September 2021

‘These are our patients, our friends, our family members’: Q&A with Dr Kimberly Sue

A graduate of Harvard Medical School who also holds a PhD in sociocultural anthropology, Dr Kimberly Sue is based in New York, where she specialises in harm reduction. She is board-certified in both internal medicine and addiction medicine and until recently was a clinician-educator and staff attending physician at Rikers Island prison; she is now an instructor at Yale University. She is the author of Getting Wrecked: Women, Incarceration, and the American Opioid Crisis.

We’ll start on a slightly personal note by asking about your professional role and how you ended up in it.

I’m the Medical Director of the National Harm Reduction Coalition (NHRC), a non-profit that seeks to improve the health and wellbeing of people who use drugs.

I do a lot of technical assistance and training for physicians since I’m an internist: a board-certified addiction medicine doctor. And I’m a medical anthropologist. My book and my research are on women, incarceration and opioid use.

Now I’m also at Yale, where I’ve been an instructor in the program in Addiction Medicine since October.

How did I end up here? I was schooled at the hands of a lot of New York City HIV/AIDS activists when I was going through my training at Columbia University. I wanted to address mass incarceration in the US and, increasingly through that, I saw how drug use was criminalised in this country and started seeing substance use and addiction and thinking about how they were all intertwined.

Why does mass incarceration interest you particularly?

It felt to me like one of the most egregious human rights issues in the US. We incarcerate 25 per cent of the world’s prison population but do not have that percentage of the population globally. Trying to explore and understand that and working with people who used drugs and people who had experienced incarceration led me to think about what I could do.

You’re working in an area of medicine that’s lacking in high remuneration and prestige – why not become a surgeon?

It’s changing. I get emails from all around the world, all around the US, from people who want to do what I do, who think about treating people who use drugs and taking care of their health issues as something that they want to do.

When I went to medical school at Harvard 15 years ago, harm reduction, respectful care of people who use drugs, was not even on any part of the curriculum. For me as a physician anthropologist, thinking about why people use which substances, in which settings, based on which cultural context, with whom, over the course of their developmental trajectory, is fascinating.

Clinically, I really enjoy it. It’s not so much about the medicines but the social. That’s what is really compelling and allows me to stay engaged and fresh with every patient, whether they have problematic alcohol use or a combination of cocaine and heroin and benzos.

It’s the 50th anniversary of President Richard Nixon’s war on drugs this year. We’ve had a 50-year attempt at managing drug use issues through that kind of lens but it seems like the consensus around that is breaking down in the US.

People are beginning to understand the legacy of this drug war and the billions of dollars and the amount of harm it’s done in this country, particularly to communities of colour. Looking at Nixon’s original declaration and how it was a way to quell black power and also the hippy movement, using drugs as a lever for that, it’s all unfolding.

There are glimmers of hope – for example, the legalisation of recreational cannabis in some states.

People are realising that incarcerating has failed, and I think the Black Lives Matter movement has awoken a lot of people to the punitive and punishing ways in which the carceral state with its systems of surveillance, social control and policing intrudes on and violently harms and kills people of colour.

The USA overdose situation is absolutely dire. But it seems like overdose is mostly understood as opioid overdose and that the other contributing drugs like benzodiazepines rarely get as much attention, let alone methamphetamine or other stimulant drug overdoses. Why are we so opioid-centric?

This might have to do with funding and research streams and cultural narratives. Helena Hansen, an anthropologist and psychiatrist at UCLA, has written about the racialisation of opioids and opioid treatment, comparing buprenorphine and methadone in the US. Understanding that is critical, as is thinking back to the different waves of opioids we’ve had. There have been multiple waves of heroin, of opioids, in the US, back to the early 1900s when ladies were being prescribed cocaine and opioids as laudanum and morphine. You can go to the ’60s and ’70s when it was an urban black problem, you can jump to prescription opioid pills, and you can jump to the fentanyl era.

In the data we see cocaine and meth deaths on the rise. We see that in the western part of the US – in Colorado, for example – overdose deaths are more meth than opioids. Yet we don’t have the cultural narrative and the ability to talk about meth as honestly and openly, or cocaine, which also has a very interesting history in the US.

And benzos are involved in polysubstance use deaths, and alcohol as well. The mixing of them is very, very common; it’s rare to have just one substance in a postmortem these days. It’s often heroin, fentanyl, alprazolam, cocaine.

And when we talk about stimulants too, it’s been proposed that stimulants have a certain function and ability to help people get through this capitalist system in which we’re labouring. But there’s a lot of stigma against stimulants. For example, President Joe Biden’s son, Hunter, has put out a memoir in which he talks about his addiction to crack cocaine and alcohol. Even just seeing the public discourse around his substance use is disheartening, because it’s very negative, very pejorative.

Pharmacotherapy treatment for opioid use disorder is not mainstream general practice medicine in the US; the limitations to accessing methadone are quite significant. What does the medical profession have to offer in terms of changing this?

There’s a huge barrier and it’s been highlighted by COVID, which has brought some interesting policy changes that have deregulated methadone slightly. Maybe only 30 per cent of people are offered MOUD (Medication for Opioid Use Disorder) – either methadone or buprenorphine – after an overdose. People do not get evidence-based treatment with medications because this is seen very commonly as a crutch in the US: replacing one drug with another. So we really have to combat the stigma against a very good medication, methadone, which does better at retaining people than buprenorphine; we have people who start buprenorphine for a couple of months, then drift away, and we don’t know what happens to them. Knowing that OUD is a chronic condition, we’d prefer them to be on it longer, obviously.

