In early August, the British Columbia government said it would invest C$10.5 million ($8 million) to expand treatment services to people struggling with addiction. The province had seen a significant decline in overdose deaths in 2019 after increasing investments in opioid treatment programs, but toxic synthetic drugs and the precarity caused by the coronavirus have undercut that progress: In June, 175 people died of overdoses in the Canadian province, the highest monthly total ever recorded and a marked increase over June 2019’s total of 76.
One of the services supported by British Columbia’s investment is the expansion of centers for safe drug injection, where health professionals supervise drug use to prevent overdoses and other health risks, and connect individuals to health resources.
“What we were doing was working,” said Judy Darcy, the leader of British Columbia’s Ministry of Mental Health and Addictions. “We were headed in the right direction, and then Covid hit.”
Like British Columbia, U.S. states and cities are seeing increases in opioid-related overdose deaths A paper issued by the American Medical Association this summer found that 41 states had reported spikes in overdose deaths during the pandemic. As of mid-July, for example, more than 1,100 residents in the Chicago area had died from opioid-related overdoses in 2020, about double the number during the same period in 2019, according to ProPublica. By August, opioid overdoses in South Carolina had increased 50% over the same period last year. In some cities, current estimates are that these deaths could far exceed those from Covid-19.
But despite these increasing death tolls, much of the recent political momentum behind calls for safe injection sites in the U.S. has faded as public health priorities shift. Although several cities and states were advancing proposals to host the first legally sanctioned U.S. safe injection site, they’ve all hit setbacks over the past few months.
Safe injection sites, sometimes also called supervised injection sites, focus on what is known as “harm reduction,” the idea that public health is better served by minimizing the harms of drug use than by only promoting abstinence. Inside these centers, health care professionals and social workers monitoring drug injections are equipped with naloxone, a nasal spray that can help reverse an opioid overdose. Many sites also allow users to test their drugs and offer guidance on accessing social services.
The world’s first site opened in Bern, Switzerland, in 1986 in response to the country’s growing heroin epidemic. A number of European cities soon followed, and as of today, there are about 100 safe injection sites operating in 66 cities around the world. In 2003, North America’s first safe injection site, Insite, opened in Vancouver. In addition to overdose-prevention services, Insite has 12 rooms with private bathrooms and health staff for people who are ready to detox. Once users at Insite are “stabilized,” they are moved to a separate floor that functions as transitional housing and a space to access further treatment and social services. Since the center opened, there have been 3.6 million visits and 6,440 overdoses recorded at Insite, but no deaths. In fact, no death has ever been reported at a safe injection site.
In the U.S., these sites have remained controversial amid concerns that they enable or normalize use of dangerous and illegal drugs like heroin, and there are currently no legally sanctioned centers. But as an epidemic of opioid overdoses escalated, several U.S. cities explored opening such sites. The Trump administration responded by threatening to take legal action under a federal provision intended to ban crack houses.
In October, a federal judge granted safe injection sites a historic victory, ruling that plans to set up a site in Philadelphia did not violate federal law. But this past June, that same judge, Gerald McHugh, put plans for the site on pause by granting a stay to his original ruling, citing “frayed nerves” around the coronavirus pandemic.
“The combination of the pandemic and the momentous protests following the killing of Mr. George Floyd make this the wrong moment for another change in the status quo,” McHugh wrote in his June ruling.
This was one of several recent setbacks for the movement. A state bill in California that would have authorized a pilot program in San Francisco and Oakland failed to advance this year during a legislative session shortened by Covid-19. In 2018, a similar bill that would have sanctioned a pilot program was passed by state lawmakers only to be vetoed by then-Governor Jerry Brown, who cited threats of legal action by the federal government (though he was willing to defy the federal government on marijuana policy). San Francisco’s Board of Supervisors recently passed legislation that would allow a safe injection site in the city, but the move was largely symbolic without the passage of a state bill.
