Mon­i­tored drug use sites save lives

Baltimore Sun - - COMMENTARY - By Su­san G. Sher­man, Mishka Ter­plan and Kait­lyn Boecker Dr. Su­san G. Sher­man (ssh­er­man@jh­sph.edu) is a pro­fes­sor at the Johns Hop­kins Bloomberg School of Public Health. Dr. Mishka Ter­plan (Mishka.Ter­plan@bhs­bal­ti­more.org) is med­i­cal di­rec­tor of Be­hav­ioral

Over the past five years, deaths from heroin over­dose in Mary­land have tripled, with 748 deaths in 2015 alone and 2016 on track to be even worse. In re­sponse, Bal­ti­more City has rolled out a com­pre­hen­sive and in­no­va­tive over­dose pre­ven­tion pro­gram, in­clud­ing wide dis­tri­bu­tion of nalox­one, a drug that re­verses over­doses. The state has also ex­panded ac­cess to nalox­one, as well as in­creased its sub­stance use dis­or­der treat­ment fund­ing and au­tho­rized the es­tab­lish­ment of sy­ringe ex­change pro­grams through­out the Mary­land.

But we des­per­ately need more ev­i­dence­based re­sponses to drug use to stop the cri­sis — one in par­tic­u­lar: Care­fully mon­i­tored “safer drug con­sump­tion” sites would al­low us to en­gage drug users who would oth­er­wise con­sume in public spa­ces or un­safe en­vi­ron­ments and likely wind up in the crim­i­nal jus­tice sys­tem or fall through the cracks. Th­ese spa­ces, which ex­ist through­out the world, pro­vide clin­i­cal su­per­vi­sion and a clean en­vi­ron­ment, and they al­low us to con­nect the most marginal­ized mem­bers of so­ci­ety to crit­i­cal health ser­vices. Such spa­ces main­tain a strict pro­hi­bi­tion on drug shar­ing or sell­ing. Th­ese pro­grams are not con­don­ing il­licit be­hav­ior; they are meet­ing peo­ple where they are and con­nect­ing them with life­sav­ing re­sources.

In the span of a year, such spa­ces have gone from a lit­tle-known in­ter­ven­tion in the U.S. to an in­no­va­tive ap­proach her­alded by public of­fi­cials in Seat­tle, San Francisco, New York, Ithaca and many other cities. Even USA To­day has en­dorsed their use. Though rel­a­tively new to the U.S., there are al­ready al­most 100 SDC sites op­er­at­ing in 66 cities in 10 coun­tries. Nu­mer­ous stud­ies chron­i­cle the pos­i­tive im­pacts on in­di­vid­u­als and their com­mu­ni­ties of th­ese pro­grams, and the lack of neg­a­tive im­pacts.

The key to SDC sites is that they serve as ac­cess points to sub­stance use dis­or­der treat­ment and other vi­tal so­cial ser­vices for drug users, such as med­i­cal care, hous­ing and case man­age­ment. One study of a Cana­dian fa­cil­ity found that in a sin­gle year more than 2,000 re­fer­rals were made, with more than half for ad­dic­tion coun­sel­ing, detox­i­fi­ca­tion or other re­cov­ery ser­vices. We know that many will re­quire re­peat con­tact and en­gage­ment to be brought into treat­ment. Yet we must meet in­di­vid­u­als where they are in the mo­ment with­out judg­ment in order to es­tab­lish a mean­ing­ful ther­a­peu­tic al­liance.

By pro­vid­ing a safe at­mos­phere and sta­ble ac­cess to ser­vices, we can help those strug­gling with sub­stance use dis­or­der to es­tab­lish pos­i­tive re­la­tion­ships with ser­vice providers, build trust and be­gin tack­ling the chal­lenges in their lives, in­clud­ing sub­stance use. This strat­egy re­quires in­vest­ment, but the re­al­ity is it works. In the Cana­dian fa­cil­ity, clients in­creased their use of detox ser­vices more than 30 per­cent in just one year.

There is a ro­bust sci­en­tific lit­er­a­ture to show that SDC spa­ces are associated with re­duc­tions in over­dose deaths, HIV, hep­ati­tis B and C, hospi­tal ad­mis­sions, the need for emer­gency med­i­cal ser­vices and public order con­cerns in sur­round­ing ar­eas, while de­liv­er­ing cost sav­ings and serv­ing as ac­cess points to sub­stance use dis­or­der treat­ment and so­cial ser­vices. Each of th­ese ben­e­fits comes with­out in­creas­ing com­mu­nity drug use, ini­ti­a­tion into in­jec­tion drug use or drug-re­lated crime.

In 2014, the fed­eral Sub­stance Abuse and Men­tal Health Ser­vices Ad­min­is­tra­tion es­ti­mated that of the 123,000 Mary­land res­i­dents who met cri­te­ria for a sub­stance use dis­or­der, fewer than 12 per­cent had re­ceived treat­ment. From 2013 to 2014, heroin-re­lated emer­gency depart­ment vis­its in Mary­land in­creased 41 per­cent. The United States has more drug users in prison than in drug treat­ment, and for far too long we’ve re­lied on our emer­gency med­i­cal sys­tem to en­gage those strug­gling with ad­dic­tion.

We should re­mem­ber that Bal­ti­more’s 20-year old nee­dle ex­change pro­gram was once a con­tro­ver­sial idea that many did not be­lieve would suc­ceed. To­day, the pro­gram has dra­mat­i­cally re­duced trans­mis­sion of HIV and hep­ati­tis C and pre­vented many other harms.

SDC sites are a proven harm re­duc­tion strat­egy im­ple­mented across the world. They have saved thou­sands of lives and helped many start on the path to re­cov­ery. It’s time they came to Mary­land. With­out such in­no­va­tion, we will fail to stop the heroin epi­demic.

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