Synthetic Opioid key responses
- Mapping evidence-based key responses to synthetic opioids and their implementation strategies
- Field-tested Toolkit with seven implementation guides
The Costs and Benefits of a Supervised Use Site in Denver, Colorado
In recent years, Colorado has made strides in establishing and improving vital harm reduction services like sterile syringe access programs and naloxone distribution, but our communities still experience far too many needless overdose deaths. Multiple counties in Colorado, including Denver, have had overdose rates among the
highest in the nation. Public injecting is also an ongoing concern. Just in Denver in 2018 alone, at least 25 people passed away from overdose in public locations such as parks, alleys, parking lots, and business restrooms. These deaths were unnecessary and preventable.
Along with the risk of overdose, unsafe injection practices are associated with blood-borne disease transmission and skin and soft tissue infection (SSTI)—also extremely costly, yet preventable, concerns. Injection drug use is the primary cause of new hepatitis C virus (HCV) infections in Colorado, with half of all reported cases occurring among people who inject drugs (PWID). In the past year, more than half of all PWID in the city of Denver experienced a skin or soft tissue infection, requiring them to utilize emergency rooms and hospital beds.
Prevention and treatment are important aspects of our public health infrastructure, but they are not enough. By enhancing harm reduction services that directly address the risks associated with continued drug use, we can better mitigate some of the most costly problems and improve access to effective public health resources that would better protect our communities.
The Law (and Politics) of Safe Injection Facilities in the United States
Safe injection facilities (SIFs) have shown promise in reducing harms and social costs associated with injection drug use. Favorable evaluations elsewhere have raised the issue of their implementation in the United States.
Recognizing that laws shape health interventions targeting drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Although states and some municipalities have the power to authorize SIFs under state law, federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally-authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or decided 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.
The Mayor’s Task Force to Combat The Opioid Epidemic in Philadelphia. Final Report & Recommendations
The Mayor’s Task Force to Combat The Opioid Epidemic in Philadelphia. Final Report & Recommendations
To develop a comprehensive and coordinated plan to reduce opioid abuse, dependence and overdose in Philadelphia. The Task Force ended its work in April and presented a final report to Mayor Kenney on May 19.
The projected costs and benefits of a supervised injection facility in Seattle, WA, USA
BACKGROUND: As one strategy to improve the health and survival of people who inject drugs, the King County Heroin & Opioid Addiction Task Force recommended the establishment of supervised injection facilities (SIF) where people can inject drugs in a safe and hygienic environment with clinical supervision. Analyses for other sites have found them to be cost-effective, but it is not clear whether these findings are transferable to other settings.
METHODS: We utilized local estimates and other data sources deemed appropriate for our setting to implement a mathematical model that assesses the impact of a hypothetical SIF on overdose deaths, non-fatal overdose health service utilization, skin and soft tissue infections, bacterial infections, viral infections, and enrollment in medication assisted treatment (MAT). We estimated the costs and savings that would occur on an annual basis for a small-scale pilot site given current overdose rates, as well as three other scenarios of varying scale and underlying overdose rates.
RESULTS: Assuming current overdose rates, a hypothetical Seattle SIF in a pilot phase is projected to annually reverse 167 overdoses and prevent 6 overdose deaths, 45 hospitalizations, 90 emergency department visits, and 92 emergency medical service deployments. Additionally, the site would facilitate the enrollment of 41 SIF clients in medication assisted treatment programs. These health benefits correspond to a monetary value of $5,156,019. The annual estimated cost of running the SIF is $1,222,332. The corresponding cost-benefit ratio suggests that the pilot SIF would generate $4.22 for every dollar spent on SIF operational costs. The pilot SIF is projected to save the healthcare system $534,453. If Seattle experienced elevated overdose rates and Seattle SIF program were scaled up, the health benefits and financial value would be considerably greater.
CONCLUSION: This analysis suggests that a SIF program in Seattle would save lives and result in considerable health benefits and cost savings.
The willingness of people who inject drugs in Boston to use a supervised injection facility
BACKGROUND: In Massachusetts, the number of opioid-related deaths has increased 350% since 2000. In the setting of increasing overdose deaths, one potential intervention is supervised injection facilities (SIFs). This study explores willingness of people who inject drugs in Boston to use a SIF and examines factors associated with willingness.
