O

ver the last few years, I have watched with a blend of amazement and grave concern as an odd phenomenon has unfolded against the backdrop of our nation’s opioid crisis: Despite the clear need to battle this ongoing epidemic with all of the tools at our disposal, one evidence-proven option — supervised injection facilities — is being overlooked, and even disparaged.

Back in the spring, the Massachusetts Medical Society began advocating for the establishment of a pilot supervised injection facility in the commonwealth of Massachusetts. It was not an easy decision because physicians don’t want to condone, or to be seen as condoning, the use of illicit drugs. Yet after close review and thorough debate, it was clear that the data supported their use.

A supervised injection facility is a safe, clean space where individuals can inject drugs they already possess under the supervision of trained medical staff. The facilities also offer sterile injection equipment. The advantage is that medical expertise is immediately present in case an emergency occurs. At the same time, these on-site clinicians can facilitate pathways to treatment and rehabilitation from the chronic disease of opioid abuse disorder.

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Such sites provide an alternative to dangerous injection tactics like syringe sharing, syringe reuse, and improper disposal of soiled injection materials, all of which can lead to infection with HIV and hepatitis C, as well as other painful and hard-to-treat infections that can attack the heart, bones, and other organs.

As a physician and president of the Massachusetts Medical Society, I was initially inclined to oppose the concept of supervised injection facilities. How, I thought, could a health care professional, someone grounded in ethics and an oath to “do no harm,” stand by and watch as individuals inject street drugs into their veins?

Yet the opioid crisis and the frightening rate at which it has accelerated doesn’t allow for the outright dismissal of this idea — or any others — that could have prevented even one of the more than 60,000 deaths caused by drug overdoses in the United States last year.

As a health care professional, I can’t stand idly by with the knowledge that a better way exists for reaching and caring for those suffering from the disease of addiction. We can’t allow individuals to die cruel deaths alone in alleyways or under the cover of darkness in public parks.

The concept of supervised injection facilities fits well with the overarching and proven public health philosophy of harm reduction: meeting patients where they are in their disease to eliminate existing barriers to rehabilitation.

With lives being lost each day from all segments of our society, dealing in theoretical solutions can be counterproductive. Fortunately, supervised injection facilities operating in other parts of the world have yielded substantial and evidence-backed reductions of death, disease, and expenditures.

To better understand the utility of these facilities, the Massachusetts Medical Society created a task force to examine the evidence for and against supervised injection facilities. This group produced a report that reviewed all available data regarding the use of supervised injection facilities around the world.

The report clearly showed that these facilities save lives. For example, after the Insite facility opened in Vancouver, British Columbia — the first supervised injection facility in North America — researchers reported a 35 percent decrease in the number of lethal overdoses in that area.

Of utmost importance is the fact that since Insite’s doors opened in 2003, not a single fatal overdose has occurred on premises.

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In addition to providing a safe environment for using injection drugs, Insite encourages users to seek entry into treatment for drug addiction. This effort has yielded a 30 percent increase in detoxification and an increase in methadone maintenance initiation among those using the facility.

Supervised injection facilities are not a cure-all and they aren’t for everyone. In fact, they are designed to target the most vulnerable of our population — people, often homeless, who inject drugs publicly. But they work.

Shortly after our medical society overwhelmingly voted to adopt a policy in support of a pilot supervised injection facility program in Massachusetts, the American Medical Association adopted a similar policy.

The supervised injection facility concept is not the only approach we need to confront the opioid crisis. From improving opioid-prescribing guidelines to instituting partial-fill laws and prescription monitoring systems, it’s time for an all-hands-on-deck approach to reducing the use of illicit opioids. Still, supervised injection facilities are one of many tools that can be implemented and, with the “fentanyl era” snatching lives at a sad and frightening rate, piloting a supervised injection facility now is more prudent than ever before.

Establishment of supervised injection facilities managed by individuals with the experience and resources to safely oversee the injection of illicit drugs can help reduce the harm caused by opioid abuse disorder, make clearer the path to recovery, and save lives. As we continue to look for ways to increase access to recovery programs for those with opioid use disorder, we must remember that in order to get people into recovery, they must first stay alive.

Henry L. Dorkin, M.D., is the president of the Massachusetts Medical Society.

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  • I feel physicians are too generous with scrips for pain meds. I had a shoulder replaced and was sent home with 80 Loritab. At my 2 week follow up I was asked how many pain pills I needed. I responded that since I’d only used one, I did not need any. The question was from an APNP.

