Several American cities are rallying around a new response to the opioid epidemic: safe spaces for using heroin.
The concept has gained traction in New York City, Philadelphia, San Francisco, and other cities across the US. The thinking is to allow supervised drug consumption sites where people can use drugs with sterile injection equipment and the supervision of trained staff, who are ready with the opioid overdose antidote naloxone if anything goes wrong. The sites may also link people to addiction treatment on request.
The idea: While in an ideal world, no one would use dangerous and potentially deadly drugs, many people do. So it’s better to give these people a space where they can use drugs with some sort of supervision. It’s a harm reduction approach.
Others aren’t receptive to the idea. The US Department of Justice, under President Donald Trump and Attorney General Jeff Sessions, has become a vocal opponent of supervised consumption sites (also known as safe injection sites, medically supervised consumption sites, and many other names) — even threatening legal action against cities and states that allow them.
In a statement last year about a proposal to open supervised consumption sites in Vermont, the Justice Department warned that the facilities “would violate federal law.” The Justice Department claimed in a statement, “It is a crime, not only to use illicit narcotics, but to manage and maintain sites on which such drugs are used and distributed.”
Most recently, Deputy Attorney General Rod Rosenstein published an op-ed in the New York Times criticizing the sites. He also issued a warning to city officials and potential beneficiaries of supervised consumption sites on NPR member station WHYY in Philadelphia. “It remains illegal under federal law,” he said. “And people engaged in that activity remain vulnerable to civil and criminal enforcement.”
And while advocates have credited some of the sites in Canada, Australia, and Europe with public health benefits, the research doesn’t fully support much of the enthusiasm. A recent meta-analysis from researchers at the University of South Wales in the UK found that there were only a few good studies on supervised consumption sites, and overall they didn’t seem to have big effects on drug overdose deaths or other drug-related outcomes at a population level.
There’s a cultural battle, too. After decades of the war on drugs, much of America’s drug policy is colored by a criminalized, stigmatized approach to addiction — one that demands shunning and shutting down all drug use, and trying to make sure that nothing is perceived as even remotely enabling or allowing drug use. Under this view, the idea of giving people a safe space to use drugs seems downright counterintuitive.
Now advocates are challenging the criminalized framing, arguing that if the goal is to save lives from addiction and overdose, a more compassionate approach is necessary.
In the middle of an opioid crisis, some cities are coming around to the new perspective. Drug overdose deaths in 2017 reached a record 72,000, at least two-thirds of which were linked to opioids, according to preliminary data from the Centers for Disease Control and Prevention. With the death toll mounting, policymakers are desperate for anything that may help.
Cities’ embrace of safe injection sites is triggering a broader culture war
Several cities have released plans to open a supervised consumption site, including New York City, Philadelphia, San Francisco, and Seattle. Others, such as Denver and Ithaca, New York, are considering the sites. It’s not clear when any of these will open.
It’s worth noting, however, that none of these cities would be the first in the US to open a supervised drug consumption facility should they move forward with their plans, because unsanctioned facilities have been operating in the country for years. Some of the sites are makeshift, set up by drug users in areas where they commonly use drugs. At least one, though, is secretly run by a harm reduction group that provides other kinds of services to people who use drugs — as has been documented by some studies.
One reason these older sites have never been officially sanctioned is public opposition. There’s a widespread not-in-my-backyard (NIMBY) sentiment with these kinds of services; essentially, people are worried that if a supervised consumption site opened in their area, it would attract people who use drugs to their neighborhood, and that could cause a rise in general crime and social disorder.
Critics also worry that supervised consumption sites would lead to more drug use, because they would remove a barrier — and perhaps some of the stigma — to drug use.
The Justice Department made this exact argument about Vermont: “Such facilities would also threaten to undercut existing and future prevention initiatives by sending exactly the wrong message to children in Vermont: the government will help you use heroin. Indeed, by encouraging and normalizing heroin injection, [supervised consumption sites] may even encourage individuals to use opiates for the first time, or to switch their method of ingestion from snorting to injection, the latter carrying greatly increased risk of fatality and overdose.”
It’s no coincidence that the Justice Department is making this argument. Law enforcement officials are some of the biggest opponents of supervised consumption facilities — and these officials can be particularly persuasive for politicians at the local and state level, where police hold a lot of sway over any policy related to public safety. In Philadelphia, for one, a key turning point seemed to be Police Commissioner Richard Ross going from being, as ABC News put it, “dead-set” against supervised consumption sites to “keeping an open mind if they can truly save lives.”
It’s that reformed perspective — one focused on saving lives — that advocates of harm reduction and supervised consumption sites focus on. It’s not that the public and society should embrace or enable drug use or addiction, but that strategies should instead take seriously people who use drugs, listen to why they’re doing what they’re doing, and try to minimize the harms of what they’re doing as much as possible.
