The majority of NPS overdose deaths don’t come from party drugs and knockoffs. They come from opioids, which, unlike ecstasy and hallucinogens, can be deadly addictive. Combating them requires specially tailored initiatives.
Americans take more opioids per capita—legitimate and illegitimate uses combined—than any other country in the world. Canada is second, and both far outstrip Europe. Americans take four times as many opioids as people do in the United Kingdom.
Many factors contribute to this disparity. A BBC investigation into the issue highlighted the overprescription of pills, driven by a lack of universal health care, the advertising of prescription drugs on television (which is legal only in the United States and New Zealand), poor medical training, and “a culture of medication.” Many experts believe, however, that abruptly cutting off addicted patients’ access to pain pills is not the right solution, either, as sufferers of chronic pain may well be pushed toward illicit heroin and fentanyl.
“Making it harder for people to get pain medication legally will most likely drive many to seek relief from far more dangerous and superpotent synthetic opioids,” wrote Richard A. Friedman, director of the psychopharmacology clinic at New York’s Weill Cornell Medical College. A flurry of new regulations designed to lower patients’ dependence on opioids are nonetheless going into effect. In Colorado, some doctors require their patients to take special classes before they can receive their medication. The classes suggest a variety of alternatives for battling chronic pain, including yoga, acupuncture, and dietary supplements. However well intentioned, such requirements have caused some pain patients to feel as if they were being reprimanded or worse. “I am uncomfortable with this approach because it feels like my care is being undermined, and my condition discounted,” said a Fort Collins, Colorado, patient named Shelley Neth, who suffers from conditions including osteoarthritis and was told by her doctor that she would have to attend classes to continue receiving her Vicodin. “Now I’m considered a ‘person on opioids.’” She added: “The punishment for the overdose epidemic is being exacted on chronic pain patients.”
Curbing the tide of US opioid deaths will require sweeping new public-health initiatives, including treatment programs and campaigns to educate everyone, from users and medical providers to teachers and police, about the drugs’ dangers. First responders, police, firefighters, and others who encounter overdose victims need to be better supplied with naloxone, which should be available and affordable to anyone who could benefit from it. Nonetheless, naloxone (including Narcan, the best-known brand) has faced controversy in some communities around the country. Butler County, Ohio, sheriff Richard K. Jones has declined to equip his officers with Narcan. “All we’re doing is reviving them, we’re not curing them,” he told NBC News in 2017. “One person we know has been revived 20 separate times.” (He added that police nonetheless don’t let people die, and that paramedics can instead administer Narcan.)
Some argue that naloxone enables drug abuse and express concern about so-called Lazarus parties (named for the biblical figure Jesus brought back to life), in which fentanyl users push the limit, confident that an acquaintance standing by will revive them with naloxone if they overdose. “I know it is not uncommon for users and their friends or fellow users to have Narcan available for that exact reason,” said Grand Forks, North Dakota, police lieutenant Brett Johnson.
Simply reviving overdose victims is no solution by itself. Stopping opioid overdoses will also require giving users access to drug-checking kits, like those made by Bunk Police, so they can find out whether their heroin contains fentanyl. This idea is making some headway domestically; in 2018 a Rhode Island state representative announced a bill that would cement the legality of drug-checking kits, specifically mentioning fentanyl test strips. California’s public-health department now also provides fentanyl test strips to needle-exchange facilities there, as do public-health departments in a number of US cities, including Columbus, Baltimore, and Philadelphia.
Others would take this idea much further.
“I would set up free drug-purity testing sites, that are anonymous, where people could submit samples of their drugs and then get a chemical analysis breakdown,” said Dr. Carl Hart, chairman of the psychology department at Columbia University. Hart is one of the most outspoken proponents of radical harm-reduction practices in the United States, also advocating for pharmaceutical-grade heroin to be dispensed to addicted users.
