What do the experts say?

AMA Wants New Approaches to Combat Synthetic and Injectable Drugs

June 12, 2017

CHICAGO – Responding to the health and safety threat posed by the abuse of new designer drugs that are synthesized and marketed to circumvent drug laws, the American Medical Association (AMA) today voted to support a comprehensive, multidisciplinary effort to close a gap in the nation’s ability to identify, regulate, and mitigate the dangers posed by new psychoactive substances.

New psychoactive substances – or NPS – mimic the effects of a wide range of substances, including prescription opioids, cannabinoids, stimulants, hallucinogens, and central nervous system depressants. NPS are sold as “legal highs” and alternatives to established drugs of abuse. NPS have been increasingly associated with hospital emergencies, acute adverse health consequences, and drug-induced death.

“Although Congress passed AMA-supported legislation in 2012 that placed 26 synthetic drugs in Schedule 1 under the Controlled Substances Act (CSA), drug traffickers have devised ways to circumvent federal drug laws by slightly altering the chemical structure of their products and designing new synthetic drugs,” said Patrice A. Harris, M.D., chair of the AMA Board of Trustees and the AMA Task Force on Opioid Abuse. “These new products are currently unregulated and are frequently marketed to young people as innocent products like “bath salts,” plant food, or incense. They also include variations of the extremely dangerous opioid fentanyl, which has been wreaking havoc across the country and resulting in a sharp increase in drug overdoses and deaths due to such overdoses.”

Delegates at the AMA Annual Meeting voted to support multifaceted, collaborative multiagency approach to combat NPS. Delegates also supported increased NPS surveillance and early warning systems for more actionable information that can quickly aid law enforcement, public health officials, emergency physicians, and vulnerable populations in mitigating the growing NPS problem.

Public health approaches have been used to successfully address outbreaks of NPS overdoses. When such approaches have been successful, pre-existing coordinated relationships among multiple stakeholders have allowed for a rapid and comprehensive response to a given outbreak.

In addition to the newly adopted policies for eliminating the NPS threat, the AMA is also supporting the “Synthetic Drug Control Act of 2017” (H.R. 1732) that would require the Attorney General of the United States to assign Schedule I classification to approximately 250 dangerous new synthetic substances identified by the Drug Enforcement Administration since 2012.

In an effort to consider promising strategies that could reduce the health and societal problems associated with injection drug use, the AMA today voted to support the development of pilot facilities where people who use intravenous drugs can inject self-provided drugs under medical supervision.

Studies from other countries have shown that supervised injection facilities reduce the number of overdose deaths, reduce transmission rates of infectious disease, and increase the number of individuals initiating treatment for substance use disorders without increasing drug trafficking or crime in the areas where the facilities are located.

“State and local governments around the nation are currently involved in exploratory efforts to create supervised injection facilities to help reduce public health and societal impacts of illegal drug use,” said Dr. Harris.“Pilot facilities will help inform U.S . policymakers on the feasibility, effectiveness and legal aspects of supervised injection facilities in reducing harms and health care costs associated with injection drug use.”

The examination of this issue by physicians at the AMA Annual Meeting was greatly assisted by the Massachusetts Medical Society and its recently completed comprehensive study of the literature associated with supervised injection facilities.

The Lancet

Volume 377, Issue 9775

23–29 April 2011, Pages 1385–1386

Methods

We examined population-based overdose mortality rates for the period before (Jan 1, 2001, to Sept 20, 2003) and after (Sept 21, 2003, to Dec 31, 2005) the opening of the Vancouver SIF. The location of death was determined from provincial coroner records. We compared overdose fatality rates within an a priori specified 500 m radius of the SIF and for the rest of the city.

Findings

Of 290 decedents, 229 (79·0%) were male, and the median age at death was 40 years (IQR 32–48 years). A third (89, 30·7%) of deaths occurred in city blocks within 500 m of the SIF. The fatal overdose rate in this area decreased by 35·0% after the opening of the SIF, from 253·8 to 165·1 deaths per 100 000 person-years (p=0·048). By contrast, during the same period, the fatal overdose rate in the rest of the city decreased by only 9·3%, from 7·6 to 6·9 deaths per 100 000 person-years (p=0·490). There was a significant interaction of rate differences across strata (p=0·049).

Interpretation

SIFs should be considered where injection drug use is prevalent, particularly in areas with high densities of overdose.

Funding

Vancouver Coastal Health, Canadian Institutes of Health Research, and the Michael Smith Foundation for Health Research.

Scientific American

Safe Injection Facilities Save Lives

To fight the opioid crisis, let substance users shoot up under medical supervision

## By THE EDITORS on January 29, 2018

Annual opioid fatalities have now surpassed the yearly number of deaths from AIDS at the height of that epidemic in the mid–1990s. In 2016 drug overdose deaths numbered 63,000, more than the U.S. death toll from the entire Vietnam War. The trend is terrifying: the problem is getting worse each year.

Cities and states reeling from opioid deaths need to give serious consideration to setting up safe injection rooms, which could significantly reduce fatalities. These are places where a drug user can go to consume illegal drugs under the supervision of health workers. They have been used in Europe, Canada and Australia for decades, and evidence and experience there shows they are very effective. This may not seem like an obvious way to fight an abuse epidemic, but there are few other options. While in the U.S., many cities’ efforts to establish such sites have stalled, Philadelphia is now poised to open the country’s first officially sanctioned safe injection site.

