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Harvard Medical School: Safe Injection Sites and Reducing the tigma of Addiction

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Harvard Medical School: Safe Injection Sites and Reducing the tigma of Addiction

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The school finances the reports sent by their medical team. This blog reimagines the effects of medical conditioning and how the treatment can help reshape the perception of drug abuse.

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Imagine a chronic medical condition in which the treatment itself has serious side effects. Examples of this are plentiful in medicine. For example, in diabetes, giving too much insulin can cause hypoglycemia (low blood sugar), a dangerous and potentially life-threatening condition. That doesn't happen very often, but imagine that it was a common complication of treating diabetes because doctors couldn't really tell how powerful a given dose of insulin actually was. And suppose that doctors and patient safety experts advocated for places where patients with diabetes could be carefully monitored when taking their insulin. Would you be opposed to this idea? Would you blame the patient for developing diabetes, or for needing this carefully supervised medical treatment in order to live? I suspect that the answer is "of course not!"

Now, let's shift gears and discuss opioid addiction, specifically people who use illicit drugs like heroin and black-market fentanyl. Heroin is the strong opioid substance derived from the poppy seed that has been used for thousands of years. Fentanyl is a synthetic opioid that can be hundreds of times more powerful than morphine or heroin. Increasingly, illicit heroin is adulterated with fentanyl and similar chemicals, which public health experts believe is the reason for the continued rise in opioid-related deaths despite aggressive measures to decrease opioid prescriptions, increase substance use disorder treatment facilities, and widely distribute naloxone, the antidote to opioid overdose.

Saving lives in the face of increased risk for dying of a heroin overdose

People who use heroin are now at significant risk for overdose death, mainly because the opioid content can vary considerably from dose to dose. Previously, a little too much could have caused a decrease in respiratory rate and a high dose could lead to overdose. Now, with the variability of potency from the synthetic opioids, the strength of each dose can be markedly different. Furthermore, the uptake of fentanyl in the brain is so rapid that a fatal overdose can occur much more quickly than with heroin alone.

If we, as a society, are truly serious about saving lives, we have no choice but to allow people who use injectable opioids to do so in safe, monitored locations without fear of negative repercussions (e.g., being arrested). If you had asked me about this several years ago, I never would have believed that I could write the preceding sentence. I would have said, "Why empower junkies to abuse illegal drugs? Why make it easier on them instead of harder? Why should society condone this activity?"

However, I was wrong - dead wrong.

Good reasons for a change of heart

It turns out that addiction (called substance use disorder or, more specifically here, opioid use disorder in medical jargon) is a disease that can affect any one of us, just like diabetes or high blood pressure. It does not discriminate and does not represent a moral failure on the part of the individual who develops it. It is a condition that no one chooses, but when it attacks, it changes the brain of those with the disease. We can actually visualize those changes with tests like functional MRIs. It leads people to make choices that destroy their lives and the lives of others, such as loss of job, isolation and loss of relationships, incarceration, and even death. We also now know that this is a treatable disease, but the window for successful treatment depends on the psychological state of the person. We must be ready to engage them in treatment at that moment when they are ready.

My opinions changed drastically after a visit to a local needle exchange facility. By current law, individuals can't inject inside the building. They have to take their chances outside and then they can come inside to be monitored after injecting. I initially envisioned the facility to be sterile, dirty, and depressing. Instead, I was surprised to see that it looked like a living room. There were sofas and a television. There was a warm light, and it appeared to be a welcoming place. Across from the sofas were two desks where staff members sat. Their job is to watch for any signs of overdose (a person who is too sleepy or who is breathing too slowly) and then rapidly respond by providing a nasal dose of naloxone to reverse the overdose. More importantly, they are there to help people right when they are open to treatment for substance use disorder. The staff will help connect them to treatment resources, whether it is group therapy or medical treatment like buprenorphine (Suboxone) or methadone.

If that moment of opportunity in which the individual is receptive to treatment passes, the consequences can be deadly.

Furthermore, the facility is all about harm reduction. There are boxes of free supplies: needle kits so that people do not share needles, condoms for safe sex, kits to help treat small skin infections, even little clean cups to freebase injectable drugs. Naloxone kits are also provided free of charge. There is no judgment there. It is only about reducing a person's risk of serious, life-threatening infections like HIV and hepatitis C, or the risk of death. And it makes sense. If we are going to agree that opioid use disorder is just another medical condition that needs to be treated, then the compassionate thing to do is to remove the stigma associated with it and reduce associated harms while a person is suffering with substance use disorder. Plain and simple: people with this disease are going to use drugs. Is it better for them to use in the shadows, risking transmission of serious infectious diseases, or monitor them when they are using and be there for them to get them treatment at the moment they are ready?

