UPDATE: Today, a coalition of public health experts and people who have lost loved ones to overdoses announced that they are suing to block Initiative 27, which would ban supervised drug consumption sites throughout King County, on the grounds that public health decisions are outside the scope of the initiative process. The group, called Protect Public Health, argues in their lawsuit that under state law, King County and its public health department are responsible for making public-health policy decisions for the county, and “[i]t would be antithetical to this scheme to allow citizens to delay or override urgent action on a public health crisis merely by raising sufficient funds to qualify a referendum or initiative.” (You can read the full complaint here.)

Last week, the King County Elections Department confirmed that initiative supporters had collected enough signatures to qualify for the February 2018 ballot; a last-minute effort backed by Republican King County Council member Kathy Lambert to put the measure on the ballot in November was unsuccessful.

With safe consumption very much in the news this week, I thought it would be a good time to hear from some advocates on both sides of the safe consumption issue. First up: Brad Finegood, a drug policy expert at King County with a mouthful of a title: Assistant Division Director, King County Dept. of Community and Human Services, Behavioral Health and Recovery Division. As deputy director of the recovery division, Finegood was a member of the King County Heroin and Prescription Opiate Addiction Task Force, which released a set of recommendations for addressing the opiate addiction epidemic last year. Those recommendations included promoting safe storage and disposal of prescription medications; wider access to treatment for opiate addiction, including medication-assisted treatment with drugs like suboxone and comprehensive treatment on demand; and wider distribution of naloxone, the overdose-reversal drug.

But by far the most controversial recommendation the task force made was that the county open two supervised drug consumption sites, where users could consume their drug of choice—heroin, meth, cocaine, whatever—under medical supervision. The intent, the task force wrote in its report, was to reduce drug-related health risks and overdose deaths; provide access to treatment and basic health care, reducing drug users’ use of emergency services; and “improve public safety and the community environment by reducing public drug use and discarding of drug using equipment.” Many communities didn’t buy the task force’s logic for recommending the sites (which have been common in many European countries for decades) and have passed city-level laws banning them; in February, King County voters will have their say on Initiative 27, which would prevent the county from opening a supervised consumption site anywhere, including in Seattle, where some communities especially hard hit by the heroin epidemic, such as Capitol Hill, have been open to the proposal.

As a King County employee, Finegood can take no official position on I-27, and we didn’t discuss the initiative explicitly during our conversation. But his longtime support for supervised consumption is no secret. For Finegood, the issue is more than political—it’s personal. A longtime drug counselor who worked extensively in the criminal justice system, he lost his own brother several years ago to a heroin overdose, and believes that a supervised consumption site could save the lives of people like his brother—both by preventing and reversing overdoses, and by reducing the stigma and shame that keeps drug users from reaching out for help. I talked to him at his downtown Seattle office last month.

Here’s Finegood:

My brother and I were three years apart and we were always really close growing up. We grew up in a lower-to-middle-class neighborhood with two very hardworking parents and we both had really good educations. We both went to college together at Michigan State. I saw him every single day. But I never knew there was an opiate issue. That was really hidden to me and my family.  I would say, looking back, that there were probably some telltale signs. I’d go over to his house at noon, one o’clock, and knock on the door and he wouldn’t be awake. But I always figured, he was in college, he went out late, it was summertime and he didn’t have school or work.

Then he got married and went off into the working field, and there was a lot that I didn’t know, that was hidden. Some telltale signs of drug use would be marks on people’s arms or track marks or baggy eyes, and I never really saw any of that, so there was no reason to be concerned. A lot of stuff was obvious in retrospect. His wife wanted to gain some space from some of the people that he was involved with, so they moved to the East Coast to get away. Then they ended up getting a divorce and he came back to town and ended up connecting with a person who also had opiate use disorder but also hadn’t used in a long time. So when they connected, they started sharing stories, and saying, ‘Wouldn’t it be fun if we could get high together?’ She was in a different city, but they would rendezvous and go see music and get high.

That happened a couple of times. Then they got together and went on a three-day party binge for New Year’s, and he didn’t wake up on New Year’s Day.

“He cared a lot about his family, and didn’t want to let us down. There’s so much stigma that goes along with having opiate use disorder.”

We didn’t even know there was an opiate problem. And then he passes away and we meet this girl who he had been friends with, and she tells us some stories about what happened. His ex-wife then started telling me stories about past seven years of his life, when I had seen or talked to him every single day, and we started to piece together all these pieces.