The misuse of prescription opioids such as OxyContin is inextricably linked with that of street drugs such as heroin. Nearly half of young people who inject heroin started by abusing prescription drugs. Then they turned to the cheaper, more readily available alternative. The path from pills to needles has meant that U.S. deaths from heroin have increased by a factor of five since 2010, topping 15,000 people in 2016. The number of dead is continuing to climb as people overdose on heroin laced with fentanyl, a synthetic opioid that makes heroin much more potent—and thus more deadly.

That’s where safe injection sites would come in. At more than 90 such locations in Europe and elsewhere, if someone overdoses at one of these sites, a health worker or other first responder quickly administers an antidote. The injection facilities also have proved they can reduce the transmission of blood-borne infections, partly through needle-exchange programs. They can also save money: in San Francisco, for example, one analysis concluded that for every dollar spent on such sites, $2.33 in emergency medical, law enforcement and other costs would be reduced, producing a yearly net savings of $3.5 million.

The evidence for increased safety is compelling. At Insite, a safe-injection site in Vancouver, for example, there was a 35 percent reduction in fatal overdoses in the area around the facility, compared with a 9.3 percent reduction in other parts of the city that may have had other interventions. People who used Insite were also much less likely to share needles than individuals who shot up in unsupervised places. And Insite helped get people clean. Of the 6,532 people who visited the facility in 2015, 464 were referred to addiction treatment, and more than half of them completed it.

Critics argue, correctly, that safe injection sites are not a perfect solution on their own. Our country needs more drug-treatment beds and counseling options, medication assistance to help with drug withdrawal and other evidence-based care to alleviate the crisis. Safe sites also work best in places where drug use is centralized, such as in specific urban neighborhoods rather than rural areas. And of course, they are controversial because they require officials to tacitly accept illegal drug use.

That is why no American city has yet cleared the necessary hurdles to proceed with establishing an injection site. San Francisco and Denver are among the jurisdictions that have considered this option. Seattle, too, has called for two safe-consumption rooms and has even set aside funds to support them, but its effort has been mired in legal battles. Federal law currently makes it illegal to use nonprescribed opiates and opioids, so Philadelphia officials have said they would not fund or operate such a facility. They would instead encourage private efforts to open one—which would perhaps providing slightly more legal distance than if they were to finance and manage it themselves. Still, the U.S. Department of Justice may choose to prosecute the city for supporting the move. (The Mayor’s office told Scientific American in a statement that “We’re aware of federal concerns but given the depth of the problem and the number of lives impacted, we need to be bold in our approach.”)

But the stakes are high. If this site does get off the ground, it could finally pave the way for other cities to follow suit—giving communities new hope that the rising death toll from the opioid crisis might finally begin to reverse.

Annals of Internal Medicine

New Strategies Are Needed to Stop Overdose Fatalities: The Case for Supervised Injection Facilities

Jessie M. Gaeta, MD, and Melanie Racine, MPH

Last summer, the lifeless body of a 26-year-old heroin-using man, Tim (not his real name), was dis- covered in the shadows of a side street in Boston. Ninety minutes before, he had come to our clinic at Boston Health Care for the Homeless Program, mere blocks away, pleading for help. He told us with certainty that he was going to relapse that day, ending 6 weeks of hard-earned sobriety. Our nurse offered to connect Tim to treatment at the nearby methadone clinic or our office-based addiction treatment program, but he refused. He said he wasn’t ready to enter another treatment program: What he wanted, simply, was accompaniment while he used. “I’m just looking for a ‘buddy’ to go with me. I don’t want to die.”

The nurse made sure Tim had a naloxone rescue kit in his pocket and counseled him that his tolerance was lower than usual and he should start with a reduced “test” dose. With no friends available to accompany him, and without the legal authority to allow him to stay in our building, our staff watched Tim walk out the door for the last time. When he was found an hour and a half later—in the shadow of a world-class medical center and a large needle-exchange program, with naloxone at arm’s length—alone, we found ourselves agonizing over the limits of our current options for helping people like him.

With the explosion of highly potent fentanyl and its analogues in the illicit drug supply, overdose fatalities are occurring with alarming frequency and speed—often within minutes or even seconds of injection, leaving little time for first responders to find and resuscitate victims. For this reason, we often advise people to use with a friend and recommend that persons who use drugs, or who are around those who use drugs, carry the overdose reversal drug naloxone. Most of them do, and thousands of “peer saves” in Boston and across the country have been credited to expanded naloxone education and distribution. We regularly connect patients to detoxification programs, residential treatment pro- grams, medication for addiction treatment, and a host of other resources for treatment of substance use dis- order. But in too many cases we are constrained in our ability to save people like Tim: the ones who are unable to stop using today but don’t want to die.

It was this desperation that drove us to open the Supportive Place for Observation and Treatment (SPOT) in 2016 (1), where Tim had presented that day and where we’d gotten to know him over the previous months. SPOT is a nonjudgmental space focused on reducing the harms of drug use, where people who have ingested drugs nearby and who are over sedated can walk in to be medically monitored and connected to services and treatment. This program has allowed us to forge deep relationships with people who actively use drugs and be as close to them as possible while they are intoxicated. In the first year at SPOT, we saw 500 unique, high-risk people in more than 3800 encounters. In addition to preventing emergency department visits by providing medical monitoring on site and responding to overdose with supplemental oxygen, intravenous fluids, and naloxone as needed, we’ve used SPOT as a key conduit to treatment: In a sample of 409 patients who received care at SPOT, 23.5% were referred directly to substance use treatment, which could include inpatient detoxification, methadone treatment, office-based addiction treatment with buprenorphine or naltrexone, behavioral therapies, or some combination of these. Fifty-five percent of persons referred to treatment directly from SPOT successfully accessed it.