Currently it's still illegal in the US to allow people to inject in these supervised environments, but the tide is turning. The city of Ithaca, NY is contemplating a safe injection space, as is Seattle. Multiple studies have confirmed that they work. In Vancouver, Canada, where such facilities were implemented in 2003, they concluded: "Vancouver's safer injecting facility has been associated with an array of community and public health benefits without evidence of adverse impacts." Massachusetts is also contemplating a similar pilot supervised injection facility program. With the crises of the opioid epidemic now claiming more than 30,000 lives every year in the US, it's time to change our biases and old ways of thinking - people's lives depend on it.

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Safe injection sites and reducing the stigma of addiction - Harvard Health Blog

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Imagine a chronic medical condition in which the treatment itself has serious side effects. Examples of this are plentiful in medicine. For example, in diabetes, giving too much insulin can cause hypoglycemia (low blood sugar), a dangerous and potentially life-threatening condition.

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John Hopkins Bloomberg School for Public School: Public Support for Needle Exchange Programs, Safe Injection Sites Remains Low in U.S.

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John Hopkins Bloomberg School for Public School: Public Support for Needle Exchange Programs, Safe Injection Sites Remains Low in U.S.

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John Hopkins has a medical school. Can't find if there are any unseen financiers or donors with agendas.

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Johns Hopkins Bloomberg School of Public Health

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June 5, 2018

Implementing these harm-reduction strategies will be difficult as long as the stigma of opioid abuse remains high, suggests a large nationwide survey

Two strategies that research indicates would help alleviate America's opioid crisis lack widespread public support, according to a study led by researchers at Johns Hopkins Bloomberg School of Public Health.

The study, published in the June issue of Preventive Medicine, is the first to poll a large, nationwide, representative sample of Americans for their views on safe consumption sites (also sometimes called "safe injection sites") and syringe services (sometimes referred to as needle exchange) programs. Both of these harm-reduction strategies have been found to reduce drug overdoses and HIV transmission.

The results suggest that average Americans tend to view these strategies negatively. Among the 1,004 adults sampled, only 29 percent supported legalizing safe consumption sites in their communities and only 39 percent supported legalizing syringe services programs in their communities. Respondents who had negative views about these strategies also tended to have very negative views of opioid users.

"These results suggest that we need to reduce stigma toward people who use opioids and do a better job educating the public about why these strategies work," says study lead author Emma E. McGinty, PhD, an assistant professor in the Department of Health Policy and Management at the Bloomberg School.

Syringe service programs provide clean syringes to people using drugs to reduce the transmission of HIV and other viruses by needle sharing. More than 300 of these programs are already in place across the U.S., including in cities such as Baltimore that have long been plagued by heroin use. Numerous studies have shown that they are effective in reducing disease transmission.

"Safe consumption site" programs provide spaces where users can legally use previously purchased opioids or other drugs under medical supervision. Studies have found that these programs, which have been implemented in Canada and multiple European countries, can decrease overdose deaths and public drug use. Although they have not yet been implemented within the U.S., a number of cities hard-hit by the opioid crisis are considering establishing them, including San Francisco, Philadelphia, New York City and Seattle.

Prior to the new study, there was no nationwide data on Americans' attitudes towards safe consumption sites and no recent nationwide data on syringe service programs. Despite growing public attention to addiction prompted by the rapidly rising rates of opioid overdose deaths, the last national survey to assess public attitudes about syringe services programs was conducted in 2000. McGinty and colleagues conducted their web-based survey using the GfK Knowledge Networks (GfK) panel, a representative nationwide group of more than 65,000 U.S. adults. They administered the survey to a random sample of 1,429 people and received responses from 1,004.

Among the respondents, Democrats and Republicans diverged in their views. While only 18 percent and 30 percent of Republicans favored having safe consumption sites and syringe services programs, respectively, in their communities, the corresponding figures for Democrats were higher at 39 percent and 52 percent. Unemployed respondents and those with a bachelor's degree or higher were also more likely to favor these programs. However, attitudes did not differ much by age, race or gender, and no demographic category was associated with strongly favorable views of these programs.

