The Controversial Answer To America’s Heroin Surge

This is a fantastic article on heroin use and harm reduction. If drug reform, harm reduction or drug use in general is interesting or important to you, please read!

First published on, May 15, 2014, at 8:26 p.m. by John Knefel

On a chilly Monday morning in mid-March on Coney Island, down Surf Avenue from the famous Wonder Wheel and Cyclone, a parked

Dodge van blasts its heater. Stuffed with all manner of injection-drug paraphernalia HEROIN CRISIS— needles of different gauges, cookers, ties, pearl-sized cotton balls, alcohol wipes — as well as plastic bags of nonperishable food items called “pantry” and thousands of condoms and lube packets, it’s a clinical stockroom meets therapist’s office on wheels. The van has these supplies to make using drugs safer, all for free — though getting high in the van is not permitted.

Ian, 60, sits in the back of the van, rubbing his hands to keep warm. “I used for over 45 years. Last 25 years was basically crack,” he says. He suffered what he calls “three minor strokes” that doctors said should have killed him, but kept getting high. So when someone slid a flier under his door for something called harm reduction — an approach to combating drug use that allows the person to continue to get high, but in a safer way — he was interested. Slowly, he decreased his use from daily, to weekends, to monthly — until he could finally quit. Now he works for FROST’D (Foundation for Research on Sexually Transmitted Diseases) — one of New York City’s harm reduction programs and the organization that runs this mobile unit — as a peer educator, a paid, part-time position that serves as a bridge between the staff and the communities they serve.

Next to him, Scott Spiegler, 28, flips through a binder of anonymized client information. Scott is one of FROST’D’s outreach workers, and delights in explaining safer sex practices to anyone who enters the van, which is parked here every Monday and Thursday — and regular corners throughout the boroughs other days of the week. Later this afternoon he’ll tell one woman, a new client named Brooke, that flavored lube for blow jobs “is like dinner and a movie: You can give head and eat a peach.” When she tells Scott she’s never heard of a female condom, he lights up. “I love telling people about the female condom,” he says. “It’s, like, my jump-off.”

NEEDLE EXCHANGESAround 11 a.m., the first client of the day shows up. Willy, late forties, knocks on the van’s sliding door and hops inside. In limited English, he says he’s homeless and has been sleeping a few blocks away on 22nd Street with his wife. Scott offers to connect him with their housing program, but Willy doesn’t like shelters. “Too many people stealing,” he says. He’s been using heroin for three years (including this morning) and has cirrhosis of the liver.

He’s come to the van today just for the pantry — pasta, cans of beans — and he’s already taken home plenty of clean needles. “Do you know about alternating veins?” Scott asks. Willy does, but he says he has trouble finding others. After showing him (with a capped needle) the 15-degree angle he’ll want to aim for if he decides to shoot up in his hand, Scott warns him about the powerful, fentanyl-laced heroin that’s going around — the type that Philip Seymour Hoffman was initially thought to have used when he overdosed. Willy wants nothing to do with it. “No, no, I don’t want to die,” he says with a smile.
Willy is one of the approximately 669,000 people in the United States who used heroin in 2012, a 65% increase from rates in 2002, according to the most recent National Survey on Drug Use and Health. Other trends also show heroin use and availability is increasing at alarming rates. The same survey found that people “with heroin dependence or abuse in 2012 (467,000) was approximately twice the number in 2002 (214,000).” According to DEA numbers, heroin seizures at the Southwestern border “increased 232 percent from 2008 (558.8 kilograms) to 2012 (1,855 kilograms).” Drug overdose is now the leading cause of accidental deaths, eclipsing car crashes, though pill abuse far outpaces heroin use. More than 12 million people in 2010 abused painkillers, according to the Centers for Disease Control and Prevention, and data supports the much-repeated narrative that many newer heroin users got started on pills.

But Willy, and many of the people who use FROST’D’s services, are not the kind of RURAL DRUG USERSpeople the media has put forward as representatives of the endlessly touted heroin crisis. The face of the new crisis is a familiar one: the white, middle-class kid who should never have become a junkie. Whether the story is in Time, any number of local reports from major cities, or small-town Wisconsin, the takeaway is always the same: Heroin use among young, middle-class users in the suburbs and rural areas is increasing. And that number will undoubtedly rise as pain pills continue to get more expensive.

