved by naloxone,” Lever says. “He’s been in this constant cycle of being in treatment, getting sober, living in sober housing—and then, almost every single time, right when he gets his check [from the VA], he goes and spends it and he’s back in that cycle.”

Although one of his brothers quit “cold turkey” and “turned his life around,” Lever has slim hopes for his homeless sibling. “We’ve tried everything. It’s been 15 years, and he’s been so lucky to survive, but we know one day we’ll get the call,” he says. The VA has provided Lever’s brother with a place to stabilize himself and access health care and treatment, and it has probably helped him stay alive this long. But it hasn’t gotten him sober.

While one argument against safe consumption sites is that anything that allows addicts to continue using is the wrong solution to the opioid crisis, there are other objections.

Some who are opposed to safe consumption sites say the sites will bring crime and addiction to neighborhoods where drugs and crime were not previously a problem, or worry that the sites simply enable addicts to “slowly kill themselves by taking drugs and harming their bodies,” as Republican King County Council member Kathy Lambert, who represents Sammamish, Redmond and Issaquah, said back in June.

But the Vancouver Insite experience has proven otherwise. Insite founder Evans says the amount of street disorder around the facility has declined significantly since it opened in 2003, and that Insite staffers have reversed more than 6,000 overdoses; in 14 years, not one person has died at the site. Vancouver’s Downtown Eastside, where Insite is located, is a rough-edged but gentrifying neighborhood near the city’s Chinatown that has been plagued by drugs and crime for decades. Seattle has no real equivalent, since drug use here is more widely distributed throughout the city, which is one reason advocates here have argued for more than one safe consumption site.

That information, however, doesn’t sway opponents like Lever.

“The compassionate side of me says we shouldn’t be [pushing I-27], but the strategic side of me says we should, because we should be focusing on better solutions than safe injection sites.”

Ultimately, the initiative may be unnecessary. In June, a majority of the King County Council voted to prohibit funding in the amended 2017–2018 budget for supervised drug consumption sites except in cities that explicitly approve them, and to bar county funding for any site outside Seattle. The vote effectively means that a safe consumption site couldn’t open until 2019 at the earliest, because the only potential funding source for a site in Seattle, the countywide Mental Illness and Drug Dependency tax, is already spoken for.

Officials in Seattle have not identified a specific site, but City Council and County Council members who represent the city, such as King County Council member Jeanne Kohl-Welles of District 4 (which includes Ballard, Fremont, Crown Hill and Wallingford), have said it will not be in any neighborhood that doesn’t want it, making Capitol Hill a more likely location than, say, Magnolia.

Dave Upthegrove, a Democratic County Council member who represents Burien and other South King County suburbs, says that while there is a lot of misinformation about the risk of safe consumption sites, “people’s emotions are real, and we need to be respectful of people’s fears.” He adds, “Even folks who have experienced heroin addiction in their own families are divided.” He fully supports the sites, however, and supports Seattle becoming the first city in the region to have them.

Roberts, who has been open about his own struggles with addiction, believes that the fears people have about drug users can only be addressed by destigmatizing addiction; more people also need to understand that even “good people” can get swept up by addiction. “There tends to be an attitude of ‘My child would never do that’; I really want to sway that view,” he says. “In one year, there were at least three overdoses at Amber’s high school. There’s just not enough awareness of the problem.”

With the dramatic increase of overdose deaths, he says, “there’s not going to be anyone around to deal with it anymore.”

Although Roberts and Lever—both King County residents whose families have been devastated by the impact of heroin addiction—have reached vastly different conclusions about how to solve the problem, they agree on this point.

“What I fear most is we’re going to die our way out of this epidemic,” Lever says.

The Europe Experience

Safe consumption sites are still rare in the United States, but they have a long history in Europe, where the first supervised injection site opened in Bern, Switzerland, in 1986. Since then, more than 75 such sites have opened across the continent: in Germany, the Netherlands, Spain, Norway, Luxembourg, Denmark, Greece and France.

Although the services offered by safe consumption sites vary slightly from country to country (some are strictly safe injection sites; others provide medically assisted treatment right on site), the basics are the same: They include a safe space to consume illegal drugs indoors and under medical supervision, clean needles, basic medical care, and connections to addiction treatment and other health and social services.

Numerous studies across Europe have concluded that safe consumption/injection sites not only reduce risky behavior, such as sharing needles, but lower the number of overdose deaths in cities. Safe consumption sites also have been found to reduce the number of violent, property and nuisance crimes associated with street drug use, and increase the number of people who get into treatment—a result that holds true in North America, too, where more than 60 peer-reviewed studies have concluded that Insite, the safe consumption site in Vancouver, British Columbia, has increased the number of people seeking treatment without increasing crime.

