RTI International studying effects of supervised injection sites for drug users

Alex Karl, an epidemiologist for Cary-based nonprofit, says underground safe havens may save lives

Paramedics display a dose of the opioid overdose reversal drug Narcan, or Naloxone Hydrochloride, in an ambulance in Peabody, Massachusetts, U.S., August 8, 2017. REUTERS/Brian Snyder

RESEARCH TRIANGLE PARK (Reuters Health) — While policymakers continue to block supervised injection sites in the U.S., a anonymous nonprofit secretly opened an unlicensed five-booth facility in an undisclosed location where visitors shoot up heroin and other drugs under the watchful eye of trained staff.

The clandestine operation – the first disclosed in the U.S. – probably saved the lives of two visitors in two years when staffers used the medication naloxone to reverse their overdoses, according to an American Journal of Preventive Medicine report by researchers who evaluated the facility.

Lead author Alex Kral called the privately funded social services organization’s opening of the unsanctioned site in a hidden urban location an act of “civil disobedience.”

A San Francisco-based epidemiologist, Kral directs the behavioral and urban health program at RTI International, a nonprofit research institute with headquarters in Research Triangle Park, North Carolina.

Operators of the underground program opened the site in September 2014 after they tired of waiting for legislators to sanction supervised injection facilities, Kral said in a phone interview.

“They basically said, ‘We’ve got too many people dying,’” he said.

An estimated 100 drug users injected themselves 2,574 times in the hidden site in its first two years, according to statistics Kral and his co-author Peter Davidson of the University of California, San Diego, compiled from anonymous and confidential surveys.

The vast majority were homeless white men who injected heroin purchased elsewhere. If not for the unsanctioned injection facility, most of the site’s visitors told researchers they would have shot up in a park, public restroom, street or parking lot.

As far as Kral knows, the facility he evaluated is the only one of its kind in the U.S., though 11 other countries, including Canada, have authorized supervised injection sites.

Since the first supervised injection facility opened in the Swiss city of Berne in 1986, about 100 similar facilities began operating in 66 cities across 11 countries.

As public health officials have wrestled with the fallout from a growing opioid epidemic, U.S. cities from Seattle to New York have considered allowing supervised injection sites. But no U.S. city or county has been able to clear the political and legal hurdles.

Overdose deaths killed more than 52,000 people in the U.S. in 2015, according to the U.S. Centers for Disease Control and Prevention.

Dr. Alex Walley, a Boston Medical Center addiction specialist who was not involved with the new study, said the findings illustrate the benefits of supervised injection sites.

“In the midst of the opioid crisis, which is hitting the United States harder than any other country now, we need to use every tool that’s working,” he said in phone interview.

“Not everyone who has opioid-use disorder wants treatment,” he said. “It’s really important that we keep people safe and alive until they come into treatment.”

In May, President Donald Trump appointed North Carolina Gov. Roy Cooper to a bipartisan national opioid task force of governors.

“We have been fighting this problem and realized that we cannot arrest our way out of this problem; particularly at the user addiction level,” Cooper said at the first commission meeting on June 16. “We need help from the federal government to stop drugs like fentanyl and others from coming into our country and fighting the drug kingpins and the traffickers. But at the addiction level, we need treatment and prevention.”

While Cooper has expressed interest in transitioning from jail time to treatment for drug users, he has not publicly commented on his stance on supervised injection sites.

(L-R) North Carolina Governor Roy Cooper, Rhode Island Governor Gina Raimondo and Massachusetts Governor Charlie Baker take part in the “Curbing the Opioid Epidemic” session at the National Governors Association summer meeting in Providence, Rhode Island, U.S., July 13, 2017. REUTERS/Brian Snyder

Critics object to enabling addicts to flout laws about illicit drugs and say injection facilities could thwart efforts to treat and prevent drug use. Advocates, however, contend that the sites save lives, prevent needle-sharing diseases like HIV, and steer drug users into treatment.

Advocates also argue that supervised sites help communities by keeping drug users out of public places, where they can leave dangerous refuse, unnerve passersby, and disturb businesses.

Some restaurant managers and librarians have begun to keep naloxone on hand because people regularly overdose in their bathrooms, Walley said.

In a prior study, Kral estimated that a 13-booth supervised injection facility in San Francisco could save $3.5 million a year, mostly in reduced medical costs.

To avoid telltale lines, the unsanctioned site allows access to fewer than 60 people at a time. Employees of the social services agency that runs the facility must invite visitors to the site, which is open four to six hours a day five days a week.

The facility consists of two rooms, one with five stainless steel injection stations equipped with mirrors and stools, and an adjoining room for post-injection monitoring.

The facility is tiny compared to similar facilities elsewhere in the world. In Vancouver, for example, in just three days, drug users inject the same number of needles – about 2,500 – as injected within two years at the unsanctioned site, Kral said.

Unsanctioned and unsupervised injection sites are popping up all over the nation, including in an abandoned church in Philadelphia, said Leo Beletsky, a professor of law and health sciences at Northeastern University School of Law in Boston, who was not involved with the research.

Plumbers frequently are summoned to fix public restroom pipes clogged with discarded syringes, he said in a phone interview.

“We need to transition from having these spaces be hidden and unsafe to being open and safe,” he said. “We can’t go on pretending this is not happening.”

Reporting by Ronnie Cohen for Reuters News Service and Mollie Young for North State Journal, with sourcing from American Journal of Preventive Medicine, online August 8, 2017.