On June 12th, the esteemed, powerful, and generally staid America Medical Association came out in support of piloting safe injection facilities (SIFs), a truly encouraging sign that organization is ready to embrace research-based strategies to address drug problems in U.S. In doing so, they followed the lead of the Massachusetts Medical Society, which recently published a report that reviewed the evidence-base supporting the efficacy of SIFs.
Supervised injection facilities, also know as safe consumption spaces (SCSs), are controlled health care settings where people can more safely inject drugs under clinical supervision and receive health care, counseling, and referrals to health and social services, including drug treatment. SCSs operate in at least 68 cities around the world, but there are currently none in the U.S., though several municipalities are considering opening them.
The data are clear. SCS programs reduce overdose and the transmission of blood borne diseases and increase access to drug treatment, and there is no evidence that they increase drug use or drug-related crime. In a field where fear, misinformation, and stigma often drive policy, the AMA’s reliance on research and data are welcome.
The statement from the AMA is significant because historically many in the medical profession have shied away from addressing issues of addiction. Following the Harrison Narcotics Act of 1914, when doctors were explicitly prohibited from using pharmaceuticals to treat addiction, the drug treatment system developed relatively independently from mainstream medicine. For example, methadone -- until recently the primary medication available for the treatment of opioid addiction—is governed under a completely separate and highly regulated, bureaucratic and stigmatized system from medicine.
This historical separation means that many doctors are simply not adequately equipped to address addiction. Despite the prevalence of substance use problems, separate courses in addiction medicine are rarely taught in medical school, and experts in the field have bemoaned the insufficient education and poor quality of addiction services provided by most physicians. For example, less than one percent of primary care doctors are certified to prescribe buprenorphine, a life-saving medication used to treat opioid dependence. It wasn’t until 2016 that the American Board of Medical Specialties officially recognized Addiction Medicine as a medical subspecialty. Not surprisingly, research has also documented that doctors have many of the negative attitudes and stereotypes about people who use drugs held by the general public.
In recent years, there has been a renewed effort to by some to overcome the divide between addiction treatment and medicine and move addiction treatment into the medical mainstream. More training is underway, and with the failure of the criminal justice-driven strategies of the drug war growing ever more apparent (along with the perception that the opioid crisis is affecting predominantly white communities), policymakers and the media have increasingly framed addiction as a public health and/or medical problem more appropriately addressed by medical professionals than law enforcement. In addition, harm reduction services to help people who are actively using drugs -- once seen as highly controversial -- have found growing acceptance as an evidence-based solution to drug problems, as the AMA’s recent statement on SIFs makes clear.
Unfortunately, in the same statement, the AMA also revealed the limitations of the American medical establishment in understanding drug policy and the needs of people of use drugs. Appropriately concerned about the emergence of novel psychoactive substances (NPS), drugs that seek to mimic the effects of traditional illicit substances, the AMA said that they support a “multifaceted, collaborative multiagency approach to combat NPS.” They cite some important public health measures, such as surveillance and early warning systems, but then make the misstep of supporting legislation that would “require the Attorney General of the United States to assign Schedule I classification to approximately 250 dangerous new synthetic substances identified by the Drug Enforcement Administration since 2012.”
The problem is that the prohibition of NPS has actually led to their proliferation. As soon as one substance gets banned, dozens of more substances—about which even less is known and which are potentially even more dangerous -- are developed to skirt the ban. In addition, such bans lead to the criminalization of people who use these substances saddling them with a life-long criminal record and creating barriers to education, housing, and employment. These bans also make it nearly impossible for researchers to study these substances – some of which may actually be helpful in treating addiction or other medical conditions. At a minimum, we need research to study the health impacts of these drugs. By supporting this kind of ban, the AMA is turning its back on research and turning towards strategies we know don’t work.
The AMA is to be applauded for embracing the evidence-based approach of SCSs, which if opened in the U.S., will undoubtedly save lives. But clearly the education of the medical profession regarding addiction is incomplete. When it comes to NPS and other areas of drug policy, they should do what they did in recommending SIFs -- follow the evidence, always opting to ground drug policies in public health, not punishment.
Jules Netherland is the director of the Office of Academic Engagement at the Drug Policy Alliance.