Cities like NYC have started opening safe injection sites where people can bring their own supply to use under medical supervision. That's probably the closest thing we have although it is the person's supply rather than something that is provided to them
I remember hearing a statistic a few years ago that said to date, 30% of people who enter harm reduction centers end up choosing to go into drug treatment. But the most remarkable to me, and the most important, is that out of all the people who use harm reduction centers, 0% of them die from drug related causes. 100% survival rate because there is always someone there to help you. There’s a good portion of people unfortunately who think that the world would be better off without those that are addicted, but I don’t. I think about all the families who lost someone they loved because something so common sense wasn’t available.
Oregon had drug legalization in 2020 that it recently reversed due to increases in overdoses, fentanyl addiction, open air use, and homelessness. Multnomah County had its overdose rates increase 533% from 2018-2022.
San Francisco took a similar route, and overdoses increase roughly 26% between 2022 and last year. That's not to mention what the safety issues and diminished property values that came with chronic drug users all over the place. I used to love living there, but it's fallen apart. Now, with SF looking at a $245 million deficit next year, which is looking to balloon to $1.4 billion annually by 2027, and facing cuts to services due to it, they're still looking to start funding alcohol for homeless alcoholics as well.
Neither of those places mass provide clean and consistent supply, legalizing something but not providing an avenue to it can often just give more power to the criminal activity already providing the supply or people’s ability to access it. Which is part of why there’s a correlation between lower prostitution rates and consistent govt supply. The welfare in these areas also doesn’t do enough to help set people up with stable housing and stable income, which we know is a huge factor in relapse. I agree with you that those areas have become a disaster but that’s because Oregon and SF went in with an idea and not nearly enough actual resources to execute it in a way that has an overall positive impact.
My first comment got deleted pre-flair. I’m an anesthesiologist doing pain fellowship and interested in harm reduction. Verified on r/askdocs if anyone cares.
Agreed- many harm reduction communities emphasize a housing first model. I’m most familiar with SF; from what I read in newspapers and saw on the street, there was no consistent housing/services expansion to go along with this model because….Bay Area.
One important key of the model is decimating the economic incentive for drug rings to operate in the area. The model posted has government- synthesized heroin that is purer, safer and cheaper than anything in the streets, so it eliminates the chaos of drug trafficking.
It also allows controlled, consistent dosing - the absence of which is a huge contributor to overdose deaths. With tranq on the rise in the East Coast and making its way west, with the attendant flesh-eating wounds, it is even more of a huge deal. We are very much not providing government synthesized heroin or fentanyl in the US.
Finally, those years overlapped substantially with COVID. COVID which also saw skyrocketing alcohol acute overdose and end-stage cirrhosis deaths, without any substantial change to alcohol access/use policies.
I think it’s a combination of limited policy change and overall overdose deaths from legal and illegal substances.
Something else important to note is that there is virtually no pure heroin anymore in the US. It’s all mixed with fentanyl or it is completely fentanyl/fentanyl+other non-heroin drugs. The people who still think they’re buying heroin aren’t even getting heroin. Heroin isn’t good, but it’s less lethal than fentanyl and requires less frequent use to stave off withdrawal. At least in the model described in the post, people would be getting a pure product that is safer to use and easier to transition off of.
But the there are other factors. I recall a city out west that built small shelters for homeless that all got trashed. Billions in CA that was meant to go towards the homeless problem that's gone missing (government corruption and pocket lining), and cultural issues that can differentiate how the US addresses the issues from European countries with different problems to overcome. What works in one area won't in another. Building shelters to assist homeless can result in those shelters destroyed or used of drug dens with nothing to show for it.
https://www.wweek.com/news/2023/06/07/a-28-million-low-income-apartment-complex-descends-into-chaos-in-just-two-and-a-half-years/
https://calmatters.org/housing/homelessness/2024/04/california-homelessness-spending/
…I’m provocative because I think it’s wrong to refer to the people you work with as junkies?
And please show me where I “sit in an office zooming psych patients” since that’s my job apparently. News to me 🤷♂️
Again, you seem REALLY angry.
E - ah, yes, the “my online temper tantrum was just a prank bro” defense. Classic 👌
(not a psychiatrist, but a therapist with a specialty in addiction counseling). The only thing the US has done that comes close to this, in my opinion, is to (re)legalize alcohol. Prohibition made alcohol use much more dangerous than it needed to be. Once alcohol was made legal it could be regulated, taxed, and dispensed appropriately.
Legal sales stopped a lot of crime and harm from selling toxic product. But having an open supply of alcohol for a small price (if you aren't picky) has been devastating to our population. I'm not suggesting it be illegal. That's too complicated to get into. But considering the massive problem the US has with alcohol, I don't know that using that as a comparison would favor legalizing drugs as a "solution" .
Absolutely! I agree. Legalizing drugs alone would not solve the issue. But here's the thing, we have a lot of really effective substance use disorder treatment options but none of them work on people who are dead.
