By TINA ROSENBERG
January 18, 2017
It has been nearly 30 years since the first needle exchange program opened in the United States, in Takoma, Wash., in 1988. It was a health measure to prevent injecting drug users from sharing needles, and therefore spreading H.I.V. and hepatitis.
The idea was controversial, to say the least. Many people felt — and still feel — that it enables drug use and sends a message that drug use is O.K. and can be done safely.
Today the evidence is overwhelming that needle exchange prevents disease, increases use of drug treatment by winning users’ trust and bringing them into the health system, and does not increase drug use. Its utility has won over some critics. When Vice President-elect Mike Pence was governor of Indiana, he authorized needle exchange programs as an emergency response to an H.I.V. outbreak. “I do not support needle exchange as antidrug policy, but this is a public health emergency,” he said at a news conference in 2015.
Needle exchange saved New York City from a generalized H.I.V. epidemic. In 1990, more than half of injecting drug users had H.I.V. Then in 1992, needle exchange began — and by 2001, H.I.V. prevalence had fallen to 13 percent.
America has another epidemic now: overdose deaths from opioids, heroin and fentanyl, a synthetic opioid so powerful that a few grains can kill. A thousand people died of overdose in the city last year — three times the number who were killed in homicides. Nationally, drug overdose has passed firearms and car accidents as the leading cause of injury deaths.
If there is a way to save people from overdose death without creating harm, we should do it. Yet there is a potent weapon that we’re ignoring: the supervised injection room. According to a report by the London-based group Harm Reduction International, 90 supervised injection sites exist around the world: in Canada, Australia and eight countries in Europe. Scotland and Ireland plan to open sites this year. In the United States, state officials in New York, California and Maryland, and city officials in Seattle (where a task force recommended two sites), San Francisco, New York City, Ithaca, N.Y., and elsewhere, are discussing such facilities.
Do you think needle exchange sends the wrong message? Boy, are you going to love this.
A supervised injection facility is a walk-in center where drug users can get clean equipment and use (their own) drugs under the watchful eye of staff armed with naloxone, the antidote that instantly reverses overdose. Some facilities are open to people who inhale drugs as well.
These facilities, like all harm reduction measures, are always part of a larger antidrug strategy. The response to America’s opioid crisis requires legal crackdowns on the supply chain, especially fentanyl shipped from China; intensive prevention measures; and no-waiting, locally available long-term treatment, especially the most effective treatment, which uses Suboxone or methadone.
The government response lags far behind the problem; only a tiny percentage of people who need treatment have been able to get it so far.
Supervised injection sites save lives. There has yet to be a single overdose death in a site anywhere in the world, said Rick Lines, executive director of Harm Reduction International. A recent survey of scientific studies found that the sites — which serve the most hard-core, marginalized users — do many things. They get people into health care. They do not increase drug injecting. They don’t increase trafficking or crime in the surrounding neighborhoods — their neighborhoods, in fact, saw less public injecting and fewer dropped syringes. And by averting H.I.V. and Hep C infections and reducing ambulance use and hospitalizations, they save money.
Like all harm reform measures, this idea assumes that people who are addicted to injecting drugs will do so somewhere. It’s better for them — and for everyone — if that place is not an alley, playground or Burger King bathroom. They should not be alone. You can’t enter treatment if you’re dead.
The only sites in North America are in Vancouver. But Canada is seeing record overdose deaths and the spread of fentanyl, so Ontario’s government just announced it would fund three sites in Toronto and one in Ottawa. Montreal plans to open some, too. “There is no higher priority in the health ministry,” said Adam Vaughan, a member of Parliament from Toronto, The Globe and Mail reported.
The largest and oldest Vancouver clinic is Insite, established in 2003 in the city’s Downtown Eastside neighborhood, where drug use is concentrated. Most of its funding comes from the province government.
“Insite is for long term, serious IV drug users,” said a spokeswoman, Anna Marie D’Angelo. Peer counselors, doctors and nurses screen out novices or minors, she said. Clients average around 30 years old, and some clients are in their 70s and have been shooting heroin for decades.
Clients pick up clean injecting equipment and go to one of 13 clean, well-lit carrels — mirrored, so staff can watch. After they inject, they can go to a chill room to talk with peer counselors and nurses. These conversations build trust between clients and a determinedly nonjudgmental staff. The “no lecture” part of harm reduction bothers a lot of people, but clients must trust staff if they are to accept help.
Insite says that the vast majority of referrals it makes are to treatment or detox — many to Onsite, the detox center right upstairs. Researchers found that Insite was associated (pdf) with a 30 percent increase in use of detox services, which in turn increased the use of long-term treatment and decreased injecting drug use.
Randy Fincham, a staff sergeant at the Vancouver Police Department, said that Insite was not an easy sell with police. “It’s hard for police officers to look the other way if someone’s going to consume,” he said. But Insite’s record was convincing, he said — clients have overdosed about 5,000 times and were revived in every single case. “It’s not the be-all and end-all. It’s a Band-aid for opioid consumption until other solutions are introduced. It’s taken a few years, but now our members are fully supportive — because of the need.”
To measure Insite’s impact on overdose deaths, researchers tallied deaths in Insite’s neighborhood in the two years before it opened and then in its first two years of operation, and compared them to deaths elsewhere in the city. Within roughly a third of a mile of Insite, overdose deaths dropped by 35 percent. In the rest of Vancouver, deaths dropped by 9.3 percent.
Researchers also found no increase in crime, and a decrease in public injecting and discarded needles. It has made the neighborhood better, not worse. The same is true in Sydney. Australian researchers found that three-quarters of residents and businesses in the area around Sydney’s facility support it (pdf). “SIFs cannot be expected to solve all of the drug-related problems within a particular area, but can contribute to their reduction or minimization,” said Australia’s Salvation Army — an organization normally focused on abstinence.
A caution: Small is not beautiful. Insite’s 13 carrels are not enough — each day starts off with a line around the block. This is bad for the neighborhood, and counterproductive for drug users. It’s very hard to stand in line for an hour with a bag of heroin in your pocket.
And to make a difference, sites must be near the clients. Vancouver is unusual in the concentration of its drug injecting in one neighborhood — which is also why there are lines. This is a challenge for other cities where drug use is more disperse, and especially problematic in rural areas; people won’t travel to go inject safely.
In New York, Linda Rosenthal, who represents Manhattan’s Upper West Side in the State Assembly, is preparing to introduce legislation laying the legal groundwork that would allow cities to establish the sites. She believes the facilities should go into buildings that already serve injecting drug users with services such as needle exchange, detox, counseling and connections to social programs.
The New York City Council is funding a $100,000 study by the Department of Health and Mental Hygiene that will look at the feasibility and possible impact of sites in New York City. The money came out of an already budgeted sum designated for H.I.V.-prevention, so the council has not yet debated the issue.
It’s a first step — given the politics, possibly the only step. The idea came from City Councilman Corey Johnson, who heads the health committee. He thinks that if the scientific evidence doesn’t convince council members, the financial argument might help. “We can centralize a point of outreach to heroin addicts that actually does save significant money and resources in our fight against multiple epidemics,” he said.
“I’m not sure we’ve been able yet to have the larger, substantive conversation that would hopefully educate people,” he said. “At first glance, it’s ‘why are we going to set up facilities to allow people to inject really lethal drugs?’ It’s hard to comprehend why a government would do that.”