Overdose Prevention in New York City: Supervised Injection as a

Overdose Prevention in New York City:

Supervised Injection as a Strategy to

Reduce Opioid Overdose and Public

Injection

TABLE OF CONTENTS

Executive Summary 03

Background 07

Overdose in New York City

HealingNYC 12

Expanding New York City’s Response to the Overdose Crisis

A Legacy of Public Health Innovation in New York City 17

Why Supervised Injection Facilities? 20

A Review of the Evidence

Would New Yorkers Support Supervised Injection Facilities? 23

Community Support for and Concerns about Supervised Injection

What Would New York City Gain from Supervised Injection Facilities? 33

Estimating the Health and Fiscal Impacts of Supervised Injection in New York City

How Could New York City Implement Supervised Injection Facilities? 36

Viable Legal Frameworks for Supervised Injection Facilities in New York City

Case Studies: Supervised Injection Facilities at the Municipal Level 40

Update from Seattle, San Francisco, and Philadelphia

Recommendations 43

Acknowledgments 48

References 51

Appendix A 55

Institutional Support for Supervised Injection

Appendix B 57

Statement of Support for Supervised Injection from the American Medical Association

Appendix C 59

Statement of Support for Supervised Injection from the American Public Health

Association

Appendix D 81

Letter of Support for Supervised Injection from amfAR, the Foundation for AIDS

Research to New York State Governor Andrew M. Cuomo

Appendix E 83

New York City Supervised Injection Facility Impact Report

Appendix F 127

Legal Challenges to and Avenues for Supervised Injection Facility Implementation in

New York City

EXECUTIVE SUMMARY

Overdose deaths in New York City have risen steadily over the past 15 years, growing to

the crisis we now face. In 2017, provisional data confirmed 1,441 overdose fatalities in

New York City—the deadliest year on record.

Someone dies from a drug overdose in New

York City every seven hours, and more people died from overdose in New York City in 2017

than from suicide, homicide, and motor vehicle accidents combined.

Since 2014, fentanyl,

an opioid 50 to 100 times more potent than morphine, has driven the dramatic increase in

overdose deaths.

The opioid overdose epidemic in New York City persists despite current efforts, which

include availability of treatment services, collaborative interventions between public

health and law enforcement, and increased access to the emergency overdose rescue

medicine naloxone. Recognizing that opioid-involved overdose deaths are preventable, the

City has redoubled its efforts with a broad, multi-agency cross-sector approach known as

HealingNYC. This comprehensive strategy aims to reduce opioid overdose deaths by 35%

by 2022. Key components of HealingNYC include: expanded access to effective treatment;

innovative methods of overdose prevention that reach individuals at high risk; education

aimed at clinicians and communities to prevent substance misuse before it starts; and

using new methods to reduce the supply of drugs.

As HealingNYC moves forward, the City

maintains its commitment to deploying strategies grounded in science and to considering

all evidence-based interventions that could prevent people from dying in the present

overdose crisis.

Supervised injection facilities (SIFs) are one public health strategy to reduce overdose

deaths, infectious disease transmission, and public drug use. Supervised injection facilities

offer hygienic spaces for people to inject drugs obtained offsite using sterile equipment

under medical supervision. There are 100 SIF locations worldwide, including a recent

expansion to three cities in Canada. In the United States, SIFs have not been implemented

but are under consideration in at least five cities. Through co-location or referral, SIFs also

provide people who inject drugs access to a range of health, substance use, and social

services. As such, SIFs serve as an early entry point along the continuum of care for people

with substance use disorders. Finally, SIFs have garnered support and endorsement from a

range of professional health bodies, including the American Medical Association,

the

American Public Health Association,

the International Drug Policy Consortium,

and the

European Monitoring Centre for Drugs and Drug Addiction.

To explore the potential impact of incorporating supervised injection into City’s opioid

response strategy, the New York City Council provided funding to the New York City

Department of Health and Mental Hygiene (DOHMH) to assess the feasibility of establishing

a SIF. DOHMH began with a literature review to summarize the international experience

with SIFs. Additionally, an Expert Advisory Panel comprised of national and international

drug policy experts, scientists, and advocates was assembled to guide the study. A list of the

Expert Advisory Panel members can be found in the Acknowledgments.

