Overwhelmed by overdoses, clinic offers a room for highs
It has become a grim workplace routine: the “code blue” crackling over the loudspeaker. The all-hands-on-deck emergency response. Then, in more than half the calls, the discovery of a nonresponsive person — blue lips, shallow breathing, and constricted pupils, all telltale signs of a drug overdose.
“It’s happening everywhere,” said Dr. Jessie Gaeta, chief medical officer at Boston Health Care for the Homeless Program, headquartered in the South End neighborhood infamously nicknamed Methadone Mile.
“People literally slump over in the waiting room. . . . At the pharmacy window, in the lobby, in the dental clinic, in the respite clinic,” she said. “Everywhere.”
Alarm over the rocketing fatality rate, and the need to better manage staffing disruptions from all those overdoses, has led Boston Health Care for the Homeless to adopt an unorthodox and controversial plan: On Tuesday, it will open a room where drug users can ride out their highs under medical supervision, with the aim of preventing deaths.
“When you initially hear we’re going to cooperate with someone using heroin, it might be a little shock to the system,” said former state senator Steven Tolman, who served on Governor Charlie Baker’s opioid task force. “But with the level of pandemic we’re dealing with — and I say pandemic because it’s no longer just an epidemic — any effort to get this problem under control is a worthwhile experiment.”
Called the “SPOT,” short for a Supportive Place for Observation and Treatment, the space will be located in a first-floor former conference room, making it easily accessible from the street. It will be furnished with monitoring equipment and up to nine reclining chairs, and will be staffed by an addiction nurse and case manager. Visitors will not pay for the service or be required to give their names, and will be accepted on a first-come, first-served basis.
Many emergency rooms and needle exchange programs have areas where people can rest while coming down off a high, but Boston Health Care for the Homeless officials believe it is the only place in the nation to supplement that service with medical monitoring.
The site will not permit people to inject illegal drugs since that would violate federal law, although supervised injection facilities exist in several other countries. Instead, patients will be monitored and medical staff will intervene if needed, most likely with the overdose-reversal medication Narcan.
Still, critics consider the move wrong-headed and counterproductive.
“It’s ridiculous,” said Brianne Fitzgerald, a nurse practitioner at Boston Medical Center and the Gavin Foundation, a South Boston substance abuse treatment center. “It’s one of the highest forms of enabling, and it gives up hope on people who use IV drugs.”
The health care system, she said, should be putting more emphasis on getting addicts off drugs rather than “dumbing down the expectation that people will get well.”
In Massachusetts, opioids — including heroin, as well as prescription painkillers such as oxycodone and fentanyl — are now claiming at least 100 lives a month. Users often follow a familiar route from prescription drug addiction to cheap, potent heroin, which can be purchased for as little as $10 a hit.
Meanwhile, demand for treatment far outstrips supply in the state, a problem worsened when the Long Island bridge closure in 2014 resulted in the shutdown of numerous shelters and addiction treatment facilities that had operated on the island.
Boston Health Care for the Homeless’s overdose room was borne of a combination of practicality and desperation. Its staff was responding to overdoses two to five times a week in the building, and even more frequently outside. The organization began considering a so-called safe space for drug users after examining updated data on mortality rates for the city’s homeless population.
“What we saw was shocking to us,” Gaeta recalled.
Opioid use is now the number one killer of Boston’s homeless population, causing 80 percent of all deaths. That prompted the nonprofit to offer more addiction treatment services at its clinics throughout the city and prescribe fewer opiates for patients in need of pain relief. But overdose deaths continue to rise.
Exacerbating the situation, hundreds of homeless residents and addicts displaced from Long Island were relocated to the neighborhood surrounding Boston Health Care for the Homeless, which sits at the corner of Albany Street and Massachusetts Avenue.
As a result, Gaeta and her staff — many of whom now carry Narcan at all times in case they encounter someone in distress — must increasingly respond to overdose emergencies, hampering the facility’s daily operations; it offers free primary care services, as well as counseling and psychiatry.
A designated overdose room, they hope, will let medical personnel respond earlier and more efficiently, develop relationships with patients who may eventually seek treatment, and keep addicts from dying in alleys, on street corners, and in public restrooms.
Many drug abusers, Gaeta acknowledged, will not be coherent enough to seek out the room, and are more likely to be walked into the site by friends, passersby, or medical personnel. News of the overdose room, which is meant for people in the immediate vicinity of the facility, is being spread mostly by word of mouth.
“I know people are very worried about the enabling issue,” Gaeta said, “but this is harm reduction. We know that people are continuing to use. We know that people are continuing to die. Our goal is to save lives and make it less dangerous while people continue to use.”
The Boston Police Department did not respond to requests for comment, but the plan has the backing of the Boston Public Health Commission and the Massachusetts Society of Addiction Medicine, whose president-elect, Dr. Michael Bierer, said that “providing safer environments for people who are going to use anyway is a pragmatic and very reasonable approach.”
Bierer, an addiction specialist at Massachusetts General Hospital, dismisses concerns that the room could encourage poor behavior, citing studies showing that despite similar fears about needle exchange and condom availability programs, that didn’t happen.
“This behavior is going to go on,” Bierer said. “It’s part of our environment, and what we need to do is save lives.”
With the opioid crisis continuing to escalate, even some skeptics are willing to give the idea a chance.
“Sure, let’s try it,” said John Hoving, a social worker at the Gavin Foundation, “but I just don’t see it as being one of the real solutions.
“So many times I’ve heard people say they were given Narcan and the first thing they did next was get high again because the Narcan ruined their high. So are we preventing them from dying, or are we just delaying it?”
Ron Hill, 68, a recovering addict who lives in Roslindale, shares those doubts.
“We keep putting a Band-Aid on a sore,” he said. “There’s no long-term treatment for these folks, and that’s why they keep using — they’re using at Cumberland Farms, 7-11, McDonald’s, anywhere there’s a bathroom — and that’s why they keep dying.”
The chief executive of Boston Health Care for the Homeless, Barry Bock, said he is aware of those views and has been meeting with neighborhood groups to hear their concerns.
“I think we wish the same thing,” he said of Hoving and Hill’s perspectives. “I wish we didn’t have a need for the SPOT. I wish there were more services and treatment. But I do think we’ll be able to get some people into treatment, and the ultimate goal is to help people.”