Health Care Workers for Supervised Consumption Spaces Release Open Letter

To: Mayor Ed Murry, King County Executive Dow Constantine, King County Council, Seattle City Council, King County Board of Health

From: Health Care Workers for Supervised Consumption Spaces Coalition – Seattle/King County

We write to you today to express our strong and urgent support of supervised consumption spaces (SCSs), referred to as Community Health Engagement Locations (CHELs) in the King County Heroin and Opiate Overdose Task Force final report.

The Health Care Workers for Supervised Consumption Spaces Coalition launched in December of 2016 to draw attention to the urgent need for this evidence-based harm reduction service. We are over 100 nurses, doctors, social workers, case managers, and public health professionals who work on the front lines and see the harms caused by outdoor drug use to our patients, clients, and neighbors on a daily basis. We observe the ways in which our health system fails those living on the margins—service centers are inaccessible to those without secure housing or transportation, care options are rarely holistic and often abstinence-focused, and stigma still prevents many from reaching out to get the help they need.

As health care workers, it is our duty to do everything in our power to minimize the harm experienced by those we serve. It is also our duty to advocate for the change we know is required for them to have access to every available path toward healthier living. In the midst of the opiate epidemic, the King County Task Force has come up with a comprehensive and interconnected set of interventions that represent our community’s best chance of addressing this complex issue from every angle. Supervised consumption spaces are an integral part of this, as they are designed for our patients who are most excluded from the system—the ones who have no care options that work well for them, and who are dying in alleys and on stoops as a result.

We must recognize that if we hesitate to implement supervised consumption spaces, we are making a moral choice. Each time a person uses drugs in a public park when we could have given them the option to use in a private, indoor space with clinical supervision and connection to social services, an opportunity is missed and a risk is incurred to that person and to the community at large. The necessity of supervised consumption spaces is well established, and we have outlined some of the most pertinent reasons for bringing them to our community. It is our coalition’s position that Seattle-King County cannot afford to stand by out of trepidation while opportunities for saved lives, reduced harm, and improved health are missed.

1. Naloxone distribution is necessary but not sufficient

Naloxone saves lives in the event of an overdose by reversing the effects of opiates. Expanding community access to naloxone is a vital component of the Task Force recommendations, but it is only one part of a comprehensive approach. There are those who claim that naloxone distribution alone is sufficient to curb the opiate overdose epidemic. It is necessary. It is not, however, sufficient to address the various harms caused by drug use. 

Naloxone can save a life, but it alone cannot change one. Behavior change happens gradually, and most often through relationships. Naloxone can keep someone alive in the moment, but it cannot refer someone to treatment, cannot talk to someone about their drug use, cannot educate someone about how to use more safely and minimize risks such as endocarditis or soft tissue damage.

In a supervised consumption space, not only can someone who experiences an overdose be saved by vigilant staff, but a myriad of other risks can also be mitigated. Hand washing stations and a hygienic environment can help prevent bacterial infection, clean supplies can help prevent transmission of HIV and Hepatitis C, and education from a knowledgeable health care provider can help prevent infections, abscesses, and other harms associated with poor injection practices. Through repeated interaction and the development of trusting relationships, health care workers are better able to serve those deemed “service resistant”, better able to help someone stop or reduce their drug use, better able to promote behavior change, and better able to treat the whole person, not just a symptom of substance use disorder.

2. Recovery is not linear and treatment does not replace the need for harm reduction services

The moment someone would like to enter treatment, be it methadone, buprenorphine, or
otherwise, it is imperative they be able to do so. However, many individuals find that when they finally have the commitment and support necessary to enter treatment, there are no options available and are instead put on a waitlist. While treatment is often one’s best chance for achieving sobriety, it is important to note that recovery is rarely linear and abstinence is not a cure all.