And even though a 2013 study shows that people with an annual household income of less than $20,000 were much more likely to begin using heroin than those in higher income brackets, the perception that the crisis is primarily affecting middle-class America seems to have had an effect on the potential for political action. There’s the just-passed plan to have New York City police officers carry a heroin “antidote” to reverse overdoses, part of a $5 million program; the state legislature passed a Good Samaritan law to protect users who call 911 if they witness an overdose and another law that decriminalizes heroin residue in used needles. At the federal level, Attorney General Eric Holder has endorsed first responders carrying similar kits, and a spokesperson for the Drug Enforcement Administration echoed support for the programs. But a significant reason for the shift in lawmakers’ attitudes is the advocacy work done on the national level by groups like the New York City-based Harm Reduction Coalition, and the local organizing that groups like Brooklyn’s VOCAL-NY are doing on the city and state level.

Over the next five hours on Surf Avenue, 10 more clients will come to the van and request condoms and needles and cookers, as well as phone numbers for detox and rehab programs. One young Ukrainian woman was clean until she ran into friends and had a party weekend. One guy just got out of a 30-day bid in Rikers for having a cooker, and despite the methadone they gave him in jail, the withdrawal was terrible.

PILLS VS HEROINSome of their bodies will show signs of drug use — scabs, bruises — and some will not. Some will express disgust at their habit (“I’m fucking sick of this shit,” one guy spits, standing outside the van), while others will say they want to keep using heroin. But all of them will walk away with tools that, for today at least, workers at FROST’D say make it less likely they’ll contract HIV, hep C, or any other communicable disease from reusing needles or having unprotected sex. And that idea — meeting people where they are without judgment — is at the heart of harm reduction, a philosophy that, after decades of false starts, is finally finding political traction, and not a moment too soon.

Harm reduction — as opposed to abstinence models — is not a new idea. Needle exchanges go back to the 1970s, and a drug called naloxone that reverses overdoses from heroin and opiate painkillers was created a decade earlier. Naloxone (also known by its trade name Narcan) works by blocking opioid receptors in the brain and sending the overdosing person into withdrawal almost immediately. It doesn’t get a user high, is nonaddictive, and doesn’t negatively affect someone who isn’t OD’ing on opiates — the only downside is that it’s a temporary fix, and if the survivor doesn’t get to the ER, the person could fall back into overdose. Still, it requires a prescription, which makes it harder to get in the hands of drug users and their families.

Seven states have what’s called a “standing order” provision for naloxone, which means a medical professional doesn’t have to be on site to write individual prescriptions, similar to a flu shot. In the vast majority of states, however, if a parent comes to a needle exchange and asks for a drug that could save their child — unless a doctor is on site at the moment — it’s illegal to give them a take-home kit.

New York isn’t alone in adopting new, more liberal drug policies. At least 17 states and Washington, D.C., have Good Samaritan laws, a number that seems to get larger almost every month. States and cities from Massachusetts, to Ohio, to Wisconsin, to California, and beyond have created pilot programs to equip EMTs and cops with naloxone. Even Paul Lepage, the governor of Maine who came out against giving naloxone to family members of drug users, has softened his position. (His office didn’t respond to a request for comment.)


A vial of naloxone, also known by its brand name, Narcan, at the South Jersey AIDS Alliance in Atlantic City, New Jersey. 

The efficacy of the new laws and policies remains to be seen, however, as some advocates worry beat cops either won’t be aware of the changes or won’t follow them. Similarly, the naloxone pilot programs in New York andNew Jersey are funded through asset forfeiture, a controversial policy that allows the police to seize property they believe was connected to illegal activity — even without securing a conviction. “There’s probably not a single better potential use of civil asset forfeiture funds, but it’s a corrupt system,” says VOCAL-NY Policy Director Matt Curtis.

