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‘There’s No Detox When You’re Dead’: Boston Wants Users To Get High Under Medical Supervision

CREDIT: SHUTTERSTOCK/DYLAN PETROHILOS
CREDIT: SHUTTERSTOCK/DYLAN PETROHILOS

Dr. Jessie Gaeta is just trying to keep people from dying.

“This is the struggle we’re facing at this point,” says Gaeta, the chief medical officer at a health clinic that serves homeless people in Boston’s South End. “We just want to save their lives.”

That’s why she’s taped a hastily-made sign onto a door in the clinic’s main hall. “SPOT,” it reads in bold type. “Supportive Place for Observation and Treatment.”

Put simply, SPOT is a room for drug addicts to ride out their high under medical supervision. Lined with couches and reclining chairs, SPOT offers visitors a quiet, safe space to rest after dosing themselves with opiates — a regular sight on the busy street outside. Drugs are not allowed in the room. While patients drift through a heavily-sedated high, often lasting an average of three hours, doctors track their breathing and heart rate. With oxygen IVs and the overdose-reversing drug Narcan on hand — but tucked politely out of sight — doctors can address a dangerous reaction before it’s too late.

Gaeta knows it might sound extreme. But in South End, the opiate epidemic has reached a boiling point.

“This is an option created out of desperation,” she says. “You’d like to look so much further upstream to address the problem where it starts. But there’s no detox when you’re dead.”

“This is an option created out of desperation.”

In the past month, a man overdosed while injecting heroin in a nearby construction site port-a-potty. His body was found eight hours later. Another person high on a mix of opiates stumbled into the busy Albany Street traffic and was quickly hit by a passing dump truck. Just last week, Gaeta’s clinic — the Boston Health Care for the Homeless Program (BHCHP) — hit a new, sobering record: Five patients overdosed on site within a 24-hour span.

SPOT has been open for less than a month, but its popularity has already forced Gaeta to turn people away.

“We’re stuffed to the gills,” she says. “People are bringing in their friends, sometimes carrying them in their arms, now that they know they can trust us.”

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SPOT is the only program of its kind in the country. Unlike mainstream addiction programs, it’s based on a “harm reduction” model, where the priority is treating the negative consequences that come with drug use before tackling the addiction itself. Seen by critics as a way to enable drug use, programs like SPOT have a hard time garnering support in most U.S. cities.

Dr. Jessie Gaeta, inside SPOT after hours, explains how doctors can track patient’s vital signs while they ride out their high. CREDIT: Alex Zielinski
Dr. Jessie Gaeta, inside SPOT after hours, explains how doctors can track patient’s vital signs while they ride out their high. CREDIT: Alex Zielinski

But in Boston, a city hit especially hard by opiates, SPOT has seen surprisingly little pushback. Most residents can tell you about a person they know that’s addicted — a niece who was on the path to an Ivy League college, a classmate they knew in elementary school. For all who are witness to the painful reality of addiction on Boston’s streets, any program that softens the blow is welcomed with open arms. These programs are even respected and supported by the local police and city officials — including Mayor Marty Walsh, whose past battle with alcoholism has made him a fierce advocate for addiction care.

There’s only a pane of glass between SPOT’s occupants and the crowded street outside, where groups of anxious, weary-eyed people wait for a handful of change, a bite to eat, or — if they’re lucky — the fleeting relief of a narcotic high.

But behind the window’s blinds lies a sliver of hope, especially for the public health workers and homeless service providers who’ve seen far too many people die on the street before getting into treatment. If its immediate success says anything about SPOT’s future, the small program could ignite a movement needed to uproot drug addiction’s tightening grip on the country.

Even as opioid-fighting legislation has accelerated to the top of the country’s priority list and become a focal talking point on the presidential campaign trail, most of the proposed solutions target only the first and last steps in the cycle of addiction.

