Can Supervised-Injection Sites Stem the Epidemic of Opioid Deaths?

Can Supervised-Injection Sites Stem the Epidemic of Opioid Deaths?

Can Supervised-Injection Sites Stem the Epidemic of Opioid Deaths?

If Trump were serious about reducing the number of fatal opioid overdoses, he might have considered this solution.

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Dozens of doctors, nurses, medical students, and others descended on Seattle’s City Hall in early December last year, determined to be heard. Like the HIV/AIDS activists of an earlier era, they invaded the building’s glass-lined lobby and collapsed on the floor in dramatic fashion. Their motionless bodies were meant to make an urgent point.

“There is no time to wait. There is no time to deliberate,” says Carolanne Sanders, a 26-year-old former EMT and expert in health-care policy, recalling the message of the die-in nearly a year ago. “The more our elected officials drag their feet, the more people will die.”

Sanders is part of a militant group of health-care workers who have been pressing the city of Seattle and surrounding King County to radically alter their approach to the opioid crisis that is ravaging the region and the rest of the country. The group and its allies want their local government to establish professionally operated sites where people can consume the heroin, fentanyl, and other opiates that together caused more than 200 overdose deaths in the region last year. Seattle and King County officials have largely supported the idea, but political considerations, including the emergence of a ballot initiative meant to block the sites’ creation, as well as the recent resignation of Seattle Mayor Ed Murray, have hampered progress. And so, health-care activists continue to agitate for these sites, which they say could save countless lives.

They aren’t the only ones who think so. From Seattle and Philadelphia to Baltimore, San Francisco, and Ithaca, New York, a cohort of cities across the country are embracing the idea of supervised-consumption facilities, as they are sometimes called, to combat the opioid epidemic. Already widely used in Europe and Canada, these facilities provide places where drug users can consume narcotics in the presence of doctors and nurses and social workers trained in addiction treatment, disease prevention, and overdose mitigation. If they take root in the United States, they will provide a potent new tool in reducing addiction’s most harmful effects and fighting the overdose crisis that is currently the leading cause of death for Americans under 50. In 2016, overdoses killed approximately 64,000 people in this country—and the number is expected to keep rising in 2017, notwithstanding Donald Trump’s announcement that the opioid crisis is a public-health emergency.

Still, supervised-consumption facilities are also deeply polarizing, and so far not a single one has been built on this side of Canadian border. “Canada, Europe, and Australia have been operating [these sites] for decades and yet their success has been ignored in the United States,” says Lindsay LaSalle, a senior staff attorney at the Drug Policy Alliance, a group that works to reduce the criminalization of drug consumption. “And I think that is primarily because of the stigma people associate with drug users.” In order to change “hearts and minds,” she adds, “we have to humanize the issue. We have to humanize the people who are using.”

This, says Sanders, is precisely what she and her allies in Seattle, along with other public-health organizers and activists across the country, are trying to do.

“We as a society have to be pushed and agitated to action when it comes to supporting marginalized groups and protecting their health,” she says. “Everyone in this coalition expects it to be a fight until the every end, but we see that as our responsibility as health professionals.”

Supervised-consumption facilities, also called supervised-injection sites, safe-consumption spaces, or some variation on the theme, are not a new idea. Indeed, they have existed legally since at least 1986, when an official facility opened in Switzerland. Today, at least 66 cities in 11 countries, including the Netherlands, Germany, Spain, and Australia, sanction spaces where drugs can be consumed under the watchful eye of medical professionals.

The first such facility in North America opened to the public in Vancouver in 2003. Called Insite, it has provided more than 3.6 million clients with a safe place to consume drugs—a place where they can receive immediate treatment should they overdose and where they can also get access to clean needles and a variety of social and rehabilitation services. Since its inception, and despite more than 6,400 overdoses at the facility, not a single person has died there.

“There has never been a fatality at Insite,” says Tim Gauthier, a registered nurse and the clinical coordinator there. “I am actually unaware of any overdose fatality at any supervised-consumption site in the world.”

Indeed, across the board, and according to compelling evidence, supervised-consumption facilities are extremely effective at limiting the most devastating harms associated with drug addiction. “A large body of evidence-based, peer-reviewed studies has demonstrated the public health impacts and cost-effectiveness of [supervised-consumption sites], owing to significant reductions in the transmission of HIV and HCV [Hepatitis C], a reduction in other morbidities such as abscesses, and a reduction of fatal overdose deaths,” writes the Abell Foundation, a Maryland-based nonprofit, in a recent report commissioned for the city of Baltimore. “Further, [supervised-consumption sites] are uniquely effective at sustaining contact with the most marginalized [people who consume drugs] in public places, and positively impacting the communities in which they are situated by reducing public drug use.”

These concrete and life-saving benefits are why cities are interested in opening facilities of their own. There’s Seattle, of course, where a task force convened in 2016 by elected officials in the city and surrounding King County called for the establishment of two supervised-consumption sites as soon as possible. In Philadelphia, a task force convened by Mayor Jim Kenney to combat the opioid epidemic recommended in May that the city explore opening one or more supervised-consumption sites on a pilot basis. And in Ithaca, the 30-year-old mayor, Svante Myrick, has been a vocal advocate of the idea. In February 2016, his city released a plan that expressed its interest in exploring the creation of a supervised injection site, among other interventions to fight the epidemic.

