Tag: heroin

Safe Injection Opponent Miloscia: “My Opinion Didn’t Change At All” on Safe-Consumption Sites

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Insite founder Liz Evans and Portland Hotel Society manager Coco Culbertson at the Rainier Hotel in Vancouver

Yesterday, I gave a brief account of my recent trip with state Sen. Mark Miloscia and city council member Lisa Herbold to Vancouver, B.C., where we visited Insite, North America’s only supervised injection site for illegal drugs, a zero-eviction women’s housing project eviscerated by government budget cuts, and a prescription heroin clinic. After the trip, I sat down with Miloscia, who is running for state auditor, to talk about his impressions of the trip and his own views about the role of government in responding to addiction.

Miloscia, a Republican, has said publicly that he plans to introduce legislation preempting King County from moving forward with two supervised drug-consumption sites recommended by a county task force on opiate addiction. A former B-52 pilot with, as he puts it, “18 nukes on my wing,” Miloscia says he had a religious awakening during his time in the service and became a pacifist; his political views also did a 180, and he became a vocal opponent not only of abortion rights and the death penalty, but of drug decriminalization, which he previously supported.

The C Is for Crank [ECB]: Did anything you saw in Vancouver surprise you?

MM: A few things surprised me. One is the passion and compassion of Liz [Evans, the founder of Insite] and the people there. Two, I think in the big scheme of things, we’re not that far apart. She gets the failures of the system absolutely, and I’m the same way. She said she’s a disrupter, and so am I, because we both recognize the evils and the shortfalls of the current system. It’s not working. That’s why I got into government, why I ran for office–because the human services and criminal justice side is a complete failure, and we don’t want to fix it, and people die. It’s mind-boggling to me.

The first question out of the first reporter [at KING 5, which did a brief story about the visit] was, ‘What struck you there?’ And I said, ‘That street.’ [East Hastings Street, where Insite is located, has long been Ground Zero for the drug trade in Vancouver]. I never saw that many drug addicts on one street. I grew up in New York City, but that was horrible. I saw that need, our brothers and sisters dying on the street. And then you have that clean, very well-maintained facility, government-run, and it’s like, we’re contributing to that. We’re not helping them. They’re already on death’s doorstep. They’re dying right there, and we should be helping them five years before they get to that point.

ECB: But Insite does save lives. The data, which Liz and the other Insite staff cited to you, prove that it saves lives that would have been lost to overdoses, HIV, or wound infections.

MM: You’re absolutely right. Maybe they are. But I talked to Liz about this and Liz admitted that it’s just a little patchwork process in the entire homeless heroin addiction system, which is completely broken. It’s like, stupid government! What are they doing? Do something! They have all the money, all the authority, and they’re blowing it.

“The entire way our planet operates is about telling people what to do. Criminal justice, societal pressure—everything is about telling people what to do. Now, when they have an addiction, when the drug takes over their life, that’s when they need that more than ever before.”

And she said that she hated the government getting involved, because it’s gold-plated and ineffective and the compassion goes away when bureaucrats are running it. And ultimately it doesn’t work. I believe there’s got to be accountability and prevention, because once they get into that… What’d she say, it’s going to cost $30,000, $24,000 a year? I can’t remember what figure she gave but it was an insane act of money. We’ve got, what, 50,000, 40,000 addicts in King County? Do the math.

ECB: But they’re already costing us money. The highest number I heard for any service while we were in Vancouver was around $25,000 for someone to use the prescription heroin program, and the director pointed out that that was still much cheaper than jail, which can cost as much as $150,000 a year.

MM: And that’s why I’m a big believer in any sort of diversion program at all. You need to be able to identify people as being a danger to self or a danger to others, and once you do that, you can force people into treatment.

ECB: Liz told you that there’s no evidence to suggest that forcing people into treatment works—it just gets them off the street for a few days or weeks, at huge expense, just like jail. What do you say to that?

