Q&A: Philadelphia supports safe injection sites to fight opioid crisis

John Kelly
John F. Kelly
Lawrence Greenblatt
Lawrence Greenblatt

According to the CDC, drug overdose deaths and opioid-related deaths continue to grow at an alarming rate in the United States, with an average of 115 Americans who die from opioid overdose every day.

Overall, more than 600,000 people died from drug overdoses between 2000 and 2016, according to the CDC. The agency estimated that more than 64,000 drug overdose deaths occurred in 2016, with the sharpest increase seen among deaths related to fentanyl and synthetic opioids, which accounted for 20,000 overdose deaths. The number of overdose deaths involving opioids was 5 times higher in 2016 compared with numbers seen in 1999.

Kevin P. Hill

In October 2017, President Donald J. Trump declared the opioid addiction crisis a public health emergency. With the current presidential administration committed to combatting the opioid epidemic, interventions remain necessary to control overdose deaths in the U.S.

Philadelphia officials have announced their plan to curb the crisis with safe-injection sites, where people who inject drugs can do so under medical supervision. Officials in Philadelphia — which sees the highest opioid death rate of any large U.S. city, according to CBS News — will encourage private organizations to establish the first-ever safe injection site in the country. Such an intervention aims to lessen the vast and growing number of overdose deaths related to opioid use and has the potential to save money.

“No one here condones or supports illegal drug use in any way, but we recognize how difficult addiction is — the grip of addiction interferes with its own treatment,” Philadelphia Public Health Commissioner Thomas Farley, MD, MPH, said in an article on WHYY. “We are talking about the people who are the most hard to reach, the most stigmatized. We need to make it easy for them to come in so you can then engage them.”

Drug overdose deaths and opioid-related deaths continue to grow at an alarming rate in the United States, with an average of 115 Americans who die from opioid overdose every day, according to the CDC.
Photo credit: Shutterstock

To discuss how setting up these safe injection sites will affect the overall opioid epidemic, Healio Psychiatry spoke with three experts: John F. Kelly, PhD, ABPP, Elizabeth R. Spallin associate professor of psychiatry at Harvard Medical School, director of the Massachusetts General Hospital Recovery Research Institute, program director of the MGH addiction recovery management service and associate director of the MGH Center for Addiction Medicine; Kevin P. Hill, MD, MHS, assistant professor of psychiatry, Harvard Medical School and director of addiction psychiatry, Beth Israel Deaconess Medical Center; and Lawrence Greenblatt, MD, FACP, professor of medicine in the department of community and family medicine, co-chair of the Opioid Safety Committee and Duke Health.

What impact can safe injection sites have on the opioid epidemic, overdoses and the spread of disease?

John F. Kelly, PhD: Quite simply, as the name suggests, these resources can reduce overdose risk, as well as other health risks including the spread of HIV and hepatitis C through shared needle use. They offer an opportunity to engage with health care professionals, which can also increase the chances of treatment engagement and remission. Use of these facilities are likely to reduce the incidence of injecting in public places, such as often happens with those who are homeless, in particular.

Kevin P. Hill, MD: Safe injection sites have been studied for years. Most are located in Europe, while there are some in Canada and Australia as well. The evidence shows that they are effective in reducing opioid overdoses as well as the transmission of HIV and hepatitis C. Safe injection sites save lives. These sites are not associated with increases in drug use, drug trafficking or crime. Safe injection sites also increase the likelihood that people who are addicted to opioids get the treatment they need.

Lawrence Greenblatt, MD: Safe injection sites have been used in Canada and throughout Europe with improvement in the number of outcomes. Specifically, overdose deaths in the communities served by the safe injection sites have fallen by between 35% and 50%, and new cases of HIV and hepatitis C fall dramatically because sterile needles are made available. Transports to the ED via ambulance and hospitalizations also are reduced significantly. In addition, because users are provided with clean needles, clean conditions, and time to inject properly, there is a reduction in blood-borne infections and local soft tissue infections.  Personnel can be stationed in safe injection sites who can respond to overdoses quickly with naloxone, thus, reducing the risk of overdose death.

Is there research to suggest this is an effective route for governments?

Kelly: Preliminary studies suggest that use of these facilities reduces incidence of injecting in public places and is associated with safe disposal of needles, reduced needle sharing and, consequently, lowered incidence of HIV transmission and dramatically lowered overdose rates.  