Supervised-injection sites are another form of harm reduction. Located in a dozen or so countries around the world, including Canada, France, Norway, the Netherlands, and Switzerland, they are clinics where people can use drugs like heroin and fentanyl free of legal repercussions. Doctors and nurses monitor them, providing counsel, care, and clean needles. Often funded by governments, the clinics have been found to provide dramatic societal benefits, including helping to reduce HIV transmission and fatal overdoses.
As of this writing, however, the United States has no officially sanctioned supervised-injection sites, although at least one has operated secretly in recent years. “In an undisclosed location in the US, a social services agency has secretly overseen more than 2,500 injections by around 100 people who take drugs—in an effort to fight the overdose crisis,” wrote Vice in August 2017. A planned site in Philadelphia drew a lawsuit from the federal government in February, 2019; its fate was unclear.
Canada has clinics across the country, including in Vancouver, Toronto, Montreal, and its capital, Ottawa. After the opening of Vancouver’s first facility, InSite, in 2003, overdose fatalities dropped significantly, though the center has since been hard hit by the rise of fentanyl use, and administrators hope to increase its annual $3 million budget. In recent years proposals for supervised-injection sites have been considered in US cities including Seattle and San Francisco, and New York City mayor Bill de Blasio has supported the idea, but opposition has been too fierce to overcome. As this book went to press, Denver’s city council had approved a pilot program for a site (which would include testing of users’ drugs for fentanyl), but approval by the state legislature was still required.
In March, 2017, when officials in the Seattle area were considering approving a pair of supervised-injection rooms, Lisa DuFour, a lawyer, published an editorial in the Seattle Times with the headline, “I Lost My Son to a Drug Overdose: Say No to Safe Injection Sites.” Her piece was powerful, and it raised a number of objections to the proposal: “Heroin is illegal. Will the police allow illegal drug use at a ‘heroin house’ and yet arrest people elsewhere who use the same drug? … A major cause of overdose is the different strengths of drugs and the combination with other drugs like fentanyl. Will the staff test drugs for purity or safety? And why should taxpayers be burdened with the costs of providing a ‘heroin house’ and paying for the lawsuits when we cannot solve our homeless problem?”
While legitimate questions, asked in good faith, they overlook the fact that well-regarded supervised-injection rooms, such as Baluard in Barcelona, are having a huge impact.
Baluard is housed inside a giant medieval stone fortification known as the Wall of Drassanes. It is located near the Port of Barcelona, is part of what was once the Barcelona Royal Shipyard, which dates back to the thirteenth century, and once served as a bulwark to defend against intruders. The symbolism is not lost on anyone.
Opened in 2004, Baluard was the first center of its kind in Barcelona. At that time, the city was overrun by people using heroin in public places. Some twelve thousand used syringes were collected from city streets and parks that year; by 2016 that figure had dropped to one thousand. Today more than a dozen similar facilities can be found in the area—and eighty in the encompassing Catalonia region, including mobile buses. There are even needle-exchange programs in prisons. Baluard itself is close to tourist spots like Las Ramblas, the famous strip of eateries and shops, but it feels a world apart. In the grassless park in front of the facility, men lie on benches, and transients mill about, their dogs and plastic bags of belongings near at hand. Baluard has become the center of their universe, even when they are not in the facility.
Inside, the staff members wear lab coats but interact casually with patients, while upbeat Spanish pop plays over speakers. A calendar of events advertises movie nights for the users, as well as museum visits, table tennis (entrenamiento de ping-pong), and theater classes. Also advertised are workshops on how to administer Narcan and how to convert cocaine to crack, so it can be smoked instead of shot up, which has some health benefits. (Baluard does not provide recreational drugs.)
The shooting-up room looks surprisingly antiseptic and clinical, like a hospital room, with blue dividers separating spaces at a table that holds five users at a time. There are fresh supplies of needles, tourniquets, antiseptic wipes, and sterile water in which to dissolve heroin. The users inject themselves, but staff is on hand if someone overdoses, ready to assist in the small infirmary nearby. The staff also helps users ensure their heroin is pure, with the assistance of Energy Control.