As King County Grapples With Heroin, Another Lethal Drug is on the Rise

Image Credit: SBSArtDept

This story originally appeared at Seattle Magazine.

As political leaders focus their attention on the ongoing epidemic of heroin and prescription opiate addiction—an epidemic that claimed 132 lives in King County in 2015, the last year for which statistics are available—another drug crisis may be developing right under their noses.

Since 2010, according to data just released by the University of Washington, the number of deaths related to methamphetamine has risen steadily throughout Washington State—from 1.8 deaths per 100,000 state residents in 2010 to 4.9 per 100,000 in 2015. In King County, the number of meth-related overdoses increased by 257 percent between 2003 and 2015. Dr. Michael Sayre, the medical director for the Seattle Fire Department and a Harborview-affiliated emergency medicine doctor, calls the uptick in meth ODs “the most significant trend in drug-related mortality” in the region.

Caleb Banta-Green, a researcher with the University of Washington’s Alcohol and Drug Abuse Institute and a member of the King County Heroin and Prescription Opiate Addiction Task Force, says one reason for the uptick in meth use is the fact that “cocaine availability has tanked in the last five years.” Meanwhile, meth has become more potent and readily available than ever before. People appear to be using meth as a cocaine substitute, even though, according to Banta-Green, the two drugs are quite different—cocaine is shorter-lived and less intense than meth, which can provide 20 times the dopamine hit and last many hours longer.

“You don’t hear a lot of people saying, ‘I use cocaine because it helps me stay at my job longer.’ You do hear people say that about methamphetamine,” Banta-Green says.

So why haven’t you read about this emerging epidemic? One of the reasons may be simply that, unlike for opiates, there aren’t any particularly effective medical interventions for meth overdoses or addiction. When someone overdoses on heroin, for example, emergency responders, or even a lay person with the right equipment, can quickly reverse the overdose by giving the victim a shot of Narcan, a drug that restores heart function and breathing. There is no similar drug for meth ODs, which overload the cardiovascular system with adrenalin and can lead to heart failure, stroke, seizures and hyperthermia (overheating). A stimulant overdose “definitely requires medical attention,” Sayre says. “It’s not something that a layperson or even a medically trained person without the proper resources can appropriately manage.”

 

So why haven’t you read about this emerging epidemic? One of the reasons may be simply that, unlike for opiates, there aren’t any particularly effective medical interventions for meth overdoses or addiction.

 

Methamphetamine addicts seeking treatment face a similar dearth of medical (as opposed to behavioral) treatment options as those with other addictions. While heroin addicts have the option of medication-assisted treatment with methadone or buprenorphine (Suboxone), two prescription opiates that serve as replacements for more harmful drugs like heroin, there is still no medication-assisted treatment for stimulants like meth. Drug replacement therapy with other stimulants like Adderal (a drug that’s very closely related to meth) doesn’t appear to work and can be dangerous to users who already have high blood pressure and enlarged hearts; and although two antidepressants, buproprion (Wellbutrin) and mirtazapine (Remeron) have shown some promise in reducing meth use in chronic users, neither has been widely tested or shown impressive results.

“I’m not very optimistic that we’re going to get a good medication any time soon,” says Dr. Andy Saxon, who directs the Center of Excellence in Substance Abuse Treatment and Education at the Veterans Administration in Seattle.

Instead, Saxon says that the best treatment he’s found for meth addiction is a behavioral approach called contingency management, where users are given rewards with some monetary value if they stop or reduce their use. The VA, for example, uses what Saxon calls the “fishbowl technique.” Veterans who pass a drug test get to pull a card from a fishbowl (or more than one card if they’ve passed several tests in a row); the reward on the card could be anything from verbal reinforcement (“Nice work”) to a $100 gift card for the VA store. The idea is to replace the hit of dopamine produced when a user takes a drink or a hit with a monetary reward, since both rewards act on the same pleasure center in the brain. Other moderately effective treatments include cognitive behavioral therapy, relapse prevention, and motivational interviewing, all mainstays of traditional treatment programs.

None of those treatments is particularly effective (according to Saxon, about half the people who are in the VA’s behavioral treatment programs manage to reduce their use), and all are significantly more expensive than medication-assisted treatment for opiates, which may consist of nothing more than a prescription for a replacement drug. Nor is it easy to reach meth addicts, particularly those who are homeless or living in marginal housing; unless they are injection users or use other injection drugs like heroin, meth users aren’t coming in to needle exchanges, and they typically leave emergency rooms with little more than a recommendation to seek further treatment and a “good luck.”

