A room with a nurse, some soft chairs and basic life-saving equipment. Together, this is the latest tool a group of local doctors and nurses plans to create to fight the state's opiate epidemic.
Though it doesn't have all the funding yet, Boston Health Care for the Homeless Program (BHCHP) plans to open the so-called "safe space," where heroin users could ride out a high under medical supervision, at the beginning of next year at the corner of Mass. Ave and Albany Street.
"It really is the epicenter of opiate overdose in Boston," Dr. Jessie Gaeta, the BHCHP chief medical officer, says of the area where, if all goes according to plan, the space will open.
Gaeta says she and her colleagues are desperate to offer an option for the people they see overdose every day, whom they must sometimes step over to get into the program's clinic.
"The epidemic feels like it's been crescendoing on this block," Gaeta says of the stretch of Mass. Ave known as the "Methadone Mile." "We've got to try new things."
There have for months been hushed conversations among opiate addiction providers about creating a Supervised Injection Facility (SIF) in Boston. Nine countries around the world have such facilities -- where men and women inject heroin or ingest other illegal drugs, under the guidance of a nurse or other medical professional. The only one in North America is in Vancouver.
There does not appear to be much political support for creating an SIF in Boston. The room at Boston Health Care for the Homeless would just be a supervised space where men and women in the throes of a high would be monitored, and then urged to try treatment.
"It’s not a place where people would be injecting," Gaeta says. "[It would be] a place where people would come if they’re high and they need a safe place to be that’s not a street corner or not a bathroom by themselves, where they’re at high risk of dying if they do overdose."
Too many people, Gaeta says, are dying alone in public restrooms, cars and alleys. BHCHP records show that overdoses have become the leading cause of death among Boston’s homeless men and women.
'Able To Respond Immediately'
Picture a conference room. Move the table out and roll in reclining medical chairs and oxygen monitors. There’s some free juice and sandwiches in a kitchenette.
BHCHP has asked local foundations to help fund the $250,000 cost of the "safe space." A nurse and street outreach worker would move among 10 or so users to check breathing, other vitals and general health.
"If you overdose, we’re going to be able to respond immediately, save your life," Gaeta says. "We’re going to talk to you about treatment options, we’re going to offer it, ideally, on demand, like the moment you’re interested in methadone maintenance or Suboxone or a detox program, we’re going to work like heck to get you in that day."
BHCHP is also considering setting up its own detox program.
Many needle exchange programs, including Boston's, have waiting rooms where men and women sometimes crash during a high. The BHCHP goes a step further with a nurse and quick access to care. There's not much to compare it to across the country.
There is a lot of research about supervised injection facilities. A review of 75 research articles found that SIFs reduce overdoses. Surveys of heroin users in Vancouver and Sydney show that patients who use drugs in these rooms are more likely to end up in treatment than patients who don't.
But again, Boston Health Care for the Homeless is planning something different: Patients would not be allowed to take illegal drugs in the room.
Skeptics question whether the room would be used.
"Are they going to shoot up right outside the room and then go in?" asks Richard Winant, who runs Kelly House, a sober home for men in Wakefield.
Winant applauds the goal of preventing overdoses. But he doesn't think heroin users will have the wherewithal to come in or be open to talking about treatment if they do come in.
"When [heroin users] come down from that high, they’re not going to be feeling well," Winant says. "How long do you expect them to be in the room?"
Patients would be free to come and go. Gaeta says the goal is for nurses and recovery workers to build relationships and trust with heroin users over time.
Ray Tamasi, the CEO at Gosnold, an addiction treatment network on Cape Cod, says his staff tried a similar approach with alcohol addiction about 15 years ago.
It was marginally successful, Tamasi says, "but it was taxing, very labor intensive and difficult. You have to have the resources to be able to do it."
Supervised heroin use or highs underscore a divide in the approach to addiction treatment.
"The controversy is, does it encourage people to keep using if we make their lives less dangerous and less miserable, or can we scare people into care?" says Dr. Barbara Herbert, president of the Massachusetts chapter of the American Society of Addiction Medicine.
Herbert and many doctors who specialize in addiction medicine have moved away from the tough love, abstinence-or-nothing approach and favor options like the BHCHP safe room.
"There’s a lot of evidence that where people don’t have access to safe spaces, they are at higher risk for death," Herbert says. "It’s not that we don’t want people to be drug free, but dead people don’t recover."
Some addiction experts argue that Massachusetts must focus more on ways to reduce the harm from drug use and stop expecting users to just stop. We are, they point out, in the middle of an epidemic.
"We're having problems reducing people's involvement with drugs," says Vaughn Rees, an addiction expert at the Harvard School of Public Health. "Short of being able to implement treatment, we need to think about how we can reduce the risk of drug use."
Rees said the state needs more needle exchange programs, more education in schools, easier access to methadone and Suboxone and more primary care physicians who screen for and treat addiction disorders.
Some public health and political leaders contacted for this story did not want to speak on the record about a room that would be set aside for heroin users. But Boston Mayor Marty Walsh says the supervised space could be a unique way to bring a heroin user into short-term care.
"I’m up for trying anything when it comes to addiction and active using," Walsh says. "If we can help some folks, homeless folks in particular, we should try anything."
Maybe even a supervised injection facility like the example in Vancouver.
"I'd be interested in finding out the intent," Walsh says. "If Vancouver's doing it and it turns out that somehow there's a way of intervention that's successful, I would be open to it, but I don't know enough to comment on it."
Boston police say they have no concern about the room BHCHP plans to open, but would not support allowing injections inside.
"We can't allow the illicit distribution or sale or transfer of narcotics to be happening and not take action against that," says Lt. Det. Michael McCarthy, a Boston Police Department spokesman.
Some in the addiction community say a room where heroin users would get care, not criticism, while high is another sign that attitudes about addiction are shifting.
"I think we’ve come a long way," says Joanne Peterson, who started the parent support network, Learn to Cope. "There’s a lot more talk and a lot more compassion and understanding because there’s been so many deaths. This is an enormous epidemic."
1/5 Update: Gov. Charlie Baker addressed the proposed space with reporters. His full answer:
I've been involved in Health Care for the Homeless for 25 years, dating back to the original McGinnis House, which was the first respite facility that they worked with the commonwealth on to develop here in the city of Boston.
And while I'm not familiar with what they're proposing to do here, I have tremendous faith in them and think because they are on the ground and because they are closer, most of the time, than practically anybody else who's working with the homeless population, they tend to be a pretty good bellwether about good ideas and I'll certainly be interested to hear about what they're proposing and how it works. For me, the real thing is: How many things are we going to find that's going to work, that we can try to replicate?