Yet, as Tim’s case painfully reminds us, SPOT is not enough. In our urgency to bring an end to these senseless deaths, we now support a strategy that other countries adopted as early as 1984: supervised injection facilities (SIFs). Approximately 100 of these facilities in 11 countries across Europe, North America, and Australia have been studied for decades. They offer sterile equipment and a hygienic environment for medically supervised injection of drugs obtained off site. They also offer education about reducing harms; access to lifesaving naloxone; and connection to primary health care services, counseling, and treatment for substance use disorder.

More than 100 peer-reviewed studies on SIFs have offered compelling evidence that they reduce mortality (2) and overdose (3) while increasing the safety of injection behaviors (3) (which is linked to reduced infectious disease transmission) and access to addiction treatment (4, 5). At the same time, research has shown that they do not increase public disorder or attract drug-related crime to an area (3) or increase relapse rates (6).

The Massachusetts Medical Society and the American Medical Association now both support development of pilot SIFs in the United States (7, 8) as part of a multi pronged approach to this devastating epidemic. Pilot programs would allow us to study the effect of these facilities while providing despairing communities with an additional strategy to mitigate overdose deaths and connect people to treatment.

Would widespread SIFs be accepted by people who inject drugs? From our experience, the answer is a resounding “yes.” Not only do we hear this on a daily basis in our clinics, but in a survey of 237 people who use drugs at Boston’s needle-exchange program, we have found that 91% of participants reported they would be willing to use a SIF (9). Furthermore, Kral and colleagues (10) recently documented the high utilization an unsanctioned SIF in an undisclosed U.S. city.

If the opioid overdose epidemic continues at any- where near its current rate, more than half a million more persons will die in the United States in the next 10 years. As health care practitioners, we have a duty to advocate for the development and study of interventions that have shown promise in promoting health and saving lives. We endorse SIFs as 1 piece of a comprehensive continuum of care for this chronic, relapsing disease. Only by heeding the calls for help of those suffering with substance use disorder will we find a way out of this epidemic. As Tim’s death demonstrates, sometimes, in the moment, treatment is not the only help that is needed: Sometimes it is bringing addiction out of the shadows.

From Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, and Section of General Internal Medicine, Boston Medical Center, Boston, Massachusetts (J.M.G.); and Institute for Re- search, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, Boston, Massachusetts (M.R.).

Disclosures: None disclosed. Forms can be viewed at www. acponline.org/authors/icmje/ConflictOfInterestForms.do?ms Num=M18–0258.

Corresponding Author: Jessie M. Gaeta, MD, Institute for Re- search, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, 780 Albany Street, Boston, MA 02118; e-mail, jgaeta@bhchp.org.

Current author addresses and author contributions are available at Annals.org.

Ann Intern Med. 2018;168:664–665. doi:10.7326/M18–0258

References

  1. Gaeta J, Bock B, Takach M. Providing a safe space and medical monitoring to prevent overdose deaths. Health Affairs Blog. 31 Au- gust 2016. Accessed at www.healthaffairs.org/do/10.1377/hblog 20160831.056280/full/ on 29 January 2018.

  2. Marshall BD, Milloy MJ, Wood E, Montaner JS, Kerr T. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population- based study. Lancet. 2011;377:1429–37. [PMID: 21497898] doi:10 .1016/S0140–6736(10)62353–7

  3. Potier C, Laprévote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend. 2014;145:48–68. [PMID: 25456324] doi:10.1016/j.drugalcdep.2014.10.012

  4. Wood E, Tyndall MW, Zhang R, Stoltz JA, Lai C, Montaner JS, et al. Attendance at supervised injecting facilities and use of detoxification services [Letter]. N Engl J Med. 2006;354:2512–4. [PMID: 16760459] 5. DeBeck K, Kerr T, Bird L, Zhang R, Marsh D, Tyndall M, et al. Injection drug use cessation and use of North America’s first medically supervised safer injecting facility. Drug Alcohol Depend. 2011; 113:172–6. [PMID: 20800976] doi:10.1016/j.drugalcdep.2010.07 .023

  5. Kerr T, Stoltz JA, Tyndall M, Li K, Zhang R, Montaner J, et al. Impact of a medically supervised safer injection facility on community drug use patterns: a before and after study. BMJ. 2006;332: 220–2. [PMID: 16439401].

  6. Massachusetts Medical Society, Task Force on Opioid Therapy and Physician Communication. Establishment of a pilot medically supervised injection facility in Massachusetts. 2017. Accessed at www .massmed.org/advocacy/state-advocacy/sif-report–2017 on 30 January 2018.

  7. American Medical Association. AMA wants new approaches to combat synthetic and injectable drugs. 2017. Accessed at www.ama -assn.org/ama-wants-new-approaches-combat-synthetic-and-injectable -drugs on 30 January 2018.

  8. Leó n C, Cardoso L, Mackin S, Bock B, Gaeta JM. The willingness of people who inject drugs in Boston to use a supervised injection facility. Subst Abus. 2017:1–7. [PMID: 28799847] doi:10.1080 /08897077.2017.1365804

  9. Kral AH, Davidson PJ. Addressing the nation’s opioid epidemic: lessons from an unsanctioned supervised injection site in the U.S. Am J Prev Med. 2017;53:919–922. [PMID: 28801014] doi:10.1016/j. amepre.2017.06.010

Annals.org

Annals of Internal Medicine • Vol. 168 No. 9 • 1 May 2018 665

Current Author Addresses: Dr. Gaeta and Ms. Racine: Institute for Research, Quality, and Policy in Homeless Health Care, Boston Health Care for the Homeless Program, 780 Albany St., Boston, MA 02118.

