It's Time for Uncomfortable Solutions to the Opioid Epidemic

By Abraham Gutman 04/18/18

The results of the War on Drugs: an America that is the most incarcerated nation in the world, a sharp decrease in the price of heroin, and a new Jim Crow for Black communities.

Cubicles in a safe consumption room in Vancouver, Canada
A safe consumption room in Vancouver, Canada

Not every problem has a solution that we are comfortable with. The opioid epidemic and the overdose crisis are two examples of such problems. There has been a lot of work by states and cities to tackle the epidemic and mitigate harm. Laws limiting opioid prescriptions have been enacted (controversially), DEA regulations on who can administer treatment were laxed, Prescription Drug Monitoring Programs were founded, and states of emergency were declared.

“The United States has seen a vigorous legislative response to the opioid epidemic,” writes Scott Burris, the Director of the Center for Public Health Law Research at Temple University, in a recent article, “but legislators are running out of easy targets as the most popular ideas are adopted in all the states.

With no more low-hanging fruits left on the tree, and with the epidemic still raging, it is time to confront the solutions that we are less comfortable with. Philadelphia found itself in the middle of this conversation after city officials announced that they would encourage private organizations to operate comprehensive-user engagement sites, commonly known as safe-consumption sites.

While Philadelphia is the first city in which officials gave their blessing to open a safe-consumption site, other cities—including DenverSeattle, and New York—are currently considering opening such sites. Two weeks after Philadelphia’s announcement, San-Francisco announced that the city is expecting to be the first city with a site coming July 1st of this year.

Safe-consumption sites are a harm reduction measure that has been shown to enhance access to primary health care for people who use drugs, reduce overdose mortality, and reduce transmission of disease such as HIV/AIDS. The evidence further suggests that the sites reduce the level of public consumption of drugs and dropped syringes without causing an increase in drug use, drug trafficking or crime in the vicinity of the site. Last summer the American Medical Association voted to support the development of pilot safe consumption facilities.

The debate about safe-consumption sites is mostly not about the evidence that supports the efficacy of the practice but about whether it is the right path to take. One opponent in Philadelphia wrote, “we don’t need to enable drug addiction. We need to keep kids off drugs in the first place. We need to help addicts who want to stop using.”

The truth is: we don’t know how keep kids off drugs in the first place. Furthermore, medication assisted treatment, the gold standard treatment for opioid use disorder, is heavily regulated on the state and federal level leading to barriers in access.

America spent billions of dollars in an attempt to convince the nation’s youth to “just say no” to drugs. The phrase that was first used by First Lady Nancy Reagan to respond to an elementary school girl in Oakland in 1982 became a national and international campaign, and a myth. Telling kids to “just say no” doesn’t work. In fact, it might have the exact opposite effect.

If we can’t make kids say no, maybe we can prevent anyone from offering them drug in the first place. This was the logic of Donald Trump in his first State of the Union when he declared that “we must get much tougher on drug dealers and pushers” and that “open borders have allowed drugs” to enter the country. In a recent speech in New Hampshire, Trump doubled down on this line of thinking and called for the death penalty for some dealers.

Getting tough on drugs is in no way a new idea, in fact it is almost 100 years old. America conducted a horrifying policy experiment to see if this idea works. This experiment, known as the War on Drugs, was conducted with communities of color as the subjects. The results are an America that is the most incarcerated nation in the world, a sharp decrease in the price of heroin with virtually no change in the number of high school seniors using illicit drugs, and a new Jim Crow for Black communities. Renewed calls to get tough on crime are either driven by blindness to the realities of the War on Drugs, racism, or a combination of both.

Tightening the border is not doing much to prevent drug abuse either. While Trump believes that a wall will prevent drugs from entering the US, most drugs that cross the southern border do so through legal entry ports to the U.S., according to the Drug Enforcement Administration. In fact, some argue that the tightened border security gave rise to proliferation of Fentanyl, a deadly synthetic opioid much stronger than heroin, because drug traffickers can make profits from very small volumes. Executing drug dealers as a means to reduce the supply of illicit drugs is dehumanizing and racistunconstitutional, and won't work.

If we can’t completely stop illicit drug use, we can at least provide easily accessible treatment. When it comes to opioid use disorder we even have effective treatment to offer: medication-assisted treatment using methadone, buprenorphine, and naltrexone. But access to medication-assisted treatment is far from sufficient to meet the growing need, with some in rural areas having no providers within a 350 mile radius. Investing in treatment is extremely important, however stigma and regulatory barriers from federal law and DEA regulations make increasing access very difficult.

The fight over increasing access to medication assisted treatment is a worthy and necessary fight that we should engage in with full force. That said, we need to be realistic about how long it will take to change established laws, regulations, and hearts and minds. Meanwhile people who use drugs are actively dying from overdose, suffering from injection related wounds, and contracting bloodborne diseases such as Hepatitis B and C and HIV/AIDS.

Safe-consumption sites are in no way a silver bullet that will defeat the opioid epidemic. They are a strong tool that should be utilized to end the overdose crisis. More than 64,000 Americans died in 2016 from drug overdose. Not taking action on evidence-based practices because the solution doesn't feel intuitive should not be an option.

Some still view safe-consumption sites as “enabling” drug use (even though that is not supported by the evidence). “If the current epidemic can teach us anything, it’s that drug use is soaring unassisted,” writes Dr. Sarah Wakeman, the Medical Director of the Substance Use Disorder Initiative at Mass General Hospital. “The time has come to think instead about how we can enable people to stay alive.”

The effort to end the opioid epidemic is a marathon and not a sprint. As a society our goal must be to ensure that as many people who are currently using drugs cross the finish line with us - alive and with the least irreversible damage. The next steps to do that might go against many of our gut instincts but at the end of the day we must trust the evidence and embrace harm reduction measures.

Please read our comment policy. - The Fix
Abraham Gutman.jpg

Abraham Gutman is an Israeli economist and independent writer based in Philadelphia.He works at the Center for Public Health Law Research as a senior data and policy analyst. His research focuses on the impact (or lack thereof) of laws on health and racial justice. Opinions are his own. Follow him on Twitter @abgutman.