Mind and Body

A public community conversation about saving lives

In the first event of its kind, panelists discuss the merits of creating a safe injection site in Rhode Island as part of a larger statewide harm reduction strategy

Photo by Carlos Romero

Roxanne Newman talks at the community discussion on medically supervised consumption centers, held on March 1 at the Warren Alpert Medical School at Brown University. From left, Aubri Esters, Raynald Joseph, Michelle McKenzie, Newman, and Brandon Marshall.

By Ian Knowles
Posted 3/5/18
The introduction of fentanyl into the illicit drug supply, not just in heroin, but in cocaine, counterfeit pills, and even in marijuana has made the state’s deadly drug overdose epidemic even deadlier. Despite the hard work by the Governor’s Task Force on Overdose Prevention and Intervention, the need for a comprehensive statewide harm reduction strategy, including the potential of safe injection facilities, needs to become part of the conversation. The recent community conversation held on March 1 was a giant step forward.
What is the best way to clarify the legal standing for the creation of a safe injection facility in Rhode Island? What sources of funding can be used to underwrite such a facility? Would legislative leaders and law enforcement officials be willing to undertake a visit to Vancouver to investigate how Insite works? Could such a facility be created as a pilot clinical study program under the auspices of the Brown medical school? Is the discussion of a comprehensive harm reduction strategy politically toxic in an election year?
Rhode Island is not alone with wrestling with the idea of implementing safe injection facilities. Seattle, Philadelphia, Ithaca, and Boston are seriously considering creating such facilities, and legislation has been introduced in Maryland, Vermont and California. Globally, safe injection facilities have demonstrably saved lives in 66 cities in 10 countries, including Australia, Canada, Denmark, France, Germany, Luxembourg, Netherlands, Norway, Spain and Switzerland.
There are numerous names used to described medically supervised consumption centers. They include: supervised injection sites, safe injection facilities, safer injection services, overdose prevention sites, comprehensive injection facilities, and in Seattle, community health engagement locations.
There is no current consensus about what such a proposed Rhode Island facility should be called.

PROVIDENCE – Roxanne Newman, a woman in long-term recovery, and one of four panel members on what was billed as “Medically Supervised Consumption Centers: A Community Conversation,” held on March 1 at the Warren Alpert Medical School at Brown University, articulated an important context about the conversation.

“I was thinking as I was driving here, this is a life-saving measure that we are talking about,” Newman told the audience of nearly 100 in attendance. “But does anybody else go to a forum to talk about saving lives when it comes to cancer, to mental health? Do we have forums about it?” she asked rhetorically, and answered: “No.”

Yet, continued Newman, who serves as president of RICovery, the on-campus student recovery organization at Rhode Island College, “[Here we are], we’re having a discussion about whether we should provide a service that saves lives.”

The event, which was co-sponsored by the Rhode Island Communities for Addiction Recovery, or RICARES, and Protect Families First, took place in a large, well lit and somewhat sterile high-tech lecture room at the medical school – a room not unlike the room shown on a slide of a safe injection facility now in operation in Vancouver, British Columbia.

In addition to Newman, the panel included: Brandon Marshall, an associate professor of Epidemiology at Brown; Raynald Joseph, the prevention supervisor at AIDS Care Ocean State; and Aubri Esters, a co-founder of SIFMA-NOW and the Boston Area Drug Users Union. Moderating the panel was Michelle McKenzie, a senior project director at The Miriam Hospital and the coordinator of Prevent Overdose and Naloxone Intervention, or PONI.

The conversation attracted a very diverse audience, including: representatives from the Office of the U.S. Attorneys, the R.I. State Police, the Smithfield Police Department, three opioid treatment programs, the R.I. State Nurses Association, the R.I. Medical Society, Project Weber/Renew, House of Hope, Blue Cross and Blue Shield of R.I., the R.I. Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, the Democratic Socialists of America, the New England Drug Users Union, The Center for Prisoner Health and Human Rights, two Rhode Island College professors, more than a dozen Brown medical students and faculty, one state legislator [Sen. Joshua Miller], and Ryan Erickson from Gov. Gina Raimondo’s office.

Fentanyl as the game changer
McKenzie introduced the topic of safe injection sites with the observation that fentanyl is now present in most of the illicit opioid supply, and that it is fentanyl that is requiring us to start talking about enhanced harm reduction strategies and specifically about safe injection facilities.

Marshall then defined a medically supervised consumption center as a clinic where people use pre-obtained illegal drugs under medical supervision. He noted that the facilities also provide a range of other services, such as access to medical care, facilitated referrals to addiction treatment, and characterized such centers as “part of the continuum of care for substance use disorders.”

Marshall said that he had been part of the scientific team that conducted an intensive evaluation of Insite – the safe injection facility that opened in 2003 in Vancouver, British Columbia.

The study results
Marshall said that from 2003 through 2016, Insite had more than 3.6 million visits and there was never a death in the facility and, in fact, he claimed that there has never been a death in any safe injection facility anywhere in the world.

“Overdose death is preventable,” Marshall said. “Overdoses can always be reversed with the right medical care and supervision.”

To bolster his argument, Marshall presented study data from the region of Vancouver where Insite is located:

The overdose death rate declined by 35 percent vs. a 9 percent decline in the rest of the city

People who regularly used the facility were 72 percent more likely to enter treatment than those who did not

People who interacted with a peer recovery coach at the facility were two times more likely to enter treatment than those who did not

Marshall then presented study data that addressed some of the myths about safe injection sites:

The myth: Local drug trafficking would increase in the area of a safe injection facility [the “honey pot” effect]; the fact was that crime in the area of the facility actually declined.

The myth: There would be an increase in the initiation of drug use; the fact was that there was no impact.

The myth: There would be an increase in the number of people who resumed opioid use [after a period of use cessation; the fact was that there was not an increase.

Marshall also noted that safe injection facilities are also used as a venue to provide other harm reduction strategies, such as the distribution of fentanyl test strips.

Recovery is not a straight line
Newman self-identified as a former heroin and cocaine IV drug user who was homeless and whose life had been in “shambles.” She revealed that she overdosed 29 times, saying that she “wouldn’t be here today if it wasn’t for Narcan. And, if I wasn’t here today, neither would my beautiful 19 month old daughter.”

Newman told the audience that her initial reaction to safe injection facilities was: “Absolutely not, that’s crazy, who would do that?”

However, Newman continued, that was before the national – and Rhode Island – OD death rates began their precipitous climb. Her opinion has now changed.

“Recovery is not a straight line,” she said, and that it was of “the utmost importance that we keep people alive long enough to choose recovery.”

Success in harm reduction
Joseph of AIDS Care Ocean State spoke about the syringe exchange program that he operates as an example of a successful harm reduction program.

Aubri Esters, a young woman who described herself as “a regular person with a part-time job who shoots dope on weekends,” was working with homeless people in Boston when she asked herself the question, “Why aren’t we talking about my friends who are dying?”

Esters said she formed a collaboration to advocate with state officials, and a bill to authorize a safe injection facility has been introduced in the Mass. state legislature.

[Aubri was one of two representatives from a drug users union at the event. The other representative was Jess Tilley, the Executive Director of the New England Drug Users Union.]

How should a safe injection site be planned, implemented?
Most of the questions and comments from the audience focused on how such a medically supervised safe consumption site would be implemented.

Here is a sampling:

John, who works at an opioid treatment programs, asked if there is a strategy to engage the substance use disorder treatment providers.

Sean, who identified as being in recovery, asked if there is a strategy to involve people “in the street” in the conversation as opposed to having a conversation “in a fancy building like this.”

Brad noted that this is a very politically charged issue.

Mike, who self-identified as an addictions clinician, asked about funding for both start up and for sustainability.

Jess pointed out that not all drug users are “on the street,” and that the participation of users in planning is critical as they are the source of local expertise and local idiosyncrasies around such issues as patterns of use and specific women’s issues.

Sen. Miller pointed out the need to address the primary hurdle: the legal status of such efforts. While the legal status of safe injection sites in the U.S. is unclear, it is clear that the primary activity that occurs in safe injection sites illegal. Miller suggested there was a need to consider how to navigate current law in order to save lives.

Marshall condensed the recurring theme of the evening: “The goal is to get people on treatment and to live happy and successful lives.”

Newman concurred: “We need to keep people alive until they can find recovery.”

Ian Knowles is the project director at RICARES.

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