To explore the feasibility of SIFs in New York City, three key questions were addressed:

1. Would New Yorkers support supervised injection facilities?

The New York Academy of Medicine (NYAM) and DOHMH conducted structured

focus groups and individual interviews regarding perspectives on supervised

injection services with key community and institutional stakeholders. Participants

represented a range of constituencies: law enforcement, health care, social and

community services, faith traditions, business development, and harm reduction.

Input from elected officials serving in New York City and State offices also was

solicited.

2. What are the potential health and fiscal benefits of a supervised

injection facility to New York City?

Researchers at Weill Cornell Medical College projected the impact of a supervised

injection facility on opioid overdose deaths and direct health care expenditures in

New York City, looking at emergency medical service usage, emergency department

visits, and hospitalizations. A Technical Advisory Group composed of global leaders

in supervised injection with expertise in economics, policy analysis, and clinical and

behavioral sciences offered guidance and oversight to this study.

3. What are the viable legal frameworks within which New York City could

establish a supervised injection facility?

A legal scholar from Columbia Law School assessed the current legal barriers to the

establishment of a supervised injection facility in New York City to identify potential

avenues for implementation. This review assessed federal, state, and municipal

criminal and civil laws and regulations that could be relevant to the establishment of

a SIF in New York City, as well as examples and lessons learned from other

jurisdictions across the United States. The findings from this review support the

feasibility of supervised injection facilities.

Supervised injection is an evidence-based health intervention for people who

inject drugs

Scientific evidence suggests that SIFs—like methadone maintenance treatment and syringe

exchange programs established in response to the previous opioid and HIV/AIDS crises—

prevent overdose and reduce the harms associated with injection drug use, including HIV

and hepatitis C transmission. Supervised injection facilities provide support and

connections to health and social services to marginalized individuals, particularly shelter

residents, so people who inject drugs can reduce their risk of death and take positive steps

toward healthier lives. In addition to the individual benefits, research from other

jurisdictions shows that SIFs may lead to long-term reductions in individual-level drug use

and community-level drug-related crime in areas where they are located, and thus save

taxpayer dollars on health care and crime control.

Key community leaders recognize the benefits of and challenges to establishing

supervised injection as a strategy to prevent overdose and reduce crime

Findings from NYAM’s community assessment and DOHMH’s stakeholder interviews

suggest that supervised injection facilities have the support of many medical, harm

reduction, business, faith, community, and elected leaders. Stakeholders acknowledged the

seriousness of the overdose crisis, the need for new solutions, and the functional approach

of SIFs. Stakeholders particularly appreciated SIFs’ role in linking participants to needed

medical, social, and community services. Some stakeholders highlighted potential

community concerns that SIFs could convey that drug use was being condoned or create

geographic concentrations of people who inject drugs. These community concerns could

lead to challenges with SIF placement, although these challenges may be mitigated through

co-location within existing harm reduction services as part of the continuum of care.

Almost all leaders and community representatives interviewed, however, acknowledged

the public health and safety benefits of supervised injection. Stakeholders emphasized that

meaningful community engagement and education would be critical to the success of SIFs,

particularly in any neighborhoods that could be selected for SIF placement. Additional

engagement is needed to best capture all community perspectives, as current findings are

limited to those who agreed to participate at the time of the study.

Establishment of four supervised injection facilities could conservatively avert

up to 130 overdoses and save up to $7 million in public health care costs

annually

Results from the impact study conducted by Weill Cornell Medical College found that

locating SIFs in four New York City neighborhoods most severely affected by fatal drug

overdose could prevent up to 130 overdose deaths each year and reduce associated annual

costs to the City health care system by up to $7 million. The estimates generated by this

study are conservative, as they do not include reduction in crime or chronic disease

treatment costs associated with injection drug use. The cost-savings of a SIF would be

offset by the costs to operate a SIF. These costs would vary depending on the model and

hours of operation. On the low end, a SIF could be implemented for $250,000 annually; on

the upper end, a new, freestanding facility with long hours could cost between $2 and $3

million.