At any given point in time, a significant portion of the population struggling with substance use disorder is not ready or able to access treatment. We know that a willingness to engage in treatment often ebbs and flows and that successful entry into a program is often a matter of being at the right place at the right time. Our priority for these individuals must be to ensure their safety and wellbeing so that when they are willing to enter treatment, they are able to do so. People who die before they access treatment never have the opportunity to do so and safe consumption spaces have a proven track record of preventing overdose deaths.

Substance use disorder is defined as a chronic, relapsing disease. Just as it takes many people multiple attempts to stop eating sugar, drinking caffeine, or smoking cigarettes, relapse is a common experience for those seeking to stop their drug use. Thus, if relapse is an expected detour on the journey to sobriety, it is our responsibility as providers to help people reduce the risk by anticipating and planning for it. Data shows us that people are at heightened risk for overdose immediately following a period of sobriety due to diminished tolerance. With this in mind, it is essential that we provide services to keep individuals safe during this risky time and SCSs are an essential part of our toolbox. Without a safety net, without a place where they can seek help and services without judgement when a relapse occurs, all too often individuals retreat to some of the least safe places possible out of shame, fear, and embarrassment. When health care workers are provided the opportunity to engage someone who has experienced a relapse, the chances of that person achieving a better outcome can only increase. Likewise, when someone who has experienced a relapse has the opportunity to stay engaged in their health care – even while they use drugs – their outcomes can only improve.

Harm reduction is often conceived as meeting individuals where they are without judgment and providing the services they need in the moment to improve their health. Harm reduction and treatment for substance use disorder are not in opposition to each other. They are part of the same spectrum of services, and they work together to reduce the harms and complications of drug use. Thus, whether a patient is on the waitlist for a treatment center, has recently experienced a lapse in their sobriety, or is simply not yet ready to move towards sobriety, SCSs help ensure that they live another day and are provided another opportunity to move towards a healthier life.

3. Stigma is counter-productive and does not promote health

A state senator recently went on the record claiming that to help people who use drugs, we should increase the stigma surrounding drug use. Evidence shows that stigma does not promote health or health-seeking behaviors, such as seeking treatment, but actually increases harm. As health care workers, we see daily the danger and shame that stigma can produce. Stigma can cause people who are in recovery to feel immense shame for relapsing, leading them to use alone when they do relapse, thereby dramatically increasing fatal overdose risk. For many people who are living with severe substance use disorder, life is already challenging and difficult. Making life more difficult through stigma is unlikely to improve outcomes. Syringe exchange and
supervised consumption spaces save lives and save money. Stigma does not.

In conclusion, the King County Heroin and Opiate Overdose Task Force recommendations form a comprehensive response to the opioid epidemic. The recommendations work together to create a continuum of care that can help move people who seek treatment into it as quickly as possible while also promoting health and safety for those who are not yet ready to do so.

Health care should be determined by the evidence and the needs of the population, not politics, fear, or stigmatization. As health care workers, we strongly support supervised consumption spaces because the evidence strongly supports supervised consumption spaces and because we know that it will aid our patients and clients in leading healthier, fuller lives. Now, more than ever, we must stand behind science, evidence based practices, and compassionate care. We ask that you fully fund and implement the Task Force recommendations, including the recommendation for supervised consumptions spaces with the speed required in an emergency. Our patients’ and clients’ lives depend upon it.