METHODS: A cross-sectional survey of a convenience sample of 237 people who inject drugs and utilize Boston's needle exchange program (NEP). The drop-in NEP provides myriad harm reduction services and referrals to addiction treatment. The survey was mostly self-administered (92%).
RESULTS: Results showed positive willingness to use a SIF was independently associated with use of heroin as main substance (odds ratio [OR]: 5.47; 95% confidence interval [CI]: 1.9–15.4; P = .0004), public injection (OR: 5.09; 95% CI: 1.8–14.3; P = .002), history of seeking substance use disorder (SUD) treatment (OR: 4.99; 95% CI: 1.2–21.1; P = .05), having heard of SIF (OR: 4.80; 95% CI: 1.6–14.8; P = .004), Hispanic ethnicity (OR: 4.22; 95% CI: 0.9–18.8; P = .04), frequent NEP use (OR: 4.18; 95% CI: 1.2–14.7; P = .02), current desire for SUD treatment (OR: 4.15; 95% CI: 1.2–14.7; P = .03), hepatitis C diagnosis (OR: 3.68; 95% CI: 1.2–10.1; P = .02), posttraumatic stress disorder (PTSD) diagnosis (OR: 3.27; 95% CI: 1.3–8.4; P = .01), report of at least 1 chronic medical diagnosis (hepatitis C, human immunodeficiency virus [HIV], hypertension, or diabetes) (OR: 3.27; 95% CI: 1.2–8.9; P = .02), and comorbid medical and mental health diagnoses (OR: 2.93; 95% CI: 1.2–7.4; P = .02).
CONCLUSIONS: Most respondents (91.4%) reported willingness to use a SIF. Respondents with substance use behavior reflecting high risk for overdose were significantly more likely to be willing to use a SIF. Respondents with behaviors that contribute to public health burden of injection drug use were also significantly more likely to be willing to use a SIF. Results indicate that this intervention would be well utilized by individuals who could most benefit from the model. As part of a broader public health approach, SIFs should be considered to reduce opioid overdose mortality, decrease public health burden of the opioid crisis, and promote access to addiction treatment and medical care.
Using drugs in un/safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States
Background: Supervised injection facilities (SIFs) are spaces where people can consume pre-obtained drugs in hygienic circumstances with trained staff in attendance to provide emergency response in the event of an overdose or other medical emergency, and to provide counselling and referral to other social and health services. Over 100 facilities with formal legal sanction exist in ten countries, and extensive research has shown they reduce overdose deaths, increase drug treatment uptake, and reduce social nuisance. No facility with formal legal sanction currently exists in the United States, however one community-based organization has successfully operated an ‘underground’ facility since September 2014.
Methods: Twenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples’ lives, including the impact of lack of formal legal sanction on service provision.
Results: Participants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being ‘underground’ included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services.
Conclusion: Unsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction.
Willingness to use a supervised injection facility among young adults who use prescription opioids non-medically: a cross-sectional study
Background: Supervised injection facilities (SIFs) are legally sanctioned environments for people to inject drugs under medical supervision. SIFs currently operate in ten countries, but to date, no SIF has been opened in the USA. In light of increasing overdose mortality in the USA, this study evaluated willingness to use a SIF among youth who report non-medical prescription opioid (NMPO) use.
Methods: Between January 2015 and February 2016, youth with recent NMPO use were recruited to participate in the Rhode Island Young Adult Prescription Drug Study (RAPiDS). We explored factors associated with willingness to use a SIF among participants who had injected drugs or were at risk of initiating injection drug use (defined as having a sex partner who injects drugs or having a close friend who injects).
Results: Among 54 eligible participants, the median age was 26 (IQR = 24-28), 70.4% were male, and 74.1% were white. Among all participants, when asked if they would use a SIF, 63.0% answered “Yes”, 31.5% answered “No”, and 5. 6% were unsure. Among the 31 participants reporting injection drug use in the last six months, 27 (87.1%) reported willingness to use a SIF; 15 of the 19 (78.9%) who injected less than daily reported willingness, while all 12 (100.0%) of the participants who injected daily reported willingness. Compared to participants who were unwilling or were unsure, participants willing to use a SIF were also more likely to have been homeless in the last six months, have accidentally overdosed, have used heroin, have used fentanyl non-medically, and typically use prescription opioids alone.