Sayre suggests a few solutions that could help meth users in the immediate and long term. First, he says, the state needs to do everything it can to ensure that users in crisis feel safe seeking help. Existing “Good Samaritan” laws, which shield people seeking medical help for an overdose from prosecution, should be expanded to cover people who are on parole, on probation, or who have outstanding warrants. Second, existing outreach programs, such as needle exchanges, should provide incentives for meth users to come in and access their services, such as providing new, unbroken meth pipes. (The People’s Harm Reduction Alliance, which runs a needle exchange in the University District, already does this.) And third, “maybe we need to think more seriously about offering safe spaces and more help for people who are tweaking”— overstimulated on meth—where they can get access to treatment and other services.

As it happens, the county has already proposed creating such a space. It’s called a community health engagement location (colloquially known as a safe consumption site). But it’s generated significant controversy, and is currently the subject of an initiative designed to ban all such facilities across the county.

Morning Crank: Planning Is Necessary. Stalling Is Not.

L-R: Commissioners Vickie Rawlins, Brendan Donckers, Eileen Norton, Bruce Carter, Charlene Angeles

1. The Seattle Ethics and Elections Commission dealt another blow to defenders of Mayor Ed Murray yesterday afternoon, agreeing unanimously that the mayor’s supporters couldn’t create a legal defense fund and solicit unlimited anonymous contributions on his behalf.  Moreover, the board ruled that the supporters’ backup plan—limiting the amount of contributions and disclosing the names of donors—was equally unacceptable, on the grounds that the city’s ethics rules contain no provision allowing legal defense funds for elected officials.

“Given our current ethics code, or what we care about in the city about transparency and accountability, I don’t see a path for you,”  commission chair Eileen Norton addd.

Murray’s supporters proposed creating the fund to help the mayor defray the cost of defending himself against charges that he sexually assaulted a young man in the 1980s, and some speculated that one reason the mayor announced he would not run for reelection was to eliminate one objection to the fund—that it would violate campaign-finance rules.

 

“There is concern about whether the mayor has the resources” to defend himself, Flevaris said, “and the folks putting the fund together want to address that issue and make sure that the lawsuit can’t be used as a political tool” against him. “When you have a scandalous lawsuit like this, we think [that] informs this issue.”

“I don’t think the emotional issue around the lawsuit should inform our decision,” Norton responded.

Flevaris and Lawrence argued that by keeping the names of contributors to the fund anonymous and requiring donors to sign a nondisclosure agreement, the fund would avoid any appearance of political impropriety. However, commission director Wayne Barnett countered that if, for example, “someone involved with the development of an arena in SoDo makes a substantial gift to the legal defense fund, I don’t see how an unenforceable nondisclosure agreement is going to persuade a reasonable person that it was not given with an intent to influence” city policy.

Moreover, Barnett said, if the commission granted the defense fund the right to solicit anonymous, unlimited contributions, the commission wouldn’t have a leg to stand on the next time a campaign came before them asking for the right to take anonymous contributions, which has happened in the past.

Murray can still accept very nominal gifts under the city’s gift rules, but the commission did not appear to leave any path for the legal defense fund to proceed. After the vote, Flevaris said he was glad that the commission had given the attorneys for the fund some “clarity” on whether they could proceed. Once Murray’s term ends on December 31, he will be a private citizen no longer subject to the city’s ethics rules; however, Flevaris said “time is of the essence” in the lawsuit. Paul Lawrence, another attorney for the mayor’s supporters, said he hadn’t “heard anything to suggest” Murray would resign in order to start collecting contributions to help him defend against the lawsuit.

Turina James: “I’m the face of a heroin addict. Just a year and seven months ago, I was right out there with all of them. Without harm reduction … I don’t know what I would have done.”

2. Also yesterday, the King County Council’s Health, Housing, and Human Services Committee decided to delay for another month a motion that would direct King County Executive Dow Constantine to prepare a report and work plan for the creation of two pilot supervised drug consumption sites in King County. Citing the number of people (about 40) who showed up to testify in the middle of the afternoon, committee chair Jeanne Kohl-Welles postponed the measure that was the subject of all that testimony on the grounds that there was too much else on yesterday’s agenda.

Most of those who turned out to testify—including emergency room nurses, recovering addicts, Real Change vendors, and residents of neighborhoods, like Belltown, where injection drug use is common—supported the sites. However, the delay speaks to the disproportionate weight of opponents’ voices.  Yesterday, those opponents claimed, as they always do, that supervised consumption sites will turn entire neighborhoods into apocalyptic landscapes overrun by strung-out zombies who shoot up, turn tricks, and lie half-dead with their faces on the sidewalk in front of “legalized shooting galleries” that exist to “enable human suffering.”

“You seem to be forgetting that heroin is illegal,” one opponent, who identified himself as a recovering addict, said. “This plan is completely insane,” argued another.

Peer-reviewed studies from supervised-injection and -consumption sites around the world show that they reduce deaths from overdoses, infections, HIV, and hepatitis C, and connect people struggling with addiction to services and treatment.