Sincerely,
Health Care Workers for Supervised Consumption Spaces

L. Paul Gianutsos, MD, MPH
Dan Otter MPH, BSN, RN
Katie Heidere, MSW, Disease Intervention
Specialist
Anuj Khattar, MD
Christine Steele, ARNP
Gregory Maddox, MD
Sarah Stronghorse Anderson, MA
David Sapienza, MD
Patrick Henry, PharmD
Jennifer Fritschy, RN
Shoshana Aleinikoff, MD
Nathan Kittle, MD
Hailey Wilson, MD
Socia Love-Thurman, MD
Liz Rambus, RN
Darin Keuter, LMHC, CDP
Christian Eaton, MD
Amy Hagopian, PhD
Carolyn Wakeman, MD
Matty Whyte, RN
Hetty Hei-Wah Wong, MD
Jamie Felton, Nursing Student
Julia Rosenfeld, Lead Case Manager
Benjamin Lang, MPH, MD
Lauren Sonderegger, MD
Michael Ninburg, MPA, Executive Director
of Hepatitis Education Project
Rachel Nickel, MSW, LICSW
Maryross Olanday, MSW
Angelica Bedrosian, MSW
Chelsie Porter, MPH
Stephanie Ngo, MD
Jessica Guh, MD
Camille Johnson, MD
Gretchen Mjelde, MD
Lilian Chan, MD
Jim Walsh, MD
Vania Rudolf, MD
Donna Livingston, RN, BSN
Amelia Bertozzi-Villa, MPH
Madeline Turner, MD
Jacqueline Wong, MD
Lauren Lawler, MD
Elizabeth Loft, MD
Glenna Martin, MD
Shannon Waterman, MD
Brett Bell, MD
Kristin J Anderson, MD, MPH
Summer Scavone, MD
Mikaela Alger, MD
Laura Krinsky, MD
Patrick Gemperline, MD
Jayne Taylor Gaubatz, MD
Bryn Chowchuvech, MD
Marie Hennelly, MD
Jeremia Bernhardt, MD
Trevor Dickey, MD, MPH
Lisa Chan, MD
Erin Cooley, MD
Jen Flament, MD
Kirsten Hansen-Day, MD
Collette R. Harris MD, MS
Barry Saver, MD MPH
Amy Chabitnoy, MD
Ally Zaballa, MD
Sunil Kumar Aggarwal, MD, PhD,
Palliative Medicine Physician, Medical
Geographer, UW Affiliated
Chanda Moellenberg, RN, MPH
Pamela Williams, ARNP
Tranisha Arzah, Peer Advocate
Lily Alexander, MPH
Chloe Gale, MSW
Ashlin Mountjoy, MD, MPH
Carolanne Sanders, MPH
Joseph Friedman, MPHc
Claire McNellan, MPHc
Geneva Kelly MPH
Kevin McCarthy, PhD
Steve Kroiss, PhD
Laina D Mercer, PhD
Luis Manriquez, MD
Paige R. Hulsey, BA Public Health
Malaika Schwartz, MPH, Research Scientist
at the UW Department of Family Medicine
Timothy Kelly, Medical Student
Courtney Large, B.A. in Public Health
Cathy Speelmon CDP
Tracy Roberts, RN
Brenda N. Martinez, MPH
Jessica Mogk, MPHc
Robert Platt, Medical Student
Alaina Butler, Medical Student
Kit Wu, Medical Student
Amanda dos Santos, Medical Student
Darla Mosse, RN, BSN
Chad Dahlman, RN, BSN
Nick Schultz, RN, BSN
Natalie Andrews, RN, BSN
Phillip Bergreen, RN, BSN
Allison Greaney, MD/PhD student
Elizabeth Polsin, Medical Student
Brendan Korb, Medical Student
Andy Wen, Medical Student
Paul Zemann, HIV & STD Program, Public
Health Seattle & King County
Chris Cates, REACH/Vital Care Manage
Mandy Sladky APHNc
Francesca Collins, MPHc
Heather Gates, MSN ARNP
Emily Henderson, Community Health
Outreach RN
Sarah Marris-Swann, RN
Cecilia Goetz MPHc
Antoinette Sarge, MPHc
Tony Ting, Disease Modeler
Elizabeth Reed, Medical Student
Melyssa McCown-Barnard, Medical Student
Amanda TeBlunthuis, Medical Student
Elizabeth Chang, Medical Student
Emilie McIntyre, Medical Student
Melissa Carpenter RN, BSN