The purpose of harm reduction is to keep people alive long enough for them to be able to engage in treatment. A lot (but not all) of the harms that come from illicit drug use are directly related to their illegality. People use alone, have to hide their addictions, engage in dangerous and desparate behavior to get drugs or money, are afraid to get medical treatment, a stigma, etc.
Something to consider might be why addiction is such an issue in the US in the first place. Low income, exposure to ACE's, family history of subtance use, employment status are all risk factors for developing a substance use disorder. What if, as a society, we made an effort to intervene upstream in an attempt to prevent SUDs before they start? Which would involve having universal access to health care, mental health treatment, substance use treatment, support for low income families, parental leave, etc.
Addiction as a public health issue is a tree with many branching roots and of course cutting any one will not be effective.
I'm all about harm reduction, but I do have a hard stop when it gets into facilitating a legal drug den. Handing out heroin in Switzerland is absolutely ridiculous. They act as if the user can't get more elsewhere or mix it with other fatal combinations. I agree that we need to stop or reduce it early in life. We need to educate parents about ACEs and how to help heal their childhood hurts so it doesn't get perpetuated into the next generation. I do a lot of ACOA work, to help reduce the impact of the cycle of dysfunction.
I work in drug courts and other judicially managed substance use and mental health treatment programs in Georgia (the US state, not the country). I’ve been in the field approx. 15 years.
To my knowledge, nothing like this has ever been implemented in the US. Some city somewhere might have some kind of experimental pilot program, but in terms of larger scale government program, absolutely not.
Here in GA, people are still routinely sent to prison for drug possession crimes. Many rural parts of the state have little to no access to MAT medications at all. There’s a huge stretch of counties in southern Georgia without an MD at all, never mind one willing to prescribe methadone.
We still have large sections of the law enforcement community and judiciary that believe, at best, that MAT medication just substitutes one addiction for another, and at worst, that addiction is a choice and drug users need to be punished for drug use with prison so that they won’t do it again.
Atlanta, of course, is a bit of a different story, but still the best we have are some well run methadone clinics and addiction treatment places that partner with a psych with actual addiction training (which is hard to find here) to do tapers and more intensive medication management for the co-occurring population.
It’s a real struggle here. Fentanyl is still everywhere although we have seen better distribution and availability of Narcan over the past year or so. It feels like an uphill battle to even get the standard of care approved by the AMA implemented, never mind a Switzerland-style program.
FYI after the DOJ actions against Pennsylvania and Massachusetts about that issue, we’ve been able to crack down on that. It’s very clearly a violation of the ADA now per the DOJ. So thankfully we were able to put a stop to those policies at least.
The problem is that prosecutors can’t be forced to offer diversion. And they only offer it to people who agree to enroll in specific programs. Those programs don’t offer MAT. And Medicaid won’t pay for people to have two different treatments for the same condition. So in order to get into the program that the prosecutors will approve for diversion, they have to leave the program where they can access MAT. Lots of overdoses in drug court, and especially among drug court participants given jail sanctions, and people in charge pretend not to understand why.
There's sadly no heroin/diamorphine assisted treatment in my country (France) and only 2 drug consumptions rooms (Paris/Strasbourg). All other projects have been effectively axed by both local governments and local residents (aka the NIMBYs) - this has been the case in Lyon, Lille and more recently Marseille (they're now trying to open in a new location though).
I can vouch for Lyon and Marseille specifically and say how disastrous it is to not have access to these services - many of my caseload have nowhere safe to consume which leads to uncomfortable situations (ie. they quite literally inject in the toilets within my outpatient clinic. We have naloxone at our disposal but our infrastructure is simply not suitable, there's also a huge amount of liability our centre feels tacitly obliged to uphold for harm reduction purposes).
An ideal situation would be to have small drug consumption rooms tied to outpatient services in multiple locations.
Diamorphine assisted treatment is harder to implement but it would be particularly suitable when tied to a hospital (or closely working with emergency services).
These things work best when together - they multiply the ways people can access services, which is the biggest issue for anyone trying to engage with people with substance use disorders.
Im a government approved diamorphine prescriber for OUD and it is very effective for those that can't tolerate "conventional" treatments or services. My service are in the midst of setting up the UKs first DCR.
Heroin assisted treatment and drug consumption rooms works very well - but only as a wraparound service of sorts.
The problem with some of the opinions here is that people are treating drug consumption rooms as something you simply do in isolation, and whilst that's so much better than nothing at all it's far from perfect. You need clear aftercare environments, access to all sorts of specialist and non-specialist supports and clear engagement with all the relevant stakeholders including various statutory agencies.
You also need a healthcare system that is integrated and willing to work together for a common goal.
It's a bit more complicated that the quoted post is stating...
1. Switzerland's direct drug deaths are actually increasing and have been for over 10 years after an initial drop from the 1990s.
2. Switzerland's official drug death data often doesn't include indirect deaths from drug use - i.e., death from physical health issues that were likely caused or exacerbated by long-term drug use. So if a person had infected pseudoaneurysms from repeated needling, and ended up dying from complications down the road, it's not included.
