The overlooked streets of Newmarket Square in Boston are littered with debris, piles of clothes, shanty shelters, and used hypodermic needles. People sleep on sidewalks and up against buildings, and are sometimes found by emergency services to actually be overdosed. The sound of sirens responding to various emergencies in the neighborhood is an incessant reminder of the crisis-state of this area. Listless people in drug-induced stupors shuffle off sidewalks into traffic. A police officer stands inside McDonald’s, a usual presence there to deal with the frequent fights and petty crime that abounds in this neighborhood known to many as “Methadone Mile.”
Along Melnea Cass Boulevard, fences surround the small amounts of grass and green space, shutting off pedestrian access in order to prevent pop-up shantytowns. Before the fences, these grassy knolls were filled with assortments of shopping carts overflowing with personal belongings, makeshift cardboard shelters, and second-hand tents.
This is the intersection of the opioid crisis and homelessness in Boston, and many of the services available for people with substance abuse disorders are available here, bringing this crowd of people in crisis. Recently, Boston City Hall has been exploring the possibility of adding a new and controversial service to the list—safe injection sites.
It’s an uncomfortable proposition. Safe injection sites (SIS) are facilities staffed by medical personnel where people with substance abuse disorders can inject illicit drugs. The theory behind this? It will prevent people from overdosing and dying on the streets or in risky areas. “SISs are associated with lower overdose mortality, 67% fewer ambulance calls for treating overdoses, and a decrease in HIV infections,” concluded one University of Alberta study.
There are many optimistic reports and studies from safe injection facilities in other countries, but these are not as easily applied to Boston, as the areas studied often vary in the density of drug users, demographics, and specific socioeconomic conditions. The crux of the issue is not the data, though—implementing a site requires navigating a complex web of legal, ethical, moral, and practical dilemmas.
Boston City Councilor Annissa Essaibi-George has immersed herself in the opioid crisis here, chairing the city’s Homelessness, Mental Health, and Recovery Committee. She has traveled to Vancouver and Toronto to inspect existing safe injection sites (permitted by a waiver from the Canadian government) as well as in Philadelphia, which will shortly be opening the first SIS in our nation.
“What I saw in Vancouver was a distressing sight for sure,” Essaibi-George remembers as she describes the high concentration of people dealing with substance abuse disorders and homelessness surrounding the safe injection site. In Toronto, Essaibi-George found the sites distributed throughout the city, with a less striking visual impact on the surrounding area. Though she was taken aback by what she witnessed in Vancouver, this was not Essaibi-George’s main issue with safe injection sites.
“I am not a proponent of safe injection sites because I have not seen a correlation between SIS and individuals seeking long-term recovery,” she explains, and this conclusion is not unfounded. Champions of SISs argue that the concept is simple (reducing harm and saving lives when possible), but the city councilor, on the other hand, sees an evolving illicit drug crisis unfolding on Boston’s streets.
“There is no more heroin on the streets, it's all fentanyl,” Essaibi-George says. “In Boston, we are even beginning to see other drugs laced with fentanyl.”
Authorities are finding fentanyl laced into cocaine, crystal meth, and other illegal drugs. Many of these drugs are snorted, not injected, which effectively negates the benefit of safe injection sites. As the risk of opioid overdose increases with drugs not normally injected, the city is searching for the most effective avenue to achieve broad results. SISs may yield a result that benefits only a specific population of people with substance abuse disorders, but there are still other issues with SISs that have caused the city to question their benefit.
“Studies have shown that individuals will not travel more than a quarter-mile to safe injection sites,” said Essaibi-George, highlighting the complexity of locating sites in Boston. It is likely that the city would need several placements, and with this comes more worry about the detriment these could bring to their host neighborhoods.
In a Boston Herald article, City Councilor Frank Baker asks about these possible negative effects, displaying the wariness of many Bostonians: “What [would] it look like out front of [an SIS]? Is that going to bring open drug dealing to neighborhoods?”