"The biggest take-home message from these sub-group analyses is that there are not many differences in attitudes across demographic categories, with the exception of political party identification." McGinty says.

The survey measured the stigmatizing attitudes of respondents towards people who use opioids by asking, for example, about their willingness to have a person who is using opioids marry into their family or to start working closely with a user on a job. To those two questions, only 16 and 28 percent of respondents answered favorably. Respondents with highly negative views of people who use opioids were much less likely to support the two harm-reduction strategies.

While the general public shows low support for legalizing safe consumption sites and syringe services programs, these harm-reduction strategies are supported by research and could play important roles in alleviating the public health burden from the opioid epidemic. McGinty and colleagues are now considering how to design information campaigns to boost public support for them.

"We need to do more research on what messages are effective in correcting myths about syringe services and safe consumption programs and reducing the stigma attached to them to save lives," says Susan Sherman, PhD, MPH, a professor in the Bloomberg School's Department of Health, Behavior and Society and study co-author.

"Public support for safe consumption sites and syringe services programs to combat the opioid epidemic" was written by Emma E. McGinty, Colleen L. Barry, Elizabeth M. Stone, Jeff Niederdeppe, Alene Kennedy-Hendricks, Sarah Linden and Susan G. Sherman.

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Media contacts for the Johns Hopkins Bloomberg School of Public Health: Barbara Benham at 410-614-6029 or bbenham1@jhu.edu and Robin Scullin at 410-955-7619 or rsculli1@jhu.edu.

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Public Support For Needle Exchange Programs, Safe Injection Sites Remain Low in U.S.

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June 5, 2018 Two strategies that research indicates would help alleviate America's opioid crisis lack widespread public support, according to a study led by researchers at Johns Hopkins Bloomberg School of Public Health.

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EMCDDA: Drug Consumption Rooms -  An Overview of Provision and Evidence

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EMCDDA: Drug Consumption Rooms -  An Overview of Provision and Evidence

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Written by the EMCDDA (The European Monitoring Centre for Drugs and Drug Addiction), an agency of the EU designed to be "factual and objective" with the subject.

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Pacific Standard: How the 2018 Mid-Terms Could Shape States' Approaches to Supervised Injection Sites

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Pacific Standard: How the 2018 Mid-Terms Could Shape States' Approaches to Supervised Injection Sites

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The mid-term elections have reopened the discussion of SIS establishments in the US. Also involved with the Social Justice Foundation.

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(Photo: Sebastien Bozon/AFP/Getty Images)

Coming into the mid-term elections, several cities and states across America were considering opening supervised injection sites -controversial clinics where people can inject drugs, knowing that there is staff on hand to administer aid if they overdose. Proponents claim the facilities are an important tool for preventing overdose deaths and encouraging drug users to get help, while opponents say governments shouldn't enable drug use in this way.

Many states considering opening supervised injection sites are also host to gubernatorial races this year. So what do those contests mean for supervised injection plans across the country? Below, highlights from a few states where safer drug consumption and harm reduction are major issues:

California

In August, the Mercury News of San Jose reported Democratic gubernatorial candidate-and onetime mayor of San Francisco- Gavin Newsom as being open to supervised injection. His Republican opponent, John Cox, called the idea a "disaster."

Then, in September, Governor Jerry Brown vetoed a bill that would have allowed San Francisco to open a facility. In response, San Francisco's current mayor, London Breed, released a statement saying, "we will still continue to work with our community partners on trying to come up with a solution to move this effort forward."

Maryland

State House and Senate bills in Maryland, authorizing supervised injection, have failed, BuzzFeed reported in September. The Republican incumbent, Larry Hogan, has previously called the bills "absolutely insane." In his proposed opioid plan, Hogan's Democratic opponent, Ben Jealous, doesn't mention supervised injection at all.

Massachusetts

After more than a year of intense debate in the public sphere, the Massachusetts Senate finally killed a proposed pilot supervised injection site this summer. Soon after, the state attorney general told WBUR his office "would seriously consider prosecuting the people involved" in opening such a facility. Still, the Democratic nominee for governor, Jay Gonzalez, told WGBH that Maryland should try supervised injection. "We've got to try new and bold things," he said. "We're not being aggressive enough." Incumbent Charlie Baker, a Republican, is more skeptical of the facilities.

New York

This spring, the mayors of New York City and Ithaca both said they want to open supervised injection sites. But they need authorization at the state level. In a recent debate, Democratic incumbent Andrew Cuomo said he's open to the idea and that the state is already studying it. Republican candidate Marc Molinaro is against supervised injection.

