Needle debris: some thoughts from the ED.

[18 Sep/18 Edit: This post is getting a lot of attention which is great. Comments are welcome, but overtly derogatory or threatening ones will be deleted. Thanks for your respectful discussion.]

Like many places, my medium sized Alberta city has been experiencing a crisis of illegal drug abuse, and a second crisis of outrage over the public risk from drug associated crime, needle debris and other fallout. While frustration and fear for the community and public safety is completely understandable given current conditions, I worry that misinformation and a lack of background understanding is generating a lot of unfocused or misdirected anger towards people and institutions that are either not responsible for or are unable to directly address people’s concerns. There is a lot of blame being placed on organizations trying to address the problem, and while feedback and accountability are important, so is understanding what they are doing and why. With a bit more background perspective, I’m hopeful this public energy could be better directed towards efforts for realistic and workable solutions.

I work as an Emergency department physician in the city, but my views are my own, and I’ve had no direct professional involvement with the safe consumption site or the organization that runs it. While I can’t speak for the program or its management, I can provide a few insights on the nature of the drug crisis as I have seen it. I also can’t tell you what the best solutions may be, except to reassure you they are neither quick nor simple. Perhaps what I say will at least broaden a few perspectives, and stimulate someone to learn more about the roots of the crisis in our community and explore how they can be part of the solution.

Illegal drug abuse and the associated crime, violence, disease and death is not new here. It has been in our city for a very long time. There have been community outreach programs for many years offering clean needles, disease screening and treatment, addictions counselling, and access to nearby detox facilities. It is a hard thing for people to escape and a hard thing for health care providers to treat. The roots of addiction often run deep within communities and families, and are often linked to inter-generational trauma and childhood abuse and abandonment. There are a lot of poor choices being made for sure, but often by people who never had the benefit of someone to teach them how to think about making choices.

Getting out of this addiction requires a community of supports and often complete socioeconomic and cultural life changes. This requires deliberate and repeated choices by the addict to accept help and make these hard changes, often developing an entirely brand new way of thinking. That’s in addition to traditional medical detox. Detox can be an important step, but if you leave a facility and return to an old life with family and friends who are addicted and have little to no resources to change their circumstances, you have a very poor chance of staying clean. There are success stories, but not enough. The purpose of harm reduction is to hopefully keep a person alive and healthy enough through their addiction years that they have the chance to go through this process when they have decided it’s time to change, and can achieve a reasonably healthy life in recovery.

Drugs have always ruined too many lives, but a few years ago the illegal drug market in North America changed. What we call “synthetic opioids” arrived and started killing users in unprecedented numbers. Opioids are powerful pain killers. They are effective but can be dangerous if misused. They are addictive because in addition to numbing physical pain, they can also temporarily release you from emotional pain and distress, and replace it with a sense of comfort and euphoria. Those who have lived lives of pain and disconnection from loved ones are primed for opioid addiction. Additionally, regular use will make you more susceptible to both physical and emotional pain when you stop using them. Too much will sedate you. A little more will slow your breathing and eventually stop it. This is how they kill.

Over-prescription and street diversion of medical opioids is a problem that has been around for a while that the medical community is working to address. However, when the “meth lab” industry learned how to make cheap synthetic opioids the game changed. This is the fentanyl crisis you may have heard of. It is NOT diversion of carefully regulated prescriptions, but the black market distribution of crudely made crystals, liquids or pills containing entirely variable and unknown doses of synthetic fentanyl (or its more potent cousins carfentanil and remifentanil). Because small amounts are so potent, and illegal drug labs are not known for their quality control, drug concentration is variable and dangerously unpredictable. One pill might give you a bit of a buzz. The one next to it might kill you. Distribution of the drug spread quickly because it was cheaper to get than other drugs, and it could be cut into anything else (cocaine, meth, marijuana) to provide a “better buzz,” that would bring customers back more often, and at less cost to the supplier. If they survived of course.

Front line police, paramedics, and emergency staff began to see the effects immediately. Opioid overdoses became common, daily occurrences. When a new batch of drugs hits the streets we see dozens of cases a day for several days, slowly tapering off over a few weeks until the next batch arrives. Administering Naloxone (brand name: Narcan) – a medication that rapidly reverses opioid effects – became the obvious first treatment for almost any suddenly unresponsive patient, and often quickly turned around a life threatening event. During my residency training not many years ago, I hardly saw Narcan used at all. Back then, it was rare to see someone who had managed to consume or inject a life threatening dose of opioids outside of a few inner city hospital centers. Now it is common almost everywhere.

Not only is fentanyl killing regular drug abusers who risk death with each high, but it is a serious risk to more casual drug users. You might not know this, but there are people around you living normal lives, holding good jobs who indulge in the occasional “cocaine party” or similar on the weekend. These people’s bodies are not as accustomed to opioid exposure as those of a drug addict, and a lower dose of fentanyl cut into whatever they think they are taking is often enough to kill them. Despite a few years of this madness, drug abuse continues. In fact, I suspect for whatever reasons, rates of abuse are even higher.

