Providing “Insite”: Overdose-Prevention and Supervised-Injection Sites
Amidst record-high and ever-increasing drug-related deaths, public health officials in North America are finding themselves at the centre of an acute crisis. The numbers are staggering: in 2015 alone, 52,000 people in the United States died of drug overdoses – 1,000 more than of AIDS in the deadliest year of that epidemic. In 2016, more Americans died of drug overdoses than in the entirety of the Vietnam War. In 2018 this number rose to 72,000 deaths. The magnitude of overdose and drug-related deaths in recent years is largely attributable to the prevalence of fentanyl, an opioid 50 times stronger than heroin. Of 2018 drug overdose deaths in America, 29,000 were the result of fentanyl. North of the border, Canadian opioid related deaths have also skyrocketed over the past decade. In the first six months of 2018 alone, over 2,000 people lost their lives to opioids (a classification to which fentanyl belongs), a death rate of 11.2 per 100,000 population.
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Prescribed by doctors, fentanyl abuse often occurs as a result of patients developing a reliance and addiction. However, its destruction has resulted largely from its entrance into the illicit drug trade. Fentanyl is frequently mixed into other illicit drugs (which are “cut” with fentanyl) to increase the potency, often with fatal consequences. Because this is done without drug users’ knowledge, they are subjected to toxicity levels far beyond the typically expected strength. Fentanyl has been found in heroin, cocaine, and many other common street drugs that already bring significant risk to the user. Much of what is seen on the street is sourced not from domestic hospitals or over-prescription, but from illicit foreign smuggling.
The effects of fentanyl and other opioids can be reversed by administering the drug naloxone in a timely manner, typically sold as a brand under the name “Narcan”. However, overdosing drug users are typically unable to self-administer the drug, and, if alone, by the time they are discovered it is often too late. Naloxone can be difficult and expensive to procure, and users might avoid doing so for risk of outing themselves. As a result of a 2016 change in Health Canada regulations, Naloxone is now available free of charge in pharmacies across Canada. While this is a positive step forward, it alone is insufficient to address this growing crisis.
Much like the AIDS epidemic, many of the people affected by the opioid epidemic lack political power or are socially ostracized. In addition to the stigmatization of drug use, victims are typically homeless and low income. This, coupled with unwillingness of legislators to meaningfully pursue harm reduction techniques for fear of appearing ‘soft on crime’, has led to a generally slow public response.
An innovative solution that evidence suggests significantly reduces overdose deaths is the supervised- or safe-injection site (SIS) model. First employed in North America in Vancouver’s downtown east side at Insite, a facility jointly operated by Portland Hotel Society and Vancouver Coastal Health, SISs provide a space for drug users to inject or ingest drugs where they are given clean supplies and are supervised by medical staff. In the case of injury, overdose, or any other medical emergency, trained staff members are able to intervene. Insite, which first opened in 2003, has seen significant success in preventing overdose deaths and aiding drug users to access long-term treatment. It operates legally due to a ministerial exemption to Canada’s criminalization of drugs, a decision backed by the country’s Supreme Court. In 2016, Insite was visited 214,898 times by 8,040 individuals. In the same year it performed 1,781 overdose interventions, saving lives that otherwise would have been lost, many of which involved fentanyl.
The success of Insite and SISs generally has been studied by public policy makers and the medical community, with overwhelmingly positive discussion of their ability to reduce overdose and other drug-related deaths. Most notably, a 2011 study in The Lancet found that deaths occurring in city blocks proximate to Insite decreased by 35% after it opened. Supervised-injection sites are also economically beneficial. A study examining San Francisco’s potential cost savings estimates a single site will save $3.5 million in medical costs of drug users.
The genius of centres like Insite is that they are not, first and foremost, addiction treatment centres. While Insite does provide referrals to other service providers for users that wish to seek treatment, its primarily goal is harm reduction. As a result, drug users do not feel as though they have to commit to addressing any addiction issues they may not be ready to tackle. They are also not left to use drugs in private where, if an overdose or other potentially fatal incident occurs, they would likely be left helpless. Insite saves lives primarily by allowing drug users to carry on their business – providing further help if requested – in a safe and clean environment. While it is not a panacea for the opioid crisis, Insite’s model is a first step in addressing rising deaths.
As opioid fatalities continue, the example of Insite in Vancouver is a solution that policymakers would do a disservice to ignore. However, despite strong evidence that supports the success of Insite and other SISs, institutional and political factors will likely delay or prevent the implementation of similar programs across North America. In the absence of publicly-run sites, there citizens and advocacy organizations have set up unapproved sites in a desperate attempt to address local needs. Long-term, the academic evidence supportive of SISs that has begun to penetrate the medical and policy communities must also make its way into public view for greater consumption. While public attitudes are beginning to shift, greater emphasis on public education and de-stigmatization can help SISs gain salience in electoral politics as a moral, economic, health, and evidence-based issue.
Greta graduated from McGill University with a B.A. (Hons.) in Political Science, Economics, and Middle Eastern Studies. Her research interests include the role of the courts in the policy process, the effect of universal basic income on wellbeing and skills, and health inequalities of diverse communities. Prior to commencing the MSc, Greta worked as a management consultant at a global firm and held positions in the Office of the Minister of National Defence and the government of Ontario. She was also previously a student researcher at the Institute for Health and Social Policy in Montreal.