MM: That is a crock. The entire way our planet operates is about telling people what to do. Criminal justice, societal pressure—everything is about telling people what to do. Now, when they have an addiction, when the drug takes over their life, that’s when they need that more than ever before, and the question is getting them into a treatment that works. And to be honest, it’s almost a lifetime of treatment they need, because 30 days is the worst type of treatment. You might as well not even try. You might as well get them into detox and then kick them out onto the street. And that’s what we’re not fixing.

ECB: If 30 days of treatment isn’t enough, and that costs tens of thousands of dollars already, how are you going to pay for more intensive treatment for more people?

MM: You’ve got to focus on prevention. That’s the only way you rightsize the problem. Do an analysis of why people are turning to drugs. If you want to solve the problem rather than just maintain it, slow the growth. To solve any problem, it’s all about preventing the causes. That’s where it’s cheaper. That’s where you get results. And that’s, to be honest, where the bulk of the money needs to be spent. We’re triaging now. If we do everything in a system-wide manner, yes, there’s a way I see her program working–if it’s just a temporary stair-step program to get people into treatment. I try not to get visibly angry over the destigmatization of drugs and ‘It’s all about choice’–but that’s the wrong approach. It’s hard for people to choose to get out of their addiction. It’s carrots and sticks, for all of history–that’s how you motivate people. If you have no stick, you’ll never get a person to the point [of entering treatment] unless they hit literally rock bottom and are at death’s doorstep.

ECB: But if every addict decided they wanted to get into treatment tomorrow, we’d be thousands of beds short. And we don’t currently have the capacity to put every heroin addict on Suboxone or methadone. Are you in favor of funding treatment on demand?

MM: What I believe is when people want treatment now, you get them treatment now. So yes, that’s where you probably get your most success. If I was going to put money into triage, absolutely, get that right now. But do the math. We’re going to need $5 billion. And that’s why we’ve got to do prevention and stop it.

“I try not to get visibly angry over the destigmatization of drugs and ‘It’s all about choice’–but that’s the wrong approach. It’s hard for people to choose to get out of their addiction.”

ECB: Will you concede that you’re never going to stop from using drugs and doing dumb stuff through prevention, though? You can conceivably reduce it, but it’s going to be above zero, because people are going to continue to use drugs. What do you do with the people who are going to still use drugs and end up getting addicted?

MM: I’m going to slightly disagree with your assumption, because at the end of the day, this whole discussion we’re having is a distraction from, what is our plan to cut heroin drug use down from 50,000 down to a manageable 1,000? [It needs to be] done right, with a huge cultural stigmatization–this is controversial when I say it–and going after the root causes.

“I firmly believe that just like with homelessness, literally half the money we’re spending is spent on ineffective programs, wasteful programs, and we don’t get results because we don’t measure that.”

I started having that conversation with Liz, I said, ‘Why do people start using drugs?’ And she said, ‘Pain, broken relationships.’ That’s just another name for religion, family, community: Those networks that keep people sane and that stabilize people before it reaches the state of, you’re living in the Jungle with your heroin buddies and part of a gang. When you‘re part of a strong community like that, it’s really hard to move there. The societal, community, family, pressure prevents you from going there. The bottom line is that’s what it takes for people to get out of their addiction. You’ve got to develop that support structure around them.

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A nurse at the Crosstown Clinic in Vancouver, where addicts come several times daily to inject prescription heroin.

ECB: You’ve said you don’t want a safe injection or consumption site in King County. Why do you want to interfere with local control by passing legislation making Seattle’s desire to experiment with that model impossible?

MM: Part of the reason is, if you look at where Canada’s going, with medicinal heroin, they’re still not getting rid of the root causes. They’ve still got a heroin epidemic going on, so they’re not solving the root problem. So while in the short term, I believe it slowed the deaths–instead of it taking you five years to die on the streets, it’s now taking you ten years–at the same time, it’s not solving the underlying root causes that ultimately lead to addiction.

ECB: Have you read the heroin task force report?

MM: Yeah, ten times already.

ECB: It seems to me that they’re trying to do exactly what you’re saying you want.