And despite the new laws, advocates say decades of drug-warriorism isn’t going anywhere any time soon. “I’d characterize the embrace of naloxone — coupled with the framing of the opioid epidemic in public health terms, and the repeated mantra from law enforcement that ‘we can’t arrest our way out of this problem’ — as a partial validation of harm reduction but not a full paradigm shift,” says Daniel Raymond, the policy director at the Harm Reduction Coalition. “The urgency of the overdose epidemic is translating into greater access to naloxone, but we’re unlikely to see European–style harm reduction strategies such as heroin prescription or safer injection facilities.”

To see those strategies in action, you don’t have to cross the ocean. But you do have to leave the U.S.

Insite.jpgThere is only one safer (sometimes called “supervised”) injection facility in North America: Insite, in downtown Vancouver, British Columbia. Opened in 2003, advocates in the United States speak about Insite with awe, as a sort of holy grail of harm reduction. Clients there, who sign in with an alias, are legally allowed to bring pre-obtained illegal drugs to the office. They shoot up in a booth, and in the event of an overdose, a trained nurse administers naloxone. “There’s been no overdose deaths at Insite, ever, and they get about two ODs a day,” says Anna Marie D’Angelo, spokesperson for Vancouver Coastal Health, the agency that oversees the facility.

Initially, she says, some businesses and cops in the area weren’t happy about the site. They feared an increase in crime, an increase in overdoses, and an increase in heroin use — none of which came to pass, according to more than 30 peer-reviewed studies specifically on the facility. Neighborhood overdoses dropped 35%, crime rates either stayed level or decreased, and only one of 1,065 people was a first-time injector. “If you go to Insite at 10 a.m., there’s a line of people waiting to get in,” D’Angelo says. “It’s people who have been drug addicts for a long time. There’s not any novice in there.”

She says that if a new user did “show up and is adamant they’re going to shoot up, even after all the education, all the counseling, they have the means and they’re going to go in the alley if we don’t let them in, that’s allowed. But it’s a real minority of cases, that’s not what it’s for.” Insite has a detox program one floor up, which ends up removing much of the red tape that users in the United States face.

Though some advocates in the U.S. express hope that their country will one day have supervised injection facilities, even less controversial methods are by no means universally accepted. Needle exchanges, for example, are still effectively illegal in about half of the states, and federal money can’t be used to fund them. President Obama lifted that ban in 2009, but Republicans in 2011 fought successfully to reinstate it.

Congressman Hal Rogers (R-Ky.), chair of the House Appropriations Committee, was a key part of that fight.The Atlantic previously reported a spokesperson as saying, “Chairman Rogers … is concerned that needle exchange programs only encourage drug addicts to remain addicted to drugs and perpetuate the cycle of drug crime.” His office did not respond to requests for comment, nor did House Speaker John Boehner’s.

Other observers criticize exchange programs for not being aggressive in promoting detox and rehab for heroin users, and suggest a harsher approach. “Using the criminal justice system to force them to go into treatment has proven to be very productive,” David Evans, special adviser to the Drug Free America Foundation, tells me. “The drug courts that do that have an outstanding record of success of freeing people from their addictions.” (Critics of drug courts argue coerced rehabilitation actually expands, rather than lessens, a punitive approach to drug treatment.)

harm reduction kit.jpgSome opponents of harm reduction also express skepticism about expanding naloxone access to family and friends of drug users. “Naloxone can save lives in an overdose situation, but many opioid users do not use with their family,” John Walters, who was drug czar under President George W. Bush, writes in an email. “[T]hey may use alone or in the company of other users, who may not be a reliable source of emergency medical care.” Using alone is dangerous, without question, but available data largely contradicts fears that other users can’t administer naloxone effectively. A 2013 scholarly study found that overdoses are overwhelmingly witnessed by other users, and, in the study, administration of naloxone was 98% effective in reversing the overdose.

At the state level, a recent Kentucky bill that would’ve expanded money to treat heroin addiction failed in part because it included the option for health authorities to create a needle exchange program.

But, as with all prohibitions, banning exchanges doesn’t eliminate them. They just went underground.


The Controversial Answer To America’s Heroin Surge