Pennsylvania

Early this year, Philadelphia officials announced theirs would be the first city in the United States to host an openly operating supervised injection site. (There is at least one underground operation, somewhere in the country, that has been reported in the scientific literature.) After the Department of Justice announced that it would crack down on cities that allowed supervised injection, "Philadelphia officials basically offered a collective, 'meh,'" as Philadelphia magazine put it.

Will the City of Brotherly Love also face opposition from its governor? Incumbent Tom Wolf, a Democrat, told WHYY that supervised injection sites are "not a workable solution." Republican candidate Scott Wagner's opioid plan, available on his website, doesn't mention the idea.

Vermont

In July, the city council in Burlington moved forward with a measure supporting supervised injection, but it also included an amendment "noting that the measure wouldn't actually mean the city was moving forward with a safe injection site," Seven Days reports. Then, this month, Governor Phil Scott's Opioid Coordination Council concluded that it would be "virtually impossible" to open an injection site legally. His Democratic challenger for his seat, Christine Hallquist, seems a little more amenable to the idea: She said during the primary campaign that she wants to investigate whether the state should open injection facilities.

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How the 2018 Mid-Terms Could Shape States' Approaches to Supervised Injection Sites

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Coming into the mid-term elections, several cities and states across America were considering opening supervised injection sites -controversial clinics where people can inject drugs, knowing that there is staff on hand to administer aid if they overdose.

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Fighting for Space: How a Group of Drug Users Transformed One City's Struggle with Addiction

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Fighting for Space: How a Group of Drug Users Transformed One City's Struggle with Addiction

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Book: Need more information. Has endnotes and footnotes.

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KIRO 7: King County Prosecutor Endorses Safe Injection Sites for Drugs Users

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KIRO 7: King County Prosecutor Endorses Safe Injection Sites for Drugs Users

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Dan Satterberg, the head prosecutor for King County, approved the creation of SIS.

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King County Prosecutor Dan Satterberg endorsed safe injection sites on Thursday.

Safe injection sites are designated clinics where addicts can shoot up legally.

Satterberg said that unlike the response to crack cocaine in the 80s and 90s, "I believe that the criminal justice system should not take a primary role, and that instead we should follow the lead of public health professionals."

Key developments:

Heroin crisis task force recommended 2 injections sites last year

A councilwoman suggested Belltown and Lake City

Proponents said it could say taxpayers millions in crisis services

Opponents said a consumption site condones drug use.

Washington state senator introduced bill banning injection sites in state.

Now, the King County prosecutor endorsed safe injection sites.

The Board of Health approved two pilot safe injection sites Thursday, as part of a group of recommendations from the King County Heroin and Prescription Opiate Addiction Task Force that it also approved.

People on both sides of the issue voiced their opinion before the vote.

"Quit sugar coating, quit wordsmithing it, and don't do it," Seattle resident Jennifer Aspelund said.

Another woman told the Board that as a city, "We're smart, we do the right thing, and we don't let our fears overcome what we know is the right thing to do."

"If we have a site where they can not only safely consume their injections, but [we] also provide resources, provide treatment, that's the key part of this," board member and King County Councilmember Jeanne Kohl-Welles.

Eric Seitz is a former heroin addict. He once used Vancouver's safe injection site-- the only one in North America. KIRO 7 visited the clinic in February of last year.

"I felt like people weren't going to judge me either way," he said. "They were just trying to keep me alive... long enough so that I could actually make a self-determined decision that I wanted to stop."

KIRO 7 reported in November how Seattle City Councilmember Sally Bagshaw discussed possible locations for safe injection sites in Seattle.

"Maybe one down here and one in North Seattle as an example, because we do have the facilities and the place-- one in Belltown, one in Lake City," she said then.

Today KIRO 7 asked, "So to be clear, are you looking at putting these safe injection sites in Belltown and in Lake City?"

"I don't think we know yet," she said. "I think what I was really interested in was using the public health clinic that we've got-so you're not trying to reconstruct something new. But that's to get people inside and to get the treatment that they need. Now, whether we do a safe injection site there or elsewhere is still an unknown."

Bagshaw said they were examples of buildings they could use.

"We've got public health clinics around the county," she said, "and I think it's smart that we use the facilities and the manpower, the womanpower, that we have on site, having trained nurses, trained doctors."