Legal establishment of supervised injection facilities in New York City is possible

Findings from the legal review suggest that, despite legal barriers, state and municipal

options exist to establish one or more SIFs in New York City. Any avenue would require

engaging diverse representatives from public health, public safety, law enforcement,

advocacy and community groups, and elected officials in the planning process.

Taken together, these findings have led to a series of recommendations regarding the

planning and implementation of a SIF to supplement New York City’s comprehensive

overdose prevention strategy. In particular, the recommendations presented in this report

aim to leverage New York City’s existing treatment and social service resources to integrate

SIFs within established networks of care. A wide range of stakeholders in New York City

support supervised injection as a strategy, but also acknowledge potential community

concerns in establishing supervised injection services. Our recommendations around SIFs

build on the legacies of methadone maintenance treatment and early grassroots adoption

of syringe exchange programs by health advocates, medical and social service

professionals, and scientists in New York City. Additionally, New York City has a strong

network of health and social service agencies, and productive collaboration between the

public health and public safety communities—all essential partners to launch SIFs.

What follows are detailed findings from the three commissioned studies, supplementary

data collected by DOHMH, and a comprehensive review of the existing body of scientific

evidence on supervised injection. Overdose affects all New Yorkers. To learn more about

overdose prevention, we invite readers to visit: www1.nyc.gov/site/doh/health/health-

topics/alcohol-and-drug-use-prevent-overdose.page.

BACKGROUND

Overdose in New York City

The United States is in the midst of a overdose epidemic, with over 63,000 deaths in 2016

due to overdose. The majority of these deaths (66%) are caused by opioids, a drug class

that includes prescription painkillers, heroin, and the highly potent synthetic compound

fentanyl.

The entire nation—East and West, North and South, urban and rural—has been

touched by this crisis, which has shown no signs of slowing down.

Like the rest of the country, New York City has experienced alarming increases in overdose

deaths over the last 15 years. The number of deaths from overdose in New York City have

more than doubled since 2000, with an increase of over 2.5 fold since 2010. In 2017,

provisional data shows that 1,441 overdose fatalities ocurred in New York City, the highest

number ever recorded. Over 80% of these deaths involved opioids.

Someone dies every

seven hours of overdose in New York City; there are more annual deaths from opioid

overdose than from car crashes, suicides, and homicides combined.

Figure 1: Number of unintentional drug poisoning (overdose) deaths by year,

New York City, 2000 – 2017

Source: New York City Department of Health and Mental Hygiene, Unintentional Drug Poisoning (Overdose) Deaths Quarters 1-4, 2017,

New York City, released April, 2018.

200

400

600

800

1000

1200

1400

1600

Number of overdose

deaths

1,441 overdose deaths

deaths

Figure 2: Number of deaths from unintentional drug poisoning (overdose) compared to intentional self-harm

(suicide), assault (homicide), and motor vehicle crashes in New York City, 2006 – 2017

Source: New York City Department of Health and Mental Hygiene, Unintentional Drug Poisoning (Overdose) Deaths Quarters 1-4, 2017,

New York City, released April, 2018.Li W, Sebek K, Huynh M, Castro A, Gurr D, Kelley D, Kennedy J, Maduro G, Lee E, Sun Y, Zheng P, and

Van Wye G. Summary of Vital Statistics, 2015. New York, NY: New York City Department of Health and Mental Hygiene, Bureau of Vital

Statistics, 2017.

Zimmerman R, Li W, Gambatese M, Madsen A, Lasner-Frater L, Van Wye G, Kelley D , Kennedy J, Maduro G, Sun Y. Summary of Vital

Statistics, 2012. New York, NY: New York City Department of Health and Mental Hygiene, Bureau of Vital Statistics, 2013.

Although prescription painkillers helped to drive the increase in the rate of overdose

deaths in New York City from 2010 to 2011, the proportion of overdose deaths involving

opioid analgesics had decreased to 18% by 2016, from a high of 35% in 2011.

Between

2011 and 2014, a rise in heroin-involved overdoses drove the increases in overdose deaths.

Beginning in 2015, New York City has experienced the emergence of fentanyl, which was

involved in nearly half (44%) of all overdose deaths by the end of 2016.