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Legislation focuses on either regulating painkiller prescriptions or expanding rehab programs. But for the thousands of people treading water in between — those who are already addicted, but who aren’t at a point where they can successfully enter treatment — policies are harder to come by. This remains the largest population of opioid addicts in the country.

This growing population of impoverished drug users is extremely visible in Boston’s South End, an area that’s been painfully dubbed the “Methadone Mile.”

“It’s so absolutely in your face here,” says BHCHP Director Barry Bock. “There are oversedated people at every street corner.”

Working in the epicenter of Boston’s opiate crisis, it’s not unusual for Bock to stop and check a person’s vitals on his way into the office to make sure they’re still breathing.

According to a significant 2013 study published by researcher Dr. Travis Baggett, most of Boston’s homeless adults were dying from drug overdoses. That sobering evidence is what spurred the creation of SPOT. The data convinced Brock and his colleagues to change their entire focus.

Now, instead of treating overdose deaths like isolated incidences, they approach the issue more broadly from a harm reduction perspective, doing what they can to keep drug users safe. And so far, there’s been widespread support from city leaders, police officers, and community groups.

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“The police have been wonderful about this,” Bock says. “The first thing they asked was ‘How can we help? Can we bring people to you?’ They’ve really made a commitment to change the path of addiction in the city.”

Residents who live in the South End have also welcomed SPOT’s mission with relief.

George Stergios, the president of the Worcester Square Area Neighborhood Association — South End’s main community group — has watched longtime neighbors move away to avoid the risks tied to a community steeped in addiction. “People passed out on your doorstep, in front of businesses. It’s something nobody wants to see,” he says.

But he’s glad to see what SPOT is doing for the neighborhood, and hopes it will help people stop talking about addicts “like they are this lesser group.”

“I know it takes a while to break down perceptions — but when you actually face the issue, realize that these people are also members of your community, your mind opens up,” he says. “It’s hard not to support any program that will keep people from dying,” Stergios says.

And people are dying. At Addicts Health Opportunity Prevention Education (AHOPE), the city-run syringe exchange program, there’s a corner covered in photos of smiling faces, each paired with short paragraphs of text. These are obituaries. The “Memorial Wall” of people lost to overdose winds around the corner and reaches across the neighboring wall. They’re starting to run out of wall space.

Like most people working in harm reduction, Sarah Mackin wishes her job didn’t have to exist.

Mackin helps run AHOPE, which offers clean syringes, Narcan, blood tests, first aid supplies, medical referrals, and community for the hundreds of drug users in the neighborhood. Inside AHOPE, the only other harm reduction facility in the South End, it’s all too clear why Boston needs a another option.

Nestled between Gaeta’s clinic and the Boston Medical Center, AHOPE is consistently packed wall-to-wall with people in need. Rows of padded chairs and a bottomless carafe of coffee welcome visitors who may be exhausted from a sleepless night or a hit of heroin. The program’s small, tight-knit staff members weave through the crowd to register newcomers, take blood samples, or check in with drowsy-looking visitors.

A sign at AHOPE warns visitors about the dangers of Fentanyl, a deadlier opioid. The memorial wall of visitors lost to overdoses is in the background. CREDIT: Alex Zielinski
A sign at AHOPE warns visitors about the dangers of Fentanyl, a deadlier opioid. The memorial wall of visitors lost to overdoses is in the background. CREDIT: Alex Zielinski

“People come for syringes or for just a cup of coffee — we welcome anyone who comes through the door,” says Mackin, leaning against a counter crowded with Band-Aids, syringes, and gauze. On the wall behind her, a sign shouts in colorful letters: “Do you know what to do if your friend ODs?”

Ideally, the solution would be getting drug users into addiction treatment — or even cutting off their access to addictive drugs altogether. That would eliminate the need for the 135,000 syringes and 3,700 Narcan kits Mackin’s team handed out last year.

But that goal is difficult to achieve. A lot of factors need to align before a person may be ready to enter rehab.

