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Can an opioid vending machine help addicts to stop using?

‘The Canadians are working from the principle that the drug supply has become so tainted and is so dangerous for their citizens that they would rather start by keeping them alive and working from there,’ said an associate professor of medicine at the University of California San Diego

In this April 12, 2017, photo, Trac-B Exchange program manager Chelsi Cheatom demonstrates how to use a needle vending machine at the Southern Nevada Health District in Las Vegas. Several communities are trying harm-reduction techniques like needle exchanges, opioid vending machines and even safe injection sites in the face of the opioid epidemic.
Elizabeth Brumley, Las Vegas Review-Journal

SALT LAKE CITY — Imagine a vending machine that sells drugs to heroin addicts. Could something that simple cut crime rates and overdose deaths? Could it help users to overcome their addiction?

Vancouver hopes so. The Canadian city is testing MySafe, a machine that that looks like an ATM but uses biometrics to match addicts to their prescriptions before dispensing a clean dose of hydromorphone — an opioid known as Dilaudid. The dose is intended to satisfy the user’s craving and stave off withdrawals without the risks associated with buying and using street drugs like heroin.

Canada, like the United States, is in the middle of a serious opioid epidemic. As addiction-related crimes and deaths continue to climb, Vancouver is at the vanguard of remedies focused on harm reduction rather than enforcement, with programs like needle exchanges and safe injection sites.

Experts hope the MySafe pilot program will show whether making pharmacy-grade drugs accessible can, perhaps counterintuitively, reduce opioid addiction and its ripples.

Dr. Brent Kious, an ethicist, psychiatrist and instructor at the University of Utah, said opioid-directed harm-reduction efforts are measured by outcomes not just for individuals but for society. It’s not just whether fewer addicts die, but also if they are less likely to buy and use illegal street drugs, if they avoid dirty needles that can spread HIV or hepatitis C, and if they commit less crimes to support their habit.

Harm reduction can be controversial. Critics say needle exchanges and safe injection sites give tacit approval to harmful, illegal activities like drug abuse. Others call them a useful step in helping addicts to recover.

“I think the Canadians are working from the principle that the drug supply has become so tainted and is so dangerous for their citizens that they would rather start by keeping them alive and working from there,” Peter Davidson, an associate professor of medicine at the University of California San Diego, told the Deseret News. “They are coming at it from the view that this is a public health emergency and we have to solve the immediate crisis. Then we will work out what to do next.

“No one is suggesting this is ideal.”

Massive dilemma

More than 702,000 Americans died of opioid overdoses between 2000 and 2017, the last year with full data, according to the Centers for Disease Control and Prevention. Canada’s problem is just as bad. In Vancouver alone last year, 395 people overdosed and died, prompting an epidemiology professor at the University of British Columbia to propose the vending project, The Guardian reported.

Opioid addicts become physically dependent. The drug that once got them high is now necessary to keep them from getting dope-sick and sliding into symptoms of withdrawal, which can be brutal. Many turn to street drugs like heroin when their prescriptions run out, but a contaminated supply or variation in purity levels can lead to overdose and death. The idea behind harm reduction is to mitigate those risks to buy addicts time to get treatment and hopefully recover.

Vancouver was the first city in North America to create a safe injection site where heroin users could inject and be monitored by medical professionals capable of reviving them from an overdose. Other programs prescribe Dilaudid or pharmacy-grade heroin to addicts.

While Canada and Europe have experimented with such measures, few U.S. efforts are officially sanctioned and there are fears a federal crackhouse law could be used to prosecute safe injection sites. Though at least one federal judge in Philadelphia said the law would not apply, prosecution has been threatened.

There’s a ton of disagreement about what to do or what works.

Dr. Mark Ujjainwalla, who runs Recovery Ottawa in eastern Canada, told The Guardian those using illegal drugs need treatment for their addiction, not easier access to drugs. “If you were a patient addicted to fentanyl (and came to me), I would say: ‘OK, I will put you in a treatment center for one to three months, get you off the fentanyl, get you stable, get your life back together and then you’ll be fine.’ Why would I want to give you free heroin and tell you to go to a trailer and inject?”

Others say keeping people alive provides time to find answers. And they believe those receiving such help are more likely to stop using opioids than those who chase street drugs.

There are swaths of agreement: The opioid epidemic is growing. Experts agree addicts are unlikely to stop without some kind of intervention. And they note existing services already can’t meet the need and most people don’t have access to those services anyway.

Strong studies could answer some of the questions.

“Because the efficacy of a program is such an important component of determining whether it’s the right thing to do, you have to make sure you’re doing really good science and have a lot of mechanisms in place to measure its effectiveness,” Kious said.

Helping addicts stop

Safe injection sites exist to prevent overdose deaths, not to treat addiction, Kious said.

Opioid replacement therapies using drugs like Suboxone and Methadone are the most studied and proven treatments for opioid dependence, he said. And new measures may lead addicts to them.

Besides providing a better-sourced form of opioids and perhaps preventing crime related to getting drugs, the vending machine might provide a bridge to replacement therapies, Kious said. Controlled access may increase the likelihood users will switch to something like Suboxone, or enter a 12-step program or try therapy.

Providing a safer, more regulated alternative that also involves interacting with the health system in beneficial ways could change the shape of addiction “so that it becomes less maladaptive and people are better able to function,” said Kious.

In the late 1980s, Switzerland started prescribing drugs to people who had failed at least two other forms of treatment. They found people who were prescribed heroin were more likely to stop using drugs in the next 12 months than people who were on the street.

“Their data suggested that when you’re on the street using drugs, your entire life is centered around where do I get the next $20 so I can get the next dose of heroin so I don’t feel so sick. That keeps your mind very busy. When suddenly you don’t have to answer that question — you know your drug is coming from the clinic down the street — you get more mental space to be, ‘This is boring and stupid,’” Davidson said.

He also noted programs reduce the harm to others. “If you’ve got a whole group of people running around trying to hustle up $20 for heroin, that’s a bunch of petty theft and that’s a bunch of panhandling and that’s a bunch of other things that are also bad for community.”

Kious believes it’s unlikely that opioid replacement therapies keep folks enslaved by addiction. “That would be true if it were the case that people would be less likely to use if you didn’t prescribe Suboxone and Methadone, but the reality is they’re going to do it anyway. So by providing a safer, more regulated alternative that also involves interacting with the health system in beneficial ways, you don’t necessarily increase addiction or enable it, but you do change its shape so that it becomes less maladaptive and people are able to function better.”