Harrison Kalodimos, MD
Samantha Masaki, MD
Caitlin Bever, PhD, Global Health
Researcher
Kyle B Gustafson, PhD, Global Health
Researcher
Milen Nikolov, PhD, Global Health
Researcher
Kristine E Jones, PhD, Global Health
Researcher
Christian Selinger, PhD, Global Health
Researcher
Nicholas Wang, Medical Student
Caylin Cheney, ARNP Student
Thomas Leary, EMT
Jill Yang, APCHNc
Nathaniel Matthews-Trigg, MPHc
Caroline Johnson, BSPH, MPHc
Richard Waters, MD, Site Medical Director,
Downtown Homeless Programs,
Neighborcare Health (views his own, not
necessarily of his employer)
Joyce Farrell, ARNP HMC Medical Respite
Jesse Rawlins, MSW
Aleks Martin, Project NEON/Seattle
Counseling Service
Julia Daining, RN
Krystal Koop, MSW
Ryann Martinek, MPH
Leslie Brooks, PA-C, FWAM
Anna Bershteyn, PhD, Global Health
Researcher
Brittany Hagedom, MBA, Global Health
Researcher
Michael Famulare, PhD, Global Health
Researcher
Nicole Price, Program Manager
Joshua A Wallace, E.D., Seattle Area
Support Groups and Community Center
Emma Chambers, MSWc
Mandy Altman, MPA
Frank Chilelli, COO, Hepatitis Education
Project
Tarra Simmons, RN, BSN
Kelley Craig, CDP, REACH Co-Director
Nika Sulakvelidze, MS-2, UW School of
Medicine
Jamie Smeland, MPH
Malin Hamblin, MSWc, Public Health
Needle Exchange
Arman Altug, MSW
Coralie Meslin, FNPc
Erin Gilmer, BSW, NS
Asiya Shoot, LAc, ARNPc
Katherine Ly, MPHc
Jerzy Eisenberg-Guyot, MPH, PhDc
Ryann Milne-Price, MD/MPHc
Kelly Brewer, RN
Sofi Harnish, MA-C
Thea Oliphant-Wells, MSW
Vanessa Zsadanyi, BA, Nursing Student
Alyssa Hummel, Medical Student
Lee McKoin, King County Public Health
Needle Exchange Volunteer
Emily Less, MPHc
Heather Barnett, MD, PhD
Isabel Haggerty, BSN Student
Nicholas C. Markadakis, Third Year
Medical Student
Sara Marquis, MPHc,
Jahn Jaramillo, MPHc
Shane Collins, Fourth Year Medical Student
Lorelei Walker, PhD, MPH
Jonathan Halldorson BSN, RN
Sean Paull, BSN, RN
Maureen Oscadal, RN
Keith T. Johnson, CPC
Trevor Evans, CDP
Kevin Kogin, Health Educator
Angelina B., Health Educator
Melvin E LaBelle III, MA
Kaye Ramaekers, LICSW, CDP
Benjamin Beach, MSW
Ada Lin, MPH
Jessica Bielenberg, MPH
Trecia O'Neill Erlich, MPH
Kira McCoy, MPH
Alexis Maister, MPH
A. Gita Krishnaswamy, M.Ed., MPH, Public
Health Faculty
David Chen, Medical Student
Tiffany Rose Jenkins, Medical Student
Clara Bertozzi-Villa, Medical Student
Daniel Low, MD
Jonathan A. B. Motts, MD
Sean Hemmerle, Community Health
Outreach Worker
Emily Katz, BSCN RN
Mark Dailey, BA, DESC Case Manager
Steven Weir, BA, DESC Case Manager
Juliann Clark, BA, DESC Case Manager
Brittany Meek, MS, LMHCA
Sarah Wolfer, MSW, LICSWA
Tarek Sandarusi, BA, DESC Case Manger
Justin Stamschror, MD
Elyse Anderson, MA, DESC Case Manager
Savannah Goguen, BA, DESC Case
Manager
Allison Smith, BA, DESC Case Manager
Regan Rowell, BA, DESC Case Manager
Carrie Reinhart, RN, MSN
Jasmine Kaneshiro, RN, BSN
Robin Ginnis, MSW, LSWAIC
Addy Adwell, RN BSN
Petra Potts, LPN

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