MM: There’s a lot of good things in there. But we know how task forces are done, and there’s really nothing in there that I haven’t seen before. It’s all the same stuff. And anybody who’s been involved in this knows that the problems haven’t changed from the 80s. It’s the same problems. The solution is the same thing. But government never does it. Government screws up the implementation every single time. But they get to spin that report and say, ‘Oh, we’re doing something.’ But does the system, the boots on the ground, really change?

ECB: The task force is only recommending safe consumption sites for two years, as a pilot project. Why not let them try and see what happens?

MM: OK, so let’s think. We’re going to take this radical change. If we scale it up, we’re going to need to do 80 sites in King County alone. Then we’ll do medicinal heroin and we’re going to continue down that path.

ECB: But nobody’s talking about doing that here.

MM: They’re doing it in Canada! It’s the next step. It doesn’t work unless you go to the next step. That’s why everybody wants to put it in that little silo: ‘Oh, this is all we’re doing.’ But no, no–if we want to change the system, we have to have real reform. How does this scale up and look systemwide? And then when you look at that you go, ‘All our resources are going into this, it doesn’t work, per se, and we’re ignoring the key factor of prevention.’

ECB: What do you think does work?

MM: Show me the numbers. No one talks about efficiencies or effectiveness. I firmly believe that just like with homelessness, literally half the money we’re spending is spent on ineffective programs, wasteful programs, and we don’t get results because we don’t measure that. But that’s the data I want. I want to know that, ‘Okay, Mark, if you do this program systemwide, it’ll save “X” lives.’

ECB: But the only way to get data on harm reduction is to do harm reduction.

MM: Oh, true, right. But what I’d like to see is, let’s fix the $1 billion we’re spending right now, which we know at least half a billion of it are wasteful, are ineffective, are not getting results. Let’s design a plan to focus on prevention, versus, let’s get distracted and put us on the path to, frankly, legalization and decriminalization.

ECB: What do you think of the LEAD program, which diverts people committing drug crimes out of the jail system?

MM: Oh, it’s fantastic.

ECB: But that involves not arresting people.

MM: As long as they get them in a treatment plan, I’m fine. Do harm reduction and treatment, I’m fine. But there’s got to be no choice. It can’t be, ‘Well, I’m going to do this for ten years.’ It’s like Housing First. I’m for Housing First, but after 30 days, pick a time, you’ve got to get with the program. Come up to me with programs that get them from Point A to Point B. Show me the data. I know behavior modification and I know this: Human behavior has been the same for as long as we’ve been on this planet. Carrots and sticks.

ECB: Do you have an opinion on long-term buprenorphine treatment?

MM: I want to see an efficient, effective, ethical program that works, that gets results. So I’m not opposed to it, but it’s a different focus from just giving you free government help and, we’re just waiting for a light bulb to magically turn on, versus being in a program where you’re monitored with ankle [bracelets], diversion programs, all that stuff. I want to be part of that solution. I think that’s the way to go, with that public stigma. And people don’t like doing this, but you have to scare the kids and scare the adults.

ECB: I grew up in the age of Just Say No and it didn’t work. Neither did DARE. Both of those programs were geared toward trying to scare kids.

MM: Of course it didn’t work. Those are government-run programs. When the program doesn’t work, you know that within 45 days of the program starting and you change the program. But that doesn’t stop you from trying to find a program that scares people and stigmatizes them. Look at Korea. Look at Japan. There’s all kinds of cultures where it does work. But it takes thought. It’s all about culture and attitudes, so people don’t turn to drugs. There’s a whole science about why people turn to drugs or do self-destructive behaviors, and it brings us back to the family and religion discussion, or the values discussion, or the culture discussion. That’s the heart and soul of how people decide to avoid listening to the little devil on their shoulder versus the angel on their shoulder. That’s just human nature. We all struggle. All of us deal with the choices that we make.

ECB: Was your mind changed by anything that you saw or heard in Vancouver?

MM: Like I said, Liz completely shocked me. She gets the problem and the gets the solution and she admits that her thing isn’t solving the problem. She’s trying to break up the system. But the practice per se of clinics–I think, no. My opinion didn’t change at all. I still think it’s a distraction from us working on the really tough issue.

