Are safe heroin injection sites really safe?

By Stacy Nguyen
Northwest Asian Weekly

“It’s just the whole idea of having a so-called safe injection site [for heroin] doesn’t make sense to me,” said Bellevue resident Kan Qiu. “I’m a first generation immigrant from China. It’s ingrained in our culture, that we don’t touch drugs. In China, we have a vivid history of the Opium Wars. [They] made China weak. The whole nation was weak. That was because the drug was legal and readily available. That was a recipe to destroy Asia.

Heroin abuse should focus on treatment, rather than on a facility for [drug users]. It’s addiction. Addiction is like — if you provide the facility, the addiction will go on. And also, it causes a bunch of additional social problems like [increased] crime rates, drug dealing. You know, drug dealers would love a magnet of a consumption site because they would know where to sell the drug. They’d just camp outside the facility. [This is] the wrong message to send to our next generation. Totally wrong approach.”

On March 1, 2016, King County Executive Dow Constantine, Seattle Mayor Ed Murray, Renton Mayor Denis Law, and Auburn Mayor Nancy Backus announced that they put together a task force of experts, the Heroin and Prescription Opiate Addiction Task Force, to recommend immediate actions needed to confront the growing heroin and prescription opiate epidemic.

According to King County, more people in the county enter into detox for heroin than they do alcohol. 2014 saw 156 heroin-related deaths, the highest in 20 years. The County website states that substance abuse is one of the root causes of homelessness. Drug overdose is the leading cause of death among people who are homeless.

Additionally, treatment for addiction in King County has not kept up with the increase in heroin and prescription opiate addiction — about 150 people seeking treatment are on a waitlist each day, and many end up receiving treatment in expensive settings like hospitals and jails.

The Heroin and Prescription Opiate Addiction Task Force comprises about 40 stakeholders, which include medical providers, members of law enforcement, educators, legal experts, and active heroin/opioid users, and met over a period of six months (March–September 2016). The task force submitted a report of recommendations to be implemented and rolled out in 2017.

The recommendations are three-tiered, broken up into primary prevention (building public awareness, implementing secure medicine return, implementing earlier intervention and better screening practices in middle and high schools), treatment (implementing on-demand treatment, increasing medication-assisted treatment, removing barriers to treatment), and health services (using naloxone to reverse active overdoses, establishing two pilot Community Health Engagement Locations [CHELs]).

It’s the very last component of these recommendations that have stirred up substantial controversy. CHELs are also known as supervised injection sites, safe injection sites, or drug consumption facilities — sites where heroin users can safely come in to inject the drug with clean needles. The site does not supply heroin and will work in conjunction with local law enforcement. The King County CHELs would be the firsts in the United States, though Insite in Vancouver, Canada was the first legal supervised drug injection site in North America, founded in 2003.

Bothell City Councilmember Joshua Freed filed Initiative 27, an ordinance that would prohibit local governments and other organizations from establishing drug consumption sites in King County and prevent the public financing of these sites. In order for the initiative to be on the November ballot, 55,000 signatures (that is, 10 percent of total votes cast for King County Executive in the last election) need to be collected in support of the initiative by July 31.

This goal will likely be met. As of the end of June, more than 42,000 signatures have been collected.

“We’re well on our way,” said Freed. “We have overwhelming support [for I-27], but the government in Seattle seems to be really disconnected from the population that elected them. We want to focus on treatment as well as stopping the prescription drugs that lead addicts to heroin … That’s the heart of this matter.”

According to the University of Washington’s Alcohol and Drug Abuse Institute, 57 percent of people who currently use heroin were previously dependent on prescription opioids.

The racial divide of heroin

“In our [Asian] society, we rely on personal accountability,” Qiu said. “Each individual needs to be accountable to our own choices. Everyday you make your choices, and there are consequences for that. By removing accountability, you destroy the value [of our community].”

Figures related to heroin deaths in the Asian and Asian American population are actually too small to calculate percentage increase, according to the Centers for Disease Control (CDC). However, it should be noted that heroin deaths have increased within the white population the most in between 2010 and 2014 (at 267 percent), according to the CDC. (The Black population saw a 213 percent increase in the same time period, Latino population 137 percent, Native population 236 percent.)