    A few months later, after sinus surgery, I was asked about pain meds. I responded that I did not need or want them: Tylenol would do just fine. The physician must have thoughti was nuts, and until I said I had Loritab at home ( which I had legally disposed of after the shoulder surgery) he seemed to not want to discharge me. I did take Tylenol for a couple of days…the packing was far worse than any pain. I am a retired mental health worker.

    Physicians: DON’T prescribe so many pain pills!

  • Glad to see the president of the Massachusetts Medical Association come around on this issue. Further marginalizing drug users only causes more suffering, more pain, more death, and even more expense to the health care system. Supervised injection sites, together with free needle exchange and other harm reduction practices, are crucial to addressing the negative personal and social consequences of substance abuse. I’d add, as someone who works with women, that I expect women will particularly benefit from the safety of these facilities. For far too many women, drug use is part of a vicious landscape of sexual abuse. Safe surroundings, even temporarily, are key for women’s survival.

  • When we “manage” addiction we too often prolong the hell of the merry go round of withdrawal for months and years. The addict has lost the power of choice and will not choose SIS if they can get relief in the alley. We need more detox to widen the door to treatment.

  • The good doctor isn’t telling you the entire story:

    SISs are a bad idea. They perpetuate the misery of the addict by giving up on them and expect that there is no help for them except to die an eventual early death. The 100% “positive” studies for SISs are unscientific at best, self-serving at worse. They increase public overdoses, public deaths, public use, needle litter, homelessness, crime.

    My arguments against SISs is in the comment section here:

    http://www.eastbaytimes.com/2017/09/07/supervised-injection-centers-california-weighs-controversial-law-to-fight-opioid-epidemic/

  • The good doctor is only telling part of the story:

    Portugal is held up as the gold standard for “decriminalizing” drugs and not “judging” the addict. Their programs has some success due to wrap-around services and is mandatory. Portugal does not have a “Safe” Injection Program. Drug dealing is still illegal and dealt with harshly. Other EU countries tried to emulate the program. With the 2008 recession, their budgets were slashed for the addicts in program and caused overdoses, increased crime, and increased disease transmission, increased homelessness. Can you see us having an Injections Site AND wrap-around services? I don’t believe there will be funding for both. Why not use any proposed funding and increase needed detox/rehab facilities and sober living environments along with all the needed physical/mental health and social services. The way I see it, Injections Sites are prolonging the suffering and misery of the addict with the usual end result of death. Which would be more compassionate?

    http://www.vancouversun.com/little+evidence+harm+reduction+reduces+harm+more+than+good/8679087/story.html?fref=gc&dti=189308553419

    “The four pillar approach only works when each pillar is properly funded. Prevention reduces the flow of people into addiction. Treatment reduces the number of addicts including those living in the DTES. Policing keeps a lid on the open drug dealing and the affects of the associated problems on the community. Only after these three pillars are properly funded can we afford to spend money on Harm Reduction initiatives that do not encourage abstinence. Putting HR first is like running up debt on your credit card and never paying more than your minimum payments.”

    http://www.globaldrugpolicy.org/Issues/Vol%201%20Issue%203/A%20Critical%20Evaluation.pdf

    THE JOURNAL OF GLOBAL DRUG Policy AND PRACTICE
    A Critical Evaluation of the Effects of Safe Injection Facilities
    Garth Davies, Simon Fraser University

    Conclusion: Taking Causality Seriously
    On the subject of the effects of SIFs, the available research is overwhelmingly positive. Evidence can be found in support of SIFs achieving each of the goals listed at the beginning of the evaluation. In terms of our level of confidence in these studies,the assessment offered here is far less sanguine. In truth,none of the impacts attributed to SIFs can be unambiguously verified. As a result of the methodological and analytical problems identified above, all claims remain open to question.

    http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php

    Vancouver’s INSITE service and other Supervised injection sites: What has been learned from research?

    Final report of the Expert Advisory Committee

    http://www.kiro7.com/news/local/councilwomans-idea-for-seattle-safe-injection-site-locations-belltown-lake-city/466411868

    “At the Vancouver site, the manager said since opening in 2003, the overdose death rate in the area around the clinic has dropped 35 percent. But the clinic also estimates 15 to 20 percent of people using the site come from other parts of the country specifically for it.”

    http://www.seattletimes.com/seattle-news/health/is-vancouvers-safe-drug-use-site-a-good-model-for-seattle/
    “Although research appears to bear that out, many of the studies that attest to Insite’s success are small and limited to the years after the center opened. For instance, a 2011 study published in the journal The Lancet found a 35 percent reduction in overdose deaths in the blocks surrounding Insite, versus 9 percent in the rest of Vancouver.

