In many areas of public health and medicine, best practices are routinely adopted without much resistance. Sure, there is always some reluctance to switch from what’s always been done to what science tells us provides the best outcomes. But normally these snafus can be chalked up to the force of habit rather than any deep-seated aversion to the new practice. For instance, I’m pretty sure my physician grandfather continued to use Mercurochrome on his own minor cuts and abrasions—not because he was morally opposed to rubbing alcohol, but because that’s just the way he had always done it.
Unfortunately, when it comes to drug-user health, opposition to many best practices like syringe service programs or safe consumption sites can’t be traced back to something as benign as habit and routine. I know, because at one time I personally harbored the kind of instinctive opposition to best practice that holds back progress.
This also holds at a political level. Stigma, not science, is what has maintained Congress’s partial ban on providing funding for syringes and cookers at syringe service programs. Stigma is also the driving force behind the Trump administration Department of Justice’s decision to file an action to prevent Safehouse, a proposed safe consumption site in Philadelphia, from opening its doors to drug users in need.
Much like arguments about access to abortion and healthcare for transgender people, the debate around drug user health is stuck in that unenviable space—with one side supporting its argument with science and the other countering with arguments based on their conceptions of morality and tradition.
Earlier this month, the organization I work for, AIDS United, joined 11 other national medical and public health organizations in signing on to an amicus brief in support of Safehouse, which is currently embroiled in a legal battle for its very existence. The brief, which was coordinated in large part by the Drug Policy Alliance, laid out in great detail why safe consumption sites (SCS) are an evidence-based response to the US overdose crisis.
From the perspective of evidence-based, scientific inquiry, there is no debate to be had about the efficacy of SCS.
Luckily, since there are already 120 legally sanctioned SCS around the world, there is a mountain of evidence for the efficacy of these programs from a public health perspective. SCS have been found to significantly reduce overdose deaths, prevent the spread of infectious diseases like HIV, and increase access to substance use disorder treatment and other healthcare services. At the same time, studies have shown that SCS actually reduce both the number of publicly discarded syringes and the frequency with which people inject in public.
From the perspective of evidence-based, scientific inquiry, there is no debate to be had about the efficacy of SCS. They work—and we know they work because hundreds of peer-reviewed studies and the lived experiences of hundreds of thousands of people who use drugs tell us so.
In a sane and rational environment, this robust body of evidence would automatically have dissuaded the federal government from trying to stop Safehouse. Sadly, we do not live in such a place. The US government has not based its opposition on public health best practices. In fact, at no point in its complaint does the federal government—in this case the US District Court for the Eastern District of Pennsylvania—even mention the health of people who use drugs in Philadelphia. Instead it simply states that Safehouse would violate a subsection of the Controlled Substances Act informally known as the “crack house” statute, which makes it illegal to “knowingly open, lease, rent, use, or maintain any place … for the purpose of … using any controlled substance.”
I won’t get into a back-and-forth about the legality of Safehouse and other SCS, or the proper interpretation of this particular portion of the Controlled Substances Act. There are plenty of folks out there who are much better equipped to make the argument for Safehouse’s legality.
I am all too familiar with the mental gymnastics and cognitive dissonance that accompany being presented with the efficacy of SCS.
I’m trying instead to speak to anyone who is still skeptical of SCS out of a fear that they might enable drug use, or from that nagging feeling that SCS are antithetical to the traditional notion of recovery from substance use disorders.
I know these fears and feelings because I’ve experienced them myself.
As someone who found sobriety through an abstinence-based, in-patient treatment center, and who has been fortunate enough to find community and purpose at times in my life through the fellowship of 12-step groups, I am all too familiar with the mental gymnastics and cognitive dissonance that accompany being presented with the efficacy of SCS.
After internalizing the disease model of addiction and seeing an abstinence-based approach work in my own life, I had a hard time conceptualizing “going back out” or continuing to use as anything other than an irreversible descent into an ever-worsening addiction leading to “jails, institutions or death.”
Having being told over and over that half measures avail us nothing, I initially looked at these harm reduction-based interventions as just that.
It was only after I sat with my own discomfort at the notion of SCS—after I read studies and heard personal accounts of their transformative capacity in the lives of people who inject drugs—that I realized the true half measure would be to adopt an overdose prevention strategy that didn’t incorporate best practices, just because they made some people feel uncomfortable.
Total abstinence is still viewed by many in the recovery community as the only desirable outcome for someone who uses drugs, and if that’s your truth you can abide by it. But know that you can’t get sober if you’re dead. And at a time when over 68,000 people died of overdose in the US last year, creating safe consumption sites—facilities where there has not been a single recorded overdose death in the last three decades—just makes sense.