She stressed safe injection sites are just part of the solution, which includes prevention and education. As for what's next, Bagshaw said the Seattle city council does not need to vote; the city can simply move forward on recommendations from task force. It's up to its members to come up with a plan for public engagement when it comes to locations and cost.
Here's a timeline of how the discussion behind Seattle becoming the first U.S. city with sites for heroin users to safely use drugs.
Jan. 17, 2017: Washington state senator introduces bill banning sites

On Tuesday, a Washington state senator introduced legislation that would ban the creation on heroin injection sites in Washington cities.

Sen. Mark Miloscia wrote in a news release on Tuesday that he introduced a bill to ban such sites.

"We must stop the push for decriminalization of drugs," said Miloscia, R-Federal Way. "Standing idly by while addicts abuse illegal drugs is not compassionate, and it does not solve the problem."

The clinic manager of the site at Vancouver told KIRO 7 News that the overdose death rate in the area around Insite has dropped 35 percent. But Miloscia believes the safe-injection site is a failure.

"We must focus our time, money and resources on treatment options that get people off illegal drugs, not encourage drug abuse," he said.

November 2016: Where overdoses are happening and possible site locations

The King County Heroin Crisis Task Force recommended at least two safe injection sites for drug users last year. Seattle City Councilwoman Sally Bagshaw volunteered Seattle for two sites: one in Belltown and one in Lake City.

Proponents of a "safe consumption site" point to a similar housing operation in Seattle, where 75 alcoholics can drink in their rooms and have access to on-site treatment services. Studies show the operation saved taxpayers millions in housing and crisis services annually and decreased alcohol consumption in residents.

In Seattle, public overdoses are on the rise. Supporters say so-called safe injection sites are a way to combat the overdoses. In a recent KIRO 7 News investigative report, we mapped out where overdosing cases happen. Here's a 2016 map.

Overdoses are overloading Seattle Fire and diverting crews from other emergencies. Each call costs at least two-thousand-dollars, costing taxpayers millions since 2014.

September 2016: King County Heroin Crisis Task Force recommends 2 injection sites

The King County Heroin Crisis Task Force is recommending at least two safe injection sites for drug users: one located within Seattle and one outside city limits.

They announced the recommendation with a proposed number of locations in a news conference on Thursday.

"These sites will provide individuals with opiod use disorder a portal to return to healthy lives by reducing overdoses and preventing infections like Hep B & C HIV," said Jeff Duchin, a health officer with Public Health of Seattle & King County.
Read full story here.
August 2016: Local leaders take big step toward 'safe consumption site' for addicts

A majority of people on King County heroin's task force support the idea of a safe consumption site.

Proponents of a "safe consumption site" point to a similar housing operation in Seattle, where 75 alcoholics can drink in their rooms and have access to on-site treatment services. Studies show the operation saved taxpayers millions in housing and crisis services annually and decreased alcohol consumption in residents.
Read full story here.
February 2016: Seattle considering 'safe places' for addicts to shoot up

KIRO 7 News reported in February that Seattle could be the first city in the U.S. to allow safe consumption sites, where people with drug addiction can safely use drugs under medical supervision.

"I've done a lot of work looking at where are people dying of drug overdoses," said Dr. Caleb Banta-Green, a University of Washington drug researcher. "It's all across King County. It's not just downtown."

Dr. Banta-Green says the use of illegal drugs like heroin has become a public health crisis.

"I do think we have to do something," he said. "It's really quite striking."

That something, say drug prevention activists, should be safe injection or consumption sites, like in Vancouver, British Columbia, where users take drugs in a clinic without risking arrest.

Opponents say a consumption site condones drug use.
Read full story here.
So what would a consumption site look like?

KIRO 7 News went to Vancouver to see how the injection site operated and if a King County site would run similarly.

When a KIRO 7 News crew was in Vancouver, we saw people injecting on the street -- they told us because of the wait to get a booth.

The clinic does not give users drugs; it provides free, clean supplies.

"People often go with a cooker, alcohol, need a tie for your arm, a bit of water," clinic manager Andy Day told KIRO 7 News.
>> Read our Q&A: How would an injection site operate in Seattle?

There is a free clinic on East Hastings Street-the poorest area in Canada-where drug users can inject themselves under the watchful eye of medical professionals.

Staff members at the clinic refer to people who seek help as clients. Clients take their supplies to one of 13 booths fitted with mirrors and inject themselves under the watchful eyes of health care professionals. The booths are almost always full.

