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Safe injection sites save lives

Kaplan, Louise, PhD, ARNP, FNP-BC, FAANP, FAAN

doi: 10.1097/01.NPR.0000534948.52123.fb
Department: Advocacy in Practice

Louise Kaplan is an associate professor at Washington State University Vancouver, Vancouver, Wash., and family NP at Tumwater Family Practice Clinic, Tumwater, Wash.

The author has disclosed no financial relationships related to this article.

Despite nationwide efforts to prevent and decrease the use of opioids, ED visits for opioid overdoses increased 30% across the United States from July 2016 through September 2017.1 Some overdoses are treated in the community with naloxone provided to first responders, opioid users, or their friends and family, and can be used to treat opioid overdoses where and when they occur.

All states and the District of Columbia have laws providing access to naloxone. However, the laws vary widely on specific issues, such as whether a prescription is required, if a layperson who administers naloxone is immune from criminal liability, or if the law removes criminal liability for naloxone possession without a prescription.2,3

NPs can help prevent opioid deaths by prescribing naloxone or providing information on free access to naloxone. Syringe exchange programs and opioid misuse treatment programs are additional options NPs can recommend. Establishing a safe injection site (SIS) is another approach to limit opioid misuse.

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Safe injection sites

Although controversial, many cities in the United States are considering adopting policies to develop and implement SISs. Internationally, SISs, also referred to as drug consumption rooms, safer injection facilities, or safer drug use services, have been used for over 30 years.4

The first drug consumption room was established in Bern, Switzerland, in 1986.5 There are approximately 100 SISs in 10 countries: Switzerland, Australia, Canada, Denmark, France, Germany, Luxembourg, the Netherlands, Norway, and Spain. Improving the overall well-being of individuals who use drugs and improving their local communities are the two overarching goals of these programs.

Services vary by program and typically include injection supervised by healthcare professionals with naloxone availability in the event of an overdose, access to healthcare and social services, access to clean needles, and substance use disorder treatment.5

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SIS outcomes

There is evidence that SISs are effective in reducing harm. North America's first SIS, in Vancouver, Canada, has been the focus of outcome studies. Opened in 2003, a study conducted between July 1, 2004, and June 30, 2005, revealed more consistent use of the safer injection facility was associated with safer injecting practices, reduced reuse of syringes, and safer syringe disposal. These frequent users were also less likely to rush injections, which has been associated with nonsterile injection and increased risk for overdose.6

Another study of the effectiveness of Vancouver's safer injection facility compared fatal overdose deaths before and after the facility's opening. Within a 500 m radius of the facility, fatal overdose deaths decreased 35% compared with a 9.3% decrease in the rest of the city.7 An evaluation of opioid-related deaths in the vicinity of a medically supervised injection center in Sydney, Australia, had similarly positive results. Opioid-related deaths decreased 70% following the opening of the facility both in the center's vicinity and in the comparison area. There may have been confounders, such as other harm reduction efforts having an effect as well as a small sample size.8

A systematic literature review by Potier and colleagues analyzed evidence to assess the benefits and harms of SISs.9 Most studies identified were conducted in Canada and Australia, although the majority of SISs are in Europe. Main findings included safer injection behaviors and decreased syringe sharing, increased referral to treatment programs, no death via overdose within an SIS facility, and no decrease in the number of individuals who started methadone treatment; however, no direct evidence was found indicating a decrease in virus transmission.

The presence of an SIS has not been associated with increased drug use but has been associated with a decrease in public injection and fewer syringes littering public spaces. A systematic review by Kennedy and colleagues also identified evidence that SISs decrease overdose-related harms and unsafe drug use practices while increasing referral to treatment and social services.10 Additionally, SISs did not increase substance use or drug-related crime and improved the public order.

Toth and colleagues conducted a study in Denmark that included all five of the country's drug consumption rooms (DCRs).11 Participants reported Danish DCRs provided a safe environment, useful education on drug use, and chose DCRs as a way to not bother people in their neighborhoods. Interestingly, Danish DCRs provided a space for individuals who smoke drugs; however, staff spent less time in that part of the facility due to secondhand smoke. Consequently, education about safe smoking did not occur as often as education about safe injection.

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U.S. cities move toward implementing SISs

More than 30 years after the first DCR was implemented in Switzerland, the United States still has yet to open an SIS. Boston Health Care for the Homeless Program has the Supportive Place for Observation and Treatment, a harm reduction program to observe and provide treatment for up to 10 individuals intoxicated by opioids or other substances, and no illegal substances may be used in the facility.12

The innovation of SISs in the United States will likely occur in 2018, as both Philadelphia and San Francisco have approved opening an SIS. Philadelphia's city council approval does not include the city's sponsorship of an SIS, rather that the city will facilitate opening an SIS.13 San Francisco's Department of Health endorsed a recommendation to open an SIS and plans to open two facilities in July 2018, which will be operated by nonprofit organizations that will provide needle exchange and substance misuse services.14

In Washington, King County's Heroin and Opiate Addiction Task Force has recommended at least two locations for what it refers to as Community Health Engagement Locations (CHELs) in King County. These facilities are being designed to include supervised consumption and overdose prevention along with health promotion services, behavioral health treatment, social and legal services, housing assistance, childcare, and parenting support.15

No date has been announced for when the CHELs will be operating. The cities of Ithaca, New York and Portland, Maine, and the states of Vermont and Maryland are among the other jurisdictions considering SISs to address the opioid epidemic.16-19

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Controversy

Introducing SISs is often controversial. Vermont's Governor Phil Scott was not convinced to adopt SISs nor was Pennsylvania State Representative W. Curtis Thomas, who urged Philadelphia's officials to withdraw plans for an SIS.5,19 In Washington's King County, the cities such as Bellevue and Federal Way have banned SISs. A King County Superior Court Judge blocked an initiative to allow voters to decide whether to ban SISs, declaring it would infringe on the power of the King County Board of Health to protect public health.20

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Advocacy

NPs can perform a community service using clinical, population health, and policy expertise to infuse the evidence regarding positive SISs outcomes into public debates. Harm reduction approaches such as syringe exchange programs and education about safe sex mitigated the impact of HIV and hepatitis transmission. SISs are another harm reduction approach to address opioid and other substance misuse. Over 42,000 individuals in the United States died from opioid overdoses in 2016, five times more than in 1999.21 SISs may be an approach to saving lives.

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REFERENCES

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