Public health interventions aimed at injection drug users since the 1980s have had two primary goals: get people to stop using and prevent the spread of disease. Needle exchange programs arose in response to the HIV/AIDS epidemic, and proved invaluable in slowing the transmission of a deadly virus.

As the nation grapples with a new epidemic every bit the size and scope of the HIV crisis, public health authorities have had to adjust. People who inject drugs are no longer dying of AIDS; they’re dying of overdoses. And simply providing clean equipment will no longer save people injecting on the street.

That’s given rise to a new approach: bringing those people inside under the watchful eye of those who can reverse an overdose before it becomes fatal. Major cities on both coasts are considering opening the nation’s first official safe consumption sites, where people can inject illegal drugs such as heroin. Those cities face significant opposition from critics who charge, as they did with needle exchanges in the 1980s, that such sites tolerate drug use instead of fighting it.

“People exchange their needles, they get clean works, they get education, and all that type of stuff. We do everything to mitigate harm, except you can’t use here. You have to go outside around the corner and use in a very vulnerable situation where you could overdose and die,” says Brad Finegood, assistant division director of behavioral health and recovery at King County Department of Community and Human Services in Seattle. “It just doesn’t make a lot of sense.”

In harm’s way

Now that heroin and other drugs are being laced with dangerous synthetic opioids such as fentanyl and carfentanyl, the risk of overdose is much higher. Advocates say it makes little sense to force people into back alleys or public restrooms to overdose out of sight.

In a 2015 survey by the Injection Drug Users Health Alliance in New York City, 60 percent of drug users reported injecting in public locations, such as bathrooms, in the previous three months.

“I have businesses calling me, and saying, ‘I have people in my bathroom, and I’m terrified they’re going to die of an overdose,’” said Shilo Murphy, executive director of the People’s Harm Reduction Alliance, which runs the nation’s largest needle exchange program in Seattle.

Many health departments have developed bathroom policies for exchanges that tacitly acknowledge people are injecting in them, and will send staff in, anti-overdose drug naloxone in hand, to check on them if they don’t emerge in a given time.

“To my knowledge, nobody has ever died in a bathroom at a syringe exchange,” says Dr. Sharon Stancliff, medical director for the Harm Reduction Coalition in New York City. “I think I would know.”

After a sharp rise in overdose deaths in 2016, the Boston Public Health Commission opened the Supportive Place for Observation and Treatment, a drop-in facility for people intoxicated with sedating drugs such as heroin. People are not allowed to inject in the room, but can come after using to ride out their high in one of eight reclining chairs. Medical personnel monitor their respiration and can reverse overdoses with naloxone. But observation rooms still require drug use to happen elsewhere. And with the powerful opioids circulating today, that delay may mean help is too late.

A safe place

Many public health officials believe the way to battle the overdose epidemic is to follow the lead of Vancouver, Canada. The area about 140 miles north of Seattle has long struggled with the consequences of injection drug use.

Drug use is concentrated in the Downtown East Side, an area dominated by old hotels that have been converted into low-income housing. Often called Canada’s poorest postal code, 1 in 5 of its residents are homeless, 18 percent are indigenous peoples and 36 percent work in the sex trade. More than 5,000 injection drug users live the district, and thousands more visit regularly to buy and use drugs.

Those elements made the area a perfect place for Insite, North America’s first safe injection site.

Housed in a nondescript three-story building on Hastings Street in the midst of the Downtown East Side, Insite has seen more than 3.6 million visits and reversed 6,440 overdoses since opening in 2003 — with not a single death. The site provides other services, such as wound care and immunization, and can connect users to treatment. A detox facility is up the stairs on the second floor, with a recovery housing unit on the third.

Evaluations showed that after Insite opened, injection drug use in public went down, as did the amount of discarded syringes and other injection-related litter. Drug users who used the facility were adopting safer injection practices, and scores were being referred for addiction treatment. Nurses were identifying infections and abscesses earlier, when patients were more easily treated, saving on hospital costs.

