"What does the drug do for you?" I asked the woman sitting across from me in the psychiatric emergency room.
She was struggling with an addiction to heroin, hoping for a treatment referral. She repeated the question softly several times as she thought.
"I guess it makes the world feel a little less harsh, you know, even if just for a bit."
This question has become an important and illuminating part of my addictions assessment. As a resident psychiatrist in Philadelphia, I've met and treated hundreds of people struggling with addiction, chiefly to heroin and cocaine.
"What does the drug do for you?" Very rarely do people talk about the high. Most tell me about childhood trauma, poverty, regret, and loneliness, often overlaid by intense feelings of worthlessness and self-contempt.
Hearing the life stories of people struggling with addiction has changed how I relate to them — less as "addicts," and more as fellow human beings who are trying the best they can. Research has shown a consistent link between early life trauma and later addiction, a connection I see every day in the clinic. Yet most of my patients are remarkably resilient and desperately want to get better.
We know how to help them. We have medications, including methadone, suboxone, and Vivitrol, that are well proven to lead to far more lasting recovery than abstinence alone. Yet fewer than one in five Americans with opioid use disorders are being treated with them.
One problem is stigma; many people refuse to accept that drug therapy is the most direct way out of drug addiction. Sometimes I get so frustrated I wish I could force a patient into drug treatment.
But that's an emotional response; data show that forced treatment doesn't work. Nor does it respect the inherent dignity of those in addiction, which includes their right to make decisions for themselves that might be different from what I desire.
That isn't just a nice thought; I've seen over and over that behavior change and recovery are most likely in a respectful and caring relationship that affirms the patient's dignity.
I've seen this dynamic play out in the hospital, where it often takes multiple admissions for patients to trust the medical team enough to accept longer-term treatment. Some never get there. One of my patients, in addiction for several years, was admitted multiple times for relapses and overdoses. Then the treatment team took a different approach. They spent extra time with this patient, giving him space to begin to process his past traumas and their enduring impact on his life. After he left the hospital, he went to a clinic for medication-assisted treatment and psychiatric therapy. He's been able to maintain sobriety.
His story demonstrates that we need to meet people where they are, not where we wish they were.
Canada and several European countries have accomplished this by establishing safe injection sites, sanitary and nonjudgmental places where people in addiction can use drugs they have obtained elsewhere. A group in Philadelphia has just announced plans to open one here.
Professionals trained to respond to overdoses and provide education about staying safe and accessing treatment resources are always present. There are about 100 such sites operating legally in 10 countries. Studies conducted at multiple sites clearly show that they improve the health of people struggling with addiction as well as community health by reducing public injecting and unsanitary needle disposal. They serve as a place where some of the most difficult to reach and severely addicted members of our society can receive medical care and get connected to social services. Studies show a link between the opening of a safe injection site and an increase in referrals to detox and rehab programs, plus more engagement in long-term drug treatment among people who use safe injection sites.
I understand that providing a safe and clean space for people suffering from addiction to inject drugs elicits feelings of discomfort and anxiety.
It took me a while to accept that the greater danger is not opening safe injection sites.
We shouldn't allow our collective discomfort to stand in the way of evidence-based health policy and practice.
Philadelphia has one of the highest drug overdose rates of any major U.S. city. One study estimates that a safe injection site in Philadelphia could prevent 48 overdose deaths and up to 18 HIV infections annually.
Safe injection sites provide a place where the most marginalized and stigmatized members of our community can feel accepted and valued. They are a place where people struggling with addiction can form mutually respectful relationships with health and social service providers, until they are fully prepared for change and recovery.