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 run entirely on contributions from readers, which pay for my time 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.

A Conservative and a Liberal Walk Into a Safe-Injection Site

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The weekend before last, I took a second trip up to Vancouver, B.C. to visit Insite, North America’s only safe-injection site and, as such, the likely model for two proposed safe consumption sites (which will include space for people who smoke meth, heroin, crack, and other drugs as well as injection stations) in King County. (The sites are among many recommendations that came out of the county’s heroin and opiate addiction task force.) I visited Insite previously over the summer, when program manager Darwin Fisher gave me a tour of the facility and the Downtown Eastside neighborhood that surrounds it. That time, Insite was open for business, and a steady stream of clients filed through; each told the staffer at the desk her code name and what drugs she was bringing in, and settled into one of 13 mirrored booths that line one wall of the tidy facility. I watched as drug users fresh off the streets searched for veins in their feet, did their makeup, washed their hands for what might’ve been the first time in days.

This time, I wasn’t alone, and I wasn’t visiting during business hours. Instead, I was playing third wheel to an unlikely pair of elected officials—uberliberal Seattle city council member Lisa Herbold, and conservative Republican state Senator (and candidate for state auditor) Mark Miloscia. Herbold, a supporter of safe consumption sites, invited Miloscia along in hopes of getting him to see the ways that Insite has benefited the surrounding neighborhood, and to view harm reduction through a more sympathetic lens. Miloscia has said he plans to propose legislation that would bar all cities from authorizing safe consumption sites—a sort of companion bill to his proposal to prevent Seattle from relaxing its policy on encampment sweeps.

Over the course of a long morning and part of the afternoon, Miloscia, Herbold, and I toured Insite, wandered around the Downtown Eastside, talked harm reduction over lunch with City of Vancouver urban health planner Chris Van Veen and Insite founder Liz Evans, and toured a clinic that prescribes heroin to addicts who don’t respond to methadone or suboxone, two common drugs prescribed as part of treatment for heroin addiction. We also visited the Rainier Hotel, a zero-eviction apartment building for women that used to be a thriving, successful drug treatment center; in 2013, thanks to what Evans calls the government’s “culture of bureaucracy,” it lost public funds for its addiction programs and is now single-room occupancy housing.

Fisher, Evans, and Coco Culbertson, a manager at the Portland Hotel Society, the nonprofit that runs Insite, walked a very curious (and at times visibly distressed) Miloscia through the admission process (more on that here), and explained the benefits of the services Insite provides. “Coming in here from the street, where you’re going to get water wherever you can find it”—that is, from a puddle in an alley— “it’s like going from the third world to the first world in a sense, because of that running water,” Fisher said. Deaths from HIV, overdose, and soft-tissue injury infections have declined dramatically in the surrounding neighborhood and in Vancouver as a whole, and detox admissions have increased (to 400 a year, according to Fisher), because Insite builds trust with its clients and doesn’t judge them, Fisher explained. Later, Evans would say that harm reduction programs like Insite have had an unanticipated side effect: Because people are no longer dying so young, “we’re treating chronic conditions in a population that’s aging ten years more than they would have 20 years ago. That’s incredible. We’re seeing chronic health conditions win a population that used to just die.”

Miloscia, who stared, aghast, at the drug users displaying goods for sale, shooting up, and chilling out on the sidewalks around Insite as Evans explained how programs like Insite and the Rainier Hotel save money, peppered the Canadians with questions: How do you know this is working? (They have data and studies that say it is). Why not just focus on prevention? (Prevention is just one pillar; you need to deal with people after they get addicted as well). And: “When do we say, enough is enough, and you have to rejoin society?”

That question was really at the heart of Miloscia’s objections to the Canadian experiment: Why coddle people who will continue to stay addicted, according to Evans, an average of 14 years, instead of just shaming them for their bad behavior, pushing them toward their own “rock bottom,” and if all else fails, forcing them into treatment? This is a fundamental difference in philosophy between those who advocate for harm reduction and those who believe in prevention and punishment. Evans and the other advocates argued that not only does forcing people into treatment not work, blaming and shaming only pushes people further into the shadows—and further away from help. “We would like to believe that forced treatment works, but it does not,” Evans said over lunch. “If we make people feel their life matters… their outcomes are going to be way better than if we push them further away.