Studies found no evidence that the site increased drug use. A 2011 study documented that overdose rates on city blocks within a third of a mile of the facility were 35 percent lower than in blocks beyond that radius. After Insite opened, overdose rates in British Columbia plateaued. Then last year, fentanyl arrived with a vengeance.

Grass-roots solution 
to a new danger

From 2011 to 2014, the number of drug overdoses in British Columbia bounced between 269 and 368 per year. By 2016, it had hit 967, an increase almost entirely attributable to fentanyl and carfentanyl. At Insite, 80 percent of heroin being brought in by clients tested positive for fentanyl.

With emergency crews overwhelmed with overdose calls, health authorities flooded the streets with naloxone. Local residents began wearing Narcan, a brand of naloxone, in kits on their belts.

The back alley behind the Hastings Street Market was among the hardest hit.

“People were dying in the alley. We’d be working here at the market, and somebody would scream over the fence, ‘Help! There’s someone dying in the alley,’” says Sarah Blyth, a former park commissioner and community activist. “We’d throw Narcan kits over the side. It started to get so frequent, we said, ‘We’re going to put a guy there and he’s going to make sure that nobody dies in the alley.’”

On Sept. 20, 2016, Blyth and two other women from the market had seen enough. They pitched a tent in the alley, stocked with clean water and syringes, creating a bare-bones safe injection site with volunteers on hand to reverse overdoses. By November, they set up a second site around the corner.

They women launched an online funding campaign to pay for supplies and stipends for the volunteers. They set up the site and operated outside of the sanctioned health care system. They didn’t ask the city for permission.

“You put a tent up, you’ve got a guy, he’s saving lives,” Blyth says. “Who’s going to arrest you for saving people’s lives? How bad would that look?”

When the city said they couldn’t run a safe injection site, they replied that it was an overdose prevention site. When officials said they couldn’t erect a permanent tent, they moved from spot to spot. For every objection, they found a loophole that would allow them to continue to save lives.

The volunteers became de facto emergency response teams, carrying cellphones and ready to come running with Narcan if someone reported an overdose.

Vancouver police declined to intervene, considering the overdose prevention site a health issue, Blyth said. The Ministry of Health at first quietly tolerated the tents, until the health minister had a midnight revelation and gave them his unofficial approval.

“He came out and visited us, and then everything changed after that,” Blyth said.

Vancouver Coastal Health, the health plan that serves downtown Vancouver, funded a trailer, providing storage capacity, an indoor supervised consumption room, and some semblance of permanence. It’s nothing fancy: several desks at which clients can inject and a volunteer trained in overdose rescue.

The site still has its two tents alongside the trailer, one for injection drugs, the other for smoking meth or crack. The tents have bins of supplies, where users can grab what they need and consume their drugs, monitored by volunteers in fluorescent yellow and orange safety vests, almost exclusively people from the Downtown East Side. The volunteers often have years of experience with injection drugs and naloxone.

“They’re willing to do things nobody else will,” Blyth says. “They were here on the coldest nights with frozen hands in this tent, snow coming down, frozen feet, helping each other.”

As the overdose epidemic in Vancouver worsened, health officials decided they couldn’t wait for the complex process of creating more Insites. The overdose prevention site model was much faster, more nimble and could be put in place overnight. The Health Ministry established such bare-bones sites in 20 more locations.

Expanding capacity

Despite Insite’s success, it remained the only safe injection site in Canada for more than a decade. With the overdose epidemic worsening, Canadian health officials have embarked on a massive expansion of capacity, with plans to open 15 additional sites across Canada.

A half hour drive from downtown Vancouver, 135A Street in the suburb of Surrey is lined with some 30 brightly colored tents. The homeless encampment faces a police station and a drop-in homeless center that serves breakfast at 7 a.m. By 8 a.m., many of its residents make their way through a side alley to a trailer — the size of a school portable classroom — that houses Safepoint, one of Canada’s newest safe injection facilities.

Clients check in at the front desk under a pseudonym and their birth date. They pass through to a supply area, where they collect clean syringes, cookers and water. Vitamin C is provided to help break down the brown tarry heroin that is commonly sold in the region.

