A new study of an unsanctioned supervised injection facility offers proof of concept that this type of harm reduction approach can function in the United States, helping to reduce overdose deaths and transmission of HIV and hepatitis C.
“Supervised injection sites are an important evidence-based harm reduction strategy that should be considered for implementation in the U.S.,” said Alex Kral, PhD, of the research nonprofit RTI International and coauthor of the recent report in the American Journal of Preventive Medicine.
In the midst of the growing U.S. opioid epidemic, public health officials and advocates are seeking better ways to reduce the harms related to injection drug use, which range from overdose deaths to problematic street behavior.
In 2015, there were more than 33,000 deaths from heroin or prescription opioid overdoses, according to the Centers for Disease Control and Prevention. The prevalence of HIV among people who inject drugs in the United States is 2 percent, while the prevalence of hepatitis C virus (HCV) infection is much higher, at 43 percent, according to Kral.
Supervised injection facilities offer a place to inject illicit drugs obtained elsewhere under the watchful eye of trained medical staff, who can offer assistance, including Narcan (naloxone) in case of overdose. Such sites provide clean syringes and other injection equipment to prevent transmission of HIV and viral hepatitis. They also provide an alternative to street-based drug use and offer an entry point for medical care and addiction treatment.
“These sites have the dual aims of increasing the safety of people who inject drugs and reducing the public nuisance of having people injecting drugs in public spaces, including on the street or in public restrooms,” Kral and coauthor Peter Davidson, PhD, of the University of California, San Diego, wrote.
There are now around 100 supervised injection sites in 10 countries, including Australia, Canada, France, Germany, the Netherlands, Spain and Switzerland, according to the researchers.
Several cities, including Baltimore, Denver, New York City, San Francisco and Seattle, are vying to open the first supervised injection site in the United States. At his recent confirmation hearing, incoming Surgeon General Jerome Adams suggested that he would be open to supervised injection facilities if the data from pilot projects support it.
The Board of Health in King County, Washington (which includes Seattle), approved two facilities last year, following a city task force recommendation, but public officials are currently stalling their opening. San Francisco’s supervised injection task force is expected to issue a favorable recommendation in September.
Vancouver’s Insite was the first supervised injection facility in North America. Since it opened in 2003, more than 75,000 people have used the facility. Insite staff have intervened in over 6,400 overdose incidents without any deaths, according to Vancouver Coastal Health.
Last year, Kral and his colleagues published results from an earlier study showing that a supervised injection facility in San Francisco similar to Insite, with 13 injecting stations, could prevent at least three new HIV infections and 19 cases of hep C per year, encourage 110 people to start addiction treatment and save the city an estimated $3.5 million annually. A related study estimated that a single supervised injection site in Baltimore could prevent about four HIV infections and 21 HCV infections and save $7.8 million a year.
Kral and Davidson’s latest report describes outcomes at an unsanctioned supervised injection site operated by a social service agency in an undisclosed urban area in the United States. (To protect the facility and its clients, Kral was unwilling to give POZ any hints about where it’s located.)
Started in 2014, the site has five injection stations and is open five days a week. Agency clients can use the facility by invitation, with the total number of users capped at around 60 in order to avoid lines. Site users are asked to complete a brief anonymous survey before each injection session.
Over the first two years of operation, the site served more than 100 clients. More than 90 percent were men, 8 percent were women and 1 percent identified as transgender. Eighty percent were white, and 14 percent were African American. More than 80 percent said they were currently homeless. Heroin was the most commonly used drug. Nearly 7 percent reported experiencing an overdose off-site, and 9 percent had used non-sterile syringes during the past month.
The facility recorded a total of 2,574 injections during the two-year period and only two cases of overdose, both of which were reversed by trained staff using Narcan.
The researchers estimated that the site averted over 2,300 episodes of public drug injection during this period. More than 90 percent of the people who used the site said they otherwise would have injected in a public location, such as a bathroom, street or park. All syringes used at the site were discarded safely, and the researchers estimated that this represented 1,725 fewer instances of public disposal of needles and other injection equipment.
“The full benefits of a supervised injection site are not actualized in this U.S. site because it is unsanctioned. If it were sanctioned, more people could be served, licensed clinicians could provide on-site health care services, other agencies could collaborate to provide co-located, wraparound services and there would be more options for funding site activities and increasing operating hours,” Kral and Davidson wrote.
“These sterile, clinical settings have been shown to improve individual health and reduce the risk of HIV and viral hepatitis and increase enrollment in drug treatment and access to health and social services,” Kral said in an RTI press release.
Davidson added, “Research has found that supervised injection sites also help the neighborhoods in which they are located by reducing crime, publicly discarded syringes and the need for ambulances to respond to overdoses.”
Kral likened the unsanctioned supervised injection site to underground needle exchange programs operated clandestinely by AIDS activists in the 1980s, before they became legal and supported by health departments in many U.S. cities.