In 2015, the Atlantic ran a feature comparing and contrasting public response to the current heroin epidemic versus previous drug epidemics (such as the 1980s crack cocaine epidemic and the 1960s heroin epidemic, both viewed as within Black populations) titled, “How White Users Made Heroin a Public-Health Problem.” The feature pointed out that when the user population is perceived as primarily people of color, the response is to demonize and punish. When the user population is perceived as white, the tendency is oriented toward treatment.

Vancouver’s current opioid epidemic, the scope of which unfortunately eclipses that of King County, has roots in its Chinatown. According to The Province, Vancouver opium entrepreneur Yip Sang had at least 13 factories in 1888. Natural opium is secreted from poppies and contain many alkaloids, of which codeine and morphine are most used. When some of the opium alkaloids undergo a chemical reaction to make a drug more powerful and faster acting, the result is heroin, which changes to morphine when it goes into the body.

Opium was a revenue source for the government at the time and brought in hundreds of thousands of dollars to British Columbia ports between 1874 and 1899. It was reported that the clientele for opium became increasingly white, nearly half.

However, by 1908, under a tide of growing anti-Chinese sentiment and pressure from the United States, Canada passed the Opiate Act, which outlawed the possession and importation of opium. Law enforcement at the time targeted Chinese, who were jailed, fined, and often deported, according to the Province.

A 2015 study from the Proceedings of the National Academy of Sciences in the United States of America, “Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites,” found that the racial and class demographics surrounding the current heroin epidemic may be attributed to the fact that doctors have historically under-prescribed prescription pain medications to Black people, believing them to be biologically more pain-tolerant. This is an unsubstantiated belief. The study did not find the same racial/ethnic bias regarding pain with Latinos, but still found evidence that Latino patients were prescribed medication less often than white patients, both for physical and mental ailments.

On its website, the county task force stated that it considered equity and social justice in its recommendations, using the county’s racial impact statement framework.

“The task force will not seek to advance recommendations that can be expected to widen racial or ethnic disparities in health, healthcare, other services and support, income, or justice system involvement,” stated the website.

Fighting to keep injection sites away

Qiu is a small business owner and father to three boys, ages 6, 15, and 19, and he is one of the most active volunteers for I-27, gathering signatures to meet that 55,000 goal — particularly from Eastside residents of Asian descent.

Keith Schipper, campaign manager for Safe King County, the engine behind I-27, told the Northwest Asian Weekly in an email in early June that nearly 40 percent of petition requesters on their website are from Korean and Chinese communities.

“Asians particularly care about the next generation,” said Qiu. “[For instance,] they [will] spend a lot of money sending kids to piano lessons. Asians heavily invest in the next generation [in terms of] education. The last thing we want [our kids to be affected by is] drugs. We don’t want to send the wrong message to the kids. From our perception, the moment you touch high potency drugs — it’s basically like, there are [going to be] consequences. [And] by providing injection sites, you are giving people this false impression of fewer consequences. And that’s a problem.”

A case for CHELs

Twelve years ago on New Year’s Day, 2005, Gregg Finegood died of a heroin overdose. He was a college graduate with a good career. His father called Gregg’s only sibling, Brad, to tell him the news. At the time, Brad was already several years deep in his career in the addiction field.

“I can say from my own personal experience that when I first found out about [CHELs], I also said, ‘Heck no,’ ” said Brad Finegood. “I had a brother who died of a drug overdose, [so] why would I do something that would encourage someone’s use? [But then,] the more I learned about [CHELs], the more I learned that this is not at all encouraging people to use. This is about people who are using, and who are using in a very vulnerable way — and that vulnerable way can lead to their death. But there can be an alternative, and that alternative is just, ‘Hey, come indoors so you’re not vulnerable.’”

Finegood is assistant division director and a prevention and treatment coordinator for mental health, chemical abuse and dependency services at King County’s department of community and human services. He is also co-chair of the Heroin and Prescription Opiate Addiction Task Force.

Finegood says that CHELs will actually clean up public spaces and reduce healthcare costs away from already over-extended emergency rooms. He said that worldwide, there are hundreds of CHELs and there has never been an overdose death in any facility.

“People will stop using in the park and going in the public restrooms. Businesses do not have to deal with overdose in the bathroom. They do not have to deal with needles. Baristas do not have to be first responders. So [CHELs] basically takes people, brings them to a facility so that my kid or anyone else’s kid do not have to stumble upon an overdose in public.”

