Why Can’t Addicts Just Quit?

In some cities, heroin addicts have access to treatment, but many are still using. Now, Seattle is poised to open a safe-injection facility for those who just can’t stop. So why can’t they?

Author: Olgha Kazan
Posted on: The Atlantic| November 13th, 2017

SEATTLE—Mere blocks from the tourists swarming Pike Place Market, Stacy Lenny pointed out the tradecraft of some of her drug-dealing clients: “There’s Todd with a wheelchair—that’s good camo for a drug hustle,” she said, nodding toward one man sitting on the corner and dealing crack out of his motorized scooter. “Missy has a lot of drugs in that bag,” she said, about another woman passing by.
A 50-year-old mom with short, gray hair and bright-blue glasses, Lenny is a harm-reduction recovery specialist with a program called REACH. The job involves driving around Seattle finding homeless drug users, befriending them, and trying to help them with their health and housing problems.
Lenny and I drove south of the city together, down roads lined with RVs and strewn with trash. Seattle has lately been strained by both rising homelessness and heroin addiction. Last year, a record 359 people died in Seattle from drug overdoses. The majority of them involved opioids—heroin or prescription painkillers.
Working with the city’s most economically fragile addicts has made Lenny skeptical about the typical rhetoric about addiction—that it is a moral failing, that it is a choice, that users all want treatment, that addicts should be funneled swiftly into rehab. At rehab, they might be required to “admit to being a ‘junkie,’ or you detox and might die, or turn your life over to God,” she said.
That works for some people, but others spin through treatment and end up right back on the streets or using again. So instead of telling addicts what they need or where they should go, Lenny listens to what addicts tell her they need.
Eventually Lenny pulled her car over on a dirt patch surrounded by a chain-link fence. The fence was adorned with ribbons in the shape of a heart, along with a hand-drawn sign: Camp Second Chance. Alongside rows of tents and makeshift tiny houses for the homeless, there was a TV tent, a library, and a kitchen stocked with coffee cups and Cinnamon Toast Crunch. The camp doesn’t allow drugs or alcohol on the premises—the homeless people who live here decided to outlaw drugs, one resident explained to me, in an effort to avoid the awful violence that happens in non-sober homeless camps, like one nearby called “The Jungle.”
At the center of Camp Second Chance, I met Tammy Stephen, who lives in one of the few dozen domed tents that are lined up on pallets. She was sharply attired in a black dress and Uggs-style boots, and she had a similarly dignified perspective on her living situation: “We’re not homeless, we’re houseless,” she said. “This is our home.”
Our conversation turned to one of the hottest topics in Seattle, one so controversial that everyone—including an Uber driver and a Canadian border guard—offered up his own, unsolicited take when I revealed what I was there to report. Seattle is poised to become the first city in America to open up a so-called safe-injection site—a place where addicts can inject heroin openly under the watchful eyes of nurses, who could then rescue them in the case of an overdose by using the opioid antagonist* naloxone. Even in ultraliberal Seattle, where marijuana is legal and pottery shops advertise being part of the “Resistance,” the idea seems, to many, a little too much like enabling.
“We need to stigmatize the people hooked on heroin who refuse to go into treatment, to save their lives,” Washington State Senator Mark Miloscia, an opponent of the safe-injection facilities, told Al Jazeera. “We need to push people into treatment, with cultural values and cultural pressure.”
To Stephen, though, safe-consumption sites are “the best thing in the world.” If they had existed when her 27-year-old daughter, Emily Hays, was still using heroin a few years ago, “she would have had somewhere other than a Subway bathroom” to shoot up, Stephen told me. Hays overdosed several times before getting clean, and some of her friends died from overdoses.
Stephen had nagged the girl to enter treatment, saying: “Why won’t you quit? Why don’t you stop?”
“I don’t want to feel,” she remembered her daughter saying.
“Tough love didn’t work on my daughter,” Stephen told me.
The early September meeting of the King County Council, which encompasses Seattle and some of its suburbs, was packed. The pro-safe-injection side held signs that read, “Someone will overdose and die tomorrow.” Between the pro- and anti- camps, 41 people had signed up to speak, so each tried to cram a heartfelt personal story or impassioned plea into about a minute of floor time.
A young-looking dad whose 19-year-old daughter died from a heroin overdose defended the facilities as lifesaving. “If you’re dead, you can’t receive treatment,” he said.
n opponent brought up property crime, the argument being that safe-injection sites will draw criminals: “We’re not even addressing that!”
Toward the end, things took a loopy turn, as one man parodied the arguments of the anti-safe-injection crowd. “You should ban airbags and seatbelts because they encourage people to drive in a more dangerous way,” he said. “I don’t have evidence. You don’t need it anymore—our president has made this clear by rolling back DACA!”
Last year, a task force composed of advocates, law enforcement, and public-health experts came up with a list of recommendations for curbing Seattle’s opioid-abuse problems. Some of the ideas were standard: “Promote safe storage and disposal of medications.” Some were more contemporary: “Expand distribution of naloxone in King County.” But only one sparked months of litigation and acrimony: “Establish, on a pilot-program basis, at least two Community Health Engagement Locations where supervised consumption occurs for adults with substance-use disorders in the Seattle and King County region.”
Clif Curry, the King County Council’s chief legislative analyst, compared the sites to a controversial housing facility that opened in Seattle 10 years ago to deal with a population of street drunks, many of whom had cycled in and out of rehabs for decades. These chronic alcoholics had become a public nuisance—urinating and vomiting on the sidewalks—and they were costing millions in emergency-room bills and jail stays. The county placed 75 of them in a government-subsidized apartment building where they could drink as much as they wanted. They didn’t even have to promise to quit.
“Services were available to them there, but they didn’t have to make use of them,” Curry explained. Critics at the time included a local conservative radio host who derided the arrangement as “bunks for drunks” and “aiding and abetting someone’s self-destruction.” But, Curry said, “the research showed … that one out of five sought treatment on their own, even though they were allowed to continue to drink themselves to death.” And even among those who didn’t seek help, “they weren’t dying anymore,” he said. Plus, “there are no chronic inebriates on the street anymore.”