“So much plays into people’s ability to get treatment. You have people homeless, without transportation, with untreated mental health issues, penniless. Last week one of our guys missed a doctor’s appointment just because he didn’t have any clean underwear,” Mackin says. “We can’t force people into treatment here unless they ask for it, unless they’re ready. It’ll only work when you, the individual, makes the decision to change.”

Even when drug users do find themselves ready for that change, plenty of barriers still stand in their way.

“I think the medical community is finally realizing that we have to assess addicts where they’re at.”

In the U.S., the most common form of rehab often starts with the introduction of methadone or buprenorphine, opioid-based drugs that help wean people off opiates by relieving cravings and suppressing withdrawal symptoms. In Boston, like most major cities, free or low-income drug treatment programs come with long waiting lists — asking people for time they might not be able to spare. The out-of-pocket cost for an average 30-day inpatient rehab program in Massachusetts, meanwhile, can range anywhere from $2,000 to $25,000.

In March, Gov. Charlie Baker signed a new law that requires insurance companies to cover 14 days of inpatient treatment — which elicited bipartisan applause. Massachusetts’ new policies to curb addiction have quickly become models for other state and federal officials.

However, only a sliver of homeless users have any kind of insurance. And for those who do, 14 days is a superficial pause if they’re only to return to the same areas rife with drug use afterward. These policies are unrealistic “Band-Aid solutions,” according to Karen LaFrazia, the director of Boston’s largest homeless day shelter, St. Francis House.

“We, as a society, don’t like things that take time. Recovery takes time, especially when you have so many factors working against you,” she says.

While addiction has always been a problem within the city’s homeless community, LaFrazia says this recent swell of opioid addiction has been exhausting. She estimates there are an average of four overdoses per month in St. Francis House’s ten-story building, which also offers low-income housing, vocational training, and a medical center in partnership with BHCHP. LaFrazia now requires her staff to carry Narcan so the building’s overdoses don’t always have to be fatal.

“I think the medical community is finally realizing that we have to assess addicts where they’re at,” she says.

It’s easy to find well-respected harm reduction models in other areas of public health that involve this concept of meeting people where they are. People addicted to smoking cigarettes are recommended nicotine patches to reduce the risk of lung cancer, for example. And anyone who is sexually active is recommended to use condoms to prevent sexually transmitted diseases.

Dr. Karsten Lunze, a professor at Boston University School of Medicine with a focus on global addiction, points out that harm reduction tactics for drug users are similar to the common sense advice he’d give a diabetic patient.

“If I saw someone with diabetes who loved cake I’d ask them: ‘What is realistic for you? I can’t force you to stop eating cake. So how about you eat the cake with less sugar instead?’” Lunze says. “No one wants diabetes. No one wants to be addicted to drugs. But since we have to accept it, we have to find people the best ways to survive.”

Pushing for more progressive forms of harm reduction is often an uphill battle. Programs like SPOT encounter resistance because of the stigma attached to them, says Boston University School of Medicine’s Lunze. That stigma both keeps drug users from asking for help and keeps many Americans from wanting to help them.

Many U.S. lawmakers still believe that syringe exchange programs — the most well-known forms of harm reduction in the country — encourage drug use and crime, despite decades of research proving just the opposite. This belief is often rooted in the government’s long history of linking crime with illicit drug use, a major product of President Ronald Reagan’s “War on Drugs” — and the reason the U.S. prison population had skyrocketed since the 1990s.

The sidewalk outside SPOT on Albany St. CREDIT: Alex Zielinski
The sidewalk outside SPOT on Albany St. CREDIT: Alex Zielinski

Shedding the assumption that all drug users are criminal members of society hasn’t been easy for some lawmakers, even when they’re faced with public health emergencies.

Last March, 74 people in a small Indiana town tested positive for HIV, and public health officials linked the outbreak to drug users sharing syringes. Indiana Governor Mike Pence responded by allowing county health officials to start a temporary syringe exchange program in the area — despite his long-time opposition to the program. But the crisis did little to change his views.