Since opening in 2003, Day says the overdose death rate in the area around Insite has dropped 35 percent, and saving addicts in the clinic costs three million taxpayer dollars a year.

Day says that's cheaper than treating them in the hospital for the drugs, or diseases contracted because of the drugs.

Trending on kiro7.com

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King County prosecutor endorses safe injection sites for drug users

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King County Prosecutor Dan Satterberg endorsed safe injection sites on Thursday. Safe injection sites are designated clinics where addicts can shoot up legally. Satterberg said that unlike the response to crack cocaine in the 80s and 90s, "I believe that the criminal justice system should not take a primary role, and that instead we should follow the lead of public health professionals."

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Shots - Health News from NPR: What's the Evidence that Supervised Drug Injection Sites Save Lives?

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Shots - Health News from NPR: What's the Evidence that Supervised Drug Injection Sites Save Lives?

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NPR looks into the 2014 review of 75 studies of Supervised Injection Sites. The article reveals topics about the research debates over study validity and the Vancouver model of a SIS.

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Editor's note February 21, 2019: This story has been updated to reflect the fact that a study mentioned in the piece, published by the International Journal of Drug Policy in August 2018, has since been retracted.

As drug-related deaths rise to record numbers, at least a dozen U.S. cities are considering opening supervised injection sites, where people can use illicit drugs with trained staff present, ready to respond in case of an overdose.

The future of such proposals in the U.S. is uncertain. A California bill that would greenlight a pilot injection site in San Francisco awaits the governor's signature, but a representative of the Justice Department vowed to crack down on any such site in recent public statements.

Critics say supervised injection sites encourage drug use and bring crime to surrounding communities. Proponents argue that they save lives and can help people in addiction reconnect with society and get health services.

Out with the dark alley, fear and shame, they say, in with a safe space, clean injection supplies, care and compassion. It's an approach that falls under the umbrella of harm reduction, a public health philosophy that emphasizes lessening the harms of drug use.

But what does evidence say? If the policy goal is to save lives and eventually curb opioid addiction, do these sites work?

It's a tricky question to answer, although many of these sites have been studied for years.

At least 100 supervised injection sites operate around the world, mainly in Europe, Canada and Australia. Typically, drug users come in with their own drugs and are given clean needles and a clean, safe space to consume them. Staff are on hand with breathing masks and naloxone, the overdose antidote, and to provide safer injection advice and information about drug treatment and other health services.

But most have grown out of community and grassroots efforts, according to Peter Davidson, a researcher specializing in harm reduction at the University of California San Diego who is researching an underground supervised injection site in the United States. They lack big budgets for comprehensive services or for conducting high level evaluations, he says.

Still, he says the research - both "the grey" and the robust - point to the benefits, especially in preventing deaths among society's most vulnerable. No death has been reported in an injection site. A 2014 review of 75 studies concluded such places promote safer injection conditions, reduce overdoses and increase access to health services. Supervised injection sites were associated with less outdoor drug use, and they did not appear to have any negative impacts on crime or drug use.

"If there had been unintended consequences, I suspect that would have been picked up by now," says Davidson. "It's reassuring."

In another review of studies published in August in the International Journal of Drug Policy, the researchers, criminologists from the University of South Wales in the United Kingdom, found that the evidence for supervised injection is not as strong as previously thought. However, after publication, this article was retracted by the journal, with the author's consent, because of "methodological weaknesses."

Even before it was retracted, M-J Milloy, an epidemiologist with the British Columbia Centre on Substance Use and an associate editor of the International Journal of Drug Policy, which published the UK analysis, said this review was not, in his view, a good reflection of the evidence.

"Their decision to exclude all but eight studies is in my view one of the methodological flaws," he says, adding that the analysis looked at measures beyond the scope of what some individual studies set out to assess

Keith Humphreys, an addiction researcher and psychiatry professor at Stanford University, says a stronger evidence base is needed.

"Nobody should be looking at this literature making confident conclusions in either direction," he says.

Humphreys says he'd welcome better tools to address the drug crisis. He doesn't think the available evidence points to supervised injection as being harmful, but the research has not strongly demonstrated an overall reduction in overdose deaths over time.

The real problem, he says, is there just are not a lot of good studies, period, on supervised injection. "So I think we should be pretty cautious," he says.
The Canadian model
Much of the existing research for the effects of supervised injection sites comes from two places: the Medically Supervised Injecting Centre in Sydney, Australia and Insite, a facility in Vancouver, which public health officials have operated and researched for 15 years.

