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How to Solve the Opioid Epidemic: Teach Users to Inject More Safely

Safe injection sites provide a radical harm reduction approach to ending the opioid overdose crisis by educating and empowering drug users.

Celine Gounder

Image via Wikimedia Commons

This is an opinion piece by Dr. Celine Gounder, an epidemiologist, storyteller, and one of People Magazine’s 25 Women Changing the World .

Last week, Philadelphia became the second city in the United States to legalize safe injection sites, proving that some lawmakers are willing to entertain radical options to address the opioid overdose crisis ravaging this country. In the battle against opioid overdoses-- which claimed more Americans lives last year than the Vietnam War-- we should all be listening to the veterans who’ve made it out alive -- veterans like freelance harm reduction consultant Tino Fuentes.

After spending years of his life as a heroin user and dealer, Fuentes now hits the streets with drug testing kits and an open heart. His primary goal is not to get people to stop using drugs, but rather to prevent immediate harm to a user, break deadly patterns of use and act as a trusted resource for people struggling with drug addiction.

Though some may view Fuentes’ approach as a half measure, it saves people’s lives at a time when life expectancy in the United States has dropped for two years in a row--largely due to the precipitous increase in deaths from opioid overdoses. “Everybody’s life has value, right?” Tino asked me during a recent episode of my podcast In Sickness and In Health . “Nobody should die because they use drugs. That’s what I use the strips for. And I’ll continue to do it until I can’t no more. My commitment to this is really strong.”

Though some may view Fuentes’ approach as a half measure, it saves people’s lives at a time when life expectancy in the United States has dropped for two years in a row.

Fuentes is on to something many Americans aren’t aware of. Despite what mainstream coverage would have you believe, at least half of opioid overdose deaths are from illicitly manufactured fentanyl--not prescription painkillers or heroin. This detail matters because our strategies to prevent opioid overdose deaths won’t work if they’re targeted at the wrong problem. But before we start talking about solutions, it’s important to look at the stages of the opioid crisis that got us here in the first place.


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It all started with the pain pill epidemic, with the overprescribing and abuse of prescription opioids. As doctors became more wary and new regulations restricted the prescription of opioids, the supply of pain pills diverted to the black market shrank, so they became more expensive on the street. Many users who’d become dependent on opioids switched to cheaper, more readily available heroin.

Despite efforts to reduce the supply--such as spraying poppy plants, seizing drugs and arresting traffickers--the heroin supply in the U.S. grew, keeping prices at a historic low. But like any consumer, drug users are looking for most quickly attainable, most cost-effective product--and drug dealers take advantage accordingly. Our failure to recognize drug users as shoppers looking for the best deal--just like the rest of us--is part of the reason that cheap, potent fentanyl is on the rise and driving a big spike in deaths.

As the death toll from opioids continues to climb, we must ask ourselves: what can we do now to start saving lives?

Because fentanyl and other cheap analogue drugs are far more potent than heroin, you don’t need as much to get high or, more importantly, to die from an overdose. Because fentanyl has a much smaller footprint, it makes it easier for dealers to evade detection by law enforcement. Dealers can also boost their profits by adding fentanyl to weak batches of heroin and using it to make counterfeit prescription pain pills. Meanwhile, users have no idea what they’re really taking--and the results are lethal.

As the death toll from opioids continues to climb, we must ask ourselves: what can we do now to start saving lives? While there’s no panacea for the opioid overdose crisis, there are concrete steps we can take--and that starts with helping drug users consume more safely.

It’s no surprise that countries like the Netherlands and Portugal--which have embraced strategies to not only reduce drug supply and demand, but also reduce harm--have some of the lowest rates of drug overdose deaths in the world.

The American opioid overdose epidemic is unprecedented. If we want to save lives, if we think these lives matter, we’ll need to open ourselves to novel, even radical, solutions.

In the 1990s, the Dutch government set up a Drugs Information Monitoring System (DIMS), where drug users can anonymously submit their drugs for testing and find out whether they contain fentanyl or other deadly substances. This information gives users the opportunity to adjust their behavior accordingly. DIMS also functions as a monitoring system, issuing national media warnings when especially lethal substances are detected, and shares some of its data with law enforcement agencies--not to prosecute individual users and low-level dealers, but to locate the source of new or deadly drugs.

Tino Fuentes is a lot scrappier. As a freelance harm reduction worker, he doesn’t get caught up in red tape. Fuentes buys test strips--originally intended for use by health care providers to check urine for fentanyl--for about a dollar each, and uses them to see if fentanyl or other analogues are present in a user’s drugs. After he tests a batch, Fuentes talks to the user about how to inject drugs more safely: use with a buddy so that someone is available to administer naloxone, call 911 and give mouth-to-mouth if the other person starts to overdose.

The American opioid overdose epidemic is unprecedented. If we want to save lives, if we think these lives matter, we’ll need to open ourselves to novel, even radical, solutions. We’ve got to start by arming users with the information and tools they need to protect themselves. A good place to start is by donating to Tino Fuentes’ GoFundMe Campaign or the Harm Reduction Coalition. Free your mind, think big and act.