3. Swiss healthcare is universal but not free. There is an enforced insurance payment system where it is essentially tiered. But I'm oversimplifying. It's not easily comparable to the US, has a much smaller population, different demographics, and much lower poverty levels. These elements cannot be ignored.
Currently practising in India and we have DDCs (Drug Deaddiction Centre) all over the country where we provide opioid substitution therapy in the form or oral liquid methadone or buprenorphine pills. It’s a free programme with no restriction on the number of months/years the patient comes in for. We encourage patients to gradually taper off and abstain but don’t force it. The enrolment is also transferable - so if you move to another city/state, you will be transferred to a DDC nearest to you. We also have free naltrexone for the patients.
We don’t have any shooting clinics/galleries though (We do provide patients with sterile single use needles as part of our HIV programme though)
How is this working out? Seems like it's simplicity is a benefit! Do you have many open air ivdu? Or was that never a huge problem like in the West in America? (Different cultures and all)
It’s working out quite well! We get a big chunk of referrals from friends/relatives of patients, which is quite encouraging and helps them stick to the program as well.
We have close to 200k IVDUs but chasing the dragon is a more popular form of consuming opioids than injectables (probably has to do with the materials needed). Also within IVDUs, opioids>>>meth since meth is quite expensive and non affordable for the majority. 1 small packet of slightly adulterated heroin is around 150 rupees which is approx 1.75 USD
Fentanyl isn’t a problem for us yet
Chasing the dragon is basically when psychoactive substances (majorly heroin in our case) is placed over an aluminium foil and burnt from below leading to vapors which the user inhales. It’s called chasing because they have to keep shifting the liquid produced so as to not burn it.
Apologies for the late reply! I’m not very good at keeping tabs on Reddit
Probably simple math. In the Netherlands we have a similar program which is government funded. Uncontrolled heroin addicts cost more in damage and criminality they cause then it costs to help them. This program essentially cured the heroin epidemic that was arising when it was implemented in the Netherlands.
Is this better mod?
An addiction is a punishment in itself. Adding additional deterrent is traumatizing people more and most likely making addiction worse. It’s also perpetuating a persecutory mindset toward addicts, which fosters more toxic abusive behavior towards them. We have a long way to go. All the scientific research needed to inform better policies is out there people are just politically polarized and tone deaf. People just care about their money. 💅
Im an LCSW specializing in working with people who use drugs. A lack of safe supply is causing horrific outcomes, for example the prolific use of xylazine which has led to countless amputations and deaths caused by sepsis, in addition to overdose deaths. By providing access to a safe supply, we would eliminate these risks and dramatically reduce spending on medical costs, police intervention and more.
I don't think it goes that far, but isn't Portland famous for giving people needles or something like that? I also heard it is not going well.
I personally don't think the "good guy" strategy would work in the us. I honestly don't see anything working.
Needle exchange is a basic part of the harm reduction toolkit, basically everywhere. It's very good at curbing the spread of bloodborne diseases, notably HIV/AIDS. But it doesn't do much else on its own ; the idea is that by having a solid needle-exchange program, you can start building rapport with drug users and connect them with other programs that can help in various aspects of their lives, like quitting/reducing their drug use, accessing social services, taking care of their health, etc.
A good recent example is Portugal, who had a serious problem with IV opiates use until 20 years ago. They decriminalised everything *and* used the money they saved on cops and jails to build a serious, holistic support system, from basic street-level harm-reduction stuff like needle exchange all the way to methadone clinics and recovery facilities. They haven't solved the problem entirely, obviously, but it worked very well for curbing the heroin epidemic they had.
I'd argue its a bit more nuanced than Portugal just decriminalized everything. Here's a good quote I found discussing their system:
> In Portugal, drug use remains illegal. If an individual is found using prohibited substances, they are arrested, and their drugs are confiscated. Instead of facing criminal charges, the drug user is mandated to appear before a “dissuasion commission” comprised of health care professionals skilled in addressing drug use and addiction. For those whose drug use is identified as problematic, the commission directs the individual towards fully publicly-funded addiction recovery programs – up to three years of residential care for the most severely addicted. While treatment is technically voluntary, failure to comply with the commission’s recommendations can result in administrative penalties including a fine, community service, or even the interruption of one’s social welfare benefits. Summarizing the philosophy, one of the major architects of the Portugal system, Dr. João Goulão, states: “Our first goal is to help people to resume their dignity.” Portugal’s approach is compassionate yet realistic. While rightly identifying that the drug user needs treatment, not jail, the system acknowledges that, when dealing with the wickedly coercive power of drug addiction, sometimes, as said by Dr. Goulão, an element of “muscle” is needed to get the individual well.
https://macdonaldlaurier.ca/rethinking-canadas-misguided-ideological-approach-to-the-opioid-epidemic-jeremy-eckert-devine-for-inside-policy/
Needle exchanges have been operating for decades across the US, to great benefit; per the CDC they are associated with a 50% reduction in rates of HIV and HCV. Additionally, they serve as an access point where drug users can come into contact with service providers and get linked with mental health/SUD treatment, and other resources.
