Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Assessing the Evidence on Supervised Drug Consumption Sites
Current levels of opioid-related morbidity and mortality in the United States are staggering. Data for 2017 indicate that there were more than 47,000 opioid-involved overdose deaths (roughly similar to deaths from AIDS at its peak in 1995), and 1 in 8 adults now report having had a family member or close friend die from opioids. There has been a near universal call from blue-ribbon commissions and expert panels for increasing access to Food and Drug Administration-approved medications for those with an opioid use disorder; however, jurisdictions addressing opioid use disorder and overdose may wish to consider additional interventions beyond increasing access to these medications. Two interventions that are implemented in some other countries but not in the United States are heroin-assisted treatment (HAT) and supervised consumption sites (SCSs). Given the severity of the opioid crisis, there is urgency to evaluate tools that might reduce its impact and save lives. This working paper is part of a series of reports assessing the evidence on and arguments made about HAT and SCSs and examining some of the issues associated with implementing them in the United States. The target audiences include decision makers in rural and urban areas grappling with opioids as well as researchers and journalists. This working paper assesses evidence on and arguments made about SCSs. It also offers a descriptive assessment of SCSs and the logic model behind their implementation. The other parts of this series of reports include: (1) a summary report of all the components of the research study; (2) a review of the HAT literature; (3) a report on key informant views on the acceptability and feasibility of implementing HAT and SCSs in selected U.S. jurisdictions heavily affected by the opioid crisis and (4) a report on international experience with the implementation of HAT and SCSs.
Associations between perceived illicit fentanyl use and infectious disease risks among people who inject drugs
BACKGROUND: Over the last several years, fentanyl has been introduced into the illicit drug supply in the United States. While the impact of fentanyl on overdose fatalities is clear, the increase in fentanyl use may also be affecting drug use practices with implications for infectious disease transmission. We conducted a cross-sectional survey to explore associations of perceived illicit fentanyl use with opioid use frequency, injection frequency and syringe sharing among people who inject drugs in two California cities.
METHODS: People who inject drugs (PWID) were recruited from community settings in Los Angeles and San Francisco, CA from June 2017 to September 2018. Multivariable logistic regression was used to explore adjusted associations between perceived illicit fentanyl use and high frequency opioid use, high frequency injection and syringe sharing.
RESULTS: Among the 395 study participants, the median age of participants was 44 years; 74% of participants were cisgender male; 73% reported to be homeless; 61% lived in San Francisco and 39% in Los Angeles. The prevalence of perceived illicit fentanyl use in the past six months was 50.4% (95% confidence interval (CI): 45.4%-55.3%) among PWID. Findings from our adjusted logistic regression models suggested that people reporting perceived illicit fentanyl use had a greater odds of high frequency opioid use (adjusted odds ratio (aOR) = 2.36; 95% CI: 1.43–3.91; p = 0.001), high frequency injection (aOR = 1.84; 95% CI: 1.08–3.13; p = 0.03) and receptive syringe sharing (aOR = 2.16; 95% CI: 1.06–4.36; p = 0.03), as compared to people using heroin and other street drugs but not fentanyl.
CONCLUSION: People reporting perceived illicit fentanyl use were at increased risk for injection-related infectious disease risks. Actions must be taken to reduce these risks, including improved access to syringe service programs and opioid treatment and consideration of innovative approaches, such as supervised consumption services.
Bringing Safer Consumption Spaces to the United States
Report today examining current efforts to bring safer consumption spaces - protected places used for the hygienic consumption of pre-obtained drugs in a non-judgmental environment and under the supervision of trained staff - to the United States.
Research indicates that safer consumption spaces are effective at reducing overdose fatalities, hospitalizations, infectious disease transmission, while also increasing initiation and retention in health care (which leads to better long-term substance use treatment outcomes). They are also cost effective.
The report offers strategies for extending funding and advocating for legally sanctioned safer consumption spaces in a manner that focuses on the leadership and needs of people who use drugs.