Although safe injection sites are still a hypothetical, Baker's concern is not. Outside the Supportive Place for Observation and Treatment (SPOT) engagement center—part of the Boston Health Care for the Homeless Program—where overly sedated people can find medical supervision, there are crowds of people in crisis lining the street and open drug dealing (and use) is a constant. It is possible that we would see more of this outside safe injection sites, but the benefit of linking people in need with access to healthcare may outweigh the risk.
In addition to obstacles that limit local support for SISs, U.S. Attorney for the District of Massachusetts Andrew Lelling promised that “efforts to open injection facilities... will be met with federal enforcement.”
Essaibi-George has chosen to focus her efforts elsewhere on solutions that are available legally now.
“For every 30 people looking for a bed, there is only one available,” Essaibi-George said, describing the shortage of available shelter beds for those seeking care. She is laser-focused on enhancing long-term care for those in recovery, seeing this as the best course of action in improving conditions for people with substance abuse disorders. As a strong advocate for improving access to a continuum of care, Essaibi-George wants to streamline the path from addiction to recovery with as few detours as possible.
The conversation surrounding addiction and recovery is one that often involves combatting stigma. People argue that safe injection sites are only enabling and prolonging addiction by establishing an order to the process of getting high. Many believe that if society provides a safety net, it will only increase the number of users. The issue is that this argument ignores the core problem at the center of our opioid and drug crisis: mental health.
People with substance abuse disorders are often labeled “addicts” or “junkies” and forced to the alleyways of left-behind neighborhoods. However, many are victims of childhood trauma, and many have severe mental illnesses. People who have already been immensely hurt and/or neglected are then further pushed to the edges of their cold, dark world. This is unfortunately not just theory, and there are numbers to back this phenomenon up.
In his book Chasing The Scream, Johann Hari talks about the findings of the Adverse Childhood Experiences Study, which correlates childhood trauma and addiction.
“Nearly two-thirds of injection drug use, they found, is the product of childhood trauma,” says Hari.
These alarming numbers show us that when looking at people with substance abuse disorders, we must not believe that it is simply a 'personal choice.' They are victims of a society which has caused them so much pain they are forced into self-medication.
“It means that child abuse is as likely to cause drug addiction as obesity is to cause heart disease,” Hari writes.
Once it is realized that people with substance abuse disorders are likely to be suffering from pain and trauma endured as a child, it could change they way we treat them as a society as well as in policy. However, this realization may also create some uncomfortable questions. Why, at the height of the opioid crisis, did we fence off the grass on Melnea Cass Boulevard? Why is our response to people in crisis to further prevent them from any sort of comfort or aid outside of the drugs they find themselves driven to?
An old adage of the battlefield medic is “stop the bleeding, start the breathing.” If safe injection sites will prevent people from overdosing and dying, there will be an opportunity to connect with them and improve their situation. Stop the bleeding, start the breathing. First, slow the number of deaths, then work to address the larger questions of why there are so many Americans addicted to opioids and so many Americans with a history of trauma and mental illness.
Safe injection sites would serve this dual purpose of providing people with immediate safety and linking them with the healthcare network. When people are forced into dark places to use, they are at risk of an array of dangers and are outside the embrace of professional care. Most immediately, the benefits of SISs would be for the individual—someone’s brother, sister, son, daughter, cousin, or friend. Eventually, their access to healthcare will create a better world for all people.
As debates continue about how to deal with the opioid crisis, some people are recognizing the growing demand for mental health care. Essaibi-George sees this need everywhere she travels in the city—and as a city councilor at-large, she is everywhere.
“There is a desperate need for access to mental healthcare across the city,” George affirms. In response, she has repeatedly called for and is actively pursuing the formation of a mental health commission in Boston.
While there is much debate over the most effective way to combat the effects of the drug epidemic, what remains lacking is a discussion about what drives so many Americans to use drugs. Is it socioeconomic conditions, depression, or a lack of purpose? When we understand that addiction is a symptom of a greater illness, we can start to identify the structural societal change needed to prevent it in the first place. If we understand the roles that mental health and childhood trauma play in substance abuse disorders, we'll begin to look at people who suffer not as criminals, but as people in need of embrace.