Consider this: right now, nearly every drug addict I and my ED or EMS colleagues treat and pull back from the brink of a self induced death, has at least one – usually several – dead friends and family members, recently killed by the same drugs they are still taking. These people know they are risking their lives every time they indulge. I have discussed it with many of them. To anyone who believes the threat of greater legal consequences for drug use is going to be an effective deterrent, or that this is just the life users have chosen, consider how damaged a mind and disordered a thought process this activity suggests. It’s literally playing Russian roulette with every pill or injection, but they still do it. If a gun to the head won’t “change a druggies mind,” then will a fine, a court date, or a jail cell? The answer is obvious to anyone who works with this population.

Let’s look back to about a year ago- perhaps the height of the opioid crisis so far [EDIT: from my local ED perspective at least]. We did see periods of decreased overdoses, I suspect in large part due to stepped up police enforcement to get the deadly stuff off the streets. We handed out a lot of home administered Naloxone kits- saving a few more lives for a time. Still, when more opioids hit the streets, there were deaths and near deaths in droves. While I was not personally involved, it was during this time of many calls to “do something,” we heard word that the city would be rushing to set up a supervised consumption site (SCS). This was not specifically to distribute clean needles – that is something that was already long in place in our city to prevent transmission of HIV and hepatitis. This was to provide a place where someone was supervising drug consumption that was already happening in order to reduce and respond more quickly to potentially fatal overdoses. It is not a new idea, has worked elsewhere, and ideally comes as just one part of a greater package to treat drug addiction and address the multiple social and economic factors that prevent people from getting and staying clean.

I was not on any planning committees, but my suspicion is that in order to address the alarming death rates, this facility was rushed more than it would have been in less pressing times. I’m certainly led to understand that when opened the facility was immediately overwhelmed by the unexpected level of demand, and since implementation has continued to increase its capacity and hours. Predictably, this site has become somewhat of a destination for drug abusers, many of whom are homeless and do not generally have other places they are welcomed to go. I don’t know if there are more or less users than there were previously, but this centralization effect has certainly made the population more visible. It has also increased the public’s sensitivity to the negative impacts of drug abuse on the community; crime, public drug consumption, and needle and drug paraphernalia debris in particular. These are not new issues, and not caused by the SCS. They are the result of a growing drug abuse crisis, and have become more visible because 1- the crisis has deepened over the last two years, and 2- the SCS has made the issue more visible, and probably shifted more of the problem to a single area where people now know to look for it. Additionally, more public awareness and controversy also means people are more likely to publicize their experiences with drug users and needle debris on social media, and these experiences are more likely to be widely circulated than they would have been in the past.

From my perspective in the ED, I am seeing fewer fatal and near fatal overdoses. I don’t have any stats to share, but many of my colleagues have noticed the same thing. We certainly don’t experience the regular parade of overdoses we used to, including days when we ran out of Naloxone. It’s hard to confidently state cause and effect in these type of phenomena, but I believe the SCS almost certainly is behind much of that decrease.

I am very concerned about the risk to children and the public from contaminated needle debris. No one wants local businesses or tourism to suffer because people feel unsafe in certain parts of their community. Of course I want to let my children play in city parks without worrying about them encountering dirty needles or individuals using drugs nearby. But wishes don’t solve problems, and neither does attacking those who are trying to help. There’s another part to this story that might not be on everyone’s radar right now. I heard about it from a friend who works security at the safe consumption site. The site has contracted a firm to provide 24 hour security for their site, and a certain radius around it. You might assume this is to protect people and property from drug addicts, and you’d be partially right. Their mandate includes watching for crimes (including theft, drug dealing or displaying drugs in public) and either intervening or calling the police depending on circumstances and exact location. The friend I spoke with indicated he spends a surprising amount of time protecting these same people from other members of the community who seem out to cause harm.

[Edit: I have removed details of a few alleged events of violence in the proceeding and following paragraphs, not because I disbelieve the source, but because I have no first hand evidence to share, and the readership of this post has spread far beyond my original expectations. A subsequent report by global news has confirmed with both the police and SCS that violence against facility clients has been a problem. The Global report details some incidents. My intention in sharing these anecdotes in the first place was to bring attention to the fact that violence around the SCC is not only perpetrated by some site users, but also against them by members of the public]

I bring up this less publicized side of crime associated with the safe consumption site mostly to urge caution in the spreading of inflammatory material that demonizes addicts, and stokes anger at the public and non-profit facilities that help them. There may be more people than you think in our community who are easily incited to vigilante violence and will feel more justified to commit it as they hear the outrage and frustration of others.