Public Defender Association director Lisa Daugaard, a member of the task force that, almost nine months ago, recommended a supervised consumption site pilot project as part of a comprehensive package of recommendations to address the opiate and heroin addiction epidemic, said after the meeting that she was frustrated with the slow pace the committee has taken. “It’s hard to say that it’s behind schedule, given that it would be the first of its kind in the country. That said, this isn’t ideal, because these recommendations have been sitting for months.” Noting that the task force only recommended a three-year pilot project, Daugaard said the only way to demonstrate whether supervised consumption can work, or that it’s doomed to disaster, is to try it.

“The answer to those questions [opponents raised] lies is the implementation. We will find out whether there are good, bad, or neutral effects, and we will make an assessment at that point,” Daugaard said.

“But staying in this limbo is the worst of all possible worlds. Planning was necessary. Stalling is not.”

3. In response to a 58 percent increase since 2013 in the number of complaints about vacant buildings, mostly single-family houses, that have fallen into disrepair across the city, the council is considering legislation that would streamline the process for declaring empty buildings hazardous and tearing them down.

Currently, city law requires property owners to wait a full year before tearing down a building if it was most recently occupied by renters; the changes would lower that timeline to four months (which the city’s Department of Construction and Inspections says  is still plenty of time to “ensure that good-quality rental housing is not inappropriately removed”) and make it easier for the city to demolish or clean out hazardous properties and so-called squatter houses. At the city’s planning, land use, and zoning committee Tuesday, Seattle fire chief Harold Scoggins said that in the past 28 months, the fire department has responded to 47 fires in vacant buildings. “That’s very significant for us,” Scoggins said.

If you enjoy the work I do here at The C Is for Crank, please consider becoming a sustaining supporter of the site! For just $5, $10, or $20 a month (or whatever you can give), you can help keep this site going, and help me continue to dedicate the many hours it takes to bring you stories like this one every week. This site is funded entirely by contributions from readers, which pay for the substantial time I put into reporting and writing for this blog and on social media, as well as costs like transportation, equipment, travel costs, website maintenance, and other expenses associated with my reporting. Thank you for reading, and I’m truly grateful for your support

 

Murray Unveils $275 Million Levy Proposal for Homeless Housing, Shelter, and Treatment

mayor-homeless-levy-announce

At a news conference in the common room of a Downtown Emergency Service Center-run permanent supportive housing facility this afternoon, Mayor Ed Murray released details of his five-year, $275-million proposal to address homelessness, which includes short- and long-term housing vouchers, new funding for 24-hour shelters, expanded medication treatment for opioid addiction, and permanent housing for people who need intensive services. What the proposal doesn’t include is funding for transitional housing, traditional overnight shelters, or a broad expansion of inpatient treatment for people whose addictions can’t be treated by medication.

Acknowledging that the $55 million annual commercial and residential property tax levy would represent an additional burden for Seattle taxpayers, Murray said he had hoped the federal government would pick up some of the tab for addressing what is also a national emergency. “When I announced the [homelessness] state of emergency, when we announced [the homelessness response plan] Pathways Home, I emphasized … that we could not do it alone; we needed the federal government,” Murray said. “In my State of the City address, I basically conceded a point that many of you in the media have challenged me on: that federal help is not coming.” In fact, Murray said, “we will probably see less money than we see today.”

The briefing came just one day after the city removed the few remaining stragglers from the SoDo homeless encampment known as the Field, to which the city itself directed people five months ago when it cleared the vast encampment under I-5 called the Jungle. Earlier this week, residents of the camp and their supporters showed up to the 2pm city council meeting to ask the council to delay the sweep, arguing that the city had failed to respond to repeated requests for things like sawdust, additional port-a-potties, fire extinguishers, and trash pickup, making the squalor at the camp inevitable. The city argued that the camp was not just unsanitary but unsafe, citing the arrest last week of a camp resident for rape and sex trafficking of teenage girls.

Murray’s proposal emphasizes getting people indoors through “rapid rehousing” in the form of temporary rental subsidies for housing on the private market; the mayor’s proposal would divide those subsidies into “short-term, medium-term, and long-term vouchers,” Murray said today. (The proposals are based on a set of recommendations called Pathways Home, which in turn is based on a report by Columbus, Ohio consultant Barb Poppe, and another firm called Focus Strategies). Short-term vouchers could provide rental assistance for as little as three months, while medium-term vouchers could last 18 months or longer, and long-term vouchers would effectively be permanent.

