Public health advocates and researchers drilled down into the the risks and benefits of opening safe injection sites — spaces where people can legally consume or inject their own illicit drugs under medical supervision — in the U.S., during a panel discussion Monday hosted by the American Enterprise Institute.
More than 100,000 Americans died from drug overdoses in the 12-month period ending in April, according to CDC data — a number that represents a nearly 30% increase in deaths during the same window the year before.
Proponents of safe injection sites (also called safe consumption or supervised injection sites) say they prevent drug overdose deaths, while also connecting participants to counseling, treatment, and other health services.
Critics, however, like David Murray, PhD, co-director for the Center for Substance Abuse Policy Research at the Hudson Institute in Washington D.C., say the sites encourage and enable high-risk behaviors.
“If someone falls in the water, in a river, and you rescue them, and then you leave them back in the river again,” that act of saving a life is “a worthy goal … but it is not a strategy,” said Murray, who questioned whether safe injection sites are in fact saving lives.
More than 100 safe injection sites are currently operating in at least 10 countries, including Australia, Canada, France, and Germany, but none have legally opened in the U.S.
Philadelphia, San Francisco, New York, and Seattle are inching forward with plans to open such facilities, and in July 2021 Rhode Island became the first state to authorize a pilot program for safe injections.
But in every case, proponents have met roadblocks, usually in the form of local or federal officials who oppose the plans.
Closed Doors at Every Turn
One unsanctioned site has been operating in an undisclosed city in the U.S. since 2014, and has shown positive results.
That a section of the Controlled Substances Act specifically prohibits any site from opening “for the purposes of using, selling, storing [or] manufacturing drugs,” is a definite obstacle, noted Ronda Goldfein, Esq., executive director of the AIDS Law Project of Pennsylvania.
To date, there have been no fatalities at any safe injection site, said Goldfein, who is also vice president and secretary of SafeHouse, a nonprofit organization looking to establish a safe injection site in Philadelphia.
Other benefits of the sites, she said, include decreased fatalities in the surrounding area, as well as a reduction in public use of drugs and drug-related litter. Importantly, the facilities have not been shown to increase crime in the nearby community, she added.
However, proving the merits of such facilities in the U.S. is impossible without a site to study, Goldfein pointed out. “We have been threatened with arrest if we open.”
So, despite having a “great idea,” promising data, and the drive to pursue more robust research, she and other advocates are unable to move forward, Goldfein said.
The U.S. Attorney in Philadelphia sued SafeHouse in 2019 to prevent it from opening a site. The nonprofit won at the district court level, but lost at an appeals court; in October, the Supreme Court decided not to review the case, which now sits with the original district court, Goldfein noted.
She said she anticipates the Biden administration will weigh in by Jan. 5, 2022. Unlike the Trump administration, which pledged to crack down on these proposed sites, the current administration has signaled they may be more open to safe injection sites.
Nora Volkow, MD, director of the National Institute on Drug Abuse, in an email to MedPage Today in July, lauded the idea of increasing harm-reduction research, noting specifically that supervised injection facilities have shown “some promise in reducing harms and social costs associated with injection drug use.”
“If demonstrated to be effective,” she wrote, “overdose prevention centers could be another valuable and innovative tool to support and care for people with substance use disorders.”
Evidence for Safe Injection Sites
But Murray, during Monday’s panel, raised concerns over the effectiveness of these facilities.
“Are we actually saving lives?” he asked.
People who use drugs don’t inject them solely at the safe injection sites. Many inject or consume drugs multiple times a day in different locations, and supporting someone through a “mortality episode” at a particular moment is no guarantee that a life has been saved, Murray argued.
He pointed to a safe injection site in Vancouver, launched in 2003, which saw its highest participation rate ever last year. Despite providing record numbers of naloxone reversals and record doses of medication-assisted therapy, “the net result” in 2020 was a doubling in the number of overdose deaths, he said.
Teasing out the real drivers of the increased overdose deaths at the safe injection site in Vancouver is difficult, Goldfein acknowledged, but the current explosion of fentanyl — a vastly more potent and more deadly opioid than morphine — into the drug supply cannot be ignored.
“I think it’s … with all due respect, a leap to suggest that because there are more supervised consumption sites, there are more people using drugs and there are more overdoses,” she added.
How to Measure Success
Some studies of safe injection sites measure their success by the number of overdose reversals averted, but Murray discounted this benchmark, and argued that to save a life requires changing a person’s behavior of injecting illicit drugs.
Mortality should not be the only endpoint, Murray continued. The morbidities that accompany high-risk behaviors like continuous use of illicit drugs — including schizophrenia, paranoia, and psychotic breaks — are all also a relevant piece of participants’ outcomes, he said.
But there are also other ways to look at the benefits of such sites, noted Sharon Larson, PhD, executive director of the Main Line Health Center for Population Health Research at the Lankenau Institute for Medical Research in Wynnewood, Pennsylvania.
When a supervised injection site was launched in Australia, she said, researchers saw 15,000 people visit in a single year, two-thirds of whom had never been connected to health services prior to coming to the site.
And while it’s unlikely that a person walking into a facility for the first time will be ready for treatment, these are individuals who would otherwise never have even had the opportunity to be screened or referred in the first place, Larson said.
She also pointed to the costs of injection drug use as another important metric: The use of “jagged needles” or repeated use of the same needle can lead to emergency department visits, Larson said. “And the average hospital stay for someone who has a skin infection associated with using dirty needles over and over again is about 6 days.”
“You can imagine the cost,” she said. “If the city is responsible for that, that’s a huge cost.”
Challenging Population to Study
Most studies of safe injection sites tend to be observational rather than the gold standard of randomized clinical trials, and tend to rely primarily on self-reported data, noted Murray.
For example, participants may be asked to answer questions about whether they’ve increased their drug use.
They may say they have not, but there aren’t any “objective measures of the actual medical impact” beyond overdose rates, Murray explained.
This is also a demographic with high attrition rates. The individuals at greatest risk of an adverse event are the same ones that are most likely to “filter away from the participation in the sites,” he added.
Goldfein argued that just because research studies of supervised injection facilities are difficult and sometimes turn up inconclusive results, isn’t a reason not to pursue them: “The idea that we’ll wait, we’ll develop the perfect study, and then we’ll open the doors … What about the people we’re losing every day?” she asked.
As for how to measure a program’s success, Goldfein argued that focusing solely on whether participants “go on to live a long, healthy, and productive life,” shows a lack of compassion and a clear bias against people with substance use problems.
Think about all of the patients saved in the emergency department after heart attacks, she said. No one has pressured those doctors to start asking, “Well, what are the other activities that you’ve done that have put you into cardiac arrest? Do you commit to not doing them?”
Just as cancer patients may be given access to unapproved treatments when standard regimens fail, via compassionate use pathways, the public must recognize that the current approach to helping those with substance use isn’t working, Goldfein said. While the evidence for safe injection sites continues to be collected, “compassionate use” of these sites should be allowed, “because it will save lives,” Goldfein said.
Shannon Firth has been reporting on health policy as MedPage Today’s Washington correspondent since 2014. She is also a member of the site’s Enterprise & Investigative Reporting team. Follow
Source : MedPageToday