Last week, Philadelphia became the first city in the United States to officially allow safe injection facilities (SIFs), which will be operated by the private sector for people with opioid use disorders. The plan, led by the Philadelphia Department of Public Health and the Department of Behavioral Health and Intellectual disAbility Services (DBHIDS), is just part of the all-encompassing strategy the city is taking, which includes increasing outreach to medication-assisted treatment, developing warm handoffs from emergency departments to treatment for overdose victims, increasing distribution of naloxone and providing housing without requiring sobriety.
Still, the safe injection sites were the biggest news. Called Comprehensive User Engagement Sites (CUES) in the city, they are hoped to reduce overdoses and improve health, and will include referral to treatment and social services, wound care, medically supervised drug consumption, and access to sterile injection equipment and naloxone. The services are provided in a walk-in setting.
“We cannot just watch as our children, our parents, our brothers and our sisters die of drug overdose,” said Thomas Farley, M.D., Philadelphia health commissioner. “We have to use every proven tool we can to save their lives until they recover from the grip of addiction.”
The SIF recommendation was one of many made by the city’s opioid task force, for which city officials visited Vancouver, British Columbia, and Seattle, Washington, in November 2017 to study similar facilities and efforts in those cities.
“Our visits to Vancouver and Seattle really hit home that establishing CUES is just one piece of the puzzle to address the opioid crisis,” said Eva Gladstein, deputy managing director of health and human services, in announcing the SIFs on Jan. 23. “Our efforts to prevent addiction, help people access treatment, prevent overdoses in other ways, increase housing resources and address public safety concerns are already underway and must continue to grow and strengthen.”
“Having Comprehensive User Engagement Sites — or CUES — as part of our continuum to treatment is just one of the ways in which we believe we can connect Philadelphians struggling with substance use disorders to lifesaving treatment,” said DBHIDS Commissioner David T. Jones. “Of course, we will explore all opportunities that can provide people with the support and services they need, but we are confident that this option is a crucial step in helping people live healthier and happier lives.”
The city is now actively encouraging organizations like community nonprofits or medical organizations to operate and fund one or more CUES. The city will not operate one, but will bring together key stakeholders to identify organizations that are interested in operating, funding or offering such a location.
The SIF program is going forward with the support of the newly elected district attorney, Larry Krasner.
Responses from field
Responses from the field were, overall, supportive of Philadelphia’s move, although some organizations did not respond to requests for comment.
The importance of making treatment available via SIFs is stressed by many in the field. What follows are responses to ADAW’s request for comments.
Maureen Boyle, Ph.D., chief scientific officer, Addiction Policy
Forum: “While some worry that safe injection sites would increase drug use, the
research shows the opposite. It shows that safe injection sites help keep
people who inject drugs safe and create a trusting relationship with the healthcare
systems. People who use these facilities are more likely to start treatment and
stop using drugs compared to people who don’t.”
Gail Groves Scott, manager of the Substance Use Disorders Institute (SUDI) at the University of the Sciences in Philadelphia: “What works in a public health crisis? You need leadership and you need community-level interventions; this is what Philadelphia is doing by piloting safe sites. For those who say it’s radical, it’s not — we aren’t the first to do this, although we may end up being the first in the U.S. While it would be great to see the federal government be part of the solution, if they won’t, they need to at least stay out of the way. We know what the research tells us will work, yet we aren’t doing it. That tells me we need to work harder on educating policymakers. Upending the broken system we have takes funding, but the cost of this epidemic getting worse will be many billions of dollars more. The University of the Sciences was founded almost 200 years ago to train pharmacists, and now we are an interdisciplinary health sciences school. We think addressing the intersection of pain and addiction in a multimodel way will be key to the opioid crisis, and the SUDI is going to be laser-focused on making that happen, through education, research and policy advocacy.”
Jack Stein, Ph.D., director of the Office of Science Policy and Communications at the National Institute on Drug Abuse (NIDA): “NIDA supports conducting research on this strategy to address the opioid crisis and hopes that results will help shape related policies and practices.”