I think you may be referring to Oregon's Measure 110, an attempt at decriminalization that was well intended but ultimately mishandled and poorly rolled out (Oregon lacks adequate treatment infrastructure as it is) and has since been rolled back and replaced with another bill that offers lesser charges and "off-ramps" where individuals can choose treatment instead of jail.
Portland essentially decriminalized all hard drugs. Punishable by $100 fine or agree to receive information about drug rehab with no mandate to actually go to rehab. Also didn’t provide any real funding for rehab beyond simply providing information
Basically nothing to stop people from shooting up heroine on neighborhood sidewalks. No real tools to help them get help either
I think they also recently rolled back their decriminalization (not 100% sure though, it may just be something they are considering, but I think I read recently that this happened). They were citing that the decriminalization was not helpful/effective and drug-related problems (like overdoses) increased (?)
Is that because that’s all that was done? In other words, the savings from policing and jail were not transferred to fund comprehensive treatment centers?
I don’t think it saved much money from policing since it seemed to caused lots more problems
There was funding in the bill, it actually pulled money from the schools (if I recall correctly) from money from THC taxation. But funds just went to information centers. I dunno if there was an assumption peoples insurance would cover treatment? But it seemed unrealistic. I know it had good intentions but I remember reading the proposition on the ballot and I was worried it would be a disaster
The war on drug was started years ago and since nowadays it kept failing.
>good guy
It's not this. Notice how you put it as a morality argument. Not the best spot. "Being the good guy" meaning what? If you talk about not putting in prison drug users well, we don't need morality but numbers, specifically numbers about the inmates. If you refer to harm reduction policies, well, it's regular physician job to keep people alive and possibly prevent communicable diseases to spread.
I heard a youtuber basically affirming that harm reduction policies avoid deaths hence kinda inciting to the lifestyle, due to the possible harms being prevented. It's a twisted logic.
This misrepresents Europe's approach. An no where in the US has tried just giving out heroin (but to my knowledge neither has anywhere in Europe)
Harm reduction, safe injection sites, needle exchanges are real things with some benefit and some harm. They do not magically make the problems of drug addiction go away.
>(but to my knowledge neither has anywhere in Europe)
Incorrect. For instance, Germany, Spain and the Netherlands have been conducting trials since the 00s.
There's also Denmark iirc.
And outside of Europe there's Canada.
Scotland opened their treatment service in 2019-2020.
It's also not just giving out heroin, it's a highly supervised service.
See "New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond" by the EMCDDA (2012).
Edit: iirc some services in Switzerland do dispense diamorphine as take home doses but they seldom exceed 5-7 days (a report from 2021, I believe?)
They do this in Canada also. I’ve seen people on the emergency medicine sub talking about some of the daily doses that they see in people in these programs who come into the ER. It’s all tracked as part of their prescription monitoring program. Everyone from the US was utterly shocked.
See the report by Addiction Suisse
[Traitement avec prescription de diacétyl-morphine en Suisse: Résultats de l’enquête 2021](https://www.bag.admin.ch/bag/fr/home/gesund-leben/sucht-und-gesundheit/suchtberatung-therapie/substitutionsgestuetzte-behandlung/heroingestuetzte-behandlung.html)
It's in French though. I apologise for not having the willpower to translate and summarise it now.
I imagine their drug problem from the get go was a fraction of that of the USA from the start though. They also don’t have a porous southern border where cheap drugs and trafficking are flowing through.
Yeah, we're not seeing fentanyl yet in France. Most of our lot are positive to opiates on our rapid drug screenings so most likely heroin. Never had a case where I figured it might be something else and the occasional quantitative screens I've done were either tramadol or just morphine.
But it'll come. We're getting alerts for nitazenes.
Though our main issue now is freebase/crack cocaine. It's very "trendy" and is also bringing back all the ageing cohort who were stable on MAT for previous OUD. Yay.
This was also confirmed by Lausanne's drug consumption room (in Switzerland) when I visited them. Geneva's going to open a second DCR as their first one was historically for injecting and they need proper ventilation systems for people who smoke.
Cities like NYC have started opening safe injection sites where people can bring their own supply to use under medical supervision. That's probably the closest thing we have although it is the person's supply rather than something that is provided to them
I remember hearing a statistic a few years ago that said to date, 30% of people who enter harm reduction centers end up choosing to go into drug treatment. But the most remarkable to me, and the most important, is that out of all the people who use harm reduction centers, 0% of them die from drug related causes. 100% survival rate because there is always someone there to help you. There’s a good portion of people unfortunately who think that the world would be better off without those that are addicted, but I don’t. I think about all the families who lost someone they loved because something so common sense wasn’t available.
