The war on drugs failed. What now?

Public-health approaches to addiction share a compelling goal: to avoid making things worse.
August 30, 2016
REDUCING HARM: A nurse prepares for a shift at the Insite safe injection clinic in Vancouver, British Columbia, where drug users can inject themselves under observation. AP Photo / The Canadian Press / Darryl Dyck

Every day in Vancouver, Canada, anywhere from 600 to 1,000 drug addicts enter a nondescript building where they can—under medical supervision—inject themselves with illegal drugs they have brought with them, usually heroin, cocaine, or methamphetamine. They know that while at the site they will be neither arrested nor judged, and as long as they are in the building they will be safe.

The program, called Insite, is the only legal supervised injection site in North America. It’s located in the Downtown Eastside section of the city, a ten-block area full of single-room occupancy hotels. Drug users are visible on the street all day and often sleep in dumpsters and alleys. Business activity in the area reflects this population: there are lots of fast-food outlets and low-end shops and an open market where street vendors can obtain quick cash.

Once inside the center, first-time clients are interviewed by staff, who ask for identification and about the nature of their drug use. They are supplied with clean needles and syringes and enter one of 12 stalls surrounded by mirrors on three sides, which allow clients to be observed by nurses, who are available to minimize risk of injury. Clients then enter a lounge area. The second floor of the facility houses a detox unit and the third floor has an 18-bed long-term recovery unit. Individuals are not required to ask for these services, however.

It might seem counterintuitive to help addicts continue to use drugs this way, but officials in Ithaca, New York, are considering opening a site like Insite in their city. I was one of about 25 clergy who visited Ithaca last spring to hear Mayor Svante Myrick describe his plan to reform drug policy by doing what Insite does: focus on reducing harm, not on criminalization. Drug policy that is aimed at reducing harm reaches out to people where they are, considers every life worth saving, and expresses an unconditional rather than judgmental love. “Jesus was a harm reductionist,” commented one of the pastors at the Ithaca event.

The broader context for the Ithaca effort is the widespread realization that the nation’s “war on drugs” has failed. The aim of the war on drugs launched by President Richard Nixon in 1971 was to combat drug use primarily through the arrest and incarceration of drug users. After an expenditure of more than $1 trillion, it has become clear that this model has not done much to deter drug use, but it has made the United States the leading “prisoner nation” of the world, incarcerating millions of people and wreaking massive collateral damage on citizens, especially people of color.

As the failure of the war on drugs has become evident, many officials have moved toward a public health model of response. City and county prosecutors have become increasingly weary of recycling low-level drug offenders through the criminal justice system, and many have become open to the idea of “diversion”: police can choose to send offenders, many of whom they already know, directly into programs for drug treatment, housing, and job training.

One such program was initiated about six years ago when a state’s attorney in Vermont, T. J. Donovan, became aware that he was seeing the same faces over and over again in the courtroom. “Suddenly,” he recalled, “I realized my office was creating the problem. I could just start referring these individuals into treatment.” He received strong support from Vermont governor Peter Shumlin.

Five years ago, Seattle launched what has become a model of diversion. The mayor of the city, the executive of King County, city and county prosecutors and police, the public defenders association, the ACLU, and community members all committed themselves to Law Enforcement Assisted Diversion, which diverts drug users to social service programs. A follow-up study by the University of Washington showed that LEAD has led to a significant drop in the number of people caught up in the criminal justice system, a nearly 60 percent drop in recidivism, and a reduction in law enforcement costs.

The roots of the Vancouver experiment can be traced to a psychiatric nurse named Liz Evans, who in 1991 was working in a Vancouver emergency room and seeing a lot of drug addicts. “We were treating people with life crises and sending them back into the storm.” She didn’t like the way other nurses talked about addicts. “We demonized drug users: ‘They steal, they beat people up.’ I was forced to confront our inhumanity, including my own. I would go home and cry.” Evans decided a new approach was needed—“something other than ‘people are bad because they are making wrong decisions.’”

Evans decided to purchase one of the dilapidated hotels in the area and to house people who were at the end of their rope. She vowed that these people would be cared for, and no one would be evicted simply for being a drug user.

But drug use in the city continued to grow, as did the number of deaths from drug overdose. The rise of AIDS amplified the health risks of drug use. In 2000, Vancouver adopted a new approach to drug use: it would focus on prevention, treatment, law enforcement, and—a crucial fourth pillar of the program—“harm reduction.” This initiative sought to prevent overdoses and the spread of HIV/AIDS infection among drug users. By not insisting on abstinence, Vancouver adopted an approach that had been emerging in several European countries, including Germany, Denmark, and the Netherlands, for at least 20 years.

It is this “four pillars” approach that Mayor Myrick of Ithaca is proposing for his city. Harm reduction practices in­clude diverting users to treatment programs and helping users substitute methadone for heroin, enabling users to avoid both the highs and the withdrawal symptoms of heroin and eventually return to jobs and normal life. The Ithaca plan also calls for training first responders in the use of naloxone and Narcan as substances that can save the lives of overdose victims. It provides for a Good Samaritan ordinance that permits individuals at the scene of an overdose to call for help without themselves risking prosecution.

