Analysis by Terry Gotham

But until recently, politicians dismissed the idea of a safe-injection site as being too controversial. More controversial than people dying in libraries and babies picking up needles on the beach? Please. San Francisco has essentially become one big unsafe injection site.
~Heather Knight, SF Chronicle “Safe injection sites offer hope in scourge of discarded syringes”

I wasn’t sure how to start this piece, a feeling I think mirrors the paralysis many policymakers feel when it comes to moving away from puritanical, expensive & needlessly harmful criminalization of controlled substances. In the case of the city policymakers, the opioid overdose epidemic has gotten so bad, they may be getting over it.  The SF Department of Public Works collected 13,333 syringes in San Francisco. In March. That’s 430 a day. In Ohio, there were 100 accidental drug overdoses in Mongomery County, Ohio in January & February alone, with an average age of 40. Here’s the kicker, 99 tested positive for fentanyl, and, 56% tested positive for acryl-fentanyl, 3 carfentanil cases, and 24 total fentanyl analogs and metabolites were found in total. 24. The majority of the cases tested positive for more than one “fentalog.” But of course, straight from the report:

All acryl fentanyl and furanyl fentanyl cases also tested positive for fentanyl; about 45% of acryl fentanyl cases also tested positive for furanyl fentanyl.
~Research Update on Fentanyl Outbreaks in the Dayton, OH Area: Acryl Fentanyl & Furanyl Fentanyl Commonly Found in Overdose Death Cases.

One of the solutions proposed to fight the lethal flood is the Safe Injection Facility (SIF), the spiritual successor to the Syringe Exchange Program (SEP), one of the earliest harm reduction methodologies. California lawmakers may get there, but they may not. In Massachusetts, there’s some support within the medical community, but there’s nowhere near critical mass. But, with Seattle locking down locations & funding for safe injection sites, the mayor of Ithaca proposing a SIF to contain their overdose problem and Vegas deploying a first-of-its-kind needle exchange vending machine system, we are in a very forward looking time in American dependence & addiction treatment. Thankfully, not only do SIFs work, but many of the horror stories associated with them are just that, myth & fear mongering. This edition of Do No Harm aims to give you a good understanding of Safe Injection Facilities, Syringe Exchange Programs & how each can help fight the tide of Fentanyl associated overdose deaths. The Journal of the American Medical Association did a spectacular review of the literature surrounding SIFs & SEPs, so I’ll try my best to translate data into truth for those less familiar with PubMed.

The first Syringe Exchange Program started in the 1980s in Rotterdam, Holland, created by a drug user organization called “Junkiebond” in response to the first waves of needle-transmitted hepatitis B. This problem was overwhelmingly amplified when HIV/AIDS exploded in the 80’s. In 1985, 100,000 needles/syringes were handed out, swelling to 1 million by 1991. In 1987, Mayor Ed Koch had recognized the problem and started the first needle exchange programs, only to have them be banned when Koch left office. In the face of the AIDS epidemic, the AIDS Coalition to Unleash Power, or ACT UP began a program of underground needle exchanges in 1990 on the Lower East Side. They slowly gained momentum until the restrictions on distributing syringes without a prescription were waived in 1992, allowing them to come into the light. Currently there are ~200 SEPs in 33 states & DC.

They can provide anything from a simple needle vending machine (put a dirty needle in, get a clean one) to a full portfolio of harm reduction & health services, which include basic physicals, diabetes/chronic disease treatment, STD Testing LA, family planning and even referrals to social services. Supervised injection facilities (SIFs) (or Safe Injection Sites)  have many to all of these services, but also allow for drugs to be smoked/injected on the premises.

Myth: People who use Syringe Exchange Programs are just as likely to contract HIV.
Reality: A study of 1600 IV users in NYC published in the Lancet back in 1996 showed that those who didn’t use the program were 3x more likely to get HIV. More recently, Australia’s needle-syringe programs reduced the incidence of HIV by 34-70%. A more extensive review of the literature shows that “Authorities in countries affected or threatened by HIV infection should carefully consider this convincing evidence.”

Myth: Syringe Exchange Programs lead to increased use of injection drugs.
Reality: A Seattle cohort was shown to not only to stop exchanging needles (or never to start) but also to reduce injection or stop injecting all together. That Syringe Exchange programs don’t lead to increased use of injection as the avenue of drug use OR increasing use of injection drugs (two slightly different things) is a finding replicated in San Francisco over a 4 year period. An expansive review in JAMA showed that frequency of injection dropped from 1.9 per day to 0.7 per day after an SEP was deployed in San Francisco. That’s cutting the frequency of injection in half over a period of 5.5 years. This is pretty clear evidence that the fever dream of junkies abusing these centers to use heroic amounts of heroin is simply that, a dream.

Myth: Syringe Exchange Programs allow recreational users to avoid treatment.
Reality: New users of the Seattle program are five times more likely to enter drug treatment than drug takers who never used the exchange. Five times more likely to enter treatment, solely because they participated in the needle exchange program.

Myth: Syringe Exchange Programs cost more than traditional interventions.
Reality: Several studies done in the USA, Europe & Australia, have shown SEPs to be cost-effective, even when you scale them. For example, in the USA, a $10-50mill funding increase could prevent another 194-816 HIV infections alone. These types of infections generally cost $50,000+ of healthcare spend over the lifetime of an HIV positive patient, and they’re being prevented by needles that cost pennies. It’s not about moralizing, it’s about money.