Conclusions: Among young adults who use prescription opioids non-medically and inject drugs or are at risk of initiating injection drug use, more than six in ten reported willingness to use a SIF. Established risk factors for overdose, including homelessness, history of overdose, daily injection drug use, heroin use, and fentanyl misuse, were associated with higher SIF acceptability, indicating that young people at the highest risk of overdose might ultimately be the same individuals to use the facility. Supervised injection facilities merit consideration to reduce overdose mortality in the USA.
Willingness to Use Safe Consumption Spaces among Opioid Users at High Risk of Fentanyl Overdose in Baltimore, Providence, and Boston
Safe consumption spaces (SCS) are evidence-based interventions that reduce drug-related morbidity and mortality operating in many countries. However, SCS are yet to be widely implemented in the USA despite the escalating overdose epidemic. The aim of this multi-city study was to identify the factors associated with willingness to use a SCS among people who use drugs (PWUD) in Baltimore, Providence, and Boston, stratified by injection drug use status. Our secondary aim was to characterize the anticipated barriers to accessing SCS if they were to be implemented in these cities. PWUD were invited to complete a cross-sectional survey in 2017. The analysis was restricted to 326 opioid users (i.e., heroin, fentanyl, and non-medical opioid pill use). The majority (77%) of participants expressed willingness to use a SCS (Baltimore, 78%; Providence, 68%; Boston. 84%). Most respondents were male (59%), older than 35 years (76%), non-white (64%), relied on public/semi-public settings to inject (60%), had a history of overdose (64%), and recently suspected fentanyl contamination of their drugs (73%). A quarter (26%) preferred drugs containing fentanyl. Among injectors, female gender, racial minority status, suspicion of drugs containing fentanyl, and drug use in public/semi-public settings were associated with higher willingness to use a SCS; prior arrest was associated with lower willingness. Among non-injectors, racial minority status, preference for fentanyl, and drug use in public/semi-public settings were associated with higher willingness, whereas recent overdose held a negative association. The most commonly anticipated barriers to accessing a SCS in the future were concerns around arrest (38%), privacy (34%), confidentiality/trust/safety (25%), and cost/time/transportation (16%). These data provide evidence of high SCS acceptability among high-risk PWUD in the USA, including those who prefer street fentanyl. As SCS are implemented in the USA, targeted engagement efforts may be required to reach individuals exposed to the criminal justice system.
Supervised Injection Facilities and Other Supervised Consumption Sites: Effectiveness and Value
The opioid overdose epidemic is devastating families and communities across the United States (US). Epidemiological studies from the US Centers for Disease Control and Prevention (CDC) have found that overall life expectancy of Americans has declined, and this decline was largely attributed to drug-related overdose deaths.1-3 Today in the US, overdoses are classified as the leading cause of injury-related death. The public health approach to addressing the overdose epidemic is multi-faceted, involving a combination of policy, education, and community interventions. A framework developed by the Association of State and Territorial Health Organizations (ASTHO) describes a cross-sectoral response with four key strategy areas: (1) training and education; (2) monitoring and surveillance; (3) primary and overdose prevention; and (4) treatment, and harm reduction. Harm reduction strategies seek to mitigate the harms of behaviors.4 Harm reduction strategies include improved access to the antidote naloxone, syringe service programs (SSPs) that allow people who inject drugs (PWID) to obtain or exchange equipment for injections, and drug checking services that screen for risky drugs such as fentanyl. These implement an alternative to the criminalization and disease treatment models of drug use and addiction. Supervised injection facilities (SIFs) are an additional method of harm reduction. While proponents of harm reduction theory recognize abstinence may be the ideal goal for some people, they accept alternatives which reduce the risk for death and disability even if they do not promote abstinence.5 Opponents of such strategies often focus on their potential to enable activities that are criminal or perceived as immoral.6
Latest update on drug-related deaths and mortality in Europe
The EMCDDA has published its latest update on Drug-related deaths and mortality in Europe. The updates presented to shed light on important public health challenges faced by European policymakers and stakeholders, with regard to monitoring, prevention, risk assessment, harm reduction and drug treatment.
