Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
Federalism, Policy Learning, and local innovation in Public Health: The case of the Supervised Injection Facility
Evidence from international evaluations suggests that safe injection facilities (SIFs) may represent a medically effective and economically efficient strategy for reducing the incidence and harms of injection drug use among the chronically homeless and otherwise marginalized people. The success of such facilities in other countries has amplified calls for their introduction in the United States where injection drug use among the most difficult to reach groups continues to be an intractable source of numerous individual and public health harms as well as a major financial burden for certain municipalities.
In recognition of the fact that even evidence-based health interventions may fall under the ambit of laws targeting drugs and drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Our conclusions suggest that states and some municipalities have the power to authorize SIFs under their longstanding powers to protect the public’s health, but that federal authorities could still interfere with these facilities under the possession and “Crack House Statute” provisions of the Controlled Substances Act (CSA).
We analyze the applicability of these provisions and discuss possible defenses rooted in statutory interpretation, preemption and the Commerce Clause. We conclude that plausible legal arguments exist that those operating an SIF should not (and perhaps can not) be convicted under the auspices of the CSA. However, state- or locally-authorized SIFs can proceed free of legal uncertainty only if federal authorities explicitly authorize them or decide not to interfere. Given legal uncertainty and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation.
Harnessing the language of overdose prevention to advance evidence-based responses to the opioid crisis
Language has significant implications for how we view and respond to public health issues. Conventional moralistic messaging around drug use stigmatizes people who use drugs and inhibits the implementation of evidence-based harm reduction interventions that do not condemn drug use. However, within the context of the unprecedented North American opioid overdose crisis, we argue that shifting conventional moral messaging around overdose prevention and response strategies is key to supporting the rapid roll-out of evidence-based harm reduction interventions. Reframing overdose prevention to highlight the imperative to address the ongoing public health emergency is an important first step in implementing urgently needed response strategies.
Language Matters in Combating the Opioid Epidemic: Safe Consumption Sites Versus Overdose Prevention Sites
Support Increases When Opioid 'Safe Consumption Sites' Called 'Overdose Prevention Sites'.
Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility
Background: In Baltimore, MD, as in many cities throughout the USA, overdose rates are on the rise due to both the increase of prescription opioid abuse and that of fentanyl and other synthetic opioids in the drug market. Supervised injection facilities (SIFs) are a widely implemented public health intervention throughout the world, with 97 existing in 11 countries worldwide. Research has documented the public health, social, and economic benefits of SIFs, yet none exist in the USA. The purpose of this study is to model the health and financial costs and benefits of a hypothetical SIF in Baltimore.
Methods: We estimate the benefits by utilizing local health data and data on the impact of existing SIFs in models for six outcomes: prevented human immunodeficiency virus transmission, Hepatitis C virus transmission, skin and softtissue infection, overdose mortality, and overdose-related medical care and increased medication-assisted treatment for opioid dependence.
Results: We predict that for an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment.
Conclusions: We conclude that a SIF would be both extremely cost-effective and a significant public health and economic benefit to Baltimore City.
New Strategies Are Needed to Stop Overdose Fatalities: The Case for Supervised Injection Facilities
Last summer, the lifeless body of a 26-year-old heroin-using man, Tim (not his real name), was discovered in the shadows of a side street in Boston. Ninety minutes before, he had come to our clinic at Boston Health Care for the Homeless Program, mere blocks away, pleading for help. He told us with certainty that he was going to relapse that day, ending 6 weeks of hard-earned sobriety. Our nurse offered to connect Tim to treatment at the nearby methadone clinic or our office-based addiction treatment program, but he refused. He said he wasn't ready to enter another treatment program: What he wanted, simply, was accompaniment while he used. “I'm just looking for a ‘buddy' to go with me. I don't want to die.”
Overdose Prevention Site Acceptability among Residents and Businesses Surrounding a Proposed Site in Philadelphia, USA
Overdose prevention sites (OPS) are places where people use previously obtained drugs under the supervision of a health professional. They have been proposed in six United States (US) cities, including Philadelphia, to help reduce opioid-related overdose deaths and public injection. Philadelphia has the highest overdose rate among large cities in the US, which has led a local community-based organization to plan the implementation of OPS. Kensington, a neighborhood with the highest drug mortality overdose rates in the city, is a likely site for the proposed OPS. Given the dearth of research systematically assessing public opinion towards OPS prior to implementation, we enrolled 360 residents and 79 business owners/staff in the Kensington neighborhood in a cross-sectional acceptability study. Face-to-face surveys assessed participant characteristics, experiences with drug-related social problems, and OPS acceptability. Using descriptive statistics, we estimated factors associated with favorability towards opening an OPS in the Kensington neighborhood. Ninety percent of residents were in favor of an OPS opening in Kensington. Support was significantly higher among unstably housed individuals and persons who currently use opioids. In the business sample, 63% of owners/staff were in favor of opening an OPS in Kensington. A greater proportion of Asian/Pacific Islanders, Hispanic/Latinx respondents, and non-Hispanic/Latinx Black respondents were in favor of an OPS opening in Kensington compared with white respondents (p < 0.04). While details about implementation are still being considered, results indicate general acceptability among Kensington residents and businesses for an OPS, especially if it can deliver benefits that curb drug-related social problems. Should an OPS be implemented in Philadelphia, it would be important to monitor changes in drug-related social problems and acceptability post implementation.