When Insite opened, supervised injection was contentious in Canada. After years of drug-user-led activism, the government approved it as a pilot, creating a place with wrap-around addiction services under the same roof, and mandated scientific evaluations on the impact from the start.

Milloy, who is part of a team that researches Insite, says it points to the benefits of supervised injection. The research was observational, drawing from unique datasets. Since 1996, well before Insite, researchers had followed 1500 active drug users in the city as part of one of the largest long-term studies of drug users in North America. They then recruited 1,050 people at Insite, and followed them over time as well.

Since opening in 2003, the facility has supervised more than 3.6 million injections and responded to more than 6,000 overdoses. No one has ever died there.

They found no signs of a so called "honey pot effect," at Insite, meaning it didn't increase or encourage drug use.

In a study published in Lancet, Milloy and other researchers found that the fatal overdose rate sharply decreased in and around the immediate area of the site. Additional evaluations from Milloy's group and the regional health ministry found that Insite averted about 50 deaths in the first three to four years of operation; that people were less likely to engage in behaviors that would lead to HIV infections; and, that those who used Insite were more likely to initiate detoxing from drugs and access treatment like methadone, compared to those who weren't using the facility.

"That might seem odd to people. You know, you give someone a safer, cleaner, warmer drier place to inject and they end up going into addiction treatment," Milloy says. "It's a place where they can access healthcare, and where their exposure to an increasingly toxic drug supply can be managed and mitigated in an effective sense."

For people working in the field, the value of supervised injection facilities transcends the debate over death or crime statistics, because it offers something people who use drugs may not have experienced before: a non-judgmental place that accepts them for who they are.

"It's about making a space where drug users are allowed to feel like people," says Darwin Fisher, Insite's longtime program coordinator. "We're also mindful that this is a respite from the street and at times it might be difficult for people to leave the only situation that feels vaguely safe for them in a day."

Milloy concurs, describing Insite as "a place which is an official healthcare setting which is not judgmental, which does not stigmatize them for their drug use, and which accepts that they are people first and foremost."

Milloy says studying supervised injection presents challenges. Early on, they considered setting up the gold standard for a study - a randomized trial - but that would mean separating a sample of drug users into two groups, one that gets access to Insight, and one that doesn't. He says denying a potentially life-saving service to some people seemed unethical.

"It's the reason we chose the observational framework," he says.

For Sharon Larson, a longtime public health researcher who recently reviewed the evidence on supervised injection and assessed their potential impact for the city of Philadelphia, questions still remain.

Insite, she says "was a great pioneering start." It demonstrated making a difference for those who used the site. But, is it generalizable and directly replicable in other places?

Larson, a professor at Thomas Jefferson University and director of the Main Line Health Center for Population Health Research at Lankenau Institute for Medical Research, concluded in a report that the science is still limited. In part, she says, that stems from the challenge of studying an illicit behavior.

"I think it's a really hard population to count," she says.

At a citywide level, it's hard to know the size of the actual baseline population of drug users. That leaves unanswered how many sites would be needed to have a broader community impact. Plus, where should they go? Who might benefit most from a site, and what's the most effective way to bring them in?

Larson's models estimate a supervised injection site in Philadelphia could prevent dozens overdose deaths annually.

"It does not give me pause about developing these injection sites," Larson says. "What it tells me is if we want to demonstrate that this is an effective strategy for harm reduction, one of many, that we ought to be very thoughtful about how we develop data to answer the important questions."
This story is part of a reporting partnership with NPR, WHYY's health show Elana Gordon is 2018-19 Knight Science Journalism Fellow at MIT. You can follow her on twitter at @elana_gordon. and Kaiser Health News.

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What's The Evidence That Supervised Drug Injection Sites Save Lives?

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Editor's note February 21, 2019: This story has been updated to reflect the fact that a study mentioned in the piece , published by the International Journal of Drug Policy in August 2018, has since been retracted. As drug-related deaths rise to record numbers, at least a dozen U.S.

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The Seattle Times: Threat of Federal Enforcement Complicates Seattle's Proposed Safe Injection Site

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The Seattle Times: Threat of Federal Enforcement Complicates Seattle's Proposed Safe Injection Site

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Rod Rosenstein, the deputy U.S. attorney general, reopened the issue of drug law enforcement between local and federal policies. The Seattle Times is a left-leaning newspaper in a very left-leaning city and the article itself provides mostly supportive views on the sites.

