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In Harm's Way: Is the New Philadelphia Supervised Injection Site Policy a Good Thing?
This past Tuesday, Philadelphia took a quantum leap towards harm reduction in dealing with its burgeoning number of deaths due to drug overdose. With city Health Commissioner Thomas Farley's blessing, the city authorized medically-supervised facilities where people are permitted to inject illicit drugs. The sites, dubbed Comprehensive Engagement Sites, will be equipped to revive individuals if they overdose by administering naloxone and guide people with substance use issues into treatment.
The city will not be responsible for establishing these areas, but will encourage private entities to do so. In announcing the new plan, the Commissioner Thomas Farley commented. "The people in the city of Philadelphia, our brothers, our sisters, our parents, our children, are dying. And they don’t need to die." He added, "…we have an obligation to do everything we can to prevent those people from dying.” The Commissioner did stress that the move is just one element in a comprehensive plan to combat the opioid epidemic in the city.
The policy of providing safe spaces for injecting illicit drugs is a prime example of harm reduction, a strategy that aims to decrease the adverse health, social and economic consequences of drug use without requiring abstinence from using. Philadelphia officials estimate that safe injection sites would save 25 to 75 lives annually in the city, along with millions of dollars in public funds and hospital expenses while keeping neighborhoods free of people injecting drugs in public.
The bold move in Philly revives an old argument – is harm reduction a valid approach to treating addiction? Or should our health policies revolve around an all-or-nothing approach: the only true solution is to quit the addictive substance, period.
To understand harm reduction in addiction, we might reach back to the 80s, when needle and syringe exchange programs were developed to reduce the spread of blood-borne diseases (e.g., HIV and hepatitis) among injection drug users. These programs, many of which are still in place, often include drug treatment referrals, peer education, and HIV prevention, and were implemented in Amsterdam, Australia, Canada, United States, and many parts of Europe as well as the States.
According to a study posted on the U.S. Department of Health and Services website, a thorough review of 45 studies from 1989 to 2002 concluded that these programs are "effective, safe, and cost effective with no evidence of deleterious effects," despite the fact that the United States refused to use federally monies to fund them. The same study assessed the literature on supervised injection sites and found that more than 25 studies documented significant reductions in needle-sharing and reuse, overdoses, injecting and discarding needles in public spaces, reduced fatalities due to overdose, and increased enrollment in detoxification and other addiction treatment.
The research, therefore, supports the benefits of both needle exchange programs and supervised injection sites for both communities and people with substance use issues. Currently, several countries— including Spain, Norway, France, Germany, Switzerland, the Netherlands, Luxembourg, Australia and Canada—make use of supervised injection sites to mitigate their drug epidemics. In fact, Philadelphia officials visited the very first North American supervised injection site, in Vancouver, British Columbia, before moving forward with their program. Canada. The Canadian site reports that many of the people who stop in are not there to inject drugs safely; rather, many people stop by to seek counseling and other health services, and to obtain information about viable detox options.
The Vancouver program was established in 2003 and others in Canada followed suit. The very first such supervised injection site, however, was opened in Berne, Switzerland, in June 1986. Several European countries followed suit. So, what are we waiting for? Shouldn't more U.S. cities embrace and implement what has worked in other countries for years?
Granted, the answer to the U.S. opioid epidemic is not simply to open multiple nationwide safe injection clinics. To ensure success, any approach must be comprehensive and include sensible policies and procedures, such as "drug courts" that refer people with substance use issues – many of whom have a co-occurring mental health condition – to treatment and not to jail. Addiction treatment needs to be fully funded and people with issues need referral to highly-qualified facilities that offer evidence-based treatment and provide thorough follow-up and link people to community services to support their recovery. We need education to prevent people from starting on the road to substance use, and early intervention for those who do so. But harm reduction has a role to play as well.
Unfortunately, harm reduction continues to be a controversial approach, despite the plethora of data that validates its use. The Philadelphia initiative will doubtless spur a great deal of tsk-tsking by those who feel that supervised injection encourages, rather than discourages, drug use. Unfortunately, such disapproval only fuels stigma and encourages the belief that addiction is a moral failing, an indulgence, rather than the brain disease that science has shown it to be.
We don't have time to stew in old, morality-based notion about addiction. The introduction of synthetic opioids to the already toxic menu of available drugs has driven the U.S. opioid epidemic to new heights. The body count from overdose grows exponentially each year, and the number of communities and families left shattered is unbearable. We need to add every weapon available to our arsenal; supervised injection sites may be one more arrow in our quiver.
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