“Safe Sites” And The Addict’s Ecosystem

The number of drug addicts in the USA is on the rise, and opioid overdoses are killing Americans at rate where policy must adapt.

Adapt, because our attempt to incarcerate our way out of this problem has resulted in what is the greatest jailing of people in the history of the Western World, and the problem is still outrunning us. Notions of successful authoritarian solutions to this problem are belied by rampant drug addiction in Iran and Russia. We can’t incarcerate our way out of this, surely, if they can’t.

A promising adaptation is New York City emulating a world-wide experiment in establishing Safe Injection Sites for addicts to use their drugs. “Safe,” meaning if they overdose and begin to die, they will be noticed and treated.

There is plenty of devil to be conjured in the details: if the police have an arrest quota, will there be a reliable “ceasefire” around the safe site? Druggie culture will kill the Safe Site idea just on rumors of it being a lazy cop salt lick.The Safe Site program, along with all of its clinicians ready to guide the addicts into treatment, will then stand expensively idle, their quarry flown back to the invisibility of the status quo (until they are seen again in the obituaries). Will the Safe Site neighborhoods put up with the lolling horde? The NYC Chief of Detectives visited a Safe Site in Vancouver and came away disgusted by the drug dealing, and the seedy look of it (take it from me, death looks worse. I know of little kids sobbing over their dead ma’s corpse). The Bronx Assistant District Attorney in charge of prosecuting drug offenses has come right out and said there is no legal basis for doing this, a change in the law is needed, given that we are a rule of law nation. Can we trust in the functionality of our lawmakers for this? OK, I admit, that’s over-egging the pudding. How ruinous will the lawyer’s lucre be when, not if, one of the “Disciples of the Molecule” falls “on the nod” and breaks his boney ass? And most importantly: the dreamy disciples are not known for their ability to process consequences. This is true almost by definition: a person who daily shoots mysterious powders of dubious dosage provided by a murderous criminal class must have distorted notions of risk. How this broken risk-tabulator in their heads will get them to take their dose, burning a hole in their pocket, body on fire for want of it, from where they buy it, to the Safe Site is a big if.

The important point is to see the many ways this program can fail, its innovation written off, the deadly status quo returned. The libertarian point is to scratch, again, the broken record pointing out that freedom equals options: we are bound up with laws, and it should surprise nobody that we are short of legal options when we need to adapt. Laws are a bad way of solving problems, and should only be used, like war, as a last resort. America could have come to this point, like Portugal has, decades ago if we had just asked our doctors and addiction specialists for a solution, rather than our law-makers and law-enforcers. Police telling clinicians how to handle clinical problems sounds like the definition of a Police State on its face.

This body of medical knowledge knows Methadone and Suboxone work in mitigating the harm of opioid addiction. The breathing room away from harm can bring recovery and life functionality. A lot of the disciples might then work, pay their taxes, build their lives. The idea is called MAD, Medically Assisted Treatment.

We could take another step and move to a treatment model that works even better, which is HAT, Heroin Assisted Treatment. The drug addicts’ ecosystem explains HAT’s success: heroin/opioid addiction ain’t cheap: Their habit-money alone would put them right in the middle class. We see a drug addict walking around, and we should gather that an ecosystem exists that keeps him drug fed. Common sense would dictate most are not working steady jobs and paying taxes. Although I have been consistently surprised, given the “Man with the Golden Arm” dope-fiend stereotypes I’ve been weaned on, how many dope addicts are perfectly functional, 9-5 workaday people.

Many addicts are on the dole, from the State or their family. Many are on disability, many “deservedly” so (libertarian objections aside). They are psychologically disabled by the damage, ironically, caused by their incarceration. I’ve never encountered a drug addict who was not a terribly damaged person, and the damage of the addiction and (almost always) their time in jail is straining the weak foundation of a person broken (almost always) as a child.

Some drug addicts are petty criminals, but crime statistics show little rise in the face of rising addiction, so the thieving junkie seems an obsolete idea of their behaviors.

A great many female drug addicts become prostitutes. Medical ethics would identify this as a vector for disease. Problems with prostitutes proliferate, and places with legalized prostitution find it necessary to medically screen them once a month for various diseases. Ask yourself if it’s likely these diseases are staved off somehow when the whores are underground, unexamined, unseen. Community health services sees them one way or the other, and we taxpayers are paying. It’s the same concept as with addicts: they don’t disappear if you don’t (won’t) see them. Pay more, or pay less, is the only question with all of these issues of personal dysfunction, once you realize the state’s dilemma: moral hazard or overpolicing (the countries that more successfully meet this challenge accept more of the moral hazard side of the equation).

But the real ecosystem for so many drug addicts is in their drug dealing, which is to say their making of other drug addicts (four on average). And the exponential loop gets in a lot of addicts, as exponential math rules do. Junkie to the Fourth power. HAT makes it possible to attack this power law. Give the stone junkies their drugs supervised, and the law becomes exponential in the negative. The stone junkies are managed, they die less, they are less likely to damage themselves expensively, and the more casual users (only about 1/4 of opioid users become addicted) might be deterred by the scarcity. Crucially, drug habits will be kept supervised, rather than being let loose in the wild, where youngsters, who are at the greatest risk of developing addiction, might be exposed.

Incidentally, this ecosystem largely explains the spike in overdoses: prescription opioid pain medication use has spiked, and that “problem” was defined as “bad” by the legal system. Medically, the issue is more complex, since the “badness”of addiction is relative to the clinical value in having people’s pain treated successfully treated. Whatever the denominator or sum of that debate, no clinician would agree that a sudden crackdown on supply will do anything other than set large numbers of addicts, who were legal the night before, to have to suddenly access the illegal, more unstable, more dangerous drug markets, the night after they suddenly are cut off. This resulted in a bonanza for the drug dealing underworld, run mainly by the Mexican drug cartels, the most lethal crime entities the world has known. There are more drugs because of the exponential laws of there being more drugs.

I predict an expensive flop of the Safe Site program (is there any other kind in NYC?). And it won’t flop from poor results keeping the disciples alive, since we know that’s worked well, always, all over the world. The flop will be self-inflicted from all of our “normal” political failings. American policy for the last generation has been as a straight train on rails (laid by the perception of unlimited money), never with any substantive deviations: from the war on drugs, to education, to energy, to mental health care, to terrorism and Afghanistan and beyond. The failure later will likely mirror the failure today and yesterday, and the day before. I’ve seen this problem kill people my whole career long.

The reformers can be driven off by any one of the aforementioned catches: of the law, of the mind, of ugliness, of empathy. The program could be toppled by the weight of its own top-down mandatory grandiosity: why mandate special facilities and staff when we have armies of community clinicians and small clinics everywhere around the city? Can the “specialness” of all this just be medicine and be left to the grass roots medical people? The grandiosity is a feature of the system, not a bug: why else do we find Mayor de Blasio’s giant head all over the news when we have world class academies of substance abuse specialists (but nobody is really asking them, remember)? This decentralized clinic approach would mitigate the threat of junkie armies descending on communities, as the addicts could subtly slip into these places one by one. Unsaid in all of this is the “NIMBY-ism.” typical of New York City, in that all of the solutions to problems we agonize over is the elites foisting the burden on the politically weak, happy to lead in volunteering to fix the issue so long as it’s someone else being volunteered to do the fixing.

Ultimately this program will probably make a cudgel some other politician will use to beat the Mayor. Amazing (blog post for another day) that this cudgel is so powerful in a city that so loudly trumpets its progressivism.