Comprehensive User Engagement Sites (CUES) in Philadelphia: A Constructive Proposal
This paper is a study about Philadelphia’s comprehensive user engagement sites (CUESs) as the authors address and examine issues related to the upcoming implementation of a CUES while seeking solutions for its disputed questions and plans. Beginning with the federal drug schedules, the authors visit some of the medical and public health issues vis-à-vis safe injection facilities (SIFs). Insite, a successful Canadian SIF, has been thoroughly researched as it represents a paradigm for which a Philadelphia CUES can expand upon. Also, the existing criticisms against SIFs are revisited while critically unpackaged and responded to in favor of the establishment. In the main section, the authors propose the layout and services of the upcoming CUES, much of which would be in congruent to Vancouver’s Insite. On the other hand, the CUES would be distinct from Insite, as the authors emphasize, in that it will offer an information center run by individuals in recovery and place additional emphasis on early education for young healthcare professionals by providing them a platform to work at the site. The paper will also briefly investigate the implementation of a CUES site under an ethical scope of the Harm Reduction Theory. Lastly, the authors recommend some strategic plans that the Philadelphia City government may consider employing at this crucial stage.
Considering Heroin-Assisted Treatment and Supervised Drug Consumption Sites in the United States
Current levels of opioid-related morbidity and mortality in the United States are staggering. Data for 2017 indicate that there were more than 47,000 opioid-involved overdose deaths, and one in eight adults now reports having had a family member or close friend die from opioids. Increasing the availability and reducing the costs of approved medications for those with an opioid use disorder (OUD) is imperative; however, jurisdictions addressing OUDs and overdose may wish to consider additional interventions. Two interventions that are implemented in some other countries but not in the United States are heroin-assisted treatment (HAT; sometimes referred to as supervised injectable heroin treatment) and supervised consumption sites (SCSs; sometimes referred to as overdose prevention sites). Given the severity of the opioid crisis, there is urgency to evaluate tools that might reduce its impact and save lives. In this mixed-methods report, the authors assess evidence on and arguments made about HAT and SCSs and examine some of the issues associated with implementing them in the United States.
Drug use in business bathrooms: An exploratory study of manager encounters in New York City
Background: Though public bathroom drug injection has been documented from the perspective of people who inject drugs, no research has explored the experiences of the business managers who oversee their business bathrooms and respond to drug use. These managers, by default, are first-responders in the event of a drug overdose and thus of intrinsic interest during the current epidemic of opioid-related overdoses in the United States. This exploratory study assists in elucidating the experiences that New York City business managers have with people who inject drugs, their paraphernalia, and their overdoses.
Methods: A survey instrument was designed to collect data on manager encounters with drug use occurring in their business bathrooms. Recruitment was guided by convenience and purposive approaches.
Results: More than half of managers interviewed (58%, n = 50/86) encountered drug use in their business bathrooms, more than a third (34%) of these managers also found syringes, and the vast majority (90%) of managers had received no overdose recognition or naloxone training. Seven managers encountered unresponsive individuals who required emergency assistance.
Conclusion: The results from this study underscore the need for additional research on the experiences that community stakeholders have with public injection as well as educational outreach efforts among business managers. This research also suggests that there is need for a national dialogue about potential interventions, including expanded overdose recognition and naloxone training and supervised injection facilities (SIF)/drug consumption rooms (DCR), that could reduce public injection and its associated health risks.
Establishing Sanctioned Safe Consumption Sites in the United States: Five Jurisdictions Moving the Policy Agenda Forward
OBJECTIVE: Safe consumption sites enable use of preobtained drugs in hygienic settings where trained staff are available to respond to overdoses and connect individuals with health and social services. This study examined efforts to advance policies to establish safe consumption sites in the United States, where no sanctioned sites exist.
METHODS: Between April and July 2018, the authors conducted 25 telephone interviews with a purposive sample of key informants in five communities considering safe consumption site implementation. Participants included organizers and advocates, government officials, and personnel with social service and health organizations. Interview notes were analyzed by using hybrid inductive-deductive coding.
