Mayor Muriel Bowser’s “stay‐at‐home order” to all District of Columbia residents exempts individuals who are homeless but strongly urges them to shelter while asking public and private entities to “make shelter available as soon as possible and to the extent practicable.”
According to the Office of National Drug Control Policy, 66% of people who are chronically homeless have a substance use disorder or co‐existing chronic disease. Another study found substance abuse or mental health disorders, or both, in half of the district’s homeless population. A great number of them are unaware of the coronavirus outbreak. Making matters worse, the homeless are at great risk for fatal outcomes from a COVID-19 infection because many also suffer from malnutrition, poor hygiene, and compromised immune systems.
Yet public health facilities designed to reach this population are barred from doing so by an outdated federal law: 21 USC section 856, also called the “Crack House Statute.”
These public health facilities have been around since the 1970s, saving lives in more than 120 sites in developed countries around the world, including Canada and Australia. They are known as safe injection facilities. Some call them overdose prevention sites.
These centers let people addicted to intravenous drugs inject in a safe environment, free from the risks of theft or sexual assault, with clean needles and syringes, while staff stand nearby with the overdose antidote naloxone. These centers don’t just dramatically reduce overdose deaths and bring more addicted people into treatment, but they also reduce cases of HIV and hepatitis that result from needle sharing. Perhaps the greatest public health contribution these sites make in the context of epidemics and pandemics is that these sites routinely test for infectious diseases.
People who use safe injection facilities are tested for HIV, hepatitis, and sexually transmitted diseases and referred for treatment. With the COVID-19 pandemic shutting down the world’s economy, the ability to test for COVID-19 infection is key to a return to normalcy and economic restoration.
Testing allows public health authorities to screen out people who are infected and contagious, even those with minimal symptoms, and isolate them from those who are not infected. This allows uninfected people to emerge from self‐quarantine, reenter the workforce, and engage in commerce. Countries such as South Korea, Singapore, and Germany have employed aggressive testing to control their outbreaks, allowing them to end or avoid general shutdowns.
Its repeal will allow public health organizations to save not only the lives of people who suffer from addiction but of the public as a whole.
Drug addiction, particularly among the homeless, impedes social distancing. The need to get their drug overrides concerns they may have about contracting or disseminating the virus. Safe injection facilities are ideal ways to reach this population, test them for COVID-19, hospitalize or quarantine those who are infected, and start them on medication‐assisted treatment for addiction with methadone or buprenorphine while they are in isolation. Medication‐assisted treatment will prevent withdrawal and promote quarantine compliance. An added benefit is that many of these patients, upon release from quarantine, might choose to remain on medication‐assisted treatment and continue rehabilitation.
None of this is possible while the “Crack House Statute,” passed in 1986, treats these public health facilities as if they are the crack houses at which the law was originally targeted. The law makes it a federal felony to allow knowingly the use of illicit drugs to take place on one’s premises. A nonprofit group in Philadelphia has been fighting with the federal government to establish a safe injection facility there named “Safehouse.” Cities, including Seattle, San Francisco, New York, and Boston, would also like to open safe injection sites.
Mayors across the country are taking dramatic steps to control the spread of this deadly virus so life can return to normal as soon as possible. Meanwhile, a glaring public health impediment, the “Crack House Statute,” remains entrenched in the federal criminal code. Its repeal will allow public health organizations to save not only the lives of people who suffer from addiction but of the public as a whole.
Repealing that statute is a public health imperative, now more than ever.