Hill: The level of evidence is impressive at this point and has prompted many cities to consider this controversial idea. We see patients with opioid use disorder every day in our hospital and, unfortunately, some of these patients ultimately overdose and die. As a result, governments must carefully evaluate all evidence-based options.

Greenblatt: The research supporting safe injection sites largely comes from Canada and Europe. There are two publications of an ‘underground’ safe injection site run by a community organization illegally in the United States. The research is fairly convincing on outcomes, although inconclusive with regard to crime, motor vehicle collisions or drug sales. Additional evidence suggests that individuals who use safe injection sites are more likely to enroll in effective treatment programs for opioid use disorder.

How is this idea received by medical professionals outside of addiction specialists?

Kelly: The idea, at first glance, seems counterintuitive begging the question, wouldn’t we be ‘enabling’ use and therefore prolonging or increasing it? Both outside and inside the addiction field, people are often opposed to the idea until they understand how this can help reduce the harms associated with IV drug use and help keep people alive long enough that they have the chance to achieve remission and recovery.

Hill: This is an emotionally-charged topic that many medical professionals do not support. However, in 2017, the Massachusetts Medical Society publicly supported the idea of a safe injection site pilot study in Massachusetts.

Greenblatt: I believe that most medical professionals are not familiar with the concept of safe injection sites; doctors would certainly have a range of attitudes as many would see these centers as facilitating ongoing drug use, whereas others would support the implementation of these sites based on strong outcomes data from existing research. It is important to note that at this time, these sites are illegal under federal law.

When would you expect to see an impact?

Kelly: The greater the availability and mobile availability of these facilities in particularly affected communities, the greater the clinical and public health and safety impacts. We need more resources devoted to studying and evaluating the impact of implementing these harm-reduction resources in communities, so we can begin to estimate more clearly their effectiveness and cost-effectiveness. Beyond the reduction in overdose risk, the reduction in HIV transmission is likely to be highly cost-effective. We would begin to see community level impacts quite quickly as has been shown in Vancouver, Canada, for example.

Hill: Safe injection sites would likely make an immediate impact wherever they are implemented.

Greenblatt: I don’t think there will be a meaningful impact until cities are allowed to set up and run safe injection sites without fear of being shut down by the federal government. However, if the sites were allowed to set up and operate, the reduction in overdoses, infections, emergency department visits and hospitalizations would happen within months.

How can safe injection sites lead to an overall improvement in this epidemic? Does this lead to more treatment of the underlying addiction? How?

Kelly: Safe injection facilities can increase the chances of treatment engagement simply because addicted individuals are now interacting with friendly and helpful healthcare professionals who can begin conversations, help reduce the shame and stigma associated with addiction, and answer questions and offer information on treatment and recovery support services. Sometimes such health workers are individuals in recovery from addiction themselves, which instills hope that change and recovery is possible.

Hill: Safe injection sites embody the philosophy of harm reduction. Of course, we’d prefer it if no one was addicted to opioids and no one was dying from opioid overdoses. The reality is that we are in the midst of an opioid crisis and, despite great efforts in many areas, we have yet to turn things around. Therefore, all evidence-based steps should be considered. A pilot safe injection site program would be a brave step that would allow us to study the impact of these facilities in the United States. Offering comprehensive services at safe injection sites makes it more likely that someone addicted to opioids would access treatment.

Greenblatt: These sites can be effective through a variety of mechanisms. One is that individuals who come in to use injection opioids come into contact with individuals who can provide referral to effective treatment programs, provide clean needles and respond to accidental overdoses. Secondly, individuals who are using illegal drugs on the street, tend to be hurried and will reuse or share needles, which increases the risk for transmission of HIV or hepatitis C and can also result in bacterial infections due to improper injection technique. Users can be given an opportunity to clean their skin properly and to use illicit drugs in a cleaner environment. – by Savannah Demko

Disclosures: Kelly, Hill and Greenblatt report no relevant financial disclosures.

References:

CBS News. “Philadelphia backs safe injection sites to curb opioid overdose deaths.” https://www.cbsnews.com/news/safe-injection-sites-philadelphia-elected-officials-back-curb-overdose-deaths/. Accessed on Jan. 31, 2018.

CDC. Opioid Overdose: Understanding the Epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed on Jan. 31, 2018.

NIDA. Overdose Death Rates. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed on Jan. 31, 2018.

WHYY. “Funders, operators sought to start safe-injection sites in Philly.” https://whyy.org/segments/funders-operators-sought-start-safe-drug-injection-sites-philly/. Accessed on Jan. 31, 2018.