“I don’t believe effective anti-drug policy involves handing out drug paraphernalia. I reject that,” Pence said after making the decision — and added that he’d veto any state legislation proposing a statewide exchange program.

Even in a place like Boston, where so many groups are united in making progress in this area, some of the stigma around drug addiction persists. In April, a local news station aired a segment documenting the state of addiction in the city’s South End that featured clips of people walking down Albany St. in a drug-induced haze and slumped over on the sidewalk.

“These are human beings — brothers, sisters, grandparents — whose deaths are a family tragedy. If that’s what it takes to save their lives, then let’s do it.”

“These people were portrayed as zombies, setting them apart from everyone else,” says Sandro Galea, the dean of the Boston University’s School of Public Health, who met with the station producers after expressing his upset in a Huffington Post editorial. “There is reinforced dehumanization of people with substance use disorders — and we as a community are responsible for changing that.”

But public health experts keep trying. Some have called for a solution that’s even more dramatic than SPOT: legal supervised injection facilities (SIFs), which allow visitors to inject illicit drugs as trained physicians monitor them. SIFs local law enforcement to keep clients safe from prosecution while they’re inside.

“We all don’t want people to use drugs, bottom line,” says Lunze. “But if a [SIF] can lead to less infections and costs, I’m on board. These are human beings — brothers, sisters, grandparents — whose deaths are a family tragedy. If that’s what it takes to save their lives, then let’s do it.”

A few U.S. cities — most recently, Ithaca, NY — have expressed interest in opening an SIF. But that would require changing a cemented federal law, along with the minds of many unsupportive lawmakers still committed to waging a war on drugs. The politics around SIFs still leave many health experts hesitant to publicly support such a controversial program in their area.

“It’s still too emotional a discussion for some people,” Lunze says.

Outside the U.S., however, SIFs have been a reliable piece of at least 66 city public health programs for years, and decades of research have proven their success at eliminating crime, initiating a user’s recovery, and curbing the spread of disease.

The only SIF in North America — Vancouver, Canada’s Insite — was born, like SPOT, out of desperation.

“In 2002, Vancouver had the highest rate of HIV in any industrial city. We were in a public health crisis,” says Anna Marie D’Angelo, a spokeswoman with Insite’s parent organization, Vancouver Coastal Health. “It was our best option.”

In the first two years after Insite opened its doors in 2003, Vancouver saw a 35 percent decrease in overdose deaths in the area. Since then, it’s witnessed a steady climb in users entering rehab programs and a serious drop in HIV transmission in the region. But it hasn’t been easy — D’Angelo said Canada’s major police organization and many conservative members of the parliament still oppose the program.

Despite continuous resistance, the Canadian Supreme Court and other progressive lawmakers have fought to keep Insite afloat with federal funds. D’Angelo says that people come from all over the country to participate in the program.

Some countries don’t stop with SIFs. In the cases where common opioid treatments fail (methadone and buponephrine can often become addictive), sometimes the safest solution for serious drug users is actually prescribing them heroin. Like other harm reduction models, providing users with clean heroin cuts out other risks: the possibility of them injecting themselves with a tainted dose or committing a crime to obtain it. Heroin-assisted treatment has become part of the national health program in Switzerland, Germany, the Netherlands, Denmark, and the United Kingdom.

“We can’t sustainably address this problem without decriminalizing illicit drugs.”

At the far end of the harm reduction spectrum is Portugal, a country that decriminalized all personal drug use in 2001. As a result, the number of drug-addicted adults has steadily dropped, the percentage of drug-related offenders in prison has been halved, and the country’s seen a 60 percent increase in drug treatment users.

While extreme, Lunze says Portugal’s success illustrates how important a role decriminalization plays in getting people into recovery programs.

“People go at great lengths to avoid criminal prosecution,” he says. “This fear means no one will come to us for help or talk to us about their use. They can’t trust anyone. We can’t sustainably address this problem without decriminalizing illicit drugs.”