A slightly more detailed breakdown of the measure provided by the city reveals that the vast majority of the housing vouchers it would pay for would be either short- or medium-term, meaning that when they run out, formerly homeless renters will need to make enough money to pay for a market-rate apartment. (Currently, the median rent for a one-bedroom apartment in Seattle is just under $2000). About 4,250 of the 5,100 “housing exits” the proposal aims to accomplish over five years take the form of short- or medium-term housing vouchers; another 475 people would receive long-term vouchers, and 373 would be moved into permanent supportive housing.  The proposal also aims to prevent 1,750 people from becoming homeless through diversion programs, and to provide subsidies for 1,500 people to move into clean-and-sober Oxford Houses over the next five years.

housing-exits-chart

Other than the subsidies for Oxford housing, the mayor’s proposal includes no new funding for transitional housing, temporary housing that’s somewhere between a shelter and a private apartment. It does include 200 new beds at 24-hour, low-barrier shelters, which would replace some funding for traditional overnight-only shelters in the city’s 2018 budget, according to details provided by the city.

Although rapid rehousing hasn’t been implemented on the scale Murray is proposing in a city with a comparably unaffordable rental market (in the cities most commonly cited as rapid-rehousing success stories, Salt Lake City and Houston, a one-bedroom apartment costs about half what a comparable unit rents for in Seattle), council human services committee chair Sally Bagshaw said it was time to stop asking questions and start taking action. “We can debate, we can continue to study, or we can do what our experts have recommended to us,” Bagshaw said. “Do we just keep studying it, or do we invest big in what we know works?”

The proposal also includes a $10 million “housing innovation fund”—unallocated dollars that will go toward finding new housing models and building types that might be cheaper and faster to bring online than conventional low-income housing. Murray’s housing policy advisor Leslie Brinson Price said today that the fund is meant to “spur new thinking and provide a way to pilot projects” that the city might not try otherwise, like modular construction and cohousing.

Substance abuse treatment makes up a relatively small portion of the proposed levy, about $20 million of the $275 million total. That treatment consists primarily of programs that expand access to buprenorphine, brand name Suboxone, a replacement opiate that reduces cravings in people who are addicted to heroin and other opioids, and “housing with intensive outpatient substance use disorder treatment,” which Price said would also focus on buprenorphine distribution.

The measure would add 16 new inpatient treatment beds as part of a pilot project based on Philadelphia’s Journey of Hope project, which offers long-term residential treatment for chronically homeless individuals. The proposal does not appear to explicitly include treatment for alcohol addiction, which is also extremely pre homeless people as as addiction to heroin and other opiates, or other drugs with more complicated courses of treatment than taking a daily dose of Suboxone.

Asked about the relatively small emphasis on treatment—a subject that comes up often in discussions about homelessness—Murray said, “Remember, addiction treatment is not a city function, it is a county function. … We are getting into new lines of business that I hoped we wouldn’t get into, but again, if you look at the restricted nature of the county’s funding and the fact that they constantly find themselves cutting budgets, that’s why we’re getting into buying some services from them.”

sally-bagshaw

As I noted earlier this week, by gathering enough signatures to take his measure directly the ballot, Murray is effectively bypassing the city council, which tends to tinker with (and often reduce) mayoral spending proposals. Asked why he chose this tactic over the more traditional course of sending the ballot measure to the council for approval, Murray said, “I thought it was important for this to come from the community, for signatures to be gathered through a grassroots effort, rather than the usual model of doing things where the council puts it on the ballot. .. It gives people the chance to think about whether they want to sign that measure and whether they want to vote for that measure.” Then, smiling slightly, Murray added, “I mean, I’m a former legislator. [Legislators] always change the executive’s budget.”

Assuming supporters gather the requisite 20,000 valid signatures, the measure will be on the August 1 ballot—alongside Ed Murray, who is running for reelection.

If you enjoy the work I do here at The C Is for Crank, please consider becoming a sustaining supporter of the site! For just $5, $10, or $20 a month (or whatever you can give), you can help keep this site going, and help me continue to dedicate the many hours it takes to bring you stories like this one every week. This site is funded entirely by contributions from readers, which pay for the substantial time I put into reporting and writing for this blog and on social media, as well as costs like transportation, equipment, travel costs, website maintenance, and other expenses associated with my reporting. Thank you for reading, and I’m truly grateful for your support.

County, State Officials Raise Specter of Treatment Cutbacks

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Just three months after the joint Seattle-King County Opiate Addiction Task Force issued its recommendations for addressing the opiate addiction epidemic in the region, the federal government appears poised to slam the door on many of those proposals, county officials, state legislators, and experts on addiction and mental illness said Wednesday. Speaking at the county’s annual legislative forum on behavioral health at Town Hall, King County Executive Dow Constantine described a grim future if Congressional Republicans repeal the Comprehensive Addiction and Recovery Act, a move Constantine said “would reduce or roll back access to treatment, particularly for people with substance use disorders. And even if there is treatment, it is more likely to be involuntary”–in places like lockdown mental hospitals and jails, Constantine said.