Seattle’s safe-injection facility for opioid users would be the first such site in the United States. Other American cities are considering similar programs, and an unsanctioned, invitation-only site has been operating at an undisclosed location in the United States for several years.
But despite the city’s success with the chronic-alcoholic population, pushback on safe-injection sites has been relentless. Some of the outrage comes from unexpected sources. One of the women who spoke at the meeting, for example, was Amy, a local real-estate agent who didn’t want me to use her last name because she was afraid of scaring away clients. She came of age in the punk Seattle of the 1980s, doing heroin with her friends. Many of those friends have since died of overdoses, but to Amy, the deaths were expected. “That’s what happens,” she told me.
Still, she opposes the safe-injection sites. “My concern is that … when we say, ‘We’re going to make this easy, we’re going to make this safe,’ we are subtly saying, ‘This is okay,’” she said. “There is some value in things being horrible.”
Five King County cities around Seattle swiftly moved to ban the safe-consumption sites. In four, the vote to do so was unanimous. Joshua Freed, a city councilman from the nearby city of Bothell, and others introduced a ballot measure that would ban the sites throughout the county. A group of public-health experts and advocates, as well as the city of Seattle itself, sued to block the initiative, arguing that voters are not qualified to weigh public-health measures. On October 16, a judge did block the initiative, but Freed is appealing the decision. If the Bothell councilman is successful, then the King County Council plans to draw up its own initiative calling for the creation of two safe-injection sites—an initiative that would be on the ballot alongside Freed’s anti-safe-consumption measure, according to The Seattle Times.
After the county-council meeting, I sat down to coffee with Freed and Jalair Box, a resident and an opponent of the safe-consumption sites. They argue that these facilities would catch only a tiny fraction of all the users who inject drugs in Seattle on a given day. Worse, they said, it is tantamount to legalizing heroin.
Most of all, Box fears that the sites won’t do enough to help addicts get into treatment. She is upset by the possibility of a person “walking into a drug-consumption site and deciding, ‘I’m done, I want out, I want treatment,’ and the person behind the counter saying, ‘I’m sorry, we don’t have treatment for you today, but here’s your booth.’”
“That sends chills through me,” she said.
This is a common fear among opponents of these so-called harm-reduction approaches. Lawrence County in southern Indiana, for example, recently discontinued its needle-exchange program over similar concerns. “Few, if any, of the health-care professionals that I personally spoke with believe that the needle-exchange program was an effective way of getting people into treatment programs,” Lawrence County Council Member Rodney Fish told NBC News.
King County officials told me that, in addition to safe-use sites, they are working to expand overall access to the full slate of drug-treatment services “on demand.” Currently, the city offers opioid addicts the heroin-withdrawal medications methadone or buprenorphine, or residential treatment, within a couple of days to a week.
To Freed and Box, that’s not enough. “We don’t have enough resources allocated to treatment,” Freed said. “Why not spend [the safe-injection money] on treatment? That’s our heart. What are we doing enabling people to use heroin and legalizing it and, truly, making it more accessible?”
Freed also worries that the sites would become magnets for crime. I told them I planned to visit Insite, a Vancouver, Canada, safe-injection site that has been operating since 2003, the following day. Freed, who has taken several trips to Insite’s neighborhood, detailed some of the shady characters he had met there: people shooting up on the street; a woman, angered because Freed’s companion took her picture, who began stabbing a wall with a knife; women selling themselves for a hit; a “gentleman” with tattoos all over his face.
Freed urged me not to go alone. “I wouldn’t let my wife go up there by herself,” he said. “It’s a very dark place, and I get concerned about a single gal like you going up by yourself.”
I wouldn’t, in the end, get to go inside Insite. They’d had too much media interest of late, and they declined to let yet another reporter stomp around inside what is, after all, a health-care facility. I decided I’d still check out the neighborhood later that afternoon. But first, I drove to Surrey, a city southeast of Vancouver with a population of about a half-million. There, administrators of a safe-injection site, SafePoint, which opened this past June, had agreed to give me a predawn tour of the premises.
SafePoint looks like a run-of-the-mill trailer. It abuts a tent city rife with drug use, but some of its 800 clients have homes and families. Sex workers come and use before they go out for the night. Some people come and then return to their recovery homes. Once inside, addicts provide a moniker for anonymity and take clean needles or any other supplies they need. In the supply area, there’s even a bin marked “flavored condoms for oral sex.”
I asked Fraser Mackay, who manages the site, if it was all free.
“We’re universal health care,” he said, in the same tone Daddy Warbucks might have used to explain to Little Orphan Annie that she no longer had to mop the floors. “These citizens are entitled to the health-care needs they have.”
Inside, users sat at one of seven booths, and they snorted or injected their drugs as they normally would. Most SafePoint clients are on heroin or meth, but their goods are usually laced with the much deadlier fentanyl. They aren’t allowed to pass the drugs between the booths or to help each other inject. There’s a clinic next door where clients can get treatment for the sores and other medical problems that often accompany long-term drug use, or start on methadone. If a person overdoses, as happens two or three times per day, SafePoint staffers tip their chair back and administer naloxone to revive them.
They’ve had no deaths so far, and they don’t harangue people to get into treatment. The staff are “very engaging, very friendly, very accessible,” Mackay said, but “we can’t be badgering people that are not ready. When we have little windows of opening, we use those.”
“So if they’re like, ‘Man, I wish I could quit’ …” I said, probing for an example of a “window.”
“The staff would be all over that,” he said. He would send them to a detox facility or outpatient clinic where they could start to get clean right away.
I asked how many people had gone into treatment through SafePoint so far. “Not many,” he said. “I’d say a handful.” (Later, Victoria Lee, the chief medical officer for Fraser Health Authority, the health organization that runs SafePoint, estimated that about 10 percent of SafePoint users enter treatment.)

