Want to reduce OD deaths? Create safe spaces.

The Centers for Disease Control has just released preliminary estimates of drug overdose deaths for 2020 that show a 30% rise in fatalities to more than 92,000. Here in Connecticut, drug overdose deaths rose by 14.1%, to 1,372, on top of a 16.7% increase in 2019. Clearly, something extraordinary has to be done to reverse this trend.

The situation calls to mind the early days of the HIV epidemic in Connecticut, when an HIV diagnosis seemed a death sentence. Between 1987 and 1991, new HIV diagnoses among people who injected drugs averaged 640 per year, accounting for 57% of all HIV cases. At that time, there were only two legal syringe exchange programs operating in the US — Tacoma, Washington, and Boulder, Colorado — and one poorly implemented program in New York City had already been terminated. A ban on the use of federal funds for such programs had been in place since 1985. Police routinely arrested individuals operating clandestine exchanges.

Nevertheless, local elected officials and New Haven’s AIDS Task Force persuaded the Connecticut state legislature to authorize a pilot syringe exchange program through an exception to state law that prohibited syringe sales or possession without a prescription. That program opened in November 1990.

The evaluation of the New Haven program uniquely combined program data, syringe testing, and epidemic modeling to suggest a minimum one-third reduction in new HIV transmissions among people who inject drugs within five months of starting operation. The success of New Haven’s program quickly led to expansion of programs and reversal of the ban on syringe sales without a prescription. Expanded syringe access and effective HIV medications that prevent transmission, as well as keeping HIV-positive individuals alive and healthy, have reduced new HIV diagnoses attributed to unsafe injection to an average of 15 per year between 2015 and 2019. This 97.7% reduction in the rate of diagnosis is a remarkable public health accomplishment, made possible by bold, politically unpopular action. Equally bold action is needed now in response to the drug overdose crisis.

The most obvious and also the most politically contentious efforts would establish sites where people could use their potentially fatal drugs under supervision of staff trained to provide medical assistance if needed. Safe consumption spaces (SCS) have proved efficacious for ameliorating many health and human costs of the overdose crisis. SCS are spectacularly effective at reducing overdose fatality, with zero fatal overdoses reported in the 120 supervised facilities worldwide. This benefit does not stop at the door;

SCS have been linked to lower overdose deaths in the areas surrounding a site.

Injecting in a medically supervised facility has been shown to improve care for people with HIV, hepatitis C virus, and soft tissue infections. The few careful research studies of SCS have found individual level behavioral changes, including injection cessation, an increase in the use of safer sex and safer substance use supplies, and increased use of other health and social services that are otherwise lacking for people who use drugs.

Although the data overwhelmingly indicates the ways in which SCS positively impact the health and well-being of people who used drugs, a common argument against SCS is that implementation will have a deleterious impact on the surrounding community. A second argument in opposition to SCS is that they increase or encourage drug use.

Both these arguments were raised 30 years ago in opposition to syringe exchange, as was the case for exchange programs. Evidence from properly evaluated SCS shows that upon implementation, drug-related crime, violence, and “public nuisance occurrences,” such as public injection or other public drug use, public discarding of materials used for drug use decreased in the neighborhood around the site. Imagined scenarios meant to scare citizens from supporting the SCS have not materialized.

A final consideration in favor of SCS implementation is cost, or rather cost savings. After accounting for savings resulting from averted HIV and hepatitis C infections, reduced skin and soft tissue infections, prevented deaths, and an increase in the uptake of medication-assisted treatment for opioid use disorders, it has been estimated that the implementation of SCS in a U.S. city the size of Boston would save approximately $3.5 million per year.

Additionally, taking into consideration the decreased burden on the health care system as the result of SCS implementation, such as decreased ambulance rides, emergency department visits and hospital stays associated with drug use and overdose, annual savings can save an additional $3.6 to $4.2 million.

Now, approximately 120 sanctioned SCS are operating in 11 different countries around the world, indicating that SCS are tested, proven to work, and widely accepted as a way to actively provide lifesaving harm reduction for people who use drugs.

Connecticut needs to join this group and there are individuals in New Haven, who have the courage, like their counterparts did 30 years ago, to lead implementation and evaluation of Connecticut’s first SCS.

We urge the state to enact legislation to permit a pilot program and authorize DPH to award funds to conduct an evaluation.

Robert Heimer is professor of epidemiology (infectious diseases) at the Yale School of Public Health and was involved with the initial evaluation of the New Haven Syringe Exchange Program. Mariah Frank just graduated with a master of public health in social and behavioral sciences from the Yale School of Public Health and is the prevention manager for the Boulder County AIDS Project in Boulder, Colorado.