Author Contributions: Conception and design: J.M. Gaeta. Analysis and interpretation of the data: J.M. Gaeta.
Drafting of the article: M. Racine.
Critical revision for important intellectual content: J.M. Gaeta. Final approval of the article: J.M. Gaeta.

Provision of study materials and patients: J.M. Gaeta.

Annals.org

Annals of Internal Medicine • Vol. 168 No. 9 • 1 May 2018

SIF/SCSs in the news

Follow the data, governor: sites for injections work

May 8, 2017 Editorial

LAST SPRING, AFTER signing legislation aimed at curbing opioid abuse at a State House ceremony, Governor Charlie Baker broke down in tears.

Only after a swell of applause from a large crowd of legislators, law enforcement officials, and families of overdose victims was he able to speak. “May today’s bill passage signal to you that the Commonwealth is listening,” he said, “and we will keep fighting for all of you.”

The governor can be an emotional leader. But he also touts his data-driven approach to governance. And the data, it must be said, do not look good.

Last year, almost 2,000 people are believed to have died of opioid overdoses in Massachusetts, according to state officials, a record toll that defied a new wave of treatment and education efforts — including some high-profile measures in the bill Baker signed that spring day.

At the top of the list: clinics where addicts can shoot up under the watchful eye of doctors and nurses — offering clean needles, drugs that can reverse overdoses, and referrals to drug treatment.

Last weekend, the push for supervised drug-injection sites got a big boost when the Massachusetts Medical Society’s governing body voted overwhelmingly to urge a state-run pilot program that would allow for up to two such clinics in the state.

There are already 90 of these facilities worldwide, and the data — take note, governor — are quite promising. After a clinic opened in Vancouver, in 2003, researchers found a 35 percent decrease in overdoses in the surrounding neighborhood, compared to a 9 percent decline citywide. Ambulance calls for overdoses near a Sydney facility dropped by 68 percent.

There are dozens of peer-reviewed studies — more than 40 now — and some of them have appeared in the world’s most prestigious medical journals.

“This work is published in the Lancet and The New England Journal of Medicine,” said Dr. Thomas Kerr, a professor of medicine at the University of British Columbia who has studied the Vancouver clinic. “It doesn’t get tougher than that.”

The drug-injection sites have their critics, of course. The studies, however, rebut some of the most prominent objections. Intravenous drug use does not increase in the areas where clinics operate, the research shows. And opening a facility does not have a “honey pot” effect, drawing drug dealers and prostitutes to the area.

After studying six years of crime data for the area surrounding the Vancouver clinic, criminologist Neil Boyd told The Globe and Mail newspaper, “our detailed maps confirmed the hypothesis of no impact, no significant changes in relation to criminal offenses.”

A separate study appearing in the journal Substance Abuse Treatment, Prevention, and Policy found no gain in drug trafficking or robberies and assaults in the neighborhood. Vehicle break-ins and thefts actually declined.

There are significant legal obstacles to opening drug-injection sites in Massachusetts. State and federal law bars the clinics, and getting an exemption from a GOP-controlled Washington would be no small task.

But there is some precedent. In recent years, the federal government has looked the other way as states have legalized marijuana; indeed, Massachusetts is counting on that forbearance now as it rolls out its own regulatory setup for legal pot.

And with hundreds and hundreds of people dying of opioid overdoses every year, policy makers should be willing to take some chances here. “We will keep fighting for all of you,” Baker promised, a year ago.

Fulfilling that promise means supporting solutions that work — no matter how controversial.

Let Cities Open Safe Injection Sites

By The Editorial Board

An overdose is often a lonely way to die. Overdoses happen when a toxic amount of a drug, or a combination of drugs, overwhelms the body’s basic functions, first slowing and eventually stopping the brain’s drive to breathe. If someone notices the signs of an overdose — lips turning blue, restricted pupils, unresponsiveness, a loss of consciousness, among others — it can generally be reversed with drugs like naloxone, which saves thousands of lives a year. But someone must be there to notice.

Yet one of the most consistent patterns in the more than 64,000 deaths attributed to opioid and other drug overdoses in 2016 was that the victims’ last moments went unobserved. Last year, the number of deaths was most likely even higher.

In the face of this emergency, dedicated public health officials and policymakers have suggested some vital solutions. One important, rigorously tested harm-reduction method, however, is still rarely discussed in the United States: supervised drug consumption sites, also known as safe injection sites. This must change. All evidence so far shows these facilities have proved incredibly effective at slashing overdose deaths in every country that has welcomed them. If lawmakers are serious about ending the opioid crisis, American cities and states should follow their lead.

At safe injection sites, trained staffs provide clean needles, administer naloxone when there are overdoses and offer long-term treatment options. People bring their own drugs — most often heroin.

It may seem counterintuitive: Give drug users space and support to inject themselves with potentially deadly substances, even while encouraging them to stop.

But dozens of studies suggest that these sites curtail overdose deaths and increase participation in drug treatment. Despite millions of injections that have occurred at more than 90 facilities internationally over the past three decades, not a single overdose death has been recorded.

The Trump administration has threatened to prosecute safe injection sites under federal law. But just as cities and states have legalized medical and recreational marijuana, they could also pass laws authorizing these sites, preventing the local police from intervening. Federal law enforcement could then either turn a blind eye, as it’s largely done with marijuana, or bring states to court.

People are dying at a staggering rate from overdoses — more in one year than the number of American soldiers who died during the entire Vietnam War. So some cities are already, rightly, taking the risk. Seattle and San Francisco are both on track to open sites, and Philadelphia recently approved the idea as well. Boston, Ithaca and New York City are considering their own facilities.