RESULTS: Key strategies for organizing support for safe consumption sites included involving people who use drugs, engaging diverse partners, supporting allies in related causes, and using various tactics to garner support from policy makers. Major barriers to adoption included identifying the right locations, uncertainty about the federal response, mistrust arising from racial injustice in drug policy, and financing. Participants identified facilitators of progress toward safe consumption site adoption, such as building on existing harm reduction programs, securing political champions, and exposing community officials to programs operating internationally.
CONCLUSIONS: A window of opportunity may be opening to advance policy related to safe consumption sites; whether sanctioned sites become part of the broader policy strategy for addressing drug use and overdose in the United States will depend on the experiences of the first sites. Organizing around this issue may facilitate engagement among people who use drugs in broader conversations about drug policy.
Establishment of a Pilot Medically Supervised Injection Facility in Massachusetts
At the Massachusetts Medical Society’s Annual Meeting in 2016, the Society’s policymaking body, the House of Delegates (HOD), adopted as amended Resolution A-16 A-104, Establishment of a Pilot Medically-Supervised-Injection Facility in Massachusetts. The Society’s Board of Trustees (BOT) referred item 1 of the Resolution to the Task Force on Opioid Therapy and Physician Communication (Task Force), in consultation with the Committee on Public Health, Committee on Ethics, Grievances, and Professional Standards, the Committee on Professional Liability, and the MMS Office of the General Counsel, and item 2 to the MMS Presidential Officers:
1. That the MMS perform an internal evidence-based study of the ethical, legal, and liability considerations and feasibility of a medically-supervised injection facility (MSIF) in Massachusetts.
2. That at the conclusion of an internal study of medically-supervised injection facilities (MSIF), the Board of Trustees will report back to the House of Delegates, no later than A-17, with recommendations for an MMS advocacy position on MSIF.
Estimated impact of supervised injection facilities on overdose fatalities and healthcare costs in New York City
BACKGROUND: The opioid epidemic in the United States has resulted in over 42,000 U.S. opioid overdose fatalities in 2016 alone. In New York City (NYC) opioid overdoses have reached a record high, increasing from 13.6 overdose deaths/100,000 to 19.9/100,000 from 2015 to 2016. Supervised injection facilities (SIFs) provide a hygienic, safe environment in which pre-obtained drugs can be consumed under clinical supervision to quickly reverse opioid overdoses. While SIFs have been implemented worldwide, none have been implemented to date in the United States. This study estimates the potential impact on opioid overdose fatalities and healthcare system costs of implementing SIFs in NYC.
METHODS: A deterministic model was used to project the number of fatal opioid overdoses avoided by implementing SIFs in NYC. Model inputs were from 2015 to 2016 NYC provisional overdose data (N = 1852) and the literature. Healthcare utilization and costs were estimated for fatal overdoses that would have been avoided from implementing one or more SIFs.
RESULTS: One optimally placed SIF is estimated to prevent 19–37 opioid overdose fatalities annually, representing a 6–12% decrease in opioid overdose mortality for that neighborhood; four optimally placed SIFs are estimated to prevent 68–131 opioid overdose fatalities. Opioid overdoses cost the NYC healthcare system an estimated $41 million per year for emergency medical services, emergency department visits, and hospitalizations. Implementing one SIF is estimated to save $0.8–$1.6 million, and four SIFs saves $2.9–$5.7 million in annual healthcare costs from opioid overdoses.
CONCLUSIONS: Implementing SIFs in NYC would save lives and healthcare system costs, although their overall impact may be limited depending on the geographic characteristic of the local opioid epidemic. In cities with geographically dispersed opioid epidemics such as NYC, multiple SIFs will be required to have a sizeable impact on the total number of opioid overdose fatalities occurring each year.
FAQ: Supervised Injection Facility
What is a supervised injection facility (SIF)? Does the facility provide the drugs? Does a SIF increase the amount of crime in a neighborhood? What is the benefit of a SIF? Why not just get users into treatment? ...