We are well aware in the health care field that drug abusers tend to be very unpleasant people to deal with. We have all been sworn at, spit on, and assaulted by someone whom we just saved from death, while they were about to storm out and try to reverse the help we just gave them. They can be aggravating, threatening, unthankful, and frustrating to treat, and it’s hard to make a positive difference in their lives. We also know they are still people who are vulnerable and living terrible lives with very few options and opportunities to turn things around.

So yes, I would like to see fewer needles in the community. Yes, I’m concerned about crime rates, and the safety of public spaces in the city. But I know closing the doors of facilities that serve users and hoping the problem will go away is not going to solve the problem. It certainly won’t stop needles from showing up in parks. It is a complex issue, and won’t quickly or easily be resolved. All large cities, and even many smaller deal ones with it. If it is a bigger problem here than in other similar sized cities, then we need to look at the socioeconomic reasons why, and try to address them. We need better addiction treatment facilities, so when someone tells me in the ED that they want to change, I have a workable and accessible program to immediately point them towards. We are opening new detox beds at the hospital in November (EDIT: changed from October with new information]. That’s a good next step, but won’t make a big difference alone. Hopefully there are more solutions coming, and I’d encourage anyone passionate enough about seeing change to get engaged and find out how they can help these changes come to pass. We need to continue good law enforcement to keep drugs off the street. We need to continue educating kids that yes, drugs are still bad – even if there is a trend towards more legalization and less punishment for use and possession, they are still potentially life destroying.

And yes, it’s appropriate to talk about how needles are being distributed to achieve harm reduction while minimizing risk to the community. It’s important to continually re-examine harm reduction programs to make sure we are helping without enabling, and minimizing unintended negative consequences that may arise from these programs. It’s important to talk about neighbourhood solutions in trouble areas and respect local businesses, homes and parks. Accountability on the part of city and organization officials working on the problem should be expected. Making those expectations reasonable requires some education about the problem and thoughtful consideration on the solutions. I hope my musings have been helpful to some. Thanks for reading.

19 thoughts on “Needle debris: some thoughts from the ED.

  1. Ok your points are (mostly) correct.
    The numbers of fatal and even ems responses to ODs are lower……. the number of calls about drug debris and needles is lower……. people are complaining over less but just think they can complain more because of the media attention of the success the scs is in reality having……

    Even in my own personal experience of security related work down town the scs has made problems and medical and garbage/disposal issues less….

    Many people wanted a much larger place for the SCS, but city council members said no….. we have also needed a largwr homoess shelter for a decade again a resounding “no”…….

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  2. Hello there. Thankyou for this illuminating article. I am co founder of a group called Moms Stop The Harm. We have more than 550 members, most of whom have lost a loved one to drug related death. We would like to contact you as we have some moms in Lethbridge who are doing education in your community around harm reduction. One has written a book about Opioid related issues in the Lethbridge area. I think you’d both benefit by meeting one another. One of our members is also a physician who would like to meet you. Please check out our website and Facebook group you will see the photos of our loved ones. This is my story http://www.momsstoptheharm.com/lorna-thomas/

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    1. I’m glad you and your group found the article of interest. It sounds like you are doing important work. I’m not sure how much further help I can be to you from my position, but I’m happy to have a discussion about it. I’ll reach out through your facebook group or webpage for further contact information.

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  3. I can totally understand the need to get this drug epidemic under control but I also totally understand the voices of others against it .
    There are elderly ppl who struggle financially to try to Live and not become homeless …. there are children that STILL go to school hungry ( more programs needed to feed these children ) there are families struggling w cancer finding support and care for loved ones , then there’s our retired military people who sacrificed everything to only come back home with little or no support mentally or financially .
    There are families who struggle trying to find work , feed their children and have a safe , warm house for them ….. all these people are TRYING to make a better life for themselves and their loved ones
    And that’s the frustrating part for many to try to understand why money is going to druggies rather than people who are trying to make life “ better”
    Yes there are programs out there but not enough 😦

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    1. Thanks for taking the time to read and comment. I hear similar concerns often in response to almost any use of resources towards a particular problem. As always, the need for resources in one area does not preclude addressing needs in other areas. No one person or program can deal with all of society’s ills, so it’s important to have people passionate and involved in many different areas.

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    2. Good response for when people ask why are we giving money to junkies rather than others “more” deserving is “the druggies you see today were those exact same more deserving people not that long ago. These individuals are all deserving of humane treatment and access to compassionate caring service providers.”

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  4. I also believe your not seeing as many fatal over doses in your in your department because your frontline workers ems and fire crews are responding and giving narcan and the the patients refuse transport or running off, speaking from experience if you ever want to see what happening outside the department have a ride along. I agree with a lot of what your saying thou and appreciate your input and yes there is a lot more to this that public doesn’t understand.