At the first supervised site in North America, which opened in Vancouver in 2003, there was a 35 percent reduction in overdose deaths in the immediate vicinity, compared with a nine percent reduction in the rest of the city, according to a study published in The Lancet.

And four separate studies have shown a positive association between using a safe injection site and starting addiction treatment.

Neighbors and city officials sometimes challenge sites like these because they fear they will promote drug use and increase crime. Research instead suggests that they lead to increases in public order, with fewer discarded needles on the street and less drug use on the sidewalk, and have no impact on drug-related crimes.

Such sites certainly don’t solve the problem of drug overdoses — Vancouver has had a recent spike in fentanyl-related overdose deaths, for instance. But they’re effective as part of a larger harm-reduction movement, which assumes that no matter how many well-intentioned programs exist to prevent people from starting or continuing to use drugs, there will always be people who shoot up. It’s better for everyone, the thinking goes, if they do that as safely as possible, with clean needles that are discarded properly. If the goal is to get drug users into treatment, the first step is to make sure they don’t die.

So far, President Trump has advocated the opposite approach, focusing on law enforcement instead of harm reduction and promising to be “really, really tough” on people who deal drugs — an old idea that hasn’t worked to save lives. The administration’s 2019 budget plan proposed $13 billion over two years to address the opioid crisis, but it didn’t include much detail about what, exactly, that money would fund. In December, the attorney general’s office made its position on safe injection sites clear in response to a proposed facility in Vermont: “It is a crime, not only to use illicit narcotics, but to manage and maintain sites on which such drugs are used and distributed.”

“In short, opiate addicts need treatment, not a place to continue using,” the office wrote.

Advocates agree on the need for evidence-based treatment and services to help homeless drug users find housing or mental health care, but that’s not a reason to prosecute people trying to save lives at safe injection sites.

There is at least one unauthorized, invitation-only site in the United States that a small nonprofit has been secretly running, in an unadvertised location, for more than three years. Staff members have been able to reverse all eight overdoses that have occurred on-site.

Critics of such sites raise legitimate concerns about normalizing drug use that could be fatal. But so far, the wealth of available evidence shows two things: Most of America’s past policies have failed catastrophically, and the regions that have tried these sites have saved people.

States and other cities should follow the lead of Seattle and Philadelphia to open safe injection sites. One of the most meaningful things the Trump administration could do to help drug users and their families is to stay out of the way.

A version of this article appears in print on February 25, 2018, on Page SR10 of the New York edition with the headline: Let Cities Open Safe Injection Sites.

War on drugs requires new tactics: Our view

The Editorial Board , USA TODAY Published 4:56 p.m. ET May 16, 2016 | Updated 6:39 p.m. ET May 16, 2016

Supervised heroin injection sites show promise in Canada, Europe.

With an average 78 Americans dying each day from overdoses of prescription opioid painkillers and heroin, it’s clear that the U.S. is losing the war on drugs. The epidemic has spread to suburbia and rural areas. The death toll from heroin has more than tripled since 2010. And the nation is desperate for answers.

Congress is working on bipartisan measures that would give states, localities and non-profit groups money to finance an array of education, treatment and law enforcement programs. Final passage can’t come a moment too soon. But it’s all rather standard fare.

To deal with people who are already addicted, some unconventional thinking is required, and here’s one idea worth considering: supervised injection facilities, where an addict can bring heroin and inject it in a clean, safe environment under medical supervision, with easy access to counselors and health care referrals.

Yes, we know, this might look crazy at first glance. We thought so, too, but the results where this approach has been tried suggest it just might make sense.

This is not a ploy to legalize heroin, weaken law enforcement or replace treatment. It’s an idea that has been effective in Europe, where about 90 such centers operate, and in Vancouver, where the only center in North America opened in 2003.

According to researchers at the University of British Columbia and the Center for Excellence in HIV/AIDS, the Canadian center has prevented overdose deaths, reduced the risk of HIV and AIDS through the use of clean needles, cut down on public injections and their dangerous debris of used needles, and promoted detox and treatment.

The facility, called Insite, has saved lives after on-site overdoses, and in the 27 months after it opened, overdose deaths dropped 35% in the blocks around the facility — four times the decrease in the rest of Vancouver. The facility, which receives funding from the British Columbia government, has saved taxpayers money by reducing expensive-to-treat HIV and AIDS cases.

Critics have tried to debunk findings of Insite’s success, and in the mid–2000s, a new Conservative Party prime minister moved to shut it down. But the battle became the center’s savior. National medical, public health, and nurses associations intervened on its side, and in 2011 the Canadian Supreme Court unanimously rejected closure, finding that “during its eight years of operation, Insite has been proven to save lives with no discernible negative impact on the public safety and health objectives of Canada.” That opened the way for more facilities. Now Toronto, Montreal and Ottawaare considering the idea.

In Europe, such injection centers have been around for 30 years. Since the first one opened in Switzerland, the idea has spread to Germany, the Netherlands, Luxembourg, Denmark, Norway and even Sydney, Australia. Like Insite, they’ve made it more likely that addicts will enter treatment, according to the European Monitoring Center for Drugs and Drug Addiction. Not surprising, when you put the hardest-to-reach addicts in a place where counseling is readily available.

Impressed by these results, a handful of city officials and state lawmakers in the USA are interested. The mayor of Ithaca, N.Y., is pushing the idea, and the county prosecutor is on board. In Seattle’s King County, Sheriff John Urquhart, a former narcotics detective, told TheSeattle Times he is “still trying to wrap my head around this. But the more I hear, the more open I am to the possibility.”