The United States isn’t going to decriminalize drugs anytime soon. But there are small signs of progress in Boston.

“I’m especially struck by this different doctor-patient relationship,” Dr. Gaeta says.

To her surprise, the wall of distrust between drug users and doctors seems to crumble once people step into SPOT — something that actually leads to huge benefits in the medical community’s effort to better treat addiction.

In BHCHP’s main clinic, patients won’t speak openly because they’re afraid of criminalization. Instead of admitting to their drug use, Gaeta says, many often blame a sleepless night in a shelter or a long day outside for their drowsy behavior.

“Now they come into SPOT and say ‘Okay, I’m taking this, this, and this’,” says Gaeta. “They realize nothing bad is going to happen if they’re honest with us.”’

The city has placed temporary pedestrian warning signs across Boston’s South End, since over-sedated drug users keep walking into traffic. CREDIT: Alex Zielinski
The city has placed temporary pedestrian warning signs across Boston’s South End, since over-sedated drug users keep walking into traffic. CREDIT: Alex Zielinski

This newfound honesty has led Gaeta to uncover a previously unknown trend among Boston’s drug users: No one is just on one drug. Instead, Gaeta and her staff have found every visitor to be on at least three different substances. Most come in with some opiate base in their system, like heroin or fentanyl, but they’ve added another prescription medication on top of it, to boost the high. These drugs target specific health problems that the user usually doesn’t have, which could lead to dangerous — if not fatal — outcomes.

For example, many opioid users add clonidine, a medication used to treat high blood pressure, for euphoric benefits. As a result, Gaeta’s found, some people are coming into SPOT with pulses as low as 30 beats per minute (a normal rate is usually above 60). This combination greatly increases a user’s likelihood of an overdose and could require more than just a dose of Narcan to fight.

“No one’s written about this in medical journals. It’s new data,” says Gaeta. “We’ve created a brand new window of understanding.”

Visitors have also been struck by the level of respect they’ve encountered at SPOT.

A few weeks ago, Gaeta says, a woman was brought to SPOT by a friend, and placed in a reclining chair. As she slipped into a narcotic sleep, Gaeta tucked a pillow under her head. Hours later the woman awoke, disoriented, reaching behind her neck.

“What is this — is this a pillow?” she asked the room. “Are you kidding me? Am I hallucinating?”

“Just seeing that kind of reaction reminds me how important our work is,” Geata says. “Treating people like human beings, forging a relationship with them, that’s the first step to getting them out and in treatment.”

Joanne Guarino knows this reality firsthand. After 30 years of struggling with addiction and living on the streets, Guarino was taken to BHCHP in her 50s, where she began her path to recovery. Now, Guarino lives in her own apartment, works a steady job, and volunteers as a peer counselor at SPOT. She’s able to assure people who pass through SPOT that it will get better.

“They saved my butt,” she says, laughing.

“Treating people like human beings, forging a relationship with them, that’s the first step to getting them out and in treatment.”

Guarino is the first to admit the program initially left her skeptical. “I thought they were crazy — they were going to hurt people,” she says.

But eventually, she realized just how high the stakes were. Now, she spends her time defending the harm reduction model. Recently, when one woman told her SPOT was a form of genocide, Guarino was prepared with a retort. “You know what’s genocide?” Guarino said. “The fact that people are dropping dead on the street and no one’s doing a damn thing.”

Faced with stigma-fueled political opposition and a steady wave of vulnerable people in crisis, it would be easy to lose hope. But no one at any level of Boston’s safety net shows a flicker of doubt or exhaustion in their fight.

St. Francis’ LaFrazia even calls herself an “eternal optimist.”

“It’s easier to be an optimist here than anywhere else in the world, because every day people show up, asking for help. These people are addicted to drugs, they’re sleeping on the sidewalk, they’re struggling with mental health issues. But they still show up.”

“The failure is not on them, it’s on the system,” she adds. “It’s on us to keep them showing up.”