“These delays have a cost in human lives,” said Laura Thomas, director of harm reduction policy at San Francisco AIDS Foundation. In San Francisco, she says that if opioid deaths are occurring at the projected rate of more than one per day, fatalities from overdose have likely far exceeded the number of Covid-19 deaths since the pandemic started.
A combination of factors likely contributed to the current spike in overdoses, including lack of access to treatment during lockdown and social isolation. Disruptions in the drug supply chain during the pandemic also produced a more toxic supply and led an increasing number of users to turn to fentanyl, a synthetic opioid that is 50 to 100 times more potent than morphine.
Some cities are taking steps to address the upticks. Washington, D.C., for example, is expanding the locations where people can get access to naloxone. But it’s not just safe injection site proposals that have faced new setbacks. During the pandemic, a number of states have slashed budgets for opioid crisis programs. The federal government set aside $425 million in its coronavirus relief package for behavioral health, which includes drug treatment, butsome experts say it’s not nearly enough to fill the hole.
Polls in the past few years have shown American public opinion shifting toward treatment rather than incarceration to deal with drug use, and drug policy changes in many cities and states have followed suit, but safe injection sites remain controversial for those who believe they facilitate drug use.
Opponents of safe injection sites often cite potential increases in crime, litter and drug use — and an ostensible unseemliness. Rod Rosenstein, the former deputy U.S. attorney general, wrote in 2018 that safe injection sites “destroy the surrounding community” by bringing drug dealers, violence and “despair.” But available research contradicts several of these claims. A 2014 review of 75 studies of safe injection sites found that centers did not lead to increases in drug use or crime, but did reduce public drug injections. An analysis published in The Lancet medical journal in 2018 reported that safe injection sites led to decreases in HIV cases, litter and disorder — in addition to increasing participation in drug treatment and other recovery services. However, a 2018 study by the RAND Corporation cast doubt on the rigor of some other reports, saying few had fully analyzed the indirect effects of safe injection sites. The RAND study nonetheless said that it was unlikely safe injection sites would have persisted in cities for as long as they have if they had “serious adverse consequences.”
Although there are no legally sanctioned safe injection sites in the U.S., an underground site run by a nonprofit in an undisclosed American city has been open since 2014. In August, researchers who were invited to study that site published their findings in the New England Journal of Medicine. The report found that over five years, there were 10,514 injections, 33 opioid-involved overdoses, and no deaths.
Those findings reinvigorated calls for safe injection sites in some U.S. cities, but challenges remain. Proposals for safe injection sites in Massachusetts, Seattle and New York City have all recently faced delays and pushback from political leaders that have thwarted progress. Some, like the mayor of Somerville, Massachusetts, have directly cited coronavirus as the cause for delay. Others, like Massachusetts Governor Charlie Baker, say there isn’t sufficient data. Baker said his definition of harm reduction means “doing a better job of helping people keep from getting addicted in the first place” rather than hosting safe injection sites.
Besides persistent legal and legislative problems, safe injection sites also have to overcome community resistance The nonprofit Safehouse had planned to open its safe injection site in south Philadelphia days after McHugh affirmed his October ruling that it was legal. The organization had funding and a site picked out, but angry members of the community and city council managed to thwart the plan, saying Safehouse had failed to consult the public.
“We all want the same thing — to end overdoses,” said Ronda Goldfein, co-founder of Safehouse. “But we’re never going to have full agreement on how you solve this problem.”
If Safehouse had been able to move forward with its planned site in Philadelphia, advocates say it would have also benefited public health efforts around the coronavirus, in addition to saving lives. In the U.S., safe injection sites could have allowed health officials to test more people for Covid-19 who might not have otherwise interacted with health providers and offer drug users vital information about the pandemic, Kenneth Kim, senior director of programs at San Francisco-based nonprofit GLIDE.
“There needs to be accessible spaces where people can get the health information, screening and resources,” said Kim. “It was a missed opportunity in terms of the pandemic.”
Adds Thomas, the San Francisco policy advocate: “We are engaged in a massive national experiment of what happens when you don’t double down on making people safe. There’s no reason why we can’t both disrupt coronavirus and prevent overdose deaths.”
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