They’re assigned one of seven mirror-backed booths with stainless steel desks and the strong pull of a ventilation system to keep staff safe from the fumes. The chairs are weighted so in the event of an overdose, staff can roll the chair backward on to the floor and begin a medical intervention. It’s the first safe consumption site in Canada that allows people to snort drugs and take pills.

“I had preconceived notions that it would be chaos. It’s fairly peaceful,” says Fraser Mackay, manager of the site. “People have to stay in their area. There’s no doctoring or helping each other shoot up. There’s no trading or dealing. There’s no getting up and wandering around.”

Safepoint sees 30 to 90 users a day. Over its first three weeks, staff reversed 20 overdoses.

MacKay is also incorporating safe consumption sites into more traditional health care settings. There are two consumption booths at a sobering center, allowing people to use on their way out. In the Downtown East Side, many of the low-income housing units have designated rooms as safe consumption sites, telling residents if you’re going to use drugs, use them here where we can keep an eye on you.

In the U.S.

A number of larger U.S. cities are now considering opening safe injection facilities, including Seattle, Los Angeles, San Francisco, Boston, Baltimore, Philadelphia and New York.

Seattle may be further along than any city. The King County Board of Health voted unanimously to open two safe injection sites, or community health engagement locations (CHELs), one in downtown Seattle and one in an outlying area.

“Supervised consumption sites, or what we call CHELs, are all about health engagement,” said Finegood of the King County Department of Community and Human Services. “We have to keep people alive long enough to mitigate the harm.”

CHELs are designed to engage people who face significant barriers in the traditional health care system.

“Those are the people we push to the streets. Those are the people we push further into their substance use disorder. Those are the people who have chronic mental illness that goes untreated,” Finegood says. “Those are the people who we need to do a better job of engaging in health services.”

While health authorities are on board, CHELs face significant opposition. The King County Council in July voted to bar county funding for the sites, and a citizens’ coalition pushing a ballot measure to ban CHELs appears to have collected enough signatures to put it on the ballot this fall.

The California Legislature is considering a bill that would allow local health jurisdictions to authorize safe consumption sites and override the state laws around running a space for the purpose of consuming illegal drugs. A cost effectiveness study concluded that a safe consumption site in San Francisco could save the health system $2.6 million per year by reducing treatment costs for HIV, hepatitis C, soft tissue infections and overdoses, while increasing the use of addiction treatment services.

A similar analysis for a site in Baltimore suggested savings of $6 million a year.

Temple University law professor Scott Burris says while there are no laws expressly prohibiting such sites, there are criminal drug laws that could pose challenges.

“It’s clearly illegal for people to possess controlled substances that have not been properly prescribed by a doctor, or schedule one substances like heroin,” he said. “When you have a safe injection facility, you have a number of people who are violating that law. The question is will the police decide to come and arrest them, or do they look elsewhere?”

Law enforcement authorities could view officials who run safe consumption sites as conspiring with people to engage in illegal possession.

There are also laws aimed at crack houses and organizers of raves that make it a felony to knowingly open, rent, or maintain any property for the purpose of using a controlled substance, and allows for seizure of such properties.

“What can happen is when there’s enough political, popular and scientific support for that kind of intervention, that’s kind of in a gray zone, the space is created for people to do it,” Burris says. “It kind of puts the onus on the opponents in Washington or in a state capital to come and arrest people who are saving lives. And by and large, they don’t like to do that.”

— Reporter: 541-633-2162, mhawryluk@bendbulletin.com

“People were dying in the alley. We’d be working here at the market, and somebody would scream over the fence, ‘Help! There’s someone dying in the alley.’ We’d throw Narcan kits over the side. It started to get so frequent, we said, ‘We’re going to put a guy there and he’s going to make sure that nobody dies in the alley.’”— Sarah Blyth, Overdose Prevention Society of Vancouver, 
on how the effort to create a grass-roots safe injection site began

Markian Hawryluk is reporting this series during a yearlong Reporting Fellowship on Health Care Performance sponsored by the Association of Health Care Journalists and supported by The Commonwealth Fund. For the rest of the series so far, visit bendbulletin.com/opioids.