“I know that there are people who are opposed to this (CHELs) [because of addiction experiences with] family members,” Finegood added. “At the time, I might not have wanted my brother to go to a facility like that. But now that I think about it, any facility that would keep him alive — I would want that. And this is part of the reason I feel really mission-driven. Every person out there who dies is someone’s kid, someone’s brother, someone’s friend — someone that someone else cares about. We have to do anything we can do to keep people alive enough to engage them in treatment.”

While Freed is against CHELs, he is in support of the kind of treatment that the county task force did propose as part of its list of recommendations.

“Our goal is that people aren’t dying from this,” said Freed. “From my research, we see [medication-assisted treatment] as effective, so buprenorphine would take away the mental desire for the drug. [We need] more than just a methadone clinic that gives you a pill a day or two a day. We need people to get into cognitive behavioral therapy. … We need to get them into treatment. If we truly have the goal of helping people, we need programs that will help them do that.”

The county task force recommended medication-assisted treatment (MAT) that includes opioid treatment programs, which combine cognitive behavioral therapy and medications to treat substance use disorders.

According to the Substance Abuse and Mental Health Services Administration, MAT treatment improves patient survival, increases retention in treatment, decreases illicit opiate use, and more.

The task force also recommended a “buprenorphine first” model of care. Buprenorphine is a partial opioid agonist — partially negating the effects of opioids. According to the National Alliance of Advocates for Buprenorphine Treatment, buprenorphine treatment may suppress symptoms of opioid withdrawal, decrease cravings, reduce illicit use, and help patients stay in treatment.

According to Finegood and the task force, CHELs would be an extension of existing services as well as a component of a holistic, comprehensive approach to confronting the heroin epidemic. Finegood points out that CHELs are only a small portion of the entire whole, and they are only tailored to a very small group of people — those who are currently causing a lot of harm to themselves and aren’t yet ready for treatment.

“We want treatment for everyone,” said Finegood. “The problem is not everyone is willing to access treatment [at a given moment]. That small portion of people that do not want to access treatment — it’s really important that we keep them alive. Because eventually, they will want to get better.”

“There’s a lot of attention being directed toward safe-consumption facilities,” said Dr. Maria Yang, medical director of King County’s behavioral health and recovery division and also staff psychiatrist at King County Correctional Facility. “I want to highlight that so much more energy and resources are being put toward prevention and treatment. And most communities we talk to — who’s going to disagree with prevention?”

Cultural stigma

Yang earned her undergraduate and medical degree at the University of California, Los Angeles and Davis School of Medicine, respectively. She did her psychiatry residency at the University of Washington School of Medicine and two fellowships at New York University School of Medicine and Columbia University College of Physicians and Surgeons.

“Psychiatry as it’s practiced in the U.S. is a very Western phenomenon. … I think there has been conflict between that and Eastern ideals. I’m the daughter of [Chinese] immigrant parents. I’m very familiar with the idea of, ‘There’s no such thing [as mental illness]. You’re just being weak. Maybe we need to instill more discipline in you.’ I have family members with — they weren’t using drugs, but they became very ill and impaired. It’s not fair for these people in our culture to suffer in silence, and also to not have a resource to go to, one that can’t speak to them in their language.”

“[Asians and Asian Americans] comprise a relatively small minority in the country and even in this state,” said Yang. “How many people (Asians, Asian Americans) are even using IV (intravenous) drugs — it’s hard to collect this data. Some of it has to do with small numbers, and some of it has to do with cultural shame. The answer is that we don’t know how many people in Asian communities are using substances — heroin or otherwise. [However,] because we don’t have information, people assume that we are not using.”

According to the CDC, one in five teens experiment with prescription drugs. According to Partnership for Drug-Free Kids, 95 percent of parents believe their child has never taken a prescription drug for a reason other than its intended use. “Ultimately though … how unfair is it that, just because you came from a Chinese background, if you happen to become a user, you become exiled from your community?” said Yang.

“There’s an assumption that people who choose to go [to CHELs] don’t feel shame or a lack of dignity — but for someone to go there, you have to face all the looks from people,” Yang added. “No one wants to do that. They want to live the life they deserve to live. People who have substance abuse issues can’t lead the life they live because their substance use stands in the way of that. This (CHELs) is just an option to help engage those individuals to move along the path again to treatment. Most of our energy is going toward prevention and treatment.”

For more information about I-27 or to download a petition, visit safekingcounty.org. For more information about the county task force, visit goo.gl/dKTMPm.

Stacy Nguyen can be reached at stacy@nwasianweekly.com.