It was just utter sadness and a ton of guilt—the guilt of being that close to my brother and not knowing. I was working in a clinic that served people with opiate issues, and I didn’t even know my brother was using under my nose. I think a lot of that was not wanting to let people down. He cared a lot about his family, and didn’t want to let us down. There’s so much stigma that goes along with having opiate use disorder. There was a picture that had been taken maybe two or three months before he died where he just had these raccoon eyes, and I thought, ‘Oh, that makes sense now.’ There was a lot of family system disbelief and denial that that couldn’t happen to us—’not in our family.’

One of my first jobs coming out of college was as a substance abuse counselor. I wanted to be able to help people, but I used to look at it from a criminal justice standpoint. I thought of the criminal justice system as a primary intervention for people, because I thought, people can get arrested and their drug issue could be brought up. I used to say that my brother’s biggest problem was that that he never got arrested. I had worked with so many people in the criminal justice system, and I saw that it could sometimes have a positive effect on people, if they were treated in a therapeutic environment.

You take folks who are struggling with [addiction] issues, and you put them in a confined area with other folks who are struggling with the same issues, and you don’t provide any therapeutic interventions around—then there can be some negative consequences.

I realized some of the unintentional harm that incarceration can cause people when I was working with somebody who had alcohol use disorder. He drank and got a probation violation, so the judge was going to send him back to jail for the weekend. And so I was like, ‘Hey, buddy, let’s make this an intentional experience. It’s lousy that you have to go back to jail for the weekend, but let’s get something good out of this, and you’ll come back next week and we’ll talk about it.’ So he came back the next week, and I was like, ‘So how was it? Did you learn something? And he goes, ‘Yeah—I learned how to make meth!’

That moment has stuck with me, because you realize that even the most well-intentioned intervention might have negative consequences. You take folks who are struggling with [addiction] issues, and you put them in a confined area with other folks who are struggling with the same issues, and you don’t provide any therapeutic interventions around—then there can be some negative consequences.

I was sort of raised [professionally] in the drug court world. Drug court was really the first idea that said there could be a therapeutic approach to working with people that have behavioral health issues. It’s harm reduction compared to sending someone to jail for a long period of time, but on the spectrum of harm reduction it’s not full harm reduction. That concept has evolved very much over the past 15 years to understanding that we have to be able to treat substance use disorder with a public health approach. Our partners in the criminal justice system will be the first ones to tell you, at least most of them, that criminalizing people with substance use disorder has been really unsuccessful.

“In my almost 20 years of working in this field, nobody that I’ve ever met who has opiate use disorder likes having opiate use disorder. They almost always know the risk, but they use anyway.”

The evidence [about safe consumption sites] tells the story, and the evidence is that people do not die when using those facilities. The evidence also says that when people have access to a caring environment,  they’re more likely to be able to move along the path [toward recovery]. When you provide an environment for people to feel safe, where they can come to without stigma, without prejudice, and they know that they can use on site and not die, then they’re going to continue to use that resource.

In my almost 20 years of working in this field, nobody that I’ve ever met who has opiate use disorder likes having opiate use disorder. People with substance use, especially opiate use, disorder use despite the risk of possibly overdosing. They almost always know the risk, but they use anyway. It’s a neurochemical brain disease. My brother is proof of the fact that you can be clean and sober for quite a period of time and that lure to come back is mighty difficult to fight. If you are consistently waiting for people to hit rock bottom, they’re gonna be dead.

“I think that stigma against people who have drug problems is really prejudice and discrimination against people who have drug problems.”

I think that without a doubt my brother would have benefited [from a safe consumption site.] Do I know if he would have used it? No. But do I know that there are people out there who need it and are willing to use it. Our survey from the needle exchange tells us that a significant number of people who use needle exchange services —the vast majority—would use it. And if they are willing to use it, then that means they will not be using it primarily outdoor, often by themselves, in a vulnerable situation. I know very little of the intricacies of my brother’s use, but if there was ever a time when he could have used it to make himself less vulnerable, I would have hoped he would have used it. Does it mean that my brother would be alive right now? No. But one of the things that I can say is that I believe that my brother had a lot of shame associated with his disease, and I believe that shame was because of how we as a society look at people with substance abuse disorder. I used to say, I wish my brother would have become involved with the criminal justice system. Now I wish my brother wouldn’t have felt shame. I think shame killed my brother. I think shame of having a heroin problem and having a drug problem killed my brother, because it kept him from ever wanting to ask for help. It kept him from ever admitting that he had a problem. And it kept him only trusting people that had the same problem. I think that stigma against people who have drug problems is really prejudice and discrimination against people who have drug problems.