John Kelly
John F. Kelly
Lawrence Greenblatt
Lawrence Greenblatt

According to the CDC, drug overdose deaths and opioid-related deaths continue to grow at an alarming rate in the United States, with an average of 115 Americans who die from opioid overdose every day.

Overall, more than 600,000 people died from drug overdoses between 2000 and 2016, according to the CDC. The agency estimated that more than 64,000 drug overdose deaths occurred in 2016, with the sharpest increase seen among deaths related to fentanyl and synthetic opioids, which accounted for 20,000 overdose deaths. The number of overdose deaths involving opioids was 5 times higher in 2016 compared with numbers seen in 1999.

Kevin P. Hill

In October 2017, President Donald J. Trump declared the opioid addiction crisis a public health emergency. With the current presidential administration committed to combatting the opioid epidemic, interventions remain necessary to control overdose deaths in the U.S.

Philadelphia officials have announced their plan to curb the crisis with safe-injection sites, where people who inject drugs can do so under medical supervision. Officials in Philadelphia — which sees the highest opioid death rate of any large U.S. city, according to CBS News — will encourage private organizations to establish the first-ever safe injection site in the country. Such an intervention aims to lessen the vast and growing number of overdose deaths related to opioid use and has the potential to save money.

“No one here condones or supports illegal drug use in any way, but we recognize how difficult addiction is — the grip of addiction interferes with its own treatment,” Philadelphia Public Health Commissioner Thomas Farley, MD, MPH, said in an article on WHYY. “We are talking about the people who are the most hard to reach, the most stigmatized. We need to make it easy for them to come in so you can then engage them.”

Drug overdose deaths and opioid-related deaths continue to grow at an alarming rate in the United States, with an average of 115 Americans who die from opioid overdose every day, according to the CDC.
Photo credit: Shutterstock

To discuss how setting up these safe injection sites will affect the overall opioid epidemic, Healio Psychiatry spoke with three experts: John F. Kelly, PhD, ABPP, Elizabeth R. Spallin associate professor of psychiatry at Harvard Medical School, director of the Massachusetts General Hospital Recovery Research Institute, program director of the MGH addiction recovery management service and associate director of the MGH Center for Addiction Medicine; Kevin P. Hill, MD, MHS, assistant professor of psychiatry, Harvard Medical School and director of addiction psychiatry, Beth Israel Deaconess Medical Center; and Lawrence Greenblatt, MD, FACP, professor of medicine in the department of community and family medicine, co-chair of the Opioid Safety Committee and Duke Health.

PAGE BREAK

What impact can safe injection sites have on the opioid epidemic, overdoses and the spread of disease?

John F. Kelly, PhD: Quite simply, as the name suggests, these resources can reduce overdose risk, as well as other health risks including the spread of HIV and hepatitis C through shared needle use. They offer an opportunity to engage with health care professionals, which can also increase the chances of treatment engagement and remission. Use of these facilities are likely to reduce the incidence of injecting in public places, such as often happens with those who are homeless, in particular.

Kevin P. Hill, MD: Safe injection sites have been studied for years. Most are located in Europe, while there are some in Canada and Australia as well. The evidence shows that they are effective in reducing opioid overdoses as well as the transmission of HIV and hepatitis C. Safe injection sites save lives. These sites are not associated with increases in drug use, drug trafficking or crime. Safe injection sites also increase the likelihood that people who are addicted to opioids get the treatment they need.

Lawrence Greenblatt, MD: Safe injection sites have been used in Canada and throughout Europe with improvement in the number of outcomes. Specifically, overdose deaths in the communities served by the safe injection sites have fallen by between 35% and 50%, and new cases of HIV and hepatitis C fall dramatically because sterile needles are made available. Transports to the ED via ambulance and hospitalizations also are reduced significantly. In addition, because users are provided with clean needles, clean conditions, and time to inject properly, there is a reduction in blood-borne infections and local soft tissue infections.  Personnel can be stationed in safe injection sites who can respond to overdoses quickly with naloxone, thus, reducing the risk of overdose death.

Is there research to suggest this is an effective route for governments?

Kelly: Preliminary studies suggest that use of these facilities reduces incidence of injecting in public places and is associated with safe disposal of needles, reduced needle sharing and, consequently, lowered incidence of HIV transmission and dramatically lowered overdose rates.  

Hill: The level of evidence is impressive at this point and has prompted many cities to consider this controversial idea. We see patients with opioid use disorder every day in our hospital and, unfortunately, some of these patients ultimately overdose and die. As a result, governments must carefully evaluate all evidence-based options.

