Summary/Abstract

Over half a million people have died of an overdose in the U.S. since 2000.  As of 2014, an estimated 774,434 people inject drugs in the U.S., the majority of whom inject opioids including prescription opioids and heroin. The prevalence of HIV and hepatitis C virus among people who inject drugs in the U.S. is 2% and 43%, respectively. With the U.S. in the midst of an opioid epidemic causing morbidity and mortality at unprecedented levels, policymakers and public health practitioners are in need of innovative solutions.

Content

Illicit drug use has been treated in the U.S. primarily as a criminal activity and only secondarily as a public health concern. When HIV/AIDS emerged in the early 1980s, activists and public health practitioners adopted and advocated for a more pragmatic approach to drug use—harm reduction—which consists of “a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use.”3 Prominent examples of harm reduction programs include access to sterile syringes for injection of illicit drugs through syringe access programs and expanding provision of naloxone, a life-saving opioid overdose-reversal medication, to lay, persons, law enforcement, and other first responders. Although these strategies have been shown to reduce viral transmission risk and decrease opioid overdose mortality, respectively,l4, 5 more needs to be done. Supervised injection sites are the next evidence-based harm reduction strategy that should be considered for implementation in the U.S.

Supervised injection sites (also called safer injection facilities or safer consumption services) are legally sanctioned locations that provide a hygienic space for people to inject pre-obtained drugs while observed by trained staff. 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. These locations provide a non-judgmental environment; protected time and space for injecting; appropriate guidance and equipment (e.g., clean needles, naloxone) to reduce harms; proper disposal of used equipment; and onsite or linkage to medical care, substance use treatment, and social services. Ten countries currently allow legal operation of such sites (Australia, Canada, Denmark, France, Germany, Luxembourg, the Netherlands, Norway, Spain, and Switzerland), with approximately 98 facilities operating in 66 cities worldwide. Implementation of supervised injection sites has been shown to improve individual health, such as overdose mortality rates,6 drug use and enrollment in drug treatment,7, 8 HIV and viral hepatitis risk,9 and access to health and social services.10, 11 Improvements in community health and safety are also noted in neighborhoods with supervised injection sites, including reductions in public injection and improperly disposed of syringes,12, 13 drug related crime,14 violence in the neighborhoods surrounding the site, and in the demand for ambulance services for opioid-related overdoses.15 Once implemented, these sites have been found to have high community support, which increases over time.16, 17 A recent study estimated that placing a supervised injection site in a U.S. city would net cost savings of $3.5 million (U.S.) per year.18

The legal status of supervised injection sites in the U.S. is unclear, but laws such as the federal Controlled Substances Act could potentially be used to shut them down.19 In response to legal obstacles to syringe access programs in the 1980s and 1990s, community activists engaged in civil disobedience and grassroots activism to implement this intervention, which had evidentiary support from other countries, but was initially illegal in many parts of the U.S. The country is currently in the beginning phases of similar civil disobedience and activism related to supervised injection sites.

After a year of planning and preparation, a social service agency located in an undisclosed urban area in the U.S. opened an unsanctioned supervised injection site in September 2014. The agency developed a quantitative survey to evaluate the impact of the site. The service is confidential and the survey is anonymous. The authors were approached by the agency, with whom they are not affiliated, to help evaluate their program. All evaluation activities were approved by the IRB of the University of California, San Diego.

The unsanctioned supervised injection site has one large room dedicated solely to injection and an adjoining room that provides post-injection monitoring/supervision. The injection room has five stainless steel stations with mirrors and stools (Figure 1). It is open 4–6 hours per day, 5 days per week. Use of the space is by invitation only, and the total number of people with active privileges is generally <60 in order to avoid lines. The agency provides other social services that are open to the general public. Once a person comes to the agency a few times, and appears to need supervised injection services, they are invited to use the supervised injection room. There are no formal exclusion criteria. Participants generally spend between 10 and 20 minutes in the injection room. Because the rooms are not adequately ventilated, smoking of drugs is not allowed. A staff person is stationed in the injection room at all times. Ancillary sterile injection equipment is provided by the agency, which also safely disposes of all used equipment. The staff person observing the injections has been trained in overdose prevention, resuscitation using naloxone and rescue breathing, injecting technique, and harm reduction principles.