The argument: While ideally people would not use drugs and those who are addicted would get into treatment, the reality is that many people aren’t ready to stop using. By meeting people where they are, governments and providers can mitigate some of the harms until someone is ready to stop using — and potentially save lives in the process.
So if people are at risk of transmitting HIV through reused syringes, maybe a program can give them a supply of sterile needles so that they don’t need to reuse syringes. If people are at risk of overdose, maybe a program can provide them with naloxone — or create a space where they can be supervised in case they overdose and need medical aid. In concert with these services, providers can also lay the groundwork for treatment in case people decide they’re ready for it.
It’s similar to the thinking around teen pregnancy: Perhaps parents would prefer that their teens don’t have sex at a young age, but, acknowledging the reality that they might, it’s better to provide them with condoms and other forms of birth control.
As Jonathan Giftos, an advocate and doctor focused on addiction, said on Twitter, “No one is arguing that [supervised consumption sites] are THE answer to our overdose crisis, but they would fill an enormous gap in current care model — engaging a highly marginalized group of patients — and ultimately save many lives.”
Accepting this view, however, requires a rethinking of how America approaches drugs. As Sarah Wakeman, an addiction medicine doctor and medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, has told me, “For 100-plus years as a society, we’ve punished and criminalized people who use drugs.” The harm reduction view asks that America moves away from that criminalized approach.
The evidence on supervised consumption sites is lacking — for both sides
Whether supervised consumption sites are effective remains a topic of debate in the research. Researchers have been looking into supervised consumption sites for decades (since the first one opened in Switzerland in 1986), but the evidence just isn’t rigorous enough yet to make hard conclusions one way or the other.
A recent meta-analysis published in the International Journal of Drug Policy by researchers at the University of South Wales in the UK looked at the studies done on supervised consumption sites so far. It found some evidence that supervised consumption sites have a small favorable relation to drug-related crimes — which speaks against the NIMBY concerns — but no significant effect on several other outcomes, like overdose mortality and syringe sharing. In short, it’s not that the sites appear to make things worse, but they don’t seem to make things much better, either.
The meta-analysis’s most compelling finding, though, is that most of the studies in this area don’t clear even fairly low methodological bars to be considered rigorous — particularly having a comparison group. That left the researchers with just eight (of 40) studies, which the researchers concluded wasn’t enough to make strong conclusions one way or the other about whether the sites are effective when it comes to a host of outcomes.
Keith Humphreys, a Stanford drug policy expert who wasn’t involved in the meta-analysis, called the findings “fairly disappointing.” He explained, “If you are an advocate, you could say correctly that if we assume these are effective, we do not have sufficient information to confidently overturn that presumption. But it’s equally true if you took another view — just look at it as a cold, scientific question — you could say we also don’t have the evidence to overturn the presumption that these don’t make any difference.”
The findings contradicted other reviews of the evidence. For example: Drawing on more than a decade of studies, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) in 2018 concluded that safe injection sites led to “safer use for clients” and “wider health and public order benefits.” Among those benefits: reductions in risky behavior that can lead to HIV or hepatitis C transmission, drops in drug-related deaths and emergency service calls related to overdoses, and greater uptake in drug addiction treatment, including highly effective medications for opioid addiction.
But EMCDDA’s review wasn’t a traditional meta-analysis, so it wasn’t as rigorous or selective in what studies — and what quality of studies — were included in the review. That allowed EMCDDA to include more studies, but many of those studies may have been of poor quality.
For Humphreys, the new review is more reliable than EMCDDA’s look at the research. As he put it, “If you impose even a modest methodological bar, and then those [studies’] effects go away, to me that’s worrisome.”
The problem with supervised consumption sites may come down to scale. The sites have limits in where and when they’re open, how many people they can serve at once, and who they serve. For a city dealing with potentially thousands of people using drugs — many of whom use drugs multiple times a day — the sites don’t have enough reach to help most of the population.
The meta-analysis spoke to this point, noting that “facilities are limited in the number of users they can accommodate.” Consider that Vancouver, for example, was previously estimated to have about 5,000 injection drug users. A site that can hold at most a dozen or so users at a time and is closed for some parts of the day is simply not going to have much reach in such a large group of people — servicing, the meta-analysis suggested, “a small fraction of users each day.”
That may explain why, even though these sites regularly reverse overdoses, they may not have, based on the meta-analysis, a significant effect on population-level overdose deaths.
Advocates contest the meta-analysis. Leo Beletsky, a professor of law and health sciences at Northeastern University, told me that the analysis excluded far too many studies to give “the full picture” of the research.
Still, excluding a lot of or even most studies in a meta-analysis isn’t atypical. If most of the studies don’t clear a low methodological bar, it can even be expected in rigorous reviews of the evidence.
Given the research, Humphreys guessed that the likely truth is supervised consumption sites work “really little.” It’s not that they don’t have any effect — since they seem to help people who actually use the sites by reversing overdoses and providing other services. But the effect is likely so small that it’s not going to be picked up at a population level by the research.