Greenblatt: The research supporting safe injection sites largely comes from Canada and Europe. There are two publications of an ‘underground’ safe injection site run by a community organization illegally in the United States. The research is fairly convincing on outcomes, although inconclusive with regard to crime, motor vehicle collisions or drug sales. Additional evidence suggests that individuals who use safe injection sites are more likely to enroll in effective treatment programs for opioid use disorder.

How is this idea received by medical professionals outside of addiction specialists?

Kelly: The idea, at first glance, seems counterintuitive begging the question, wouldn’t we be ‘enabling’ use and therefore prolonging or increasing it? Both outside and inside the addiction field, people are often opposed to the idea until they understand how this can help reduce the harms associated with IV drug use and help keep people alive long enough that they have the chance to achieve remission and recovery.

PAGE BREAK

Hill: This is an emotionally-charged topic that many medical professionals do not support. However, in 2017, the Massachusetts Medical Society publicly supported the idea of a safe injection site pilot study in Massachusetts.

Greenblatt: I believe that most medical professionals are not familiar with the concept of safe injection sites; doctors would certainly have a range of attitudes as many would see these centers as facilitating ongoing drug use, whereas others would support the implementation of these sites based on strong outcomes data from existing research. It is important to note that at this time, these sites are illegal under federal law.

When would you expect to see an impact?

Kelly: The greater the availability and mobile availability of these facilities in particularly affected communities, the greater the clinical and public health and safety impacts. We need more resources devoted to studying and evaluating the impact of implementing these harm-reduction resources in communities, so we can begin to estimate more clearly their effectiveness and cost-effectiveness. Beyond the reduction in overdose risk, the reduction in HIV transmission is likely to be highly cost-effective. We would begin to see community level impacts quite quickly as has been shown in Vancouver, Canada, for example.

Hill: Safe injection sites would likely make an immediate impact wherever they are implemented.

Greenblatt: I don’t think there will be a meaningful impact until cities are allowed to set up and run safe injection sites without fear of being shut down by the federal government. However, if the sites were allowed to set up and operate, the reduction in overdoses, infections, emergency department visits and hospitalizations would happen within months.

How can safe injection sites lead to an overall improvement in this epidemic? Does this lead to more treatment of the underlying addiction? How?

Kelly: Safe injection facilities can increase the chances of treatment engagement simply because addicted individuals are now interacting with friendly and helpful healthcare professionals who can begin conversations, help reduce the shame and stigma associated with addiction, and answer questions and offer information on treatment and recovery support services. Sometimes such health workers are individuals in recovery from addiction themselves, which instills hope that change and recovery is possible.

Hill: Safe injection sites embody the philosophy of harm reduction. Of course, we’d prefer it if no one was addicted to opioids and no one was dying from opioid overdoses. The reality is that we are in the midst of an opioid crisis and, despite great efforts in many areas, we have yet to turn things around. Therefore, all evidence-based steps should be considered. A pilot safe injection site program would be a brave step that would allow us to study the impact of these facilities in the United States. Offering comprehensive services at safe injection sites makes it more likely that someone addicted to opioids would access treatment.

Greenblatt: These sites can be effective through a variety of mechanisms. One is that individuals who come in to use injection opioids come into contact with individuals who can provide referral to effective treatment programs, provide clean needles and respond to accidental overdoses. Secondly, individuals who are using illegal drugs on the street, tend to be hurried and will reuse or share needles, which increases the risk for transmission of HIV or hepatitis C and can also result in bacterial infections due to improper injection technique. Users can be given an opportunity to clean their skin properly and to use illicit drugs in a cleaner environment. – by Savannah Demko

Disclosures: Kelly, Hill and Greenblatt report no relevant financial disclosures.

References:

CBS News. “Philadelphia backs safe injection sites to curb opioid overdose deaths.” https://www.cbsnews.com/news/safe-injection-sites-philadelphia-elected-officials-back-curb-overdose-deaths/. Accessed on Jan. 31, 2018.

CDC. Opioid Overdose: Understanding the Epidemic. https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed on Jan. 31, 2018.

NIDA. Overdose Death Rates. https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates. Accessed on Jan. 31, 2018.

WHYY. “Funders, operators sought to start safe-injection sites in Philly.” https://whyy.org/segments/funders-operators-sought-start-safe-drug-injection-sites-philly/. Accessed on Jan. 31, 2018.

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