A pale, middle-aged man staggered out of the trailer, having just used heroin. He would only give his name as Glen. He has been coming to SafePoint since it opened, and he likes the feeling of comfort and safety it provides.
I asked him if the SafePoint staffers ever pressure him to get into treatment, or if he felt like they should.
“That just pushes people away,” he said. Besides, he had already been to treatment, and he liked it because “I learned a lot about myself.” But he started using again anyway.
I ducked out of the rain under the awning of a nearby building. There, I met Karen Scott, a 55-year-old former user who is now clean. Soon she is going to start as a peer counselor at SafePoint.

I explained that I am from the United States, where safe-consumption sites are controversial because they appear to divert attention away from getting addicts into treatment.
“You can’t force someone into treatment,” she said. “If they’re not willing to do it for themselves, they aren’t going to end up staying.”
“Why would someone not be ready?” I asked.
“People are in addiction not because they want to be but because they’ve had some trauma in their lives,” Scott said. “Every time that trauma feeling starts coming up, they want to stuff it back down so they don’t have to feel that pain. Some people think the trauma is so bad that they won’t be able to deal with it [without drugs].”
Scott herself got clean at one point and, then relapsed because, “I never worked on the trauma that got me into addiction in the first place,” she said. With the help of mindful meditation, she made peace with her abusive past. Now, she’s able to resist temptation so much that she lives in an apartment just a block away from SafePoint, in the heart of Surrey’s drug zone.
This seemed to be a common theme among the active and recovered addicts I met in Canada and elsewhere: Though some do start using for fun or on a lark, for most, inner turmoil underpinned their substance use.
As Lenny, the outreach worker in Seattle, put it to me, after people quit, “they have to start dealing with their feelings, their problems. And treatment doesn’t really help with that.”
From Surrey, I drove to Insite in Vancouver and hung out on the sidewalk in front of the building for a few hours. While it was not quite the parade of horrors Freed had promised, it also did not seem like the picture of happy harm reduction. Next to a guy selling cellphone chargers on a folding table, one man shot heroin on the sidewalk, while another walked by and asked me for “jim”—local slang for speed. While I was there, there was some sort of commotion on the corner, and the police quickly cordoned off the area. The word on the street was that someone got stabbed.
Defenders of safe-consumption sites say the Vancouver neighborhood was already like this, even before Insite came on the scene. It’s a low-income area whose climate—temperate, by Canadian standards—makes it appealing for homeless people.
Studies of Insite have found that it has helped to reduce overdose deaths, and other research has shown that safe-injection sites in general don’t raise crime rates or lead to more drug trafficking. One study noted that use of Insite “has also been associated with increased uptake of detoxification services.” (Box, the safe-injection-site opponent in Seattle, disputed these studies as biased, and she says places like Insite don’t track long-term treatment outcomes well.)
The Insite clients I spoke with—most of whom would only give their first names or monikers because heroin remains illegal—were not belligerent. They seemed grateful.

