What would things look like if we believed they could recover?

Over the last week, there have been two noteworthy stories on supervised injection sites.

NYC planning supervised injection sites

The first story was in the New York Times and reported on NYC considering supervised injection sites and looking to Toronto for their experience.

The scouts from NYC are seeking to learn what they can to avoid quality of life problems:

The Toronto police are currently studying crime trends to figure out whether the quality-of-life issues have worsened because of the new facilities or from other factors like the general rise in drug overdoses in the city over the same period.

In Toronto, calls to 911 have risen near the biggest sites. “Public urination, public defecation, prostitution, sexual assault, robberies, noise, you name it, we’re hearing about it,” said Staff Superintendent Mario Di Tommaso of the Toronto Police Service. “And that’s all coming from the public.”

The Works, Toronto’s largest supervised injection site, sits just off the corner of Yonge-Dundas Square, the equivalent of Times Square in New York.
Indeed, groups of users, drugs in hand, are a common sight outside the biggest of these centers; many arrive before the doors open, some unable to wait to use inside.

For health officials, users and advocates, that underscores the need to have a place safe from overdose, or from worries about robbery while the drugs are taking effect. Several times in recent weeks, staff members had to revive people overdosing outside a center.

Number of references to recovery = zero.

Number of references to treatment = two (both weak references). One quote from a client saying treatment didn’t stick and describing opioids as the devil. The second just mentions that one of the injection sites also provides methadone.

The lack of attention to treatment and recovery leaves readers wondering whose quality of life they have in mind.

There are references to fatal overdose rates but it’s hard to know what to make of them:

In Toronto, the largest city in Canada, opening sites became a recent imperative: In 2013, there were 104 fatal opioid overdoses; in the first 10 months of 2017, there were 263, according to the latest data available from the city’s health department.

That’s an alarming increase, but fatal overdoses are increasing at alarming rates everywhere. The article does not provide context to evaluate the injection sites’ impact on overdose rates.

The sites are doing a lot of OD rescues and are using an approach that’s new to me.

There have been 123 overdoses through April, and most are brought back with oxygen. The goal is to treat the overdose without reversing the high — a result when naloxone is used — so that the user is not thrust into immediate withdrawal and a new search for drugs. Staff administered naloxone in fewer than a third of overdoses.

At Moss Park [another site], volunteers have reversed roughly 215 overdoses since August, usually with oxygen rather than naloxone, an overdose reversal medication; last week, a 36-year-old woman was brought back after overdosing on fentanyl.

Take the time to read the entire article.

Overdose-prevention sites set to grow in Vanvouver

The second article is in The Globe and Mail and describes the growth supervised injection sites in Vancouver, long identified as a model for the implementation of harm reduction services.

The article describes a grassroots program started in a tent.

In December, 2016 – the worst month on record for overdoses to date, with 162 dead – B.C.’s Ministry of Health not only gave Ms. Blyth’s overdose-prevention site a government stamp of approval, but ordered health authorities to open nearly 20 more across the province.

Ms. Blyth’s tent was replaced by a trailer the same month and began receiving funding from Vancouver Coastal Health. This past December, it moved indoors, into a storefront owned by BC Housing next door. The site maintains an outdoor tent for those who smoke their substances.

The overdose-prevention site has logged 180,437 visits since receiving government approval in December, 2016. During that period, there were 431 overdoses, 403 naloxone administrations and zero deaths. There have been an additional 60,000 visits by smokers since April, 2017.

In comparison, Insite, the first supervised-injection site set up in Vancouver, logged 175,464 visits in the 2017 calendar year. There was an average of 415 injection room visits a day, 2,151 overdose interventions and 3,708 clinical treatment interventions such as wound care.

I did notice that some sites were referred to as “overdose-prevention sites”, while others were referred to as “supervised-injection sites.” The article explains the distinction.

Overdose-prevention sites differ from supervised drug-use sites in that they are traditionally set up by volunteers through a quicker process as an emergency measure. Supervised drug-use sites tend to offer more robust services such as clinical care and counselling.

Number of references to treatment = zero.

Number of references to recovery = zero.

Low expectations?

These stories seemingly celebrate the expansion of these services.

When one considers the absence of any meaningful discussion of treatment, it’s hard for me to see these as as anything other than the “soft bigotry of low expectations.”

Of course, dead people don’t recover. That’s indisputably true. AND, severely ill people are very unlikely to recover without comprehensive treatment of adequate quality, intensity and duration.

What happens when we respond with compassion but without hope? What does that response do to the people suffering? What does it do to their loved ones? What effect does it have on the community?

We need to look beyond preventing death and look toward facilitating recovery by flooding these people with care of adequate quality, intensity and duration. In the context of this crisis, we need both/and approaches. As Scott Kellogg says, ” at some point you need to help build a life after you’ve saved one.”

About 10 years back, I proposed some organizing ideas for recovery oriented harm reduction.

I’ve been thinking about a model of recovery-oriented harm reduction that would address the historic failings of abstinence-oriented and harm reduction services. The idea is that it would provide recovery (for addicts only) as an organizing and unifying construct for treatment and harm reduction services. Admittedly, these judgments of the historic failings are my own and represent the perspective of a Midwestern U.S. recovery-oriented provider:

  • an emphasis on client choice–no coercion
  • all drug use is not addiction
  • addiction is an illness characterized by loss of control
  • for those with addiction, full recovery is the ideal outcome
  • the concept of recovery is inclusive — can include partial, serial, etc.
  • recovery is possible for any addict
  • all services should communicate hope for recovery–recognizing that hope-based interventions are essential for enhancing motivation to recover
  • incremental and radical change should be supported and affirmed
  • while incremental changes are validated and supported, they are not to be treated as an end-point
  • such a system would aggressively deal with countertransference–some people may impose their own recovery path on clients, others might enjoy vicarious nonconformity through clients
What would we do if patients were being revived by defibrillators and walking out of the emergency department a few hours later with a passive referral to treatment that has a long wait list?

This isn’t a matter of opposing life-saving measures, it’s a matter of expecting more. Just as we expect more than a defibrillator for people with cardiac disease. The defibrillator is life saving first aid, and we all expect that everyone whose life is saved by a defibrillator gets comprehensive cardiac care of adequate quality. intensity and duration.