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America’s opioid problem has turned into a full-blown emergency now that illicit fentanyl and related synthetic drugs are turning up regularly on our streets. This fentanyl, made in China and trafficked through Mexico, is 25 to 50 times as potent as heroin. One derivation, carfentanil, is a tranquilizer for large animals that’s a staggering 1,000 to 5,000 times as powerful.
Adding synthetic opioids to heroin is a cheap way to make it stronger—and more deadly. A user can die with the needle still in his arm, the syringe partly full. Traffickers also press these drugs into pills that they sell as OxyContin and Xanax. Most victims of synthetic opioids don’t even realize what they are taking. But they are driving the soaring rate of overdose—a total of 33,091 deaths in 2015, according to the Centers for Disease Control and Prevention.
Hence the ascendance of a philosophy known as “harm reduction,” which puts first the goal of reducing opioid-related death and disease. Cutting drug use can come second, but only if the user desires it. As an addiction psychiatrist, I believe that harm reduction and outreach to addicts have a necessary place in addressing the opioid crisis. But as such policies proliferate—including some that used to be inconceivable, such as providing facilities where drug users can safely inject—Americans shouldn’t lose sight of the virtues of coerced treatment and accountability.
What does harm reduction look like? One example is Maryland’s Overdose Survivor Outreach Program. After an overdose survivor arrives in the emergency room, he is paired with a “recovery coach,” a specially trained former addict. Coaches try to link patients to treatment centers. Generally this means counseling along with one of three options: methadone; another opioid replacement called buprenorphine, which is less dangerous if taken in excess; or an opioid blocker called naltrexone. Overdose survivors who don’t want treatment are given naloxone, a fast-acting opioid antidote. Coaches also stay in touch after patients leave the ER, helping with court obligations and social services.
Similar programs operate across the country. In Chillicothe, Ohio, police try to connect addicts to treatment by visiting the home of each person in the county who overdoses. In Gloucester, Mass., heroin users can walk into the police station, hand over their drugs, and walk into treatment within hours, without arrest or charges. It’s called the Angel Program. Macomb County, Mich., has something similar called Hope Not Handcuffs.
Another idea gaining traction is to provide “safe consumption sites,” hygienic booths where people can inject their own drugs in the presence of nurses who can administer oxygen and naloxone if needed. No one who goes to a safe consumption site is forced into treatment to quit using, since the priority is reducing risk.
In Canada, staffers at Vancouver’s consumption site urge patrons to go into treatment, but they also distribute clean needles to reduce the spread of viruses such as HIV and hepatitis C. Naloxone kits are on hand in case of overdose. One study found that opening the site has reduced overdose deaths in the area, and more than one analysis showed reduced injection in places like public bathrooms, where someone can overdose undiscovered and die.
There are no consumption sites in the U.S., but in January the board of health in King County, Wash., endorsed the creation of two in the Seattle area. A bill in the California Assembly would allow cities to establish safe consumption sites. Politicians, physicians and public-health officials have called for them in Baltimore; Boston; Burlington, Vt.; Ithaca, N.Y.; New York City; Philadelphia and San Francisco. Drug-war-weary police officers and harm reductionists would rather see addicts opt for treatment and lasting recovery, but they’ll settle for fewer deaths.
When all else fails, handcuffs can help, too. A problem with treatment is that addicts often stay with the program only for brief periods. Dropout rates within 24 weeks of admission can run above 50%, according to the National Institute on Drug Abuse. Courts can provide unique leverage. Many drug users are involved in addiction-related crime such as shoplifting, prescription forgery and burglary. Shielding them from the criminal-justice system often is not in society’s best interests—or theirs.
Drug courts, for example, keep offender-patients in treatment through immediately delivered sanctions (e.g., a night in jail) and incentives (e.g., looser supervision). Upon successful completion of a 12- to 18-month program, many courts erase the criminal record. This seems to work. The National Association of Drug Court Professionals reports that 75% of drug court graduates nationwide “remain arrest-free at least two years after leaving the program.”
What’s more, if the carrot-and-stick method used by drug courts is scrupulously applied, treatment may not always be necessary. This approach, called “swift, certain and fair,” has been successful with methamphetamine addicts in Hawaii and alcoholics in South Dakota. Some courts in Massachusetts and New Hampshire have now adopted it with opioid addicts. I predict that the combination of anti-addiction medication plus “swift, certain, and fair” will be especially effective.
With synthetic drugs similar to fentanyl turbocharging the opioid problem, the immediate focus should be on keeping people safe and alive. But for those revived by antidotes and still in a spiral of self-destruction, the criminal-justice system may be the ultimate therapeutic safety net.
Dr. Satel is a psychiatrist specializing in addiction and a resident scholar at the American Enterprise Institute.
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