At Insite, treatment is not the initial goal. “Insite is open to treatment, of course,” says Evans. “But that is not where we start. The work is about compassion, connecting with one another, sharing values common to our humanity.”

Yet participating in Insite’s programs does result in more people seeking treatment. According to a 2007 article in the journal Addiction, 30 percent more Insite clients enter a detox program than do people fending for themselves on the street.

Darwin Fisher, the project director of Insite, says, “We provide community space for people who do not have any community space. We bring them indoors. We provide running water. Sometimes a person comes in three times a day. They don’t inject three times, they just want to talk. Health care is generally delivered from the top down. Not with us. We are happy to see someone that no one else is happy to see.”

“At the beginning,” Fisher continues, “the only thing we can do is be present. We provide effective intervention in the lives of people who have been beaten down. They have infections, abscesses. They’ve just been evicted. They haven’t slept in three days. We’re open to treatment, but we can’t impose our goals. If we did that upfront, they wouldn’t [be here}. We meet people where they are.”

Fisher recalls the time he suggested detox to one individual in the recovery room of Insite. “He asked me if we could talk upstairs. We went into a room. He burst into tears. ‘I’ve relapsed five times. I’m nothing. I’m a failure.’ Every part of my being wanted to do something,” Fisher continues, “but at that moment, I just had to be present in his pain. That’s the hardest part of the job.”

Insite has met with various kinds of opposition since it opened in 2003, and its existence has been challenged in court. But in 2011 the Supreme Court of Canada, citing Canada’s Charter of Rights and Freedoms, ruled that “Insite saves lives. Its benefits have been proven. There have been no discernible negative impacts on the public safety and health of Canada during its eight years of operation.”

Police in the Downtown Eastside neighborhood support Insite’s work. Officer Ken Athans, who supervises the district, says, “Most officers are compassionate. If we arrested drug users, we’d be arresting the victims.” He points out that there are “users,” “user-dealers,” and “dealers.” His officers generally only go after the dealers.

“We didn’t get to this point overnight,” Athans observes. “I didn’t see the big picture ten years ago. We had been picking up the broken pieces. You’re not going to arrest every drug user.” He added that he is selective in deciding which officers to assign to Downtown Eastside: “Certain officers don’t do well here.”

The proposal for reforming drug policy in Ithaca faces opposition too, including legal challenges. Ithaca police chief John Barber notes the obvious: “Heroin is considered an illegal substance.” The political objections are predictable: an injection site is “preposterous” and “asinine,” says Republican state legislator Tom O’Mara. A Cornell law professor, William Jacobson, has warned that the site would be a “government-run heroin shooting gallery.”

Mayor Myrick, however, has the strong backing of county district attorney Gwen Wilkinson, who helped to design the Ithaca plan. He is optimistic that the New York State General Assembly will eventually approve it.

The epidemic in heroin use in the United States in the last few years, accompanied by a shocking increase in overdose deaths, has opened many minds to the four-pillars approach. According to the Centers for Disease Control and Prevention, heroin abuse, along with prescription pain killers, kills 78 people a day in the United States. Ithaca mayor Myrick has firsthand knowledge of the dangers of drugs: his own father died of a heroin overdose.

This epidemic has been especially pronounced in New England and the Northeast. In Massachusetts, four residents die daily from an overdose. Vermont governor Shumlin devoted his entire 2015 State of the State message to the heroin crisis in his state. “The time has come for us to stop quietly averting our eyes from the growing heroin addiction in our front yards,” Governor Shumlin said, “while we fear and fight treatment facilities in our backyards.”

In March last year, the police chief of Gloucester, Massachusetts, Leonard Campanello, became horrified when four people in his community died of overdoses in three months. He announced that if heroin users came into his office and turned over their paraphernalia, he would not arrest them but instead would take them to treatment facilities. Over 50 police departments in 17 states have followed suit. Over 200 treatment centers have signed on as partners.

The “punishment” rather than the “health” paradigm seems less compelling when police officers themselves are the ones wanting to steering drug users directly to treatment rather than arresting and incarcerating them.

A study published in 2014 in the journal Drug and Alcohol Dependence found that legal, supervised injection has proven effective in “attracting the most marginalized people who inject drugs, promoting safer injection conditions, enhancing access to primary health care, and reducing overdose frequency.” Safe injection facilities “were not found to increase drug injecting, drug trafficking or crime in the surrounding environments.”

Americans have a long history of viewing drug use as a moral weakness and drug users as criminals who need to be punished. But the failure of the war on drugs, and the evident success of other approaches, is changing minds. A fundamental shift in policy is under way—a shift toward a more humane and hopeful policy. For millions of drug users and their families, it can’t happen soon enough.

 

A version of this article appears in the September 14 print edition under the title “After the war on drugs.”

Comments

role of the church in this

The town where I go to church is one of the wealthiest in the US and it has an epidemic of heroin. In an article about this, a local drug counselor is quoted as saying he relapsed into drug abuse based on an absence of meaning in his life. Even the best public policy can't supply that. As churches we have to figure out what to do.

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