County Presses Pause on Safe Consumption Sites

Two weeks ago, rejecting the unanimous recommendation of the King County Heroin and Prescription Opiate Addiction Task Force, the King County Council voted to prohibit funding for supervised drug consumption sites except in cities that explicitly approve them—a sop to suburban cities and rural areas where residents are vehemently opposed to the sites and a slap in the face for the task force, which recommended a pilot project that would include one supervised consumption site in Seattle and one somewhere else in the county. (The county refers to supervised consumption sites by the clunky acronym CHELs, for Community Health Engagement Locations).

The council also voted to prohibit the county from funding safe consumption sites anywhere outside Seattle, and barred spending any of the county’s general fund on a Seattle site. As a result of those restrictions, any money for the pilot project would have to come from the county’s Mental Illness and Drug Dependency levy—a tax that generates about $66 million a year but is already largely spoken for. The supervised consumption pilot was never supposed to be funded entirely through the MIDD, and supporters say that as the cost estimate for the pilot has ballooned to more than $1 million, the likelihood that it can be funded MIDD dollars alone is virtually zero.

“EFFECT: Restricts the General Fund Transfers to DCHS and Public Health such that 86 no General Funds can be used to establish CHEL sites. Restricts the MIDD  appropriation such that no MIDD funds can be used to establish CHEL sites outside 88 the city of Seattle.” – King County budget amendment barring county spending on safe consumption sites outside Seattle

Kris Nyrop, who wrote an op/ed for the Stranger comparing the council’s move to the “state’s rights” politics of the 1980s, says the vote “effectively kills” safe consumption sites, at least for the next two years, because “The MIDD dollars are all already accounted for until the fall of 2018” and because “the [King County] health department has dithered so long on this that they have given the opposition time to really organize” against it.

Supervised consumption sites, where addicts can use illegal drugs under medical supervision in a location that also offers medical care, detox, and referrals to treatment, are common in Europe but almost unheard-of in North America, where more puritanical attitudes toward addiction have made them controversial. The idea behind supervised consumption is that it keeps people from dying of overdoses and treatable conditions (like wound infections), prevents disease transmission via dirty needles, and gets people who may not have seen a doctor in years into the health care and social service system, providing a lifeline toward housing, treatment, and recovery.

“We haven’t yet done the work that we need to do at the council to understand the proposal, the benefits, or the criteria for when and where these [safe consumption sites] make sense.” – King County Council Democrat Claudia Balducci

The sites are controversial for obvious reasons: Intuitively, giving drug addicts a safe place to consume dangerous, illegal drugs seems like condoning their behavior. (This view assumes that addiction is a choice and ignores the fact that forcing people into treatment, an alternative that safe consumption opponents frequently suggest, is cost-prohibitive and doesn’t work, but it’s ultimately an emotional argument, not a rational one.)

“Trust me, you don’t treat alcoholism by inviting alcoholics to the bar,” Republican county council member Reagan Dunn, who has been public about his own struggles with addiction, said before the vote. “Fifty-six percent of my constituents said they are extremely against these sites. Only 20 percent of people indicated they were open to considering these sites.” Dunn said he was concerned about the county’s liability if users OD and die inside the facility (in almost 15 years, not one person has died at Insite in Vancouver) and worried that the sites would become magnets for heroin dealers. He suggested that Seattle should be a test case for the site, “before we take the show on the road” to suburban areas that don’t have the same capacity to provide treatment and emergency services.

Republicans weren’t the only ones arguing that safe consumption sites should be limited to the state’s largest city. Suburban Democrats like Claudia Balducci (a former Bellevue City Council member) and Dave Upthegrove, who represents South King County, argued that the county would be overstepping its authority if it opened a safe consumption site where residents opposed the idea. “One of the things that always drove us crazy at the city level was when higher levels of government told us what to do at our city,” Balducci said. “I come from a city that has decided this is not what they want in their city. It doesn’t fit the needs or the desires of their community…. [Safe consumption sites] work best in locations where there’s a lot of street drug use,” she added.

Public Defender Association director Lisa Daugaard, who sat on the heroin task force, argues that “it sets a dangerous precedent to withhold funding for health services from residents of towns whose elected officials have ideological problems with those medical strategies. … The health and well-being of people who live in Kirkland and Kent affect that of people in Seattle, and vice versa.”

Larry Gossett, a Seattle Democrat, scoffed at the implication that drug addiction—particularly heroin addiction—is a problem restricted to big cities like Seattle. Noting that, nationally, heroin and opioid addiction is largely a rural and suburban problem, Gossett said, “I do not understand this concept that people who live outside of Seattle and in suburban and rural areas are different than people who live inside of cities.” Council member Rod Dembowski, whose district includes Shoreline, Kirkland, and Woodinville, added, “There is a serious rural crisis going on, with people dying every day, and I don’t think it’s fair to the citizens of my district to say, ‘No, you don’t get to have return on your investment’ if such a facility would serve their needs. … I don’t think the public health of the 2.1 million residents of this county should be decided based on fear.”

On the  phone last week, Balducci defended her vote, arguing that the budget amendment is a temporary pause, not a permanent spending prohibition. “We haven’t yet done the work that we need to do at the council to understand the proposal, the benefits, or the criteria for when and where these [safe consumption sites] make sense,” she said. “We have to do a little more background work and figure out, what are these [safe consumption] sites and who do they serve.” Balducci also suggested that a huge debate about safe consumption sites could blow up her ongoing efforts to establish the first permanent men’s shelter on the Eastside in Bellevue. “We are facing a really tremendous backlash about that, and one aspect of the opponents’ position is that this is just the camel’s nose under the tent and they’re going to legalize heroin next and [addicts] are going to be out in all the neighborhoods.”

Of course, they’re already there.

Daugaard, who still holds out hope that the council could reverse its decision during the ongoing budget process, says that if they don’t, “it will be very difficult to keep the promise that the heroin task force made to neighborhood leaders in Seattle: that Seattle would not be left alone to respond to this need, which is fundamentally unfair given the widespread use of heroin and opiates throughout the county.  Waiting until 2019 to move forward inevitably will mean avoidable overdose deaths, and no solution to drug use in unsupervised public sites like bathrooms and parks.  Hopefully we all can agree that the status quo is unacceptable. Waiting is not a plan.”

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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.

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.