Critics remain adamant that the idea is preposterous, tantamount to declaring surrender in the war on drugs and turning the government into an enabler of illegal drug use. The same arguments were used against methadone clinics and needle exchanges, which now have widespread acceptance.

Vancouver’s experience can inform U.S. decisions: Start small with modest goals — bringing addicts off the streets, preventing disease and overdoses — and provide rigorous, independent research to see whether similar programs can work here.

Once unthinkable in US, drug shoot-up rooms get serious look

By DAVID KLEPPER

May. 8, 2016 9:46 PM EDT

Across the United States, heroin users have died in alleys behind convenience stores, on city sidewalks and in the bathrooms of fast-food joints — because no one was around to save them when they overdosed.

An alarming 47,000 American overdose deaths in 2014 — 60 percent from heroin and related painkillers like fentanyl — has pushed elected leaders from coast to coast to consider what was once unthinkable: government-sanctioned sites where users can shoot up under the supervision of a doctor or nurse who can administer an antidote if necessary.

“Things are getting out of control. We have to find things we can do for people who are addicted now,” said New York state Assemblywoman Linda Rosenthal, who is working on legislation to allow supervised injection sites that would also include space for treatment services. “The idea shouldn’t be dismissed out of hand. I don’t see anyone else coming up with anything new and innovative.”

Critics of the war on drugs have long talked about the need for a new approach to addiction, but the idea of allowing supervised injection sites is now coming from state lawmakers in New York, Maryland and California, along with city officials in Seattle, San Francisco and Ithaca, New York, who note that syringe exchanges were once controversial but now operate in 33 states.

While such sites have operated for years in places such as Canada, the Netherlands and Australia, they face significant legal and political challenges in the U.S., including criticism that they are tantamount to waving a white flag at an epidemic that should be fought with prevention and treatment.

“It’s a dangerous idea,” said John Walters, drug czar under President George W. Bush. “It’s advocated by people who seem to think that the way we should help sick people is by keeping them sick, but comfortably sick.”

But proponents argue such sites are not so radical outside the U.S., pointing to examples where they offer not only a place to shoot up, but also health care, counseling and even treatment beds. In many cases, the users are there to shoot up heroin or dangerous opioids like fentanyl, though some take painkillers in pill form.

At Sydney’s Medically Supervised Injecting Centre, more than 5,900 people have overdosed since it opened in 2001. No one has died. It’s the same at Insite in Vancouver, British Columbia. About 20 overdoses happen there every week, but the facility, which is jointly operated by a local nonprofit and the Vancouver Coastal Health Authority, has yet to record a death.

“A big fat zero,” said Insite site coordinator Darwin Fisher.

Sydney’s facility is tucked between a hostel and a Chinese restaurant in Kings Cross, the city’s red-light district. Aside from the security guard posted just inside the front door, it looks like a typical health clinic.

At least two staffers, including a registered nurse, monitor the injection room. They are not allowed to administer drugs, though sterile needles are provided. If a patient overdoses, the nurse delivers the antidote Narcan, which quickly reverses the overdose.

After users get their fix, they head to a second room with a decidedly warmer feel. Colored Christmas lights hang from the ceiling; books and magazines line the shelves. Clients can relax with a cup of coffee or tea or talk to staff. Some stay for 15 minutes; others spend hours. They exit through a back door to protect their privacy.

The center opened on an 18-month trial basis following a sharp increase in heroin use in Sydney. The trial was repeatedly extended by government officials until 2010, when it was granted permanent status. It’s run by the social services arm of the Uniting Church and is funded by police-seized proceeds of various crimes.

A clinic in Amsterdam — one of three injection sites in the Dutch capital — goes even further, distributing free heroin to long-term addicts as part of a government program created for hardened addicts who might otherwise commit a crime to pay for their fix.

About 80 users visit up to three times a day. Most are men, and the average age is 60. Many began using in the 1970s and 1980s.

“We would ideally like them to cut back their use,” said Fleur Clarijs, a doctor at the facility.

But, she said, the main objective of the facility is to reduce risk to users — and their effects on the community.

In Vancouver’s seedy Downtown Eastside neighborhood, Insite offers patients treatment services just up the stairs from where they shoot up. About a third of Insite’s visitors request referral to a detox program, the clinic said.

A woman who gave her name as Rhea Jean spoke to The Associated Press after recently injecting herself there. She felt nauseous and ran outside to the curb to vomit. Her face covered with scabs, the longtime heroin user looks far older than her 33 years.

“It’s a great place for active users in full-blown addiction. It links you up to other programs,” said Jean, who herself hasn’t sought treatment through Insite.

A 65-year-old man who gave his name only as James because he’s in a 12-step program that requires anonymity said he has been using heroin since age 22. He was clean for 17 years before relapsing; he said he was sexually abused as a child and spent 23 years in prison.

He keeps returning to heroin, he said, because it provides release from his problems. Insite is the one place he can go and be treated if he reacts badly to the drug, he said.

“They saved my life three times,” he said, adding that addiction shouldn’t be demonized.

“There’s a large section of society that still refuses to accept it as a disease,” he said.

The three clinics visited by the AP initially faced opposition from politicians and members of the public but gradually won support, in part because of studies showing reductions in overdose deaths and open-air drug use in the surrounding community.

A 2010 survey of residents and businesses in Kings Cross, for instance, found strong support.

Insite was targeted for closure by Canadian Prime Minister Stephen Harper and his Conservative Party. The case went to the Supreme Court of Canada, which in 2011 told the government to issue an exemption to the drug laws allowing Insite to operate.