CARA, which President Obama signed into law this year, funds local programs to address heroin and opiate addiction, including traditional inpatient and outpatient treatment, medication disposal, distribution of the overdose-reversal drug naloxone, and medication-assisted treatment for opiate addiction with drugs like buprenorphine.

National Council on Behavioral Health president Linda Rosenberg noted that president-elect Trump and Congressional Republicans want not only to repeal the Affordable Care Act—eliminating mental health coverage for millions of newly insured Americans—but to turn Medicaid, the program that provides health care for the very poorest Americans, into a block grant to states, which would effectively end health care as an entitlement. Without ongoing funding for Medicaid expansion, King County Behavioral Health and Recovery Division Director Jim Vollendroff added, the county could find itself unable to fund drug treatment and other recommendations of the opiate task force recommendations. At the same time, “the county’s overall financial crisis threatens its ability to keep us all safe and healthy,” Vollendroff said.

One of the task force’s recommendations, supervised drug-consumption sites—where drug users could consume heroin, crack, meth, and other illegal substances under medical supervision—could be threatened from another corner of the new administration. Sen. Jeff Sessions, Trump’s nominee for attorney general, has made no secret of his opposition to drug legalization, speaking out strongly against legal weed. (“Good people don’t smoke marijuana,” Sessions once said.) It’s hard to imagine this drug warrior will sit idly by while a liberal city creates a space for people to use illegal drugs with impunity, and county officials say they are waiting on tenterhooks to see whether the new administration will crack down on innovative experiments like safe-consumption spaces.

So although the county distributed a short but ambitious list of federal legislative priorities—including full funding of CARA,  preservation of Medicaid expansion, and federal funding for 30-day treatment stays, rather than the current 15-day limit—it’s pretty clear that any real progress on improving the state’s treatment capacity will have to come from the state. The legislators gathered on stage at Town Hall last night promised to introduce a full slate of bills promoting addiction prevention and education, drug takeback programs, and programs to encourage people to enter the mental health-care field and keep them there. “The need is outstripping the number of workers in the field who can serve this community,” said freshman state Sen. Lisa Wellman, D-41. “We need to work, we need to educate, and we need to make sure this is a good paying job that people want to serve in.”

However, few legislators described how they would actually fund all these programs—Sen. Reuven Carlyle, D-36, talked about directing taxes from recreational marijuana toward treatment instead of the state’s general fund, a perennial Democratic goal—and none talked about safe consumption, the most controversial element of the task force’s recommendations. Sen. Mark Miloscia (R-30), the only Republican on the stage, has been vocal about his opposition to safe consumption sites—yesterday on Twitter, he characterized “decriminalization/legalization of heroin, rather than elimination” as “Death!”—and has proposed legislation that would prevent any local jurisdiction, such as the city or the county, from opening a safe consumption site.

Check out King County’s full list of state and federal legislative priorities here.

If you enjoy the work I do here at The C Is for Crank, please consider becoming a sustaining supporter of the site! For just $5, $10, or $20 a month (or whatever you can give), you can help keep this site going, and help me continue to dedicate the many hours it takes to bring you stories like this one every week. This site is funded entirely by contributions from readers, which pay for the substantial time I put into it as well as costs like transportation, equipment, travel costs, website maintenance, and other expenses associated with my reporting. Thank you for reading, and I’m truly grateful for your support.

An Expert Gives the Prognosis—and Makes the Case—for Medication-Assisted Addiction Treatment

Caleb Banta-Green

If you enjoy the work I do here at The C Is for Crank, please consider becoming a sustaining supporter of the site! For just $5, $10, or $20 a month (or whatever you can give), you can help keep this site going, and help me continue to dedicate the many hours it takes to bring you stories like this one every week. This site is funded entirely by contributions from readers, which pay for the substantial time I put into it as well as costs like transportation, equipment, travel costs, website maintenance, and other expenses associated with my reporting. Thank you for reading, and I’m truly grateful for your support.

The King County Heroin and Prescription Opiate Task Force wrapped up its work in September with a 101-page report recommending policy changes in three key areas: Prevention, treatment, and user health/overdose prevention. Two months have passed, and the task force has more or less gone dormant, but some of the recommendations–which include opening two new supervised drug-consumption facilities, one in Seattle and one in a still-TBD King County city–are happening behind the scenes. Some recommendations, including a new buprenorphine clinic providing medication-assisted treatment for opiate addiction at the downtown public health center, are already underway, while others are still on hold pending cost estimates, funding, and neighborhood buy-in.

Although the most controversial element of the recommendations, by far, has been the supervised consumption sites (one state lawmaker, Republican Sen. Mark Miloscia, has vowed to pass legislation that would preclude the city and county from opening any safe-consumption sites, along with legislation that would ban sanctioned homeless encampments), expanding access to medication-assisted treatment is also harder than it looks. Currently, federal drug law only allows doctors to provide buprenorphine (brand name: Suboxone) to a maximum of 100 patients at a time; doctors who want to prescribe buprenorphine have to go through special training and certification. Currently, according to the task force report, “Treatment capacity for buprenorphine is limited and far exceeded by demand.”