    But that often-cited study looked only at the period two years before and two years after the center opened, not the ensuing decade.”

    http://www.seattletimes.com/seattle-news/health/is-vancouvers-safe-drug-use-site-a-good-model-for-seattle/

    “Although Insite is paired with a drug-treatment center, called Onsite, Berner and other critics point out that completion rates are low. Of the 6,500 people who visited Insite last year, 464 were referred to Onsite’s detox center. Of those, 252 finished treatment.”

    The Vancouver Insite was placed in a crime-ridden, drug-ridden, low-income neighborhood. It only got worse.

    http://www.seattletimes.com/seattle-news/health/is-vancouvers-safe-drug-use-site-a-good-model-for-seattle/
    “Although the Insite center is a model, the Vancouver neighborhood surrounding it is nothing to emulate, advocates acknowledged.

    “If I came from a city like Seattle and I went to that Insite place, it would scare the hell out of me,” Kral said. “I would think, ‘Are we going to create one of those?’ ””

    http://news.nationalpost.com/news/vancouvers-gulag-canadas-poorest-neighbourhood-refuses-to-get-better-despite-1m-a-day-in-social-spending
    Vancouver’s ‘gulag’: Canada’s poorest neighbourhood refuses to get better despite $1M a day in social spending

    What do you think would happen if this was placed in a middle-class neighborhood, or, ANY neighborhood?

    https://www.youtube.com/watch?v=audzsuRMWBE&t=586s
    https://www.youtube.com/watch?v=wwJkqTZ5H_s

    http://news.nationalpost.com/news/canada/brian-hutchinson-thousands-of-used-drug-needles-have-become-the-new-normal-for-vancouver
    4/27/2016
    Brian Hutchinson: Finding used drug needles in public spaces has become the new normal for Vancouver

    http://www.huffingtonpost.ca/mark-hasiuk/insite-vancouver_b_3949237.html

    “Ten years later, despite any lofty claims, for most addicts, InSite’s just another place to get high.”

    The 100% positive studies on Vancouver’s Insite (Safe Injection Facility) was done “Early last decade, Montaner and Kerr lobbied for an injection site. In 2003, the Chretien Liberals acquiesced, gave the greenlight to B.C.’s Ministry of Health, which, through Vancouver Coastal Health, gave nearly $1.5 million to the BC Centre (that’s Montaner and Kerr, you remember them) to evaluate a three-year injection site trial in Vancouver.

    I asked him about the potential conflict of interest (lobbyists conducting research) and he ended the interview with a warning. “If you took that one step further you’d be accusing me of scientific misconduct, which I would take great offense to. And any allegation of that has been generally met with a letter from my lawyer.”

    Was I being unfair? InSite is a radical experiment, new to North America and paid for by taxpayers. Kerr and company are obligated to explain their methods and defend their philosophy without issuing veiled threats of legal action.”

    In the media, Kerr frequently mentions the “peer review” status of his studies, implying that studies published in medical journals are unassailable. Rubbish. Journals often publish controversial studies to attract readers — publication does not necessarily equal endorsement. The InSite study published in the New England Journal of Medicine, a favourite reference of InSite champions, appeared as a “letter to the editor” sandwiched between a letter about “crush injuries” in earthquakes and another on celiac disease.”

    Really? What kind of “science” produces dozens of studies, within the realm of public health, a notoriously volatile research field, with positive outcomes 100 per cent of the time? Those results should raise the eyebrows of any first-year stats student.”

    And who’s more likely to be swayed by personal bias? InSite opponents, questioning government-sanctioned hard drug abuse? Or Montaner, Kerr and their handful of acolytes who’ve staked their careers on InSite’s survival? From 2003 to 2011, the BC Centre received $2,610,000 from B.C. taxpayers to “study” InSite. How much money have InSite critics received?”