Myth: Safe Injection Facilities cause people to share needles, because the needles are “safe.”
Reality: Regression analyses at the Vancouver Safe Injection Site showed a reduction in syringe sharing in a population of active injection drug users, with only 50 of the 431 tracked in the study still engaging in that harmful practice 18 months after the study began. A study that evaluated 760 daily users in Vancouver reinforced this finding, with Safe Injection Facility users reusing syringes less, using sterile water, swabbing injection sites, filtering their drugs and even disposing of their syringes safely.

Myth: Safe Injection Facilities cause public nuisance, attracting vagrancy, crime and accumulating dangerous litter such as improperly disposed of needles.
Reality: A study in Sydney showed that their SIF prevented a total of 191,673 acts of public injection. A review of the Vancouver site amplified the strength of these findings, showing that the site’s opening was associated with a reduction in the mean daily number of drug users injecting in public from 4.3 to 2.4, a drop of almost 50%, in addition to reductions in the amount of syringes and injection drug use-related litter found around the SIF site.

Myth: Users don’t get treatment because they can just get high in a safe place every day.
Reality: A detailed letter to the Editor of the New England Journal of Medicine in 2006 documented a landmark finding 3 years after Vancouver’s SIF opened. Weekly use of the SIF and contact with any of the facility’s addiction staff resulted in a more rapid entry into a detox program. This deepens the case that SIF use even by users who aren’t trying to quit yet can still lead to detox and treatment.

Myth: Users die in Safe Injection Facilities because they can do as much heroin as they want.
Reality: A study published in The International Journal of Drug Policy evaluated the overdoses other adverse events at the first Safe Injection Site. While there were 336 overdose events spread across 90 different people, there were no fatalities. None.

Myth: Safe Injection Facilities are a hotbed of crime, drug dealing, car theft, assault & armed robbery.
Reality: Contrary to popular belief, Safe Injection Facilities are not a hive of scum and villainy. Crime rates in the neighborhood the SIF is located in were tracked the year before & the year after the facility opened. No increases in crimes associated with drug trafficking, assault or robbery was found. Oddly, there was a decrease in vehicle theft & break-in, which is probably just a research anomaly, but interesting nonetheless.

Myth: Money spent on needle exchange or SIFs could be better spent in other ways.
Reality: An Australian 2012 study published in AIDS estimated that needle-syringe programs returned an estimated $1.30-1.55 for every dollar invested, due to lower healthcare costs & fewer new disease patients. An American study in 2014 doubled down on these findings showing a cost savings of 6:1, dollars saved vs. dollars spent on HIV treatment.

Myth: Safe Injection Facilities encourage opiate users to try injecting for the first time.
Reality: Returning to the Vancouver injection site, a study evaluating a random sample of over 1000 users of the facility, found only one person used via IV for the first time in the center. One. Not only that, but the median number of years doing drug via IV was 15.9, with 20% reporting that they had not used clean needles the first time they injected their drugs. With the middle 50% of the sample having used drugs from 8.6-25.9 years, the claim that opiate users who have been snorting or smoking decide to take their game to the next level hasn’t been substantiated yet.

Myth: This data is a lie, it’s anecdotal and Safe Injection Sites are not good when you look at all of them everywhere in the world.
Reality: “Consumption Rooms” as they’re referred to in Europe, were seen by the EMCDDA as able to reach more long-term users, street homeless, sex workers and others at risk for traditional health problems those groups face. The Report is a fascinating look at injection drug use & harm reduction practice deployment at scale, and is a must-read for those who wish to interact with the opioid/cocaine consuming community.

Myth: Safe Injection Facilities can only help urban residents.
Reality:  This belief has propagated largely because of the calcified view that opiate abuse is an urban problem. With the lethal flood hitting rural, exurban, suburban and urban areas, more and more people are pushing for Safe Injection Sites in suburban Edmonton, Canada. With fentalog use just as much of a problem in the suburbs, SIFs could serve as a hub for drug checking, needle exchange, education and treatment resource utilization over a much larger geographic region than usually seen given the traditionally urban setting of SIFs.

The combination of clean works, regular medical care, drug checking and access to services has the potential to save billions in healthcare costs that are usually handled by emergency rooms or law enforcement. A study in the Vancouver InSite system showed that when opiates brought into the SIF were tested, 80% of drugs tested positive for fentanyl. But more importantly, those who got their drugs tested were 10x more likely to do less at the SIF. This should be a no-brainer to anyone who has worked with drug users a case management or social work environment. Wikipedia has a great look at how public health officials calculate the number of lives “saved” by these facilities, as does the article in JAMA that I’ve been pulling data from for most of this piece.

Where do we go from here? The smart people in the room are noticing that the explosion in deaths isn’t necessarily connected to a vast expansion of the heroin-using population. It’s that more and more people are getting dirty fentanyl, as that report from Ohio at the beginning of this article illustrates. The next step is “heroin-assisted therapy” or HAT. In several European countries, clean heroin is provided to ensure that street users aren’t pumping themselves full of insta-OD dirty drugs. America has massive ideological and logistical issues to rolling out a program in which drug users are being given drugs by the government. But given how fucked things have gotten, I’m not entirely sure it’s going to remain impossible for long. If you’d said to me 5 years ago that safe injection facilities would be in the contracted/broken ground stages, I would’ve asked what you were smoking. It seems fentanyl and the deaths of thousands across the country have tempered our prejudices. Here’s to hoping we can get syringe exchange programs and safe injection sites deployed across the country before too many more accidentally do carfentanil and are cold by the time the EMTs arrive.