1000

2000

2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017

Number of deaths

Deaths From Overdose

Deaths From Suicide, Homicide, and Motor Vehicle Crashes

1,441 overdose deaths

Fentanyl: A public health crisis

Fentanyl is a highly potent synthetic opioid propelling drug overdose deaths to

record numbers. While fentanyl is a prescription medication used for cancer-related

pain or palliative care, non-pharmaceutical fentanyl has been introduced into illicit

drug markets in New York City and nationally in recent years. Typically, fentanyl

found in the illicit drug supply typically is not sourced from diverted prescriptions,

but rather is produced in illicit laboratories and used as a common adulterant to

heroin, cocaine, and counterfeit pills—including opioid analgesics, such as

oxycodone, and benzodiazepines, such as Xanax. The presence of fentanyl in illicit

drugs puts people who use them at enormously increased risk of overdose.

Fentanyl’s potency is such that a small amount can induce overdose; as a fast-acting

opioid, overdoses involving fentanyl can occur within minutes of ingestion.

Toxicology analyses indicate that fentanyl drove the increase in overdose deaths

from 2015 to 2016. Deaths involving fentanyl have increased nearly every quarter

since 2015, constituting almost half (44%) of all overdose deaths in 2016.

The acceleration of overdose deaths since the introduction of non-pharmaceutical

fentanyl in the New York City drug supply has brought a mutual recognition among

the public health and safety communities that new and different strategies must be

considered.

Many people who inject drugs in New York City are aware of the risks of fentanyl

and generally do not seek it out.

Typically fentanyl is introduced into illicit drug

mixes at the level of the supplier. As a result, people who use drugs and street-level

drug sellers are unlikely to know whether a certain product does or does not

contain fentanyl.

17, 18

Additionally, other non-pharmaceutical fentanyl analogues

may not yet be identifiable by existing laboratory tests.

Figure 3: Number of drug overdose deaths and percent of overdose deaths involving fentanyl in New York

City, by quarter, 2014-2016

Source: Paone D, Nolan ML, Tuazon E, Blachman-Forshay J. Unintentional Drug Poisoning (Overdose) Deaths in New York City, 2000–

2016. New York City Department of Health and Mental Hygiene: Epi Data Brief (89); June 2017.

10%

20%

30%

40%

50%

60%

100

200

300

400

2014 2015 2016

Percent fentanyl

Number of

overdose deaths

Number of overdose deaths

Percent of overdose deaths involving fentanyl

Overdose affects all neighborhoods in New York City and cuts across lines of race, class,

age, and gender. However, certain populations and neighborhoods bear a disproportionate

burden of overdose deaths. Residents of both poor neighborhoods with endemic heroin-

related issues and affluent neighborhoods with more recent heroin- and fentanyl-related

issues experience some of the highest rates of opioid-involved overdose citywide. In 2016,

Staten Island and the Bronx experienced the highest rates of fatal overdose in New York

City in 2016 (31.8 and 28.1 per 100,000 residents, respectively), over two times higher

than residents of other boroughs. The largest numbers of deaths in 2016 occurred among

residents of the Bronx and Brooklyn, with 308 and 297 deaths, respectively. The breadth of

harm spans East Harlem in Manhattan, Hunts Point-Mott Haven in the Bronx, and South

Beach-Tottenville in Staten Island, as well as neighborhoods in other boroughs.

Taken

together, these numbers illustrate the widespread but unequal burden across the city.

Figure 4: Top five New York City neighborhoods: Rates of unintentional drug poisoning (overdose) involving

heroin and/or fentanyl by neighborhood of residence, 2016

Source: Paone D, Nolan ML, Tuazon E, Blachman-Forshay J. Unintentional Drug Poisoning (Overdose) Deaths in New York City, 2000–

2016. New York City Department of Health and Mental Hygiene: Epi Data Brief (89); June 2017.

Overdose death rates have increased dramatically among all racial groups from 2015 to

2016. In 2016, white New Yorkers experienced the highest rate (18.9 per 100,000) of

heroin- and/or fentanyl-related overdose death citywide, followed by Latino/a New

Yorkers (16.9 per 100,000); the rate among black New Yorkers was 12.3 per 100,000.

