The Washington PostDemocracy Dies in Darkness

Why it’s not ‘enabling’ to make drug use safer

Opposing needle exchanges and insisting people with addiction must hit “rock bottom” flies in the face of reality.

Pop-up injection site coordinator Sarah Blyth with an overdose naloxone kit in Vancouver’s Downtown Eastside, on Jan. 30. (John Lehmann for The Washington Post)
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In the face of an unabating overdose crisis that has already killed more than a half-million people, San Francisco, Philadelphia and Seattle have announced plans to do what was once unthinkable: open centers where people can inject illegal drugs under medical supervision. Many other cities are also debating so-called safe infection facilities (SIFs) — but unfortunately, a common misconception about addiction stands in the way.

SIFs, also known as Overdose Prevention Sites or Supervised Consumption Centers, have operated for years in at least 66 cities in Europe, Canada and Australia. They reduce overdose mortality, cut transmission of HIV and hepatitis C, decrease public injecting and the presence of dirty needles in streets and parks, and even reduce local crime and violence rates — all while improving health. Despite millions of injections carried out by thousands of people, no one has ever died of an overdose at an SIF, according to Brandon Marshall, an associate professor of epidemiology at Brown University, who has studied these programs.

Instead, opponents argue that SIFs “enable” addiction — and that by mitigating risk, they prolong drug use by preventing people with addiction from suffering the consequences needed to motivate them to recover. In 2017, anti-SIF residents and politicians in Seattle organized a ballot initiative to block the city’s SIF plans, which garnered more than 47,000 signatures and qualified it for a vote. (The referendum was later blocked by a judge for procedural reasons).

In an op-ed laying out his opposition, Redmond, Wash., city council member David Carson put it this way: “It’s difficult to see how enabling addicts to continue a terribly destructive lifestyle is compassionate. Every recovering addict will tell you that they had to hit rock bottom before they wanted to change and that desire must drive their recovery.” Similar comments have been heard from opponents in San Francisco, Philadelphia and elsewhere.

The concept of “enabling” comes from 12-step recovery, based on the self-help group Alcoholics Anonymous. The idea is that friends and family must not support loved ones while they continue to use drugs or help them avoid dangerous consequences — otherwise, they might delay “rock bottom.” The vast majority of addiction treatment providers in America teach this perspective, even though there’s no research to support the idea that “enabling” is harmful.

Gigabytes of real-world data show the opposite. In the 1990s, the “enabling” argument was used to fight clean needle programs to prevent the spread of disease — and it helped delay their implementation. Even today, states with growling levels of IV drug use, such as Indiana and Florida, continue to have fights over these programs. Officials in Indiana have shut down several because of moral fears about enabling.

People not wanting centers in their back yards and arguments about the example such programs might set for children also were common. However, European countries that didn’t have strong opposition from a treatment system imbued with the belief “enabling” is bad implemented programs far more quickly.

Cities that moved forward found — and research repeatedly demonstrated — that syringe exchanges neither encourage children to take up drugs nor deter those who are already addicted from recovery. On the contrary, people who participate are more likely to seek treatment, not less.

Yet concern about “enabling” persists, even as syringe access programs are shown to reduce the spread of HIV. New York state saw its infection rate among IV drug users plunge from 50 percent to less than 3 percent after expanding these programs.

While the United States continues to fret over SIFs, countries in Europe in Canada have moved on to other measures, including providing free, pharmaceutical grade heroin to people who are addicted. If recovery isn’t possible unless someone is forced to “hit bottom,” free heroin should keep people from even bothering to try to quit. But that’s not what happens. A review of the now-abundant literature on heroin prescribing in the United Kingdom, Germany, Holland and Canada shows that they improve health, employment and yes, treatment and abstinence rates in these otherwise-intractable cases.

If making life worse for people is the best way to spur recovery, poor folks, homeless people and prisoners should be the most likely to succeed in treatment. But again, research shows that people with more resources and support do better — not those who are in the direst straits.

This shouldn’t be counterintuitive: Addiction is defined by the National Institute on Drug Abuse and psychiatry’s diagnostic bible, the DSM, as compulsive drug use that continues despite negative consequences. The problem is not an absence of suffering but a deficit of hope and alternatives. If stigma, isolation and being ostracized fought addiction, we wouldn’t be having the worst overdose crisis in history now. If horrible experiences made people kick drugs, no one would ever relapse after one bout of cold-turkey opioid withdrawal.

It’s long past time to retire the ideas of “enabling” and “hitting bottom” and let drug policy be guided by data, not a desire to punish perceived immorality. As a person who once struggled with cocaine and heroin addiction, I know that being treated with kindness and respect can feel like a complete novelty during active addiction — and rather than responding by becoming more self-destructive, people typically become less so.

When people feel valued rather than judged, regardless of whether they continue to take drugs, they begin to value themselves more. Once people feel safe and cared for, it’s much easier to make changes that otherwise frighten them. As with needle exchange and heroin prescribing, frequent SIF users are more likely to seek further help, not less.

In medicine, there’s no other group of patients for whom “disabling” and social rejection is a treatment goal: If we truly believe that addiction is a health problem, not a moral weakness, we need to treat it like one and allow SIFs and other harm reduction programs to enable recovery by saving lives.