Daniel Raymond, deputy director of planning and policy at the Harm Reduction Coalition: “It’s a positive step forward. Philadelphia’s officials have clearly done their homework and thought this through. I hope their leadership sends a signal to other cities that this strategy is worth pursuing.”
Sheila P. Vakharia, Ph.D., policy manager for the Drug Policy Alliance: “It definitely sounds like it could be another great model after Vancouver’s Insite. Some people are using the acronym CUES to describe it because it would provide services along a continuum of care for people who visit it. At one end of the continuum, the most basic form of harm reduction will be provided — a place to safely inject using sterile equipment. However, I don’t know what the other end of the continuum might be. I haven’t heard details on what such a place in Philly would actually look like — what types of staff/professionals would be employed, whether support groups or formal treatment would be provided, or if medication-assisted treatment would be dispensed. It probably depends on funding and credentialing because more formalized treatment and prescribing may require more bureaucratic processes for licensing and accreditation.”
David Metzger, Ph.D., research associate professor and director of the HIV/AIDS Prevention Research Division in the Department of Psychiatry at the University of Pennsylvania: “In Philadelphia, there were 1,200 overdose deaths last year (80 percent were opioid-related, the majority involving fentanyl). This mortality is the most visible tip of a huge opioid abuse epidemic here. It’s estimated that there are 70,000 heroin users and 50,000 prescription opioid ‘misusers.’ So, currently there are hundreds of unsafe injection locations — public bathrooms, doorways, subway stations, abandoned buildings, even libraries). The safe injection facility being promoted in Philadelphia would begin with a single site, use private funds and provide immediate care for overdoses and injection-related infections and wounds. As recommended, it would also provide linkages to medication-assisted treatments (methadone, buprenorphine/naloxone and naltrexone) and other services. The public health impact of a single program will be limited. But as a demonstration project, it has great potential to provide a model for other neighborhoods and communities. Expanding access to medication-assisted treatment will be an important outcome.”
Charles O’Brien, M.D., Ph.D., vice chair of psychiatry at the University of Pennsylvania, and the founding director of the prestigious Center for Studies of Addiction: “My knowledge of the data on safe injection sites shows beneficial results from a harm-reduction perspective. My concern is that responsible authorities must not use this method as a substitute for treatment programs, which are more expensive. The safe injection sites might be used to attract people into treatment, which is much better for addressing the epidemic. Also, we must be sure that there are adequate numbers of treatment slots. As a member of the mayor’s commission on the opioid epidemic, I heard presentations on the Philadelphia programs and was favorably impressed. Also, the majority of members of the commission were in favor of safe injection sites. As for the U.S. as a whole, I think that we need more treatment slots and more trained clinicians. Also, we need all patients to be given a chance for medical treatment. We now know that there are both agonist and antagonist treatments that are effective. I don’t think that most patients are getting the best medication. Far too few are given the opportunity to benefit from extended-release naltrexone, which we now know gives them a chance for eventual abstinence rather than years on an agonist.”
Alex H. Kral, Ph.D, director of RTI’s Urban Health Program: “Treatment programs should definitely be involved. The state’s largest drug treatment provider (Healthright 360) signed on to California Assembly Bill 186, and the director of the California Society of Addiction Medicine provided testimony in Sacramento at the hearing. There should also be health screening and treatment. And yes, this is a public health intervention, one that should work with law enforcement. DA support is necessary but not sufficient.”
Jeff Deeney, an activist and social worker who works with drug users in Philadelphia: “The opioid task force approached me about this last year. I told them only if Krasner wins the DA race. I put them in contact with Krasner’s team, they went to Vancouver and looked at Insite, and Krasner won and got on board. The opioid task force brought the mayor on, and the city council came on board with the mayor. I’m doing this for my people.”
For the scientific review of evidence, go to http://dbhids.org/wp-content/uploads/2018/01/OTF_LarsonS_PHLReportOnSCF_Dec2017.pdf.
An experiment that will include treatment programs is moving ahead in Philadelphia — safe injection facilities, which will be privately run, where opioid users can receive a broad array of services as well as clean injection equipment and overdose rescues.