Beletsky, for his part, said that “it’s not surprising to me that the population-level impact is limited.” But he argued that more could be done to expand the sites’ reach, from removing legal barriers to establishing mobile pop-up sites that can open in communities where a fully staffed building may not always be needed or available.
“Thus far, these interventions have been limited,” Beletsky said. “They’ve been mired in legal and political battles. They’ve been artificially suppressed. They could be doing a lot more.”
The US has a lot of room for improvement in its response to the opioid crisis
Despite the conflicting evidence on supervised consumption sites, experts are confident that the US could, with the right allocation of resources, stem the opioid crisis. “We have plenty of other things that we know, with much more confidence, that work,” Humphreys said.
At the top of those other things is treatment — specifically, medications like methadone and buprenorphine. There are decades of evidence behind these medications, showing that they reduce the mortality rate among opioid addiction patients by half or more and keep people in treatment better than other approaches. When France relaxed restrictions on doctors prescribing buprenorphine in response to its own opioid crisis in 1995, the number of people in treatment rose and overdose deaths fell by 79 percent over the following four years.
But these medications, and addiction treatment in general, remain largely inaccessible in the US. A 2016 surgeon general report concluded that only 10 percent of people with a substance-use disorder get specialty treatment, in large part due to a lack of affordable and accessible treatment options. And even when treatment is available, other federal data suggests that fewer than half of treatment facilities offer opioid addiction medications.
Sticking exclusively to the realm of harm reduction, the US could do a lot more there, too. Consider needle exchanges, where users can pick up sterile syringes and trade in used needles. The decades of research show needle exchanges combat the spread of bloodborne diseases like hepatitis C and HIV, cut down on the number of needles thrown out in public spaces, and link more people to treatment — all without enabling more drug use.
Yet needle exchanges remain scarce in the US, as Josh Katz reported for the New York Times: “According to the North American Syringe Exchange Network, 333 such programs operate across the country, up from 204 in 2013. In Australia, a country with less than a tenth as many people, there are more than 3,000.”
Even some more innovative, controversial solutions appear to have more evidence than supervised consumption facilities. Humphreys said that the evidence behind prescription heroin sites, as one example, is “much stronger.”
The idea behind prescription heroin sites: A certain segment of opioid users are going to use heroin no matter what. For whatever reason, traditional therapies just aren’t going to work for them — just like some treatments for, say, heart disease or cancer don’t work for some patients. So if that happens, it’s better to give them a safe source of the drug they’re seeking and a safe place to inject it, rather than letting them pick it up on the street — laced with who knows what — and possibly overdose without medical supervision.
Researchers credit the European prescription heroin programs with better health outcomes, reductions in drug-related crimes, and improvements in social functioning, such as stabilized housing and employment. Canadian studies also deemed prescription heroin effective for treating heavy heroin users. A review of the research — which included randomized controlled trials from Switzerland, the Netherlands, Spain, Germany, Canada, and the UK — reached similar conclusions, noting sharp drops in street heroin use among people in the treatment.
There is no prescription heroin program in the US.
Humphreys argued that, in a world with limited financial resources and finite political and cultural capital, governments should first support the more evidence-based approaches than those with less.
“Should you have a culture war over something that barely engages the population and at most has a teeny effect when we still have people who can’t get methadone and buprenorphine, which have a whopping effect and can engage a huge number of people?” Humphreys said. “For me, that would be an obvious decision.”
Other experts argue that supervised consumption sites could still play a role in fighting the opioid crisis.
“We should be doing all those things that you mentioned,” Beletsky said. “But there are challenges in reaching some of the most at-need populations who can benefit from those interventions. And I think that safe consumption facilities provide a platform for reaching those folks.” He added, “Safe consumption facilities really operate as a low-threshold doorway for people who typically will not seek care in other settings.”
For example, someone who uses heroin may have had bad experiences with the criminal justice system or health care system in the past. That may make him skeptical of going to these institutions — or any other official institutions — for help. A supervised consumption site, though, can be different, since it’s an environment in which people are less judgmental about drug use. If the people running supervised consumption sites take advantage of this, they could use their better stature with people who use heroin to guide them to treatment and recovery.
But there’s no strong evidence to support the sites as an effective intervention for getting people into treatment and recovery — given that the new review of the research found no good studies that adequately evaluated for this.
That goes back to the core problem: There is a lot out there about supervised consumption sites that certainly seems promising, even intuitive, but it doesn’t have very rigorous evidence supporting it, at least yet.
Still, as tens of thousands die of drug overdoses a year, some local policymakers are very desperate to find solutions. And despite federal opposition and lacking evidence, they are moving ahead with supervised consumption sites.
Sourse: breakingnews.ie
0.00 (0%) 0 votes