    There has never been an independent analysis of InSite, yet, if you base your knowledge on Vancouver media reports, the case is closed. InSite is a success and should be copied nationwide for the benefit of humanity. Tangential links to declining overdose rates are swallowed whole. Kerr’s claims of reduced “public disorder” in the neighbourhood go unchallenged, despite other mitigating factors such as police activity and community initiative. Journalists note Onsite, the so-called “treatment program” above the injection site, ignoring Onsite’s reputation among neighbourhood residents as a spit-shined flophouse of momentary sobriety.”

    http://www.hc-sc.gc.ca/ahc-asc/pubs/_sites-lieux/insite/index-eng.php

    Reducing the Transmission of Blood-Borne Viral Infections & Other Injection Related Infections

    “Self-reports from users of the INSITE service and from users of SIS services in other countries indicate that needle sharing decreases with increased use of SISs. Mathematical modeling, based on assumptions about baseline rates of needle sharing, the risks of HIV transmission and other variables, generated very wide ranging estimates for the number of HIV cases that might have been prevented. The EAC were not convinced that these assumptions were entirely valid.
    SISs do not typically have the capacity to accommodate all, or even most injections that might otherwise take place in public. Several limitations to existing research were identified including:
    Caution should be exercised in using mathematical modelling for assessing cost benefit/effectiveness of INSITE, given that:
    There was limited local data available regarding baseline frequency of injection, frequency of needle sharing and other key variables used in the analysis;
    While some longitudinal studies have been conducted, the results have yet to be published and may never be published given the overlapping design of the cohorts;
    No studies have compared INSITE with other methods that might be used to increase referrals to detoxification and treatment services, such as outreach, enhanced needle exchange service, or drug treatment courts.
    Some user characteristics relevant to understanding their needs and monitoring change have not been reported including details of baseline treatment histories, frequency of injection and frequency of needle sharing.
    User characteristics and reported changes in injection practices are based on self-reports and have not been validated in other ways. More objective evidence of sustained changes in risk behaviours and a comparison or control group study would be needed to confidently state that INSITE and SISs have a significant impact on needle sharing and other risk behaviours outside of the site where the vast majority of drug injections still take place.”

    “It has been estimated that injection drug users inject an average six injections a day of cocaine and four injections a day of heroin. The street costs of this use are estimated at around $100 a day or $35,000 a year. Few injection drug users have sufficient income to pay for the habit out through employment. Some, mainly females get this money through prostitution and others through theft, break-ins and auto theft. If the theft is of property rather than cash, it is estimated that they must steal close to $350,000 in property a year to get $35,000 cash. Still others get the money they need by selling drugs.”

    http://www.vancouversun.com/little+evidence+harm+reduction+reduces+harm+more+than+good/8679087/story.html?fref=gc&dti=189308553419

    “In addition, the federal government’s Advisory Committee on Drug Injection Sites report only five per cent of drug addicts use the injection site, three per cent were referred for treatment and there was no indication the crime rate has decreased, as well as no indication of a decrease in AIDS and hepatitis C since the injection site was opened.”

    https://www.scientificamerican.com/article/massive-price-hike-for-lifesaving-opioid-overdose-antidote1/
    Massive Price Hike for Lifesaving Opioid Overdose Antidote

    Suddenly in demand, naloxone injector goes from $690 to $4,500

    Should we follow the money? Who would be profiting bigly from the increased use of naloxone?

    https://www.bramptonguardian.com/community-story/7520683-money-and-resources-for-drug-rehabilitation-sorely-needed-in-peel-say-advocates/

    “Setting up free injection sites to deal with the recent spate of drug overdoses does not address the root of the opioid problem, says Ted Brown, executive director of Brampton’s Regeneration Outreach Community.

    Instead, Queen’s Park and other tiers of governments should consider investing resources and dollars toward rehabilitation programs to help those dealing with addiction and mental health issues, said Brown. ”

    http://www.bcmj.org/premise/supervised-injection-sites%E2%80%94-view-law-enforcement
    Supervised injection sites—a view from law enforcement

    Jamie Graham, former chief of Vancouver Police has outlined the successful model of dealing with an epidemic: Support, mandatory treatment, abstinence, and counseling as all part of the solution. My recover(ed)(ing) addict friends say they would agree.

    https://mosaicscience.com/story/iceland-prevent-teen-substance-abuse
    Iceland knows how to stop teen substance abuse but the rest of the world isn’t listening

    In Iceland, teenage smoking, drinking and drug use have been radically cut in the past 20 years. Emma Young finds out how they did it, and why other countries won’t follow suit.