“We have been so ingrained with this belief that telling people that what they’re doing is wrong and bad works, but it doesn’t work. In 25 years, I have never seen a drug user stop using because we told them they were wrong and bad.”

Miloscia is a firm believer in stigmatizing drug use and forcing people into treatment. He thinks it works. But what Miloscia really believes in, he says, is prevention—”scaring” parents and kids, in his words, into never picking up a drug in the first place. Tomorrow, I’ll have a post-Vancouver Q&A with Miloscia in which the conservative senator talks about what he learned from Vancouver, what he thinks of King County’s current approach to addiction, and whether anything he saw changed his mind.

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 run entirely on contributions from readers, which pay for my time 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.

Universal Naloxone? Experts Say It’s Not that Simple.

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Toronto Public Health

Naloxone, the overdose-reversal drug that can bring unconscious opiate addicts back from the brink of death in moments, has been widely heralded as a miracle drug, one that can bring overdose victims back from the dead and that’s credited with saving seven lives since Seattle Police Department bike patrol officers started carrying naloxone nasal spray earlier this year. Daniel Malone, head of the Downtown Emergency Service Center, told me he was “stunned” when he learned that Seattle firefighters, who are all trained as EMTs, don’t carry naloxone; DESC itself has used the drug to reverse about a dozen overdoses since a new state law allowing agencies to get prescriptions for naloxone nasal spray went into effect last year.

Opiates slow down the respiratory system, causing a user to breathe more slowly; they kill when the respiratory system slows down too much and a person nods out, then stops breathing. Naloxone, also known by the brand name Narcan, works by stymieing the impact of heroin on opiate receptors in a person’s brain, allowing a person having an overdse to start breathing on their own.  Since SPD distributed Narcan to 60 bike officers this spring, they’ve reversed seven overdoses with the drug, celebrating each reversal as a “save.”

It’s indisputable that Narcan works. What remains in dispute is whether buying and widely distributing the drug among all first responders, including the entire police, is the best use of limited resources and  political capital, and whether Narcan actually saves as many lives as the Seattle Police Department, under intense pressure to do something to address the heroin epidemic in Seattle, has claimed.

Seattle Fire Department medical Dr. Michael Sayer sighs with exasperation when I ask him why firefighters don’t carry Narcan nasal spray. “Frankly, Narcan doesn’t really save lives,” Sayer says. “To the best of my knowledge, we have had zero cases where someone died because they had an overdose and the EMTs didn’t have naloxone.” That isn’t because Fire Department EMTs do nothing, he says; rather, it’s because EMTs get overdose victims breathing through other means, either by rescue breathing (perhaps better known as mouth-to-mouth resuscitation) or by giving the person oxygen; once they’ve started breathing again, Sayer says, the EMT can start administering a low dose of naloxone through an IV–enough to get the person breathing on their own, but not enough to send them into acute heroin withdrawal. 

“There’s different ways to do a medical intervention; naloxone isn’t the only way,” says Dr. Caleb Banta-Green, a member of the county’s Opiate Addiction Task Force and a UW addiction researcher who’s studying the results of the SPD pilot project. Sitting in his paper-strewn office a few blocks from the UW campus, Banta-Green showed me several different Narcan systems, including two kinds of nasal spray and an injection kit like the one used by SFD. In his observation of fire department medics, Banta-Green says, he saw that “they didn’t just slam [overdose victims] with a bunch of naloxone; they were very careful about how they did it, and they also monitored them really carefully and provided other medical support” to make sure they didn’t immediately go back into an overdose after the drug wore off.

Using Narcan judiciously has another side benefit, Banta-Green and Sayers say; it gives responders a better shot at getting a user to the hospital and potentially connecting him or her with services like treatment and medication.

“If we’re waking up people and we’re putting some fraction of them into withdrawal and then we’re leaving them there, I don’t feel like that’s really solving their problem,” Sayer says. 