“Insite saves lives,” Chief Justice Beverley McLachlin wrote in the decision. “Its benefits have been proven. There has been no discernible negative impact on the public safety and health objectives of Canada during its eight years of operation.”

Advocates in the U.S. have long discussed the potential benefits of injection sites — but they point to the tripling of heroin and opioid overdose deaths since 2000 as one reason why the suggestion is starting to get serious consideration.

The deaths of actors Philip Seymour Hoffman and Heath Ledger put celebrity faces on the risks of overdosing alone, and it was revealed recently that representatives for Prince sought help for his addiction to painkillers just a day before the musician was found dead.

In an effort to stay safe, some addicts are taking matters into their own hands. In Boston, after Massachusetts General Hospital equipped security guards with Narcan, the hospital began seeing an uptick in addicts shooting up in bathrooms and parking garages.

Elsewhere in the city, a nonprofit recently set aside a room where addicts can go after using drugs. The users can’t inject there, but a nurse monitors those in the room and will intervene in case of overdose.

U.S. federal law effectively prohibits injection facilities, but supporters say that if a state or city were to authorize one, Washington officials could adopt a hands-off approach similar to the federal response to state medical marijuana programs.

Kevin Sabet, a former drug policy adviser to the Obama administration, put the chances of injection sites getting approval anytime soon at zero. He believes supporters want full legalization of all drugs and are exploiting the opioid crisis to advance their agenda.

California Assemblyman Tom Lackey, who served on the California Highway Patrol for 28 years, said he understands that supporters are looking for a new approach. But he has deep reservations about legislation in his state which would create clinics where users could use heroin, crack or other drugs.

“These facilities send a message that there is a safe use, and I don’t think there is any safe use of heroin,” he said.

In Maryland, state House of Delegates member Dan Morhaim is an emergency physician who himself has administered Narcan “many, many times.” He sees his bill for supervised injection sites as just one of many creative approaches that will be needed to solve the heroin problem.

“It’s not going to cure everyone,” he said. “But moving people from more dangerous behavior to less dangerous behavior is progress.”

Marianne Jauncey, medical director at Sydney’s Medically Supervised Injecting Centre, said she would prefer better ways to help hardened addicts. Her facility will work to keep them alive until that happens.

“Given their histories,” she said, “I think the least that we can do as a society is try.”


Klepper reported from Albany, New York. Contributing to this report were Associated Press writers Mike Corder in Amsterdam, Kristen Gelineau in Sydney and Jeremy Hainsworth in Vancouver.

Editorial: Safe injection sites worth considering

Syringes left by drug users amid the heroin crisis are turning up everywhere.

Northwestern District Attorney David E. Sullivan is right to call for “outside-the-box thinking” — including supervised injection facilities — to combat the scourge of opioid deaths plaguing communities in the Valley and across the country.

Sullivan also is correct when he describes as radical the concept of sanctioned places where people can inject illegal drugs such as heroin in medically supervised settings. Those facilities should be established only after careful study addressing issues including locating them in places that are easily accessible to people who are addicted and ensuring that those drug users are educated about treatment programs.

“Supervised injection facilities are not suitable for all communities — they may not be cost effective except in large cities,” Sullivan wrote in a column published in January by the Daily Hampshire Gazette. “But I think they, and the approach they take in treating drug users with care, are an option worthy of consideration as we suffer the toll this epidemic takes in lost lives and shattered families and communities.”

Sullivan joins an increasing number of health officials and politicians who are advocating for supervised sites that provide sterile injection equipment, access to medical staff, information about reducing the harm of drug use and referrals to addiction treatment. No such safe sites currently operate legally in the United States, and, in fact, they are illegal under federal law.

However, there are about 100 such facilities in nine other countries, mostly in Europe as well as Australia and Canada. The first in North America, Insite, opened in 2003 in Vancouver, British Columbia. Nurses at Insite have supervised drug injections by some 3.6 million people in 15 years, and while there have been more than 6,000 overdoses, no one has died there, according to the Associated Press.

In 2016, there were 2,069 unintentional deaths in Massachusetts related to opioids, including heroin, fentanyl and prescription pain pills such as OxyContin.

State Sen. William Brownsberger, D-Belmont, has filed legislation that would allow state health officials to permit safe injection sites. He said the intent of the bill, which awaits action, is to save lives and get addicts into treatment.

The Massachusetts Medical Society and Massachusetts Hospital Association support consideration of supervised injection facilities. The medical society issued a report last year citing research at the sites in Canada and Australia that suggests they reduce overdose deaths and increase access to drug treatment. The medical society recommended establishing a pilot supervised injection facility program in Massachusetts, and to seek an exemption from federal drug laws.

However, there are skeptics, including Republican Gov. Charlie Baker. He testified at a Statehouse hearing in January on legislation he filed addressing the opioid crisis that, among other things, would permit police and medical professionals to bring high-risk drug users to substance abuse treatment centers for up to 72 hours, even if they do not agree. The bill does not call for supervised injection sites.

“As far as the data I’ve seen is concerned, it has not demonstrated any legitimate success in creating a pathway to treatment,” Baker said. “The harm reduction argument I think is a much better one, but I’m kind of a hard sell on that one.”

Also last month, Philadelphia officials announced that the city is seeking private organizations to set up medically supervised drug injection facilities that also would offer access to sterile needles, the overdose-reversing drug naloxone (known by its brand name Narcan) and referral to treatment and social services.