    http://www.vancouversun.com/little+evidence+harm+reduction+reduces+harm+more+than+good/8679087/story.html?fref=gc&dti=189308553419

    “The current campaign reports significant reductions in drug overdoses, yet the Government of British Columbia Selected Vital Statistics and Health Status Indicators show that the number of deaths from drug overdose in Vancouver’s Downtown Eastside has increased each year (with one exception) since the site opened in 2003.”

    https://www.usatoday.com/story/news/nation-now/2017/05/05/pigeon-nest-needles-highlights-vancouvers-drug-problem/101323878/

    Pigeon nest of needles highlights Vancouver’s drug problem

    Some graphs about how overdoses in Vancouver, BC have increased:

    https://uploads.disquscdn.com/images/4937e3e285c02900541696be294c99859dd986654fc2ea3b3b1f41f673618dc7.png

    One more: https://uploads.disquscdn.com/images/d2f8aa542d4033a1f198a3b0e3e802482a4becf1e45b04e77079e989e5c6460a.jpg

    The “Safe” Injection Movement is sponsored by the Drug Policy Alliance, an advocacy group that works to decriminalize drugs and is funded largely by billionaire George Soros. The group has pushed, thus far unsuccessfully, for similar legislation in New York, Maryland, Massachusetts and Vermont.

    Here’s some examples of their thinking:
    http://www.nadcp.org/sites/default/files/2014/NADCP%20Initial%20Response%20to%20DPA%20and%20JPI%20Reports.pdf

    http://www.nadcp.org/sites/default/files/nadcp/NADCP%20Response%20to%20DPA%20and%20JPI%20Media%20Attacks%20on%20Drug%20Courts.pdf

  • So let me get this straight Dr. Dorkin…Your advocating to allow people addicted to opioids who purchase narcotics on the street, illegally, and laced with varying amounts of fentanyl to bring their purchase into a supervised site to inject, have I got that right? Yea, great idea Doc, how about opening more treatment centers instead of promoting continuing use of a substance that will eventually kill the person using it if there is no intervention.

    I have just about had it with these kinds of idiotic ideas from people sitting behind desks who have no concrete or practical experience in the trenches dealing with this epidemic. Perhaps if more of these white collar addiction advocates got out more they would see very clearly that this is not an answer to the problem this nation is facing, it’s a bandaid and nothing more. Join us and you’ll see there are far better solutions to this problem than baby-sitting & hand holding. What’s next legalizing heroin?

    • First, who is the “us?” Second, if “there are far better solutions to this problem,” please enlighten us. Third, Dr. Dorkin makes clear that injection sites would be only one more approach to the problem of opioid addiction and would be a way to try to help these people get further help and rehabilitation. Why are you so threatened by the idea?

    • Nancy, certainly not threatened in anyway shape or form if I gave them pression that was certainly not my intent. The author referred to our clinicians in the field who are very familiar with the current epidemic and the alternative treatment possibilities as opposed to the lunacy of SIS.
      Let me ask you a question? If a loved one of yours was addicted would you want them purchasing illegal drugs on the street laced with God knows what and bringing it into a safe injection site or would you rather see a proper intervention and then placed in a detox that will treat them and then refer them hopefully to an abstinence-based program. Of course this is all dependent on whether or not your loved one actually wants to get clean in the first place. I noticed another comment above mine that I believe has a link to another story with research results on safe injection sites, they don’t work it’s just a Band-Aid and a poor Band-Aid at that.

    • The “Safe” Injection Movement is sponsored by the Drug Policy Alliance, an advocacy group that works to decriminalize drugs and is funded largely by billionaire George Soros. The group has pushed, thus far unsuccessfully, for similar legislation in New York, Maryland, Massachusetts and Vermont.

      Here’s some examples of their thinking:
      http://www.nadcp.org/sites/default/files/2014/NADCP%20Initial%20Response%20to%20DPA%20and%20JPI%20Reports.pdf

      http://www.nadcp.org/sites/default/files/nadcp/NADCP%20Response%20to%20DPA%20and%20JPI%20Media%20Attacks%20on%20Drug%20Courts.pdf

    • The way SIS saves lives is by outreach and direct overdose intervention. If you can’t see the benefit in that idk what to tell you puritanical idiots

  • I am of the opinion that drug use is rightfully a public health issue and should be covered by the same restrictions and legal ramifications placed on the use of alcohol and tobacco, and that drug users should have the same accessibility to proven appropriate treatment programs that drinkers and smokers do.

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