Caleb Banta-Green is a task force member and researcher at the University of Washington’s Alcohol and Drug Abuse Initiative who has studied the impact of the opiate epidemic and advocates for expanded access to medication-assisted treatment with suboxone or methadone. I sat down with him in his U District office the other day to ask some devil’s advocate questions about Suboxone, other addictions that can’t be treated by taking a pill, and the widespread belief that sometimes, you just have to force addicts into treatment.

The C Is for Crank (ECB): Listening to the task force and to city council members, like Sally Bagshaw, who have really dedicated themselves to working on the problem of opiate addiction, you’d think that buprenorphine treatment is the be-all, end-all of addiction treatment. That worries me a little. For one thing, it’s treating an epidemic largely caused by pharmaceutical companies with drugs prescribed by pharmaceutical companies, and they can and do jack up prices (and lie about side effects, as they did with Oxycontin). For another, it might take away pressure to provide funding for things like counseling and other supports that people need to live better lives without drugs. Should I be concerned?

Caleb Banta-Green (CBG): My analogy is always Starbucks. If you think about how so many people are coffee drinkers, well, there’s a lot of opiate users too, and they’re going to want their fix in a bunch of different ways and settings, just like coffee. Some people like espresso, some people like drip. We don’t just have one type of coffee that everyone has to drink in one setting and one way of paying for it. That’s not the way you get customers, and repeat customers, which is what we want when it comes to treatment. But that’s not what we do. We say, “Here it is, come get, and it if it doesn’t work, you’re failing treatment.” It’s like saying, “We’re making a shitty cup of coffee and you’re not drinking it. What’s wrong with you?”

My favorite, most disturbing, inspiring, frustrating thing in that Frontline piece [“Chasing Heroin“] is the woman [Kristina Block]—she was something like 20—and she said to her dad, “don’t want to use, but I’m not ready for treatment.” And I think treatment with a capital T is what she’s thinking about. Not like, “I don’t want to use and I [would like to] take buprenorphine, which I can take by mouth every 24 hours and not go into withdrawal and not get high.” She’s saying, “I don’t want to deal with the bureaucracy and the counseling and the hassle and the humiliation and the stigma.” That’s a different thing.

ECB: Assuming the county figures out a way to site and fund two supervised consumption sites on a pilot basis, is two years [the length of the proposed pilot program] long enough? I can see a scenario where a facility goes into a neighborhood and has just enough time to piss everyone off and scare them, but not enough time to show meaningful results, which obviously would be less than ideal.

CBG:  I think in two years, if you’re destroying a neighborhood or revitalizing a neighborhood, I think you can have a whiff of it pretty quick. There’s an example in Hamburg or Berlin where they put a [supervised injection facility] next to a park and basically the park looked totally different almost instantaneously, and in fact, drug dealing changed almost instantly because the only people left in the park were the drug dealers. No one was using anymore. So it changed the drug market as well. It can be very dramatic and very sudden.

“When Suboxone came out, we wasted the 2000s, 2002 to 2010, because we looked at what’s better—a 4-week detox or a 12-week detox on Suboxone? They’re both terrible.”

ECB: Leaving aside all the public health measures like emergency room utilization, overdose prevention, and money saved, is there any good way to quantify subjective quality-of-life improvements for the people who use these programs?

CBG:  Do they return to a life that’s worth living? It’s great to keep people alive, but what’s going to make them want to stay alive and have a valuable, meaningful life? And if part of that is a sense of self and identity and worth, I don’t think those are weak outcomes. What is your sense of self? Do you feel valued and respected by other human beings? Those are kind of important things. In fact, they are essential. And it is a public health outcome, because that whole sense of self is related to a person’s mental health and health care and caring for themselves.

ECB: I’ve mentioned some of my reservations about heavy reliance on Suboxone as treatment before: As an opiate drug, it can be both habit-forming and addictive, it puts users’ fate in the hands of drug companies who don’t have a good record being honest with patients about their products, and I’m skeptical of treatments that sound like magic pills because policymakers zero in on the pill as the only solution, abandoning things like long-term therapy and social supports. Can you put my mind at ease about any of that?

CBG: I’m a researcher, not an addiction medicine doctor, but every single addiction medicine doctor who I know is really clear that in their practice with Suboxone, the majority of people who have long-term opiate use disorder do the best being on Suboxone for many years. Suboxone’s only been around for 14 years, so I can’t tell you that it’s 50 years, but I can tell you that the longer the better. And I can tell you that because when Suboxone came out, we wasted the 2000s, 2002 to 2010, because we looked at what’s better—a 4-week detox or a 12-week detox on Suboxone? They’re both terrible. We wasted 10 years of research on that, even though we knew that on methadone maintenance, on average, the longer the better. So we wasted ten years and now we know the same thing’s true for Suboxone. To me, that’s not saying that a person has to be on it for 50 years. The point is, how’s the person functioning? The calendar shouldn’t be the guide for when or whether a person gets off Suboxone. It should be whether they’re functioning.