During COVID the Drug Enforcement Administration (DEA) and the Substance Abuse and Mental Health Services Administration (SAMHSA) made some regulatory changes allowing state opioid treatment authorities to liberalise take-homes. So people were allowed – depending on their state, their opioid treatment program, their maintenance, the methadone dispensing system – to jump to 14 or 28 days of medication take-homes, and that really was phenomenal for patients who were stable but struggling to get to the clinic.

There’s a movement in the Drug Users Union here called Free Methadone to basically unlock this very effective medication – these ‘liquid handcuffs’. And I provide primary care in a methadone treatment program that’s low barrier: people can walk in and get medication the same day. But I’ve just seen a patient who says he wants to get into buprenorphine even though methadone has been a highly effective medication for him for more than 30 years because sometimes he might be doing construction work two hours away at 5am and he might be there until 5pm and he can’t be at the clinic. I have another patient who says that every time he comes to the clinic is when he uses fentanyl – he comes in to get his medication and that’s where everybody is. He’s asking to get into buprenorphine to avoid this. If we could design a system where pharmacists and primary care doctors did it as regular practice and were allowed to treat opioid use disorder in the clinic it would really change the treatment landscape, because methadone is cheap and highly effective.

One of the shifts in the rhetoric around drug use management is that drugs should be a health issue, not a law enforcement issue. We all hear about Purdue and the ‘Big Pharma’ behaviour, but the prescribing and dispensing of dangerous drugs by the medical system has been a driver of the overdose epidemic and laid the groundwork for a flip to fentanyl when the time was right.

The medical field – looking at the last 100 years – has always had doubt in this country about whether it wanted to dispense and to whom. There are recurring types of people who are deemed worthy of care: little old white ladies who became addicted because of the pain of their rheumatism, versus people who were buying or using substances on the street. They had safe-supply-type clinics that did morphine in the 1920s that were shut down by what was previously the DEA.
There’s a good book by David Hertzberg called White Drug Markets. There’s always been this tension. Doctors have always been very ambivalent about, but at the same time have profited off, this; doctors and pharmacists have profited off this for hundreds of years. There’s kind of a swinging pendulum that goes back and forth between wanting to own it and wanting to not own it.

It’s very, very interesting thinking about how complicit healthcare systems are in causing addiction: in treating addiction, in treating chronic pain and not tapering people off humanely – leaving them at the hands of what they can access on the street. It’s very complicated.
With Purdue Pharma there was no training to prescribe oxycodone 160mg or 80mg but in the last couple of months there’s been eight- and 24-hour training to prescribe buprenorphine, which is way safer from a respiratory depression standpoint, so nothing makes sense. It’s just completely illogical.

International Overdose Awareness Day (IOAD) is coming up on August 31. Is NHRC doing something this year?

We’re putting on a variety of events for both the 50 years of a failed drug war and IOAD.
Over the past three years I’ve been involved in overdose prevention centre activism against certain states, because we can’t get any traction on this issue. In New York State, for example, the mayor said he was he was supportive and would start them in New York City but when it was pushed up to the governor, he stalled. There’ve been a lot of protests around the governor’s inaction.

In Australia, we are where America was 15 years ago in some ways: we over-incarcerate, our prison population is growing substantially and our overdose problem is significant. We don’t have the extreme public-facing drugs crisis that’s happened in the US and in Portugal, where that country’s reforms were born from the crisis; we have much more of a simmering, and people are losing their lives and their livelihoods as a result of that but it just doesn’t capture the public’s imagination.

It’s just like you say: these are our patients, our friends, our family members.

Maybe 500,000–600,000 people have died in the US of COVID-19; 90,000 people died of an overdose last year – but we don’t put faces and the names to these people. We need to put faces to them and really talk about people as people – change the discourse and present people’s stories and experiences.

It’s an abysmal thing. How do you stay in the field where people continue to die in their 30s and 40s – their prime? You take care of people but you’re basically playing Russian Roulette with the poison toxic drug street supply. The American policy has left people to fend for themselves.

The bigger upstream question is testing poisons, realising you have a bag of 100 per cent fentanyl. I just wonder if, 20 years from now, we’re going to be shaking our heads at how poorly we’ve done and how many people we’ve lost.

We really need to figure out ways to innovate but not force a square peg into a round hole – not keep doing another 50 years of the same thing over and over again. Why do we think that’s going to benefit us? Look at how harmful it’s been.

The US was pretty instrumental in rolling out the drug war to the rest of the world, and now we’re all more or less locked in with China and Russia in the same sort of approach; America could be a beacon of reason and hope in this area.

It depends partly on stopping the war on supply that has devastated so many countries and their economies and their people’s livelihoods, and also the criminalisation. I spoke recently with people in Malaysia about the way in which people who use drugs are beaten, tortured, incarcerated – that’s exported directly from the US.

I hope we have something different to offer. I hope we can talk about harm reduction and health strategies and ways that are cheaper and more in line with a human rights approach: that people just want to live lives with dignity and respect.