The facility’s smoking room has six chairs, and on a day in 2017 was overseen by a chipper staffer named Anna. A posted sign says the maximum amount of time to smoke heroin is thirty minutes, and crack forty-five. Pipes cannot be shared. The room is also used for smoking meth and cannabis. Anna, a former Energy Control volunteer, sat just outside the room, on the other side of a window, operating a pass-through tray (like at a bank), through which she handed out paraphernalia, including nontoxic aluminum foil for heating up heroin and special inhaling straws. She also provided crack vials and special crack pipes made of glass that resemble small bongs.
Whenever someone entered the room, Anna input the person’s information into a computer, which contains their substance abuse history. “Hola!” she said as a man entered, asking if he was there to smoke heroin. “Sí!” he responded. She passed him a sheet of foil and a straw, and he sat down at the table, unwrapping a small blue piece of paper holding his bit of “brown sugar” heroin. He put the heroin on the foil and, from below, heated it with a lighter. As the smoke billowed up he sucked it through the straw. The man was perhaps forty-five, had close-cropped hair, and wore orange and blue shoes and an almost-trendy, long-sleeved button-down shirt. After his hit, he lit a cigarette, which he puffed momentarily before setting it in a filtered ashtray, where it slowly burned down while he finished his heroin. “Adiós!” Anna said as he left, smiling. All told, he had been in the room for maybe five minutes.
Another man soon entered. He was scruffier and had come to use both oral methadone and heroin. “Hola, hombre!” Anna said. Her familiarity with her patients spoke to their health and relative longevity; with the aid of supervised-injection sites, they can more safely manage their addictions. Ideally, they would kick the habit. In reality, however, that can be incredibly difficult. Fortunately, even those who are addicted to opiates and opioids can potentially live long, productive lives, provided they have access to clean needles, care, unadulterated drugs, and safe spots to shoot up.
Baluard’s coordinator, Diego Arànega, has a shaved head and a talent for maintaining perspective amidst chaos. “The target group here is problematic users,” he said, speaking in rapid Catalan. “People who are basically in a big mess.”
A psychologist by training, Arànega directs the center and acts as a social worker here, his responsibilities varying depending on the moment. Baluard also provides free drugs for substitution therapy, to try to wean people off opiates. “The methadone is sometimes the hook, to stay in touch with the users every day,” Arànega explains, which also allows the center to treat them for infections and other maladies and to provide counseling.
Substitution therapy appears to be a breakthrough in the fight against the problems associated with heroin and fentanyl addiction—not only overdoses but HIV, criminal activity, and other abuse-adjacent personal issues. Substitution treatments use drugs like methadone, naltrexone, or buprenorphine and are “associated with substantial reductions in the risk for [overdose death] in people dependent on opioids,” according to a 2017 study led by Spanish doctor and public-health expert Luis Sordo del Castillo. According to the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA), Spain now has just about as many people using facilities like Baluard (around sixty thousand) as it has high-risk opioid users in the country as a whole. These clients aren’t coming in just for clean needles and to get high, they have a support system, and their addictions are controlled and monitored. This may not have solved Spain’s homeless problem—a concern voiced by the Seattle Times opinion writer—but the people who have started free substitution therapy at facilities like Baluard are no longer on the streets committing crimes to make money for their next fix.
Not everyone is interested in quitting heroin. About twenty-five hundred injections per month take place at Baluard, Arànega told me. No one has ever died inside the facility and, to date, there are no reports of anyone ever dying inside one of these types of centers worldwide. In 2016 in Barcelona, according to Arànega, only seventy people died from opioid use, in a city of nearly five million. The center’s clean-needle program also seems to be working. More than half of its clients have hepatitis C, and about one in eight are HIV positive, but according to the EMCDDA, HIV diagnoses “attributed to injecting” have plummeted in Spain in recent years, down from 300 in 2009 to 113 in 2016, the most recent year for which statistics were available. As a result, the public costs associated with treating HIV have gone down; when added to the money saved due to reduced crime and to other health-care savings, the financial benefits to the public are substantial, addressing another of the Seattle writer’s concerns.