Perceptions about supervised injection facilities among people who inject drugs in Philadelphia
BACKGROUND: People who inject drugs (PWID) are at high risk for infectious diseases, skin and soft tissue infections, and overdose. However, these harms are all avoidable when sterile injection equipment, hygienic places to inject, and medical care are accessible. Unfortunately, many PWID in the U.S lack these resources. The most vulnerable are forced to inject in public spaces, where individual risks are high and communal harms are sometimes many. Supervised Injection Facilities (SIFs) are an established intervention for reducing these harms. Despite positive experiences in other countries, little research explores how PWID in the U.S. perceive the value of such facilities.
METHODS: We conducted a freelisting exercise with PWID (n=42) and healthcare providers (n=20) at a syringe exchange program (SEP) that provides comprehensive clinical and social services in Philadelphia to inform in-depth semi-structured interviews with PWID (n=19) at the same location.
RESULTS: Participants expressed support for a potential SIF as a valuable public health intervention. They suggested that an SIF would improve PWID health while reducing the public disorder associated with injecting drugs in public. The latter was especially important to participants without stable housing, whose decision to inject furtively in secluded places was often motivated by desire not to upset community members, and particularly children. These participants acknowledged that such seclusion elevated the risk of fatal overdose. Despite similarly positive perceptions about an SIF, participants with stable housing reported that they would prefer to continue injecting at home.
CONCLUSION: Results both confirm and extend prior research about PWID and SIFs. Participants expressed support for SIFs as in prior survey research in the U.S. and in other countries. Facility location and housing status were identified as important determinants of facility use. Results extend prior research by illuminating PWID perceptions in the U.S. including motivations grounded in concern for public order.
Perspectives on supervised injection facilities among service industry employees in New York City: A qualitative exploration
BACKGROUND: Approximately 100 supervised injection facilities (SIFs) operate in 66 cities around the world to reduce overdose deaths, the spread of disease and public disorder, though none legally exist in the United States. Public bathrooms are among the most common public places for injection reported by people who inject drugs in New York City (NYC) and service industry employees (SIEs) inadvertently become first-responders when overdoses occur in business bathrooms. The goal of this study was to assess SIE acceptability of SIFs and the perceived effects that SIFs would have on them, their colleagues, their businesses and communities.
METHODS: Semi-structured qualitative interviews were conducted with 15 SIEs recruited through convenience sampling throughout NYC. Participants were provided with peer-reviewed scientific evidence prior to discussing SIFs. Data were analysed using a hybrid deductive and inductive approach.
RESULTS: Most SIEs had encountered drug use (93%, n = 14/15) and syringes (73%, n = 11/15) in their business bathrooms and three had encountered unresponsive individuals. Nearly all workers (93%, n = 14/15) were supportive of SIFs and believed SIFs would reduce injection drug use in their business bathrooms. Participants also believed that ‘not in my backyard’ arguments from community boards may impede SIF operation.
CONCLUSIONS: Service industry employees are critical stakeholders due to their exposure to occupational health hazards related to public injection. Those interviewed were amenable to SIF operation as a form of occupational harm reduction and their experiences provide an important dimension to the political debate surrounding SIFs.
Public drug use in eight U.S. cities: Health risks and other factors associated with place of drug use
BACKGROUND: Drug overdose is the leading cause of accidental death in the United States (U.S.). Previous studies have found that place of drug use is associated with risks including overdose, sharing of drug use equipment, and arrest, but the research on this subject in the U.S. is limited.
METHODS: Our study describes the relationship between place of drug use and health outcomes through the analysis of associations between frequent public drug use and drug-related arrest, overdose, and reuse of injection equipment. We analysed data from a cross-sectional, observational study of individuals who utilize syringe exchange services in 8 U.S. cities. Using regression analysis, we assessed associations between public drug use, demographic characteristics, and health risks.
RESULTS: Half (48%) of the respondents (N = 575) reported that at least one of their top two most frequent places of drug use is a public place. Street homelessness (AOR = 17.44), unstable housing (AOR = 3.43) and being under age 30 (AOR = 1.85) were independently associated with increased odds of frequent public drug use. Frequent public drug use was associated with increased odds of past-year arrest for drug-related offenses (AOR = 1.87).
CONCLUSION: Public drug use is associated with negative health and social outcomes. Increased access to harm reduction services, housing, and supervised consumption sites (SCS) interventions and a shift away from punitive approaches to drug use may reduce the some of the harms associated with public drug use.
