To measure the full toll of the opioid epidemic on Massachusetts, you must first understand one thing: Death is just the beginning.
Opioid-related overdoses have killed over 2,000 people in Massachusetts in each of the last two years, according to estimates from the Department of Public Health. But for every death, an untold and significantly larger number suffer, grieving lost loved ones or living with their own addiction. Some contract HIV or other diseases with lifelong consequences.
But even that is not a full accounting. Those who have devoted their lives to this crisis bear a heavy emotional burden, too — one that is rarely discussed.
“The thing that people don’t talk about is how traumatic it is . . . for us as health care providers,” said Dr. Kim Sue, who recently finished her primary care residency at Massachusetts General Hospital’s Charlestown Primary Care Center. Sue is now the medical director of the Harm Reduction Coalition, a national advocacy group.
Overdose victims — young, otherwise healthy patients suddenly dead — are “much more debilitating than I thought they would be,” Sue said.
It would be some comfort to think that we are doing all we can to keep patients alive. But we are not.
Despite a strong push from advocates and some movement in the Legislature, a proposal to begin experimenting with a controversial but lifesaving treatment strategy is on hold, possibly for years. Supervised injection facilities, or SIFs, provide a safer place to use drugs — a place where needles are clean and sterile, and where an overdose can be quickly treated by a professional.
SIFs are widely supported by doctors on the front lines of addiction treatment who point to mountains of evidence from other countries suggesting that they save lives, increase access to treatment, and even reduce costs to taxpayers.
Opponents have no such evidence. They lean on pop psychology concepts like “normalization” and “enabling” and mistake the powerful disease of addiction for something that can always be overcome by simple willpower.
But with 2,000 deaths a year in this state, fatal overdoses are already sadly normal. And if “enabling” means shielding people from the full consequences of addiction — and those consequences are death — then isn’t that a good thing?
Last month, as the state Senate considered a proposal to authorize an SIF pilot project, US Attorney Andrew Lelling issued a statement effectively threatening anyone who would use or work at such a facility with criminal charges.
“Providing a sanctuary to accommodate risky and lethal illegal drug use undermines all of the hard work of treatment providers and law enforcement across the Commonwealth,” Lelling’s statement said.
Never mind that the very treatment providers he cited have been clamoring for SIFs for years, including a thorough study by the Massachusetts Medical Society. The statement appeared to stop the proposal in its tracks.
“The only way this is going to change is at the federal level,” said state Senator Barbara L’Italien, who had included the SIF pilot in an opioid bill.
In an interview with WBUR, Lelling went even further.
“There is no convincing evidence that I have seen that supervised injection sites lead to a larger number of addicts seeking treatment, to get away from the addiction, or that supervised injection sites reduce the number of overdose deaths in a given community,” Lelling said, according to a transcript.
Lelling is welcome to say that he thinks they are “a terrible idea,” as he did in the same interview. He’s free to point out that possessing illegal drugs is, well, illegal. That part happens to be his job, though he’s also opted — wisely — to look the other way on marijuana. But to claim that he’s seen no convincing evidence that they work? Well, you sort of have to wonder where he’s been looking. Supervised injection facilities have been up and running in Canada, Australia, and other countries for years and have been studied, studied and studied again. Do they not have Google in the US attorney’s office?
To be helpful — and OK, maybe a little annoying — I sent along a study for Lelling, to his press person. Then a few more. Then more. After the third e-mail, Lelling’s spokeswoman wrote back.
“The US attorney was very clear. Supervised injection sites would violate federal law and employees and users would be exposed to criminal charges regardless of any state law or study. We do not have any further comment.”
Pretending that supervised injection facilities don’t work is convenient. Because stripped of that veneer of dispassion, the arguments against them aren’t just ill-informed, they’re callous. They’re deadly.
“Some of the most tragic cases are when it really feels like the system has failed,” said Dr. Sarah Wakeman, an addiction medicine specialist and medical director of MGH’s Substance Abuse Disorder Initiative. For 10 years, Wakeman cared for a man with a severe heroin addiction. He bounced in and out of treatment, until one day he was found dead of an overdose between two parked cars.
Whether that man would have eventually found his way back from addiction is impossible to know. But if he’d had a safe place to use, instead of crouched on the curb, he would have at least had a chance.
“Those deaths are really senseless,” Wakeman said, “when it feels like we could be doing more and our hands our tied.”
And yet here we are, tying the hands of the people doing some of today’s most challenging and necessary health care work.
In June, the New England Journal of Medicine published an essay by Harvard medical student Leo Eisenstein, who argued that feeling powerless in the face of a health care crisis like this is a pretty good recipe for burnout.
Physician burnout has in recent years come to focus on the endless bureaucratic tasks dominating doctors’ time. But it was originally understood in a clinical setting. There, an endless stream of patients arrive with underlying problems that are social or societal — things no doctor can cure. That can wear you down worse than any number of hours of data entry.
“If individual powerlessness is the crux of this source of burnout, then organizing toward collective action should be part of the solution,” Eisenstein wrote. He uses the example of the coalition that has emerged around supervised injection sites, called SIFMA NOW.
Through SIFMA NOW, and through the Massachusetts Medical Society, dedicated doctors in the trenches are telling us what they need.
We need to listen.