Could supervised injection sites save lives?

Why We Wrote This

Conflicting perceptions of safety seem to drive the debate on safe injection sites. Critics argue they enable drug use. Supporters say they enable survival.

Matt Rourke/AP
Protesters demonstrate Dec. 3, 2019, in Philadelphia in support of supervised injection sites.

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In 2017, drug overdoses in the United States claimed more than 70,000 lives. Nearly 7 out of 10 involved opioids. This ongoing overdose crisis is pushing public health officials to consider new tools. Harm reduction advocates are increasingly urging a new intervention: supervised consumption sites.

Staff at these facilities are trained to reverse overdoses, provide sterile supplies, and offer a bridge to recovery services. More than 100 of them operate worldwide, but in the U.S. legal uncertainty, community concerns, and stigma have stalled plans. Limited research suggests supervised consumption is a promising public health intervention. A supervised consumption site in Canada has reported 6,440 halted overdoses.

In Boston, Jessie Gaeta, chief medical officer at Boston Health Care for the Homeless Program, says that not allowing supervised consumption “feels like a treatment gap.” Others, such as youth football coach and activist Domingos DaRosa, are uncomfortable with the idea of permitting use of illegal drugs. As a black man, he also worries the sites could attract increased law enforcement.

“Folks who have nothing to do with [the opioid crisis] are the ones that are catching the wrong end of the stick,” he says.

The ongoing overdose crisis is pushing public health officials to consider new tools. In 2017, drug overdoses in the United States claimed more than 70,000 lives. Nearly 7 out of 10 involved opioids.

Last year logged a slight decline in fatal overdoses, provisional data show. But communities countrywide remain desperate to save more neighbors. Harm reduction advocates admit there is no panacea to the public health crisis. But they urge a new intervention: supervised consumption sites.

What exactly are they?

Also called safe injection facilities or overdose prevention sites, these venues permit the use of previously obtained illicit drugs in a clean space with medical supervision. Staff are trained to reverse overdoses, provide sterile supplies, and offer a bridge to recovery services.

More than 100 of them operate worldwide. Multiple U.S. cities have mulled opening these sites, but legal uncertainty, community concerns, and stigma have stalled plans. 

The American Medical Association endorses a pilot site. Many public health officials consider supervised consumption lifesaving. They note health risks of drug use in unhygienic public spaces, plus the rise in overdose deaths involving fentanyl – a potent synthetic opioid that can trigger an overdose within seconds.

Jessie Gaeta, chief medical officer at Boston Health Care for the Homeless Program, says despite medical monitoring available to individuals who are over-sedated, around five overdoses occur weekly in and around her building. At an October advocacy event at the Massachusetts statehouse, Dr. Gaeta said not allowing supervised consumption “feels like a treatment gap.” 

Domingos DaRosa supports treatment, but not supervised consumption. The Boston native doesn’t like the idea of permitting use of illegal drugs. As a black man, he says he’s also wary the sites could attract increased law enforcement.

The activist and youth football coach sees the overdose crisis as a public safety issue. Mr. DaRosa began cleaning up needles from playgrounds and parks years ago with children in mind. He was pricked by a discarded needle at age 12.

“Folks who have nothing to do with [the opioid crisis] are the ones that are catching the wrong end of the stick,” he says. Mayor Joe Curtatone of nextdoor Somerville, Massachusetts, is exploring plans to open a facility in 2020. The state’s U.S. attorney Andrew Lelling, however, has pledged to challenge such a site.

Mr. DaRosa and other safe consumption critics warn of quality of life issues that the sites might spur. Advocates counter these concerns are based on stigma, not science. 

So how effective are these sites?

Limited research suggests supervised consumption is a promising public health intervention. Studies on sites in Canada, Europe, and Australia have associated them with decreased risks of drug-related harms – including reduced overdose deaths – and an uptake in treatment services.

Vancouver-based Insite – North America’s first legal supervised consumption site that opened in 2003 – has reported 6,440 overdose interventions and zero deaths. Like syringe exchanges, these sites aren’t known to increase drug use or crime. 

Harm reductionists say syringe exchange models could expand to include supervised consumption. Syringe exchanges began offering sterile equipment as an effective response to the HIV/AIDS epidemic, and now operate in 40 states

Public health researchers in the U.S. acknowledge more data on safe injection sites is needed. After all, interventions that work in one place don't always perform well in others, says Peter Davidson, associate professor in the department of medicine at the University of California, San Diego.

“I'm concerned that we would go to a great deal of effort to set one of these things up here, and it would actually produce negative effects that were unintended,” says Dr. Davidson, who has studied an underground site in the U.S. “There are questions that will remain until we get [a pilot site] and test it properly,” which he supports.

Aubri, a harm reductionist with Boston Users Union, says she witnessed multiple reversed overdoses while helping run an underground site. As health professionals plan sanctioned sites, she urges collaboration with people who use drugs. “Drug users have been operating safe sites for decades,” says Aubri, who requested that her last name not be used. “We are the experts already.”  

How likely are supervised consumption sites to open in the U.S.?

At least a dozen cities have considered opening sanctioned sites, but the federal government has warned of shuttering sites that allow illegal drug use, which it has said would “violate federal law.”

In February, the government filed a lawsuit to prevent the opening of nonprofit Safehouse’s services in Philadelphia. U.S. District Judge Gerald McHugh buoyed activists’ hopes in October, ruling that Safehouse does not violate federal drug law.

Safehouse still seeks a declaratory judgment, and may face an appeal. Days after the ruling, U.S. Attorney William McSwain wrote to a lawyer for Safehouse of his intent to obstruct the services from opening if the nonprofit moved forward during an appeals process. 

Still, Ronda Goldfein, vice president of Safehouse, says she’s optimistic about opening at least one site in 2019, and hopes regular meetings with the community will help address local concerns. She adds, “We want to be good neighbors.”

Staff writer Riley Robinson contributed to this report. 

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