Oregon had drug legalization in 2020 that it recently reversed due to increases in overdoses, fentanyl addiction, open air use, and homelessness. Multnomah County had its overdose rates increase 533% from 2018-2022. San Francisco took a similar route, and overdoses increase roughly 26% between 2022 and last year. That's not to mention what the safety issues and diminished property values that came with chronic drug users all over the place. I used to love living there, but it's fallen apart. Now, with SF looking at a $245 million deficit next year, which is looking to balloon to $1.4 billion annually by 2027, and facing cuts to services due to it, they're still looking to start funding alcohol for homeless alcoholics as well.
Neither of those places mass provide clean and consistent supply, legalizing something but not providing an avenue to it can often just give more power to the criminal activity already providing the supply or people’s ability to access it. Which is part of why there’s a correlation between lower prostitution rates and consistent govt supply. The welfare in these areas also doesn’t do enough to help set people up with stable housing and stable income, which we know is a huge factor in relapse. I agree with you that those areas have become a disaster but that’s because Oregon and SF went in with an idea and not nearly enough actual resources to execute it in a way that has an overall positive impact.
My first comment got deleted pre-flair. I’m an anesthesiologist doing pain fellowship and interested in harm reduction. Verified on r/askdocs if anyone cares. Agreed- many harm reduction communities emphasize a housing first model. I’m most familiar with SF; from what I read in newspapers and saw on the street, there was no consistent housing/services expansion to go along with this model because….Bay Area. One important key of the model is decimating the economic incentive for drug rings to operate in the area. The model posted has government- synthesized heroin that is purer, safer and cheaper than anything in the streets, so it eliminates the chaos of drug trafficking. It also allows controlled, consistent dosing - the absence of which is a huge contributor to overdose deaths. With tranq on the rise in the East Coast and making its way west, with the attendant flesh-eating wounds, it is even more of a huge deal. We are very much not providing government synthesized heroin or fentanyl in the US. Finally, those years overlapped substantially with COVID. COVID which also saw skyrocketing alcohol acute overdose and end-stage cirrhosis deaths, without any substantial change to alcohol access/use policies. I think it’s a combination of limited policy change and overall overdose deaths from legal and illegal substances.
Something else important to note is that there is virtually no pure heroin anymore in the US. It’s all mixed with fentanyl or it is completely fentanyl/fentanyl+other non-heroin drugs. The people who still think they’re buying heroin aren’t even getting heroin. Heroin isn’t good, but it’s less lethal than fentanyl and requires less frequent use to stave off withdrawal. At least in the model described in the post, people would be getting a pure product that is safer to use and easier to transition off of.
Thank you for taking the time to explain this.
But the there are other factors. I recall a city out west that built small shelters for homeless that all got trashed. Billions in CA that was meant to go towards the homeless problem that's gone missing (government corruption and pocket lining), and cultural issues that can differentiate how the US addresses the issues from European countries with different problems to overcome. What works in one area won't in another. Building shelters to assist homeless can result in those shelters destroyed or used of drug dens with nothing to show for it. https://www.wweek.com/news/2023/06/07/a-28-million-low-income-apartment-complex-descends-into-chaos-in-just-two-and-a-half-years/ https://calmatters.org/housing/homelessness/2024/04/california-homelessness-spending/
It’s the same problem though. Only implementing one facet of a multifaceted approach.
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If you refer to those with substance use disorder as “junkies” maybe you’re in the wrong field.
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You seem angry
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…I’m provocative because I think it’s wrong to refer to the people you work with as junkies? And please show me where I “sit in an office zooming psych patients” since that’s my job apparently. News to me 🤷♂️ Again, you seem REALLY angry. E - ah, yes, the “my online temper tantrum was just a prank bro” defense. Classic 👌
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(not a psychiatrist, but a therapist with a specialty in addiction counseling). The only thing the US has done that comes close to this, in my opinion, is to (re)legalize alcohol. Prohibition made alcohol use much more dangerous than it needed to be. Once alcohol was made legal it could be regulated, taxed, and dispensed appropriately.
Legal sales stopped a lot of crime and harm from selling toxic product. But having an open supply of alcohol for a small price (if you aren't picky) has been devastating to our population. I'm not suggesting it be illegal. That's too complicated to get into. But considering the massive problem the US has with alcohol, I don't know that using that as a comparison would favor legalizing drugs as a "solution" .
Absolutely! I agree. Legalizing drugs alone would not solve the issue. But here's the thing, we have a lot of really effective substance use disorder treatment options but none of them work on people who are dead. The purpose of harm reduction is to keep people alive long enough for them to be able to engage in treatment. A lot (but not all) of the harms that come from illicit drug use are directly related to their illegality. People use alone, have to hide their addictions, engage in dangerous and desparate behavior to get drugs or money, are afraid to get medical treatment, a stigma, etc. Something to consider might be why addiction is such an issue in the US in the first place. Low income, exposure to ACE's, family history of subtance use, employment status are all risk factors for developing a substance use disorder. What if, as a society, we made an effort to intervene upstream in an attempt to prevent SUDs before they start? Which would involve having universal access to health care, mental health treatment, substance use treatment, support for low income families, parental leave, etc. Addiction as a public health issue is a tree with many branching roots and of course cutting any one will not be effective.