Banta-Green is blunt about the shortcomings of an approach that starts and ends with overdose reversal. “Great—so you’ve reversed an overdose. You’ve just bought them 90 minutes. Then what? You still have an opiate-addicted person who’s at continuing risk for overdose.” Waving a bottle of the one-step nasal spray, he continues, “It’s really easy for me to give you this and you go reverse an overdose and [say] we’re good. It’s a lot harder to say to someone, ‘I hear you’re opiate-addicted. Would you like some bupenorphine?” (Bupenorphrine, in combination with naloxone, is sold as the highly regulated addiction maintenance medication suboxone).

“‘Yes, I’d like some bupenorphine,'” Banta-Green continues. “Okay, we need to find you insurance and a medical provider and a pharmacy and figure out a way to keep you on this for the next 20 years. I acknowledge that’s a much harder problem, but that’s the long-term solution.”

Banta-Green says police officers tend to be “stunned” when he tells them naloxone “may or may not be the best intervention,” that the evidence to prove it works better than other interventions just isn’t there yet. Lisa Daugaard, another heroin task force member and director of the Public Defender Association, recalls a conference in Washington, D.C. at which Banta-Green, “Mr. Empirical,” responded to police departments bragging about their number of “saves”—OD reversals that departments count as saved lives—by telling them, “‘You have no idea whether those people would have died. Those aren’t saves—compared to what? Maybe that’s not the most effective thing and maybe most of those people wouldn’t have died if you hadn’t administered naloxone.’ And people were like, ‘Shut the [heck] up, because I don’t want to hear that.'”

Daugaard says that compared to the fire department, which doesn’t have a history of enforcing the punitive war on drugs, SPD may find it “hard to bring a healthy skepticism to bear on specific strategies.  Replacing the instant fix of an arrest with the instant fix of a nasal spray has an appeal that harder, deeper solutions lack.

“This is not to be critical of programs in which officers carry naloxone–I’m not clear what the opportunity costs are,” Daugaard continues. “But I do appreciate first responders who set aside how good it makes them feel to ‘save’ someone and ask harder questions about what is most effective.”

With the jury still out on whether naloxone is a good investment for police in Seattle, everyone I talked to agrees on two types of places where having the spray on hand is a good idea: In the homes of opiate users, and in rural areas, where it may take half an hour for medics to respond to 911.

Banta-Green says his primary concern is choosing the best tools for combating opiate overdose and addiction while people are still paying attention to the “opiate epidemic”—a window that may already be closing. “I’ve worked in this area for 20 years, and it’s so rare that you get to actually talk about addiction or overdose that you want to make sure you have the most impactful way to do it, and that may not be police carrying naloxone. It might be telling people about the good Samaritan laws,” which ensure that people won’t be arrested for drug possession if they report an overdose. “Naloxone has really taken up the vast majority of the attention, and the problem has been that it can deprioritize or even remove attention and funding from other solutions, like syringe exchanges,” Banta-Green says.

In reporting this story, I also talked to one person who is an unequivocal advocate of naloxone distribution, and for very personal reasons: Penny Legate, founder of the Marah Project and the mother of Marah Williams, who died in 2002 at just 19 after fighting heroin addiction for seven years.

Legate says that even if naloxone isn’t a panacea, the risks of not having it on hand outweigh the possibility that overdose victims won’t seek long-term help. “There’s no down side to administering naloxone,” Legate says. “If a person is in a heroin overdose and you have precious minutes to revive them, I don’t know why anyone would object to a police officer or a bystander or anybody administering naloxone. It’s a matter of minutes to return oxygen to the brain.  Are you just going to stand there and say, ‘This person’s not going to get help, we’ve seen it before,’ or ‘Geez, heroin withdrawal is really tough,’ or ‘Let’s just sit here and wait for the medics to show’?”

“The hope,” Legate says, “is that they will allow themselves to be transferred to Harborview, where there are social services available, and that through the process they can be convinced to get help.” But even if many don’t, “is that any reason not to give [the drug] to somebody who isn’t breathing?”