Philadelphia officials visited Insite in Vancouver, as well as Seattle, where the City Council has included $1.3 million in the 2018 budget for a safe injection site. Philadelphia officials also released a scientific review of studies concluding that such facilities reduce deaths from drug overdoses; prevent HIV, Hepatitis C and other infections; and help drug users get into treatment.

Sullivan wrote in his column, “For people who think this idea is too radical, I would say this: In order to save lives, we need to look in a clear-eyed, rational way at what works and what doesn’t work.”

We hope the state approves legislation clearing the way for a pilot safe injections site. We encourage its placement in Hampshire or Franklin county where the top law enforcement official has a progressive view about using all possible tools to combat addiction.

EDITORIAL: CITY-SPONSORED DRUG-INJECTION SITES CAN SAVE LIVES CHRONICLE EDITORIAL BOARD

February 6, 2018

San Francisco has more than 20,000 injection-drug users. Injection sites are an innovation that can reduce fatal overdoses by addicts and accidental needle sticks on the streets.

The idea of a city-sponsored drug-injection site at first sounds baffling and dangerous. To some, providing comfortable quarters and needles to shoot up is the last thing a city should do to curb drug users sprawling across sidewalks and parks.

But San Francisco, along with other major cities, is on track to do just that — and the plan makes sense. It’s a real-world answer that can lessen a runaway problem, prevent deaths and offer a pathway from addiction. Safe-injection sites have found support and success in dozens of cities in Canada, Europe and Australia.

Between now and July, city Health Director Barbara Garcia plans to clarify the scope and operations of the local sites. Her department has worked on the idea for months, mindful of the legal and health hazards that go along with enabling illegal drug use.

There are reasons for caution, but the idea is neither far-fetched nor implausible. San Francisco has more than 20,000 injection-drug users, a figure that accounts for a demoralizing sight of discarded syringes and open drug use throughout the city. Anyone walking by a huddled group splayed on the pavement should want the city to come up with an answer.

Offering a controlled setting indoors can help. It’s expected there will be medical oversight and counseling, clean needles, and safe surroundings. Police involvement to prevent drug sales needs to be worked out.

Until now, San Francisco and other cities were stalled over legal and perceptual problems. Opening the doors ran afoul of a raft of laws barring drug use. The city could be liable if an addict overdosed. Even an ever-tolerant city wasn’t completely sold that allowing serious drug use would produce anything but trouble.

But city leaders are sidestepping legal issues by lining up private organizations to provide the money to run the sites, which will begin with two locations with more to follow. Overdose fears haven’t been borne out elsewhere. As for public unease, San Francisco has become more upset over rampant drug use than over any doubts about a promising innovation.

Richard Chenery rests after injecting heroin at the Insite clinic in Vancouver, B.C., North America’s first legal injection site.

SF safe injection sites expected to be first in nation, open

San Francisco moving toward opening nation’s 1st safe injection

Why SF should open a supervised drug-injection facility

This city won’t be alone. Philadelphia announced last month it will work with local groups to open injection sites. Seattle, Denver and Baltimore are also moving in the same direction. Fueling the urgency is a wave of drug deaths linked to opioids and heroin that totaled 63,000 fatalities in 2016. That astonishing number, larger than U.S. combat deaths in Vietnam, is easing official reluctance city by city.

The spreading plans could be curtailed if the Trump administration chooses to block the sites through drug raids or court challenges. But that worry is too uncertain to stop a groundswell idea that needs to get under way.

At best, the injection sites can dent a much larger problem. There needs to be more emphasis and money for medical treatment, rehabilitation and programs that treat addiction, not punish it. That leadership is missing in Washington, where the president’s endless emphasis on drug crime masks his failure to provide serious leadership.

Injection sites are an innovation that can reduce fatal overdoses by addicts and accidental needle sticks on the streets. The status quo is intolerable. It’s time for San Francisco to give them a try.

SIFMA NOW in the news

Advocates Push For Safe Injection Sites In Boston

By Liam Martin April 30, 2018 at 5:27 pm

BOSTON (CBS) – Boston advocates for controversial “safe injection sites” made a public push Monday. Along with information, they gave people an up close look at how they say these sites can prevent overdoses and save lives.

We’re painfully aware of heroin users overdosing in back alleys, under bridges and even in public buildings, with the death toll a national crisis. Today, medical students and other advocates for what are called safe injection facilities took their campaign to the Harvard Medical School quad, talking to people about why they think Massachusetts should open the controversial sites.

“People who would otherwise be injecting and overdosing alone on the street could come in and receive medical care, be supervised so they’re using substances safely, and are connected to long term treatment,” says Kathleen Koenigs, a first year medical student and a member of the Student Coalition on Addiction.

They even set up an area that simulates what an injection site would look like. A simple desk with sterile syringes and Narcan in case of an overdose. Medical staff would be on hand for safety.

It’s modeled after this injection facility in Vancouver that has operated for 15 years. “We don’t want to lose any more of our family members, our neighbors,” says Aubri Esters of Safe Injection Facilities Now.

The facilities would look at addiction as a medical problem and offer treatment. “It’s an avenue for treatment. It’s an avenue for increased health and it’s an avenue to keep people alive,” she says.

While there are several bills at the State House that would allow for these facilities, it’s a tough sell. Gov. Baker isn’t convinced. “I really want to see literature that demonstrates, one way or the other, whether this helps people get better,” he says.

Even if Beacon Hill approved, the sites would still be illegal at the federal level. Right now there are about 100 supervised injection sites around the world. None in the United States. In addition to Boston, people in Philadelphia, Seattle and San Francisco are considering whether the facilities would be effective in their communities.

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