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The U.S. Department of Justice's threat of "aggressive action" against cities opening so-called safe injection sites dimmed the prospects of opening one in Seattle.

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With only a few words, the Trump administration this week darkened Seattle's prospects of opening up the first supervised drug-injection site in the United States, leaving local authorities and advocates struggling to plot a new way forward.

The Seattle Times' Project Homeless is funded by BECU, The Bill & Melinda Gates Foundation, Campion Foundation, the Paul G. Allen Family Foundation, Raikes Foundation, Schultz Family Foundation, Seattle Foundation, Seattle Mariners, and Starbucks. The Seattle Times maintains editorial control over Project Homeless content.

In a New York Times Op-Ed, Rod Rosenstein, the deputy U.S. attorney general, said Seattle and other cities will face "swift and aggressive action" by the federal government, including a civil injunction, if they sanction so-called safe injection sites for "illicit" use of heroin and other drugs.

The statement is the clearest indication yet of the Trump administration's opposition to the sites, and its willingness to enforce federal drug laws against municipalities and states - from San Francisco and New York City to Colorado and Maine - that have shown interest in opening them.

Seattle and King County have tiptoed in pursuit of opening one since 2017, when county Executive Dow Constantine and former Seattle Mayor Ed Murray adopted the recommendations of a task force focused on the rising number of opiate overdoses.

The task force's 2016 report called for a pilot program to open two public sites - one in Seattle and one elsewhere in King County - where drug users would receive clean needles and inject in a clean, supervised environment.

A site has been in operation in Vancouver, B.C., since 2003. While its record is mixed, local supporters believe the sites could reduce opioid-related overdose deaths, which in King County rose from 219 in 2015 to 258 last year, and better connect drug users with health care and long-term treatment.

But Rosenstein's message has removed any uncertainty about the legality of the sites, Annette Hayes, the U.S. Attorney in Seattle, said on Thursday.

"The ground has shifted under us," she said.

Emergence of the powerful opiate fentanyl, which began a new wave of abuse and overdose deaths, has led the federal government to believe there are "better ways" to address the problem, she said.

Hayes said her office will use "all the tools that are appropriate" if a local municipality moves to bring a site into operation.

Rosenstein's statement rekindled tensions between federal and local authorities, who continue to spar over Seattle policies that are at odds with Trump administration priorities.

"Last I checked, Rod Rosenstein is a very capable deputy attorney general, not a surgeon general," said Seattle City Attorney Pete Holmes, who supports opening a safe injection site.

"If we hope to simultaneously unwind the 'war on drugs' and address this crisis with real solutions, we apparently can't look to Jeff Sessions and the Trump administration for help," he said.

Holmes said his office is evaluating its options in light of Rosenstein's threat. Seattle Mayor Jenny Durkan, who has also expressed support for a safe injection site, did not immediately respond to request for comment.

Despite the support from Seattle leaders, efforts to open safe injection sites stalled out of the gates, and now appear to be at a standstill.

After Constantine and Murray embraced the recommendations, Bellevue, King County's second-largest city, banned safe injection sites. It was joined by Kent, Renton, Auburn and Federal Way.

An initiative campaign to ban them countywide, called Safe King County, collected the required 47,443 valid signatures to get on the February 2018 ballot, but the initiative was blocked by a court ruling.

A spokesman for Public Health - Seattle & King County said there are currently no plans to open a safe injection site outside of Seattle.

The Seattle City Council allocated $1.3 million in its 2018 budget to get the pilot program off the ground, but city officials say they've been unable to locate an appropriate site for a fixed "community health-engagement" location.

Since taking office last year, Durkan floated a proposal to forgo a fixed location and purchase a recreational vehicle that could travel from one location to another.

Seattle City Councilmember Sally Bagshaw said talks about the mobile option are ongoing. In the meantime, the city should take Rosenstein's threat seriously and put its weight into seeking ways to increase the availability of drug-abuse-treatment options, she said.

"I think a safe injection site is an option, but at this point the more pragmatic alternative is to invest in treatment on demand," Bagshaw said.

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Threat of federal enforcement complicates Seattle's proposed safe injection site

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The U.S. Department of Justice's threat of "aggressive action" against cities opening so-called safe injection sites dimmed the prospects of opening one in Seattle. Share story With only a few words, the Trump administration this week darkened Seattle's prospects of opening up the first supervised drug-injection site in the United States, leaving local authorities and advocates struggling to plot a new way forward.