Opiate use disorder is not the same as alcohol use disorder. The difference is that if you have opiate use disorder, you’ve had it for a long time, you have an endorphin system in your body that is potentially permanently changed. The only way for some people to feel normal—not high, but normal—is to have opiates on those receptors. Most people with opiate use disorder need opiates on the receptors to feel normal. They’re the people who, when they first took opiates, they didn’t get lethargic and nauseated and sleepy. They’re the ones that said, “Oh, I feel normal.” So where’s the issue? If the opiate makes you feel normal and it doesn’t cause euphoria and it doesn’t have side effects and it helps them function, what’s the downside of them being on it?

“If it were my kid who was addicted to opiates, even as an adolescent, I would say, ‘Let’s get this person on Suboxone, and I want them on it until they’re 25.'”

ECB: One downside might be the widely reported side effects.

CBG: Here’s the issue. The side effect of going off of it is that your mortality risk doubles. That’s the side effect I’m worried about—when you’re not on it, your mortality risk doubles. If it were my kid who was addicted to opiates, even as an adolescent, I would say, “Let’s get this person on Suboxone, and I want them on it until they’re 25.” Then we can figure out what’s going on and figure out how they’re doing physically and socially and psychologically. But the overdose risk is so high with opiates, and even more so now with who knows what the fuck’s out there, that pharma raising the price or having some liver side effect that actually has not been found, compared to your overdose risk doubling? For me personally or for a family member of mine, I’m comfortable with that.

ECB: The task force recommended safe consumption sites, rather than safe injection sites, specifically to create a space for users of many different types of drugs, who use them in different ways.  Do you think that aspect will get lost as the county and local jurisdictions hammer out the details of where these facilities are going to be?

CBG: Brad [Finegood, assistant director of King County’s behavioral health and recovery division] has been very clear about trying to make access to all types of drug treatment for everybody, and we need that. And we need to have safe and heathy places for people who are using methamphetamine. We also need to have good treatment, social support, counseling, and all of that. We’re also very  unfortunate in that the treatment solutions for alcohol, methamphetamine, and marijuana are not nearly as good as they are for opiates.

ECB: Why not?

CBG: It’s because we don’t have medications. Also, we have an antidote [for heroin overdoses, naloxone] that lay people can give. We don’t have that for any other drug. And we have treatment medications that work really well. Methamphetamine’s a bitch. If your’e using meth and heroin, it’s really a bitch. We’ve seen a huge increase in methamphetamine deaths over the last decade, mostly because people are starting to combine it with heroin.

ECB: How many people do you think could benefit from medication-assisted treatment in the state?

CBG: There’s about 10,000 people on methadone. There’s probably 15,000 on buprenorphine in the state, based on a state survey. I think we easily have need for 15,000 to 20,000 more people on treatment medications. So there’s a lot of pent-up demand out there, and I also think that the demand is not just for methadone. There’s actually not bad access to methadone right now, but I know there’s a huge unmet need for buprenrophine.

“Why would we talk about forcing people into treatment when we’ve got a line of people out there who want the right treatment?”

ECB: When I talked to Senator Mark Miloscia after our visit to Insite, a prescription-heroin clinic, and other harm reduction programs in Vancouver, he said he was unconvinced by what he saw there and still believed that forcing people into treatment will make them stop using drugs. What is your response to that?

CBG: That comes up all the time, and as a human being, I don’t like the idea of forcing a person to do that. People have free will. But forget that point—the real point is, we don’t have nearly enough treatment access for the people who do want it, and I’d love to deal with [people who don’t want treatment] after we deal with the problem of making sure we have treatment available to the people who do want it. And the way that we know that they want it is that in a state survey, at least 2/3 of people said they want help reducing their use. People don’t want to be using heroin.

But they also don’t want to access the current types of treatment that are available that may be dehumanizing, that may use behavior modification and yell at you, that may call you a bad person, that may tell you that if you don’t believe in God, then you are not trying hard enough. In what other aspect of our lives would we want to be treated that way? So why would a person with substance use disorder want to be told that they’re a lesser person and they get fewer choices? The majority of people who are using don’t want to be using, and they need the right kind of treatment to not use. So why would we talk about forcing people into treatment when we’ve got a line of people out there who want the right treatment? Let’s take care of those thousands and thousands and thousands of people before we go through a surely illegal process of eugenics and forcing people into treatment.