Arànega dispels another common fear about these centers: that they encourage addiction. The people his clinic sees are not first-time users, he said, but those with opioid-use disorder, who long ago chose this life. Now they’re trying to get well. “If they’re here, they’re not in the parks, in the streets, with children. If you are offering not just an injection room but access to psychologists and doctors, you’re doing good work.”
Officials in countries that have had success with these types of injection rooms, such as Switzerland, now see them as benefits not just to addicted users but to the population at large. “The consumption room is the best tool I have to ensure public safety in Bern,” said the police chief of the Bern region, Manuel Willi, using another term for the sites. The trend seems to be growing worldwide, as numerous sites opened across Canada, Europe, and Australia in 2017 and 2018.
Stigma, the Slovenian public-health group focused on opiate addiction, operates needle-exchange centers in Ljubljana, including one in the city center, located near a bridge guarded by a dragon sculpture. It’s a small room inhabited by people quietly drinking coffee or juice. Near the front sits a table blanketed with plastic-wrapped needles—hundreds of them, in different shapes and sizes.
Though possessing the stale air of a homeless shelter, it and similar centers across Slovenia are making an impact. The country has very few opiate or opioid deaths, and its HIV rate has dropped and is now among the lowest in Europe. This is undoubtedly aided by government-sponsored efforts to reach out to addicted users. Stigma’s director, Dare Kochmur, admitted his organization literally pulls them in from outside. “By moving people from the streets inside, you eliminate the unseen population. We don’t judge them. We don’t encourage [drug use], but our goal is to eliminate unnecessary harm.” The United States has perhaps a few hundred needle-exchange centers scattered around the country; it’s difficult to know how many, because more are opening all the time. Kentucky, New Mexico, and California each have more than forty, and New York and Washington have at least twenty each. Many states, traditionally, have been reluctant to embrace the concept, but an omnibus spending bill signed by President Obama in 2016 allowed states and municipalities to use federal funds for these exchanges in some situations, and the movement is gaining steam. Despite scattered local resistance, officials in some states have marshaled resources for these exchanges, including Republican governors in Kentucky and Indiana.
Fentanyl is barely visible in Slovenia. Harm-reduction efforts get some of the credit, according to Kochmur. Slovenia’s methadone program started in the mid-1990s, and opiate addiction rates have since fallen. The country currently boasts twenty-two methadone-substitution clinics, and Kochmur has lobbied for more. Baluard and the other European supervised-injection centers don’t see much fentanyl, either. “There’s no fentanyl here in Barcelona, because you have greater availability of heroin, and users prefer heroin,” said Energy Control’s Mireia Ventura.
Experts on both sides of the Atlantic agree that it would be easy to establish supervised-injection facilities for opioid-ravaged communities in the United States, to create one-stop shops where people could test their heroin for fentanyl, exchange needles, and shoot up safely. On-site help would be ready with Narcan, and users could also receive counseling, information, and medical assistance, likely slowing the opioid crisis wherever such practices were administered. These facilities already have a long track record of success. However, big barriers remain because the United States has not decriminalized drugs; in Canada, for example, the government had to provide supervised-injection sites with an exemption. But continuing on the current path would likely be much worse.
“Harm reduction is the only answer,” Kochmur said, offering advice to the United States. “You can’t just do primary prevention in the schools. You can’t get all the addicts clean in the health-care system. And you can’t arrest all the drug users.”
The tension in the United States is encapsulated in an October, 2018 exchange, when former Pennsylvania governor Ed Rendell announced that he had incorporated a nonprofit seeking private funding to open a supervised injection facility in Philadelphia, which at that time had the highest opioid death rate of any major U.S. city. This despite threats from US deputy attorney general Rod Rosenstein that if one opened it would be immediately shut down by federal authorities. “I’ve got a message for Mr. Rosenstein,” Rendell said. “They can come and arrest me first.”