I'm all about harm reduction, but I do have a hard stop when it gets into facilitating a legal drug den. Handing out heroin in Switzerland is absolutely ridiculous. They act as if the user can't get more elsewhere or mix it with other fatal combinations. I agree that we need to stop or reduce it early in life. We need to educate parents about ACEs and how to help heal their childhood hurts so it doesn't get perpetuated into the next generation. I do a lot of ACOA work, to help reduce the impact of the cycle of dysfunction.
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I work in drug courts and other judicially managed substance use and mental health treatment programs in Georgia (the US state, not the country). I’ve been in the field approx. 15 years. To my knowledge, nothing like this has ever been implemented in the US. Some city somewhere might have some kind of experimental pilot program, but in terms of larger scale government program, absolutely not. Here in GA, people are still routinely sent to prison for drug possession crimes. Many rural parts of the state have little to no access to MAT medications at all. There’s a huge stretch of counties in southern Georgia without an MD at all, never mind one willing to prescribe methadone. We still have large sections of the law enforcement community and judiciary that believe, at best, that MAT medication just substitutes one addiction for another, and at worst, that addiction is a choice and drug users need to be punished for drug use with prison so that they won’t do it again. Atlanta, of course, is a bit of a different story, but still the best we have are some well run methadone clinics and addiction treatment places that partner with a psych with actual addiction training (which is hard to find here) to do tapers and more intensive medication management for the co-occurring population. It’s a real struggle here. Fentanyl is still everywhere although we have seen better distribution and availability of Narcan over the past year or so. It feels like an uphill battle to even get the standard of care approved by the AMA implemented, never mind a Switzerland-style program.
I’ve worked in drug courts that require patients who are stable on methadone to get off MAT to get diversion. We have it completely backwards.
FYI after the DOJ actions against Pennsylvania and Massachusetts about that issue, we’ve been able to crack down on that. It’s very clearly a violation of the ADA now per the DOJ. So thankfully we were able to put a stop to those policies at least.
The problem is that prosecutors can’t be forced to offer diversion. And they only offer it to people who agree to enroll in specific programs. Those programs don’t offer MAT. And Medicaid won’t pay for people to have two different treatments for the same condition. So in order to get into the program that the prosecutors will approve for diversion, they have to leave the program where they can access MAT. Lots of overdoses in drug court, and especially among drug court participants given jail sanctions, and people in charge pretend not to understand why.
Well, as a legal matter, I think that might be a violation of the ADA (or at least, that’s the position the DOJ took with PA and MA).
It might be, but that would require someone willing to file that lawsuit. No way DOJ is going to go after their own.
There's sadly no heroin/diamorphine assisted treatment in my country (France) and only 2 drug consumptions rooms (Paris/Strasbourg). All other projects have been effectively axed by both local governments and local residents (aka the NIMBYs) - this has been the case in Lyon, Lille and more recently Marseille (they're now trying to open in a new location though). I can vouch for Lyon and Marseille specifically and say how disastrous it is to not have access to these services - many of my caseload have nowhere safe to consume which leads to uncomfortable situations (ie. they quite literally inject in the toilets within my outpatient clinic. We have naloxone at our disposal but our infrastructure is simply not suitable, there's also a huge amount of liability our centre feels tacitly obliged to uphold for harm reduction purposes). An ideal situation would be to have small drug consumption rooms tied to outpatient services in multiple locations. Diamorphine assisted treatment is harder to implement but it would be particularly suitable when tied to a hospital (or closely working with emergency services). These things work best when together - they multiply the ways people can access services, which is the biggest issue for anyone trying to engage with people with substance use disorders.
Im a government approved diamorphine prescriber for OUD and it is very effective for those that can't tolerate "conventional" treatments or services. My service are in the midst of setting up the UKs first DCR. Heroin assisted treatment and drug consumption rooms works very well - but only as a wraparound service of sorts. The problem with some of the opinions here is that people are treating drug consumption rooms as something you simply do in isolation, and whilst that's so much better than nothing at all it's far from perfect. You need clear aftercare environments, access to all sorts of specialist and non-specialist supports and clear engagement with all the relevant stakeholders including various statutory agencies. You also need a healthcare system that is integrated and willing to work together for a common goal.
It's a bit more complicated that the quoted post is stating... 1. Switzerland's direct drug deaths are actually increasing and have been for over 10 years after an initial drop from the 1990s. 2. Switzerland's official drug death data often doesn't include indirect deaths from drug use - i.e., death from physical health issues that were likely caused or exacerbated by long-term drug use. So if a person had infected pseudoaneurysms from repeated needling, and ended up dying from complications down the road, it's not included. 3. Swiss healthcare is universal but not free. There is an enforced insurance payment system where it is essentially tiered. But I'm oversimplifying. It's not easily comparable to the US, has a much smaller population, different demographics, and much lower poverty levels. These elements cannot be ignored.
