By Ajay K. Singh, MBBS, FRCP, MBA
March 28, 2017
I would recommend a perspective article by Sarah Wakeman in the New England Journal of Medicine as a “must read” for health care professionals wondering what still remains to be done in the dealing with the opioid epidemic. However, Dr. Wakeman’s view is not necessarily widely shared and might explain why the supervised injection facility (or site) idea hasn’t been widely adopted in the US.
In her article, Wakeman talks poignantly about the value of supervised injection facilities in saving lives. Says Wakeman,
“The cruel reality of opioid addiction is that any episode of use can be immediately fatal. Even when recovery is the goal, the path to it is circuitous, and most people with addiction have recurrences along the way. The odds of dying before arriving at the goal are tragically high.”
She continues, “But we do not have to accept this reality as the only option. Supervised injection facilities have been proven to save lives, improve health, increase neighborhood safety, reduce cost, and ultimately increase engagement in treatment. These facilities are monitored spaces, staffed by medical professionals, where people who use drugs can do so safely. Insite, a supervised injection facility in Vancouver, has seen thousands of overdoses since opening its doors but not a single death, thanks to the nurses and naloxone on site.”
Wakeman points out that several countries like Canada, Australia, the Netherlands, and Switzerland have supervised injection facilities. Their experience, and published research findings, provide support for the lifesaving benefit of these facilities.
Still, the obvious question is what are we missing here? Why doesn’t the US have even one facility? (Disclosure: Seattle and King County are planning facilities, but there are none in the US at the present time).
One reason, perhaps, is that even though the Surgeon General’s report and the publicity around it, made the case for addiction not being a “moral failing,” the view prevails. These supervised injection facilities might be viewed as “enabling” injections of opioids.
Some policy makers have expressed consternation about needle exchanges. Others have argued that allowing supervised injection of opioids goes against federal law.
In an article in the National Post, a leading Toronto Newspaper, columnist Jeremy Devine pushes back referencing, “an uncomfortable belief underlying the harm-reduction philosophy — the view that some addicts are without hope of ever leading a full, productive life free of drug use.”
“It may be true that, for some, the best we can do is safe, controlled sedation. But the medical community and society should not be so quick to condemn many others to the compromised mental prison that is the life of the addict.”
Devine concludes: “Harm-reduction researchers have conveniently neglected to investigate any potentially negative findings of their policies. Their studies focus exclusively on the obvious benefits such as decreased overdose deaths, cost savings, and so-called ‘treatment retention.’ That addicts will remain “in treatment” longer when freely administered their drug of choice is not surprising, but that this is in their best interests is highly questionable.”
In California, where the state legislature is considering allowing supervised injection sites, the California Police Chief’s Association has been resistant. Quoting an article on the KPCC website , they argue that it would “put California law enforcement in the inappropriate position of enforcing a state law at odds with federal law.” On the other hand, Californian lawmakers have pushed for decriminalizing this issue and treating addiction as a medical or social issue.
Some have made the point that supervised injection sites only address a part of the problem. For example, fentanyl is frequently ingested as a pill, and other drugs are smoked or inhaled.
The health legislation proposed by President Trump, if passed, could also have a devastating effect on the idea of supervised injection sites because Medicaid funding from states that accepted expanded Medicaid funding as a part of the Affordable Care Act (“Obamacare”) is slated for major cuts, and this will affect opioid-related care.
Perhaps Sarah Wakeman’s perspective article doesn’t resonate widely at this point, but it should, because she does have a point: “If the current epidemic can teach us anything, it’s that drug use is soaring unassisted. The time has come to think instead about how we can enable people to stay alive.”
The Opioid Use Disorder Education Program
Are you prepared to treat patients with opioid use disorder? Learn more about the latest medical and psychosocial treatment options, best practices, and legal guidelines in a free online program produced by Harvard Medical School.
The Opioid Use Disorder Education Program (OUDEP) is now available from HMS Global Academy. Comprised of 3 free online CE/CME courses produced by Harvard Medical School, these courses were developed with scientific contributions from The National Institute on Drug Abuse (NIDA) and are intended for nurses, nurse practitioners, physician assistants, physicians, and other health care providers collaborating to treat patients with substance use disorders.
Dr. Ajay K. Singh is the Senior Associate Dean for Global and Continuing Education and Director, Master in Medical Sciences in Clinical Investigation (MMSCI) Program at Harvard Medical School. He is also Director, Continuing Medical Education, Department of Medicine and Renal Division at Brigham and Women’s Hospital in Boston.