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  5. Safe consumption sites and homeless shelters instead of 1 site each may also help reduce the cpncentration. Unfortunately most people are against either and will protest having another not realizing less concentration of anything that impacts our environment is a good idea.

    The other issue is people see the consumers of drugs as druggies not people. The consuming people become viewed as disposable. They are still important. They have Mothers, Fathers, sisters, brothers, cousins, aunts, uncles or grand parents. The fact they may have grown up in a dysfunction home needs to be addressed as well.

    We need to find ways to stop harming all. Needle debris is a symptom of concentrated users, so decentralize for less debris. Put another site and shelter in a different location away from down town but still accessable to transit and soup kitchen support.

    Discrimination against the consumers of drugs needs to stop. They are more than DRUGGIES!

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  6. Wow.
    The fact that you took the time to write such an extensive, thought provoking article with such objectivity speaks volumes about your integrity and empathy. Brilliant essay. I taught grade twelve English for 37 years, and the writing was exceptional. Thank you so much for sharing😇

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  7. Fantastic article! I have been seeing a number of articles on my Facebook page regarding the safe consumption site in Lethbridge . My understanding – from what I’ve been told – is that the Lethbridge safe consumption site is averaging about 15,000 people a month, compare that to the safe consumption site in Calgary, which is averaging about 3000. For a population around 110,000, compared to one of 1.2 million that is huge demand, unintended consequences are bound to happen.

    I would like to add that one of the areas where we could be having better impact in this crisis is linking the emergency department to the prescription of Suboxone. This is something that is been pioneered in California right now to great success. We need to move away from putting people into addiction treatment programs that isolate them from their natural supports and put them into an artificial environment that can’t be maintained once they leave. The vast majority of addiction treatment programs are not evidence-based, and only have about a 5% success rate. We would be far better to follow new procedures that are being pioneered in other countries with the subscription of Suboxone combined with a hub model to provide support and therapy, rather than trying to continuously shuffle people into these addiction treatment programs that don’t have space and don’t have good outcomes. Your new detox beds would give you the opportunity to capitalize on the window you have to link people to treatment. For more on what I’m talking about check out this article.
    https://www.google.ca/amp/s/www.nytimes.com/2018/08/18/health/opioid-addiction-treatment.amp.html

    Plus, for anyone else interested in learning more about what the rest of the world has done to address their addiction crisises, get a copy of Chasing the Scream. One of the most important books I’ve ever read. I flog this book to anyone who will listen, I wish I could afford to hand out copies. This book will change the way you understand addiction and it’s full of ideas being used to great success in other countries.

    Thank your compassionate article. This is going to be a tough slog and it’s going to require new ways of thinking. I’m just sorry it takes a crisis to get there.

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    1. Thanks for your comments and ideas. I would note that the number of facility users that you referred to are (according to my understanding) a list of VISITS per month, and not unique users of the facility. The more individuals there are who use the facility multiple times a day, the more inflated those numbers will look, and don’t necessarily reflect a greater number of drug users. I’m certain that phenomenon is behind at least some of the disparity.

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  8. Hello, this is the Newsroom Manager at Global News in Lethbridge. Would be willing to contact us to speak more about this blog posting? It is receiving a lot of attention, and we would like to speak with you more about it if you’re willing to. Please call the newsroom at 403-329-2903 or email Liam.Nixon@globalnews.ca. Thanks very much.

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  9. Until the whole person is treated , change will not happen in the desire to use. 4S’s can be used to heal in so many areas of our lives, including addictions: self care, self worth , socialization , spirituality , one without the other simply does not complete the person. Support groups participation can help make that transition from where you come from to where you want to go easier through meeting others in similar situations also making the same changes . It is hard changing ones path when loneliness hits too. I see kids working to change and then going back to old friends because they are lonely and the pull back in drugs is real because it is what they simply know in socialization and enables them to feel comfortable within . Cannot clean them up in withdrawals then throw them back out into isolation , there has to be more on going teaching , how to socialize without using , how to feel good inside without getting high and this is the long term area for it is a process of reprograming some whom have basically nothing to lose in their eyes as they have done horrible things while on drugs or horrible things done to them prior to drugs . teach them to give too of themselves like in volunteering . want to create healthier whole person not just treat the addiction , or the trigger mentally and/or physically that sends them using.. Cannot fraction the person off and only address one 1/8 or 1/4 for the rest will soon return to using. Cognitive therapy is not gonna cut it on addictions , tools and skills to cope when the addiction hits or the draw mentally hits . Sometimes relocation to even get a clean start with a support system in place designed to engrave new healthy paths .Getting the person to admit they have a problem and need help is the main step and the hardest one to get them to that point Good luck for funding is never enough or never lasts through the long haul nor does it seem long term support groups can form without some funding needed in space.

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