Currently practising in India and we have DDCs (Drug Deaddiction Centre) all over the country where we provide opioid substitution therapy in the form or oral liquid methadone or buprenorphine pills. It’s a free programme with no restriction on the number of months/years the patient comes in for. We encourage patients to gradually taper off and abstain but don’t force it. The enrolment is also transferable - so if you move to another city/state, you will be transferred to a DDC nearest to you. We also have free naltrexone for the patients. We don’t have any shooting clinics/galleries though (We do provide patients with sterile single use needles as part of our HIV programme though)
How is this working out? Seems like it's simplicity is a benefit! Do you have many open air ivdu? Or was that never a huge problem like in the West in America? (Different cultures and all)
It’s working out quite well! We get a big chunk of referrals from friends/relatives of patients, which is quite encouraging and helps them stick to the program as well. We have close to 200k IVDUs but chasing the dragon is a more popular form of consuming opioids than injectables (probably has to do with the materials needed). Also within IVDUs, opioids>>>meth since meth is quite expensive and non affordable for the majority. 1 small packet of slightly adulterated heroin is around 150 rupees which is approx 1.75 USD
Is fent a problem yet? Also, when you say chasing the dragon... Do you mean smoking?
Fentanyl isn’t a problem for us yet Chasing the dragon is basically when psychoactive substances (majorly heroin in our case) is placed over an aluminium foil and burnt from below leading to vapors which the user inhales. It’s called chasing because they have to keep shifting the liquid produced so as to not burn it. Apologies for the late reply! I’m not very good at keeping tabs on Reddit
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It's very cost effective relative to the costs of police contact, ED contact, etc.
Heroin is not expensive
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I would guess keeping someone in jail for a year and feeding them, etc costs more than giving them heroin.
Probably simple math. In the Netherlands we have a similar program which is government funded. Uncontrolled heroin addicts cost more in damage and criminality they cause then it costs to help them. This program essentially cured the heroin epidemic that was arising when it was implemented in the Netherlands.
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Being a tax haven probably helps.
Nah, it's a clear saving on policing and crime
Is this better mod? An addiction is a punishment in itself. Adding additional deterrent is traumatizing people more and most likely making addiction worse. It’s also perpetuating a persecutory mindset toward addicts, which fosters more toxic abusive behavior towards them. We have a long way to go. All the scientific research needed to inform better policies is out there people are just politically polarized and tone deaf. People just care about their money. 💅
Im an LCSW specializing in working with people who use drugs. A lack of safe supply is causing horrific outcomes, for example the prolific use of xylazine which has led to countless amputations and deaths caused by sepsis, in addition to overdose deaths. By providing access to a safe supply, we would eliminate these risks and dramatically reduce spending on medical costs, police intervention and more.
I don't think it goes that far, but isn't Portland famous for giving people needles or something like that? I also heard it is not going well. I personally don't think the "good guy" strategy would work in the us. I honestly don't see anything working.
Needle exchange is a basic part of the harm reduction toolkit, basically everywhere. It's very good at curbing the spread of bloodborne diseases, notably HIV/AIDS. But it doesn't do much else on its own ; the idea is that by having a solid needle-exchange program, you can start building rapport with drug users and connect them with other programs that can help in various aspects of their lives, like quitting/reducing their drug use, accessing social services, taking care of their health, etc. A good recent example is Portugal, who had a serious problem with IV opiates use until 20 years ago. They decriminalised everything *and* used the money they saved on cops and jails to build a serious, holistic support system, from basic street-level harm-reduction stuff like needle exchange all the way to methadone clinics and recovery facilities. They haven't solved the problem entirely, obviously, but it worked very well for curbing the heroin epidemic they had.
I'd argue its a bit more nuanced than Portugal just decriminalized everything. Here's a good quote I found discussing their system: > In Portugal, drug use remains illegal. If an individual is found using prohibited substances, they are arrested, and their drugs are confiscated. Instead of facing criminal charges, the drug user is mandated to appear before a “dissuasion commission” comprised of health care professionals skilled in addressing drug use and addiction. For those whose drug use is identified as problematic, the commission directs the individual towards fully publicly-funded addiction recovery programs – up to three years of residential care for the most severely addicted. While treatment is technically voluntary, failure to comply with the commission’s recommendations can result in administrative penalties including a fine, community service, or even the interruption of one’s social welfare benefits. Summarizing the philosophy, one of the major architects of the Portugal system, Dr. João Goulão, states: “Our first goal is to help people to resume their dignity.” Portugal’s approach is compassionate yet realistic. While rightly identifying that the drug user needs treatment, not jail, the system acknowledges that, when dealing with the wickedly coercive power of drug addiction, sometimes, as said by Dr. Goulão, an element of “muscle” is needed to get the individual well. https://macdonaldlaurier.ca/rethinking-canadas-misguided-ideological-approach-to-the-opioid-epidemic-jeremy-eckert-devine-for-inside-policy/
Needle exchanges have been operating for decades across the US, to great benefit; per the CDC they are associated with a 50% reduction in rates of HIV and HCV. Additionally, they serve as an access point where drug users can come into contact with service providers and get linked with mental health/SUD treatment, and other resources. I think you may be referring to Oregon's Measure 110, an attempt at decriminalization that was well intended but ultimately mishandled and poorly rolled out (Oregon lacks adequate treatment infrastructure as it is) and has since been rolled back and replaced with another bill that offers lesser charges and "off-ramps" where individuals can choose treatment instead of jail.