Meanwhile, activists, organizers and some elected officials in San Francisco, Boston, Denver, Baltimore, and New York City have also been exploring the creation of such spaces.

Supervised consumption facilities, says Dr. Jen Bowles, a postdoctoral fellow at UC San Diego who has researched opioid overdoses in Philadelphia and who served on the city’s task force, will create “a new environment in which we can reduce both [overdose deaths and disease transmission] risks and treat people with dignity and respect in a nonjudgmental setting that can ideally connect them to other services.”

The mayor’s office there confirmed that a delegation of Philadelphia city officials is planning to travel to Vancouver in the near future to see and study Insite, the supervised-consumption facility there. In the meantime, at least one big name in the city has thrown his weight behind the proposal.

Larry Krasner, the progressive Democrat running to be the city’s next district attorney, and a civil-rights lawyer who has a history of representing ACT UP activists, staunchly supports the idea.

He says, however, that he prefers to think of supervised-consumption facilities as “harm-reduction centers”—places “where people are not going to die” and which serve the surrounding neighborhood by getting drug use off the streets. The drive to create such sites, he adds, has a movement behind it, an “organic movement of activists, idealistic medical professionals, and smart people who see the problem clearly.”

Jose Benitez is one such activist. The executive director of the needle-exchange program Prevention Point Philadelphia and a member of the mayor’s task force, he says support from political and legal leaders like Krasner is “a major step in the right direction.” Still, heroin and other opiates are illegal, and supervised-consumption facilities could put their clients and even the city at legal risk if federal or state officials decide to intervene. What’s more, there’s a lot of misinformation and ignorance and fear out there about such facilities, says Benitez, “so as a politician you are taking a political risk by standing up and saying this is something that I endorse.”

“What needs to happen now,” he says, “is the political will,” which will require public education. Toward that end, his group is holding a series of events across the city in the coming year to teach people about supervised-consumption sites, allay misunderstandings, and help speed their establishment.

If political will still must be mustered in Philadelphia, it seems to be well established in Ithaca, where supervised-consumption facilities have full-throated support at the highest levels of local government.

“I would like to see it within a year, and I don’t think that that is crazy,” says Gwen Wilkinson, a former district attorney and the city’s interim drug-policy coordinator. “I am speaking from my point of view, but from the rooms that I have been in, I think it is not outside the realm of plausibility that we could have a [supervised-injection facility] up and running within a year in Ithaca.”

This doesn’t mean it has been an easy sell. Despite the enthusiasm of top local officials, there are still people—from law enforcement groups to the county government to members of the general public—who look askance or outright oppose the idea.

“There are a significant number of people who are either agnostic or skeptical, and then are people who are entrenched in a negative viewpoint and think a safer consumption space is actually a bad thing,” Wilkinson says. But the severity of the crisis, and Ithaca’s educational-outreach efforts, including direct meetings with members of the county government, are starting to win converts. And, at the state level, the Drug Policy Alliance is working with legislators who introduced a bill in June that would effectively legalize supervised-consumption facilities in the state. This is essential because, without explicit authorization from governing bodies, these facilities and their clients may be subject to criminalization at the hands of law enforcement.

“It’s about education, giving people enough education that their humanity can kick in,” adds Wilkinson. “That’s all it is. The facts are there. The science is there. It is not ambiguous. These will work.” And, she says, they are desperately needed. “People all over the country are dying in droves.”

Seattle and King County, Washington, meanwhile, are perhaps even closer than Ithaca to founding a facility.

“We don’t have a site identified or operating,” says Dr. Jeffrey Duchin, a health office at the Seattle and King County public-health department. “But we anticipate that after the results of the [November mayoral] election—and all of the candidates have expressed support—then we may be able to move forward sometime in 2018.”

The city and county’s drive to establish supervised-consumption facilities, he explains, has been held up in recent months by a ballot initiative that sought to ban public funding for such sites. The initiative was backed by Republican state Senator Mark Miloscia, an opponent of drug decriminalization, among others. On October 16, however, a judge ruled that the ballot initiative infringed on the authority of the King County Board of Health and could not move forward.

The ruling was a victory for organizers like Patricia Sully, an attorney with the local Public Defenders Association and the coordinator of VOCAL Washington, a group that “builds power” among low-income and no-income people affected by the war on drugs, mass incarceration, homelessness, and the HIV/AIDS epidemic. “For a lot of people the first response to [these sites] can be fear,” Sully says. “And so my organization has been running a robust public-education campaign to make sure people in the community understand what these are.”

Alongside numerous allies, including Carolanne Sanders and her cadre of activist health-care professionals, VOCAL Washington has spent the last two years erecting mock supervised-consumption facilities in parks across the city where people can come see the spaces for themselves and ask questions of doctors and nurses and other harm-reduction advocates. The group has also filled local parks with shoes, balloons and other items to signify the scores of people who have died from overdoses in the county in recent years. It has held film screenings and panel discussions and protests and more. The objective is to establish supervised-consumption facilities in Seattle, yes, but the group and its allies have a more sweeping ambition too.

“Our larger goal is to start a conversation that will change our cultural norms around drug use and the people who use drugs,” says Sanders. “We are trying to destigmatize drug use. We are trying to bring a compassionate public-health approach to the issue of drug use in our community.”

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