U.S. cities grappling with opioid crisis considering new approach

Editor's note: This is the first installment of a two-part series looking at one of the many innovative ways different communities are fighting the opioid crisis.
BY ERIKA NORTON
VANCOUVER, B.C. — Due to the surge in opioid painkiller and heroin addiction in the United States, drug overdoses are now the leading cause of death for Americans under 50 — killing people at a faster rate than the H.I.V. epidemic at its peak in 1995.
But the United States is not the only country with a national opioid emergency.
Our nation's neighbors in the north are also experiencing an opioid crisis, with a Public Health Emergency declared in British Columbia, Canada, last April due to fentanyl overdoses and deaths.
What is unique about Canada is that it is also home to North America's first legal supervised injection site, a somewhat controversial approach to drugs that some government officials are looking to implement in the states.
InsiteThe facility, called Insite, uses the harm-reduction model, which strives to reduce the adverse health, social and economic effects of drug use without requiring abstinence from drug use. Those who use intravenous drugs are encouraged to come into the clinic and shoot up under supervision of medical professionals who can intervene if the person overdoses and can connect them to onsite treatment.
“If they have a drug addiction, (the goal is) detox, recovery and abstinence — that's always the goal,” said Anna Marie D'Angelo, who served as senior media relations officer for Vancouver Coastal Health for nine years. “But if we can just reduce the harm that they are doing to themselves and reduce the transmission of diseases, and all that goes with it, that's also helpful to people's health and is better for the community — better for everybody.”
The facility is located in Vancouver's Downtown Eastside, a 10-block radius where there is a high concentration of long-term intravenous drug users. The area has suffered since the 1980's, when there was an influx of hard drugs, de-institutionalization of mentally ill individuals, policies that pushed prostitution and drug-related activity out of nearby areas, and a cessation of federal funding for social housing.
When Insite opened in 2003, there was a Public Health Crisis declared because of the rise in HIV transmission.
At the time, Vancouver had some of the highest rates of HIV transmission in the industrial world, according to D'Angelo. Right now, Vancouver has almost the lowest rate of HIV in Canada, which is now among the lowest in the world.
Flash forward 14 years, the crisis has now shifted to the rise in opioid addiction, and the increasing prevalence of fentanyl — an opiate even more potent than heroin. There are now eight overdose interventions in British Columbia a day.
Many of Insite's clients are marginalized and do not have regular access to health care services, according to D'Angelo. They also can have a concurrent disorder, have a history of trauma, are experiencing homelessness, live in shelters or live in substandard housing.
While the first objective of Insite is to allow drug users to use in a safe, clean place with access to immediate care if needed, the ultimate goal is to have them enter into a detox program and then a recovery program, according to D'Angelo. To encourage users to enter into treatment, withdrawal management treatment and transitional recovery housing are all contained in the same location, called Onsite.
“When they say 'oh I want to go into detox' and you say 'okay come back at 10 and go into recovery,' they don't show,” D'Angelo said. “So if we have Onsite right above, they just go upstairs. And if you detox and just go outside again in the same group, you're back where you started. So if there's temporary housing — there's this whole kind of, it's called continuum care — a wrap around of services, that we try to do.”
There are studies to back up these claims, according to D'Angelo.
“If a drug user goes to Insite, you talk to the nurses, you develop trust, your likelihood of going into detox increases for somebody who's a long-term drug addict,” she said.
Another negative aspect of drug abuse Insite tries to alleviate is the toll on first responders. When someone overdoses, someone calls 911 and the police arrive, fireman arrive, and an ambulance arrives.
If the person is unconscious, which is likely, the ambulance will transport them to the emergency department where, according to D'Angelo, an unconscious person in the ER uses far more resources than someone who is conscious.
“There is a huge, huge draw on first responder resources, especially now in this situation with all the fentanyl in the drug supply, there's lots of overdoses,” D'Angelo said. “So if you were to go into a supervised injection site, such as Insite, you inject, you overdose, there's a nurse right there with naloxone, with oxygen, they revive you immediately. If you have to go to hospital, you're conscious, so your draw on your first responders is way less.”
Optimism and caution from medical communitySince there has been no studies on the effectiveness of supervised injection sites in the U.S. since they are currently illegal, many health professionals are open to the idea — with caution.
Dr. Lewis S. Nelson, chair of the department of emergency medicine at Rutgers New Jersey Medical School and chief of service for the emergency department at University Hospital, has witnessed the increase in opioid addiction and overdoses firsthand. He feels there is a lot of hyperbole surrounding supervised injection sites and the interpretation of their value is largely a matter of perspective.

The data to evaluate the risk/benefit of supervised injection sites is also limited and open to interpretation, according to Nelson.

“I tend to doubt that many people who would not otherwise inject would do so because of the availability of safe injection sites, but there may be some,” Nelson said. “And such sites clearly enable drug use, but that is their intent, realizing that abstinence is not an attainable endpoint for many.
“Whether continued drug use is offset by the availability of clean needles to reduce infectious complications, naloxone for users who overdose, and treatment advocates is yet to be determined,” he continued, “but it likely will prove to be.”
When thinking about how to try and reduce the number of new addictions, Nelson has a mantra: “keep opioid naïve patients opioid naïve, if at all possible.” While this likely won't completely stop the creation of new opioid addictions, Nelson sees abstinence as the best option going forward.
But once someone has already formed an opioid addiction, Nelson agreed that
harm-reduction may be effective.
“Abstinence is not a reliable solution once addicted,” Nelson said. “I would certainly try to get patients to avoid drug use, but the reality is that addiction is very hard to beat.
“Accepting the reality that most patients will continue to relapse and recover,” he continued, “making the relapses as safe as possible through harm reduction efforts makes the most practical sense.”
Others, such as Associate Director of Health Law and Policy at The National Center on Addiction and Substance Abuse, Lindsey Vuolo, see the possibility of supervised injection sites as a single component of a comprehensive approach to addressing the opioid crisis.
“Illegality and resistance to harm reduction strategies have resulted in a missed opportunity to rigorously evaluate supervised injection facilities in the U.S. to determine whether they reduce overdose deaths and improve treatment engagement,” Vuolo said. “Given the high overdose death rate, we should embrace interventions that will help prevent overdose.
“With the increased potency of synthetic opioids creating a higher risk for overdose,” she continued, “a supervised injection facility may help to decrease the risk of overdose.”
Vuolo also said that providing individuals with opioid addiction opportunities to get treatment is extremely important. Supervised injection sites meet people with addiction — who often avoid the healthcare system — where they are. Click here read the second installment in this series.