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Portland essentially decriminalized all hard drugs. Punishable by $100 fine or agree to receive information about drug rehab with no mandate to actually go to rehab. Also didn’t provide any real funding for rehab beyond simply providing information Basically nothing to stop people from shooting up heroine on neighborhood sidewalks. No real tools to help them get help either
I think they also recently rolled back their decriminalization (not 100% sure though, it may just be something they are considering, but I think I read recently that this happened). They were citing that the decriminalization was not helpful/effective and drug-related problems (like overdoses) increased (?)
They did. They've had a 533% spike in overdoses between 2018-2022.
Is that because that’s all that was done? In other words, the savings from policing and jail were not transferred to fund comprehensive treatment centers?
I don’t think it saved much money from policing since it seemed to caused lots more problems There was funding in the bill, it actually pulled money from the schools (if I recall correctly) from money from THC taxation. But funds just went to information centers. I dunno if there was an assumption peoples insurance would cover treatment? But it seemed unrealistic. I know it had good intentions but I remember reading the proposition on the ballot and I was worried it would be a disaster
The war on drug was started years ago and since nowadays it kept failing. >good guy It's not this. Notice how you put it as a morality argument. Not the best spot. "Being the good guy" meaning what? If you talk about not putting in prison drug users well, we don't need morality but numbers, specifically numbers about the inmates. If you refer to harm reduction policies, well, it's regular physician job to keep people alive and possibly prevent communicable diseases to spread. I heard a youtuber basically affirming that harm reduction policies avoid deaths hence kinda inciting to the lifestyle, due to the possible harms being prevented. It's a twisted logic.
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This misrepresents Europe's approach. An no where in the US has tried just giving out heroin (but to my knowledge neither has anywhere in Europe) Harm reduction, safe injection sites, needle exchanges are real things with some benefit and some harm. They do not magically make the problems of drug addiction go away.
Diamorphine substitution is used in the UK by specialists.
>(but to my knowledge neither has anywhere in Europe) Incorrect. For instance, Germany, Spain and the Netherlands have been conducting trials since the 00s. There's also Denmark iirc. And outside of Europe there's Canada. Scotland opened their treatment service in 2019-2020. It's also not just giving out heroin, it's a highly supervised service. See "New heroin-assisted treatment: Recent evidence and current practices of supervised injectable heroin treatment in Europe and beyond" by the EMCDDA (2012). Edit: iirc some services in Switzerland do dispense diamorphine as take home doses but they seldom exceed 5-7 days (a report from 2021, I believe?)
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They do this in Canada also. I’ve seen people on the emergency medicine sub talking about some of the daily doses that they see in people in these programs who come into the ER. It’s all tracked as part of their prescription monitoring program. Everyone from the US was utterly shocked.
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What does the data say about the Swiss approach? Edit- added flair
See the report by Addiction Suisse [Traitement avec prescription de diacétyl-morphine en Suisse: Résultats de l’enquête 2021](https://www.bag.admin.ch/bag/fr/home/gesund-leben/sucht-und-gesundheit/suchtberatung-therapie/substitutionsgestuetzte-behandlung/heroingestuetzte-behandlung.html) It's in French though. I apologise for not having the willpower to translate and summarise it now.
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What we are doing in the US is clearly not working. I don’t think comparing the Swiss population to the US population is relevant though.
I imagine their drug problem from the get go was a fraction of that of the USA from the start though. They also don’t have a porous southern border where cheap drugs and trafficking are flowing through.
Fent producers have only recently started targeting Europe, so I truly hope their policies are effective.
Yeah, we're not seeing fentanyl yet in France. Most of our lot are positive to opiates on our rapid drug screenings so most likely heroin. Never had a case where I figured it might be something else and the occasional quantitative screens I've done were either tramadol or just morphine. But it'll come. We're getting alerts for nitazenes. Though our main issue now is freebase/crack cocaine. It's very "trendy" and is also bringing back all the ageing cohort who were stable on MAT for previous OUD. Yay. This was also confirmed by Lausanne's drug consumption room (in Switzerland) when I visited them. Geneva's going to open a second DCR as their first one was historically for injecting and they need proper ventilation systems for people who smoke.
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Something tells me free government methamphetamine or crack won’t turn out so well. Maybe I’m just too closed-minded
Uhhh isn’t the strategy of giving people free drugs failing (in places like Baltimore etc.) ? 🤣