One 22-year-old, fresh off using meth at Insite, said she has been in treatment several times. “I never said I don’t want to go back,” she said. But, “I’m not ready to deal with real life.”
A 21-year-old with a devil-horn headband and scars on her arms said she likes Insite because “it’s a safe place so you don’t get busted by the cops.” She said she had “emotional issues, attachment issues” that keep her from going to treatment. Heroin, she said, “makes everything disappear.” Insite doesn’t pressure her to go into treatment. “They’re not really there to tell you to do this, tell you to do that,” she said. “When I’m ready, I’ll know I’m ready.”
When I told her we don’t have safe-consumption sites in the United States, she seemed puzzled. “Where do they get their rigs from?” she said, asking about the clean packs of needles and cookers that places like Insite provide.
A few blocks away from Insite is the Powell Street Getaway, another safe-injection facility. Compared with Insite, the area was quieter: The only person outside was a woman who appeared to be smoking something under a tarp, which doubled as her house.
One employee stepped out of the Powell Street building and agreed to speak anonymously, because she was not authorized to speak to the press and was worried about losing her job. She had a skeptical view of safe-injection sites’ effectiveness. “To me, it kind of crosses the line into enablement,” she said.
A drug user who comes to the facility knows “that guy who came out of that room is higher than a kite right now,” she added. “And you know how that feels. There’s nothing to break the cycle.” She said she regularly sees people flatline from drugs. “You would think that being clinically dead and having random strangers bring you back to life would be enough of a bottom that you see you need to make a change.” But it’s only enough for “probably one out of 30 people.”
Still, addiction experts doubt whether it’s even possible to spur people—even those who have, by every definition, hit “rock bottom”—to kick the habit.
Families who want to encourage a loved one to get treatment can attend support groups and set limits for what they’re willing to tolerate, said Linda Rosenberg, the president of the National Council for Behavioral Health. But, she added, “the belief that everyone is ready to go into treatment, it just isn’t true.”
The guidance of the National Institute on Drug Abuse similarly states: “There is no evidence that confrontational ‘interventions’ like those familiar from TV programs are effective at convincing people they have a problem or motivating them to change. It is even possible for such confrontational encounters to escalate into violence or backfire in other ways.”
“There are stages of motivation, and you are beginning with someone who is not very interested at all,” Rosenberg said. “They don’t want to face the pain of their lives if they’re not high.”
That’s what happened to Emily Hays, the 27-year-old daughter of Tammy Stephen, who I met in the homeless camp. She had been using heroin since she was 18 and entered treatment multiple times. But the treatment facilities, which relied on the 12-step model, discouraged methadone, and she relapsed repeatedly.
By 21, she was homeless—walking the streets at night and doing meth to stay awake. During the day, she would shoot heroin by ducking into fast-food bathrooms or popping behind a fence. She overdosed six times.
Her mom suggested methadone, but Hays kept using. “I remember telling my mom once that I wanted to die from a heroin overdose,” she said. “No matter how badly I wanted to get clean, I was too scared to not have that drug.”
Eventually, Hays developed an abscess on her neck, which became infected and made her face swell up “like Fat Bastard,” the Austin Powers character, as her mom described it. She went to the hospital to get it drained, turned to the doctor, and asked, “Can I have some methadone?” Thirty minutes later, she had her first dose. Today, she has been clean for two-and-a-half years.
“I’m very pro safe-injection sites,” Hays said, adding she believes they’ll keep addicts safer and reduce the amount of drug paraphernalia on the street. After all, the longer addicts are kept alive, the greater the chance they will eventually want to get help.
Hays’s experience illustrates what Lenny discovered in the course of her job: the importance of listening to addicts. As frustrating as it might be, they’re not ready until they’re ready. And when they’re ready, they’ll let you know.

Read at: https://www.theatlantic.com/health/archive/2017/11/why-cant-addicts-just-quit/545552/