Rate of overdose deaths involving

heroin and/or fentanyl, 2016

0.0

10.0

20.0

30.0

(per 100,000 residents)

Although males experience rates of overdose from heroin and/or fentanyl over four times

that of females, both male and female New Yorkers experienced substantial fentanyl-driven

increases from 2015 to 2016.

Individuals who reside in shelters or are undomiciled are at increased risk of overdose.

These individuals represented 7% of the overdose deaths in New York City in 2016, despite

comprising less than 1% of the City population.

Overdose is now the leading cause of

death for this population, overtaking heart disease in FY 2014.

Furthermore, people who

inject drugs in public or semi-public locations, many of whom are homeless or unstably

housed, are at heightened risk of infectious disease transmission (HIV and hepatitis C) and

other harms associated with injection drug use.

2015 2016

White and Black race categories exclude Latino ethnicity.

Latino includes Hispanic or Latino of any race.

*Data for 2015 and 2016 are provisional and subject to change.

Source: Paone D, Nolan ML, Tuazon E, Blachman-Forshay J. Unintentional Drug Poisoning (Overdose) Deaths in New York City,

2000–2016. New York City Department of Health and Mental Hygiene: Epi Data Brief (89); June 2017

Number of overdose deaths

Figure 5: Increase in number of unintentional drug poisoning (overdose) deaths involving

heroin and/or fentanyl, by race/ethnicity, from 2015 to 2016*, New York City

Black

Latino

White

100

200

300

400

206

416

274

211

319

HealingNYC

Expanding New York City’s Response to the Overdose Crisis

In recent years, New York City has established itself as a national leader in addressing the

overdose epidemic through public health and public safety interventions. In March 2017,

the City committed an additional $38 million annually over five years to fight overdose

through HealingNYC, an innovative, multi-pronged agenda focused on four areas. In March

2018, the City expanded HealingNYC by an additional $22 million annually.

1. Prevent opioid overdose deaths

2009: DOHMH began to provide naloxone—a medication used to reverse the effects of an

opioid overdose—to syringe exchange programs and other registered opioid overdose

prevention programs for distribution to laypeople to carry and respond to overdose.

2013: The New York City Police Department (NYPD) equipped approximately 1,000 patrol

officers in the precincts with the highest rates of opioid-involved overdose with naloxone.

2014: The New York City Fire Department (FDNY) equipped emergency medical

technicians and certified first responder firefighters with naloxone. FDNY reported using

naloxone to reverse over 180 overdoses per month in the second half of 2016.

2014: Correctional Health Services, a division of New York City Health + Hospitals (H+H),

established one of the first jail-based naloxone distribution programs at the Rikers Island

Visitor Center. As of September 30, 2017, the program has distributed over 6,000 kits to

the families and friends of incarcerated persons, who are at elevated risk of overdose

following release from jail.

2015: The New York City Commissioner of Health authorized naloxone distribution by

pharmacists under a non-patient specific prescription (standing order), and the medication

is now available to laypeople without a personal prescription in over 725 pharmacies

citywide. Naloxone is now effectively available over the counter.

2016: The New York City Department of Social Services (DSS) trained all its shelter

providers in naloxone administration to ensure 24/7 overdose prevention coverage in the

City shelter system.

As part of HealingNYC, New York City committed to:

 Distribute 65,000 naloxone kits in 100 services citywide, including, but not limited

to: treatment, detoxification, harm reduction, and other programs serving at-risk

New Yorkers and their families and loved ones

 Equip all 23,000 NYPD patrol officers with naloxone and train all officers in

overdose response

 Distribute 5,000 naloxone kits annually through the Rikers Island Visitor Center

program to directly target those individuals at increased risk

 Increase the number of pharmacies offering naloxone without a prescription to

1,000

 Distribute 6,500 kits in City shelters and continue to train Department of Social

Services shelter providers in naloxone administration

2. Prevent opioid misuse and addiction

2011: DOHMH developed New York City’s judicious opioid prescribing guidelines, which

served as the model for the guidelines issued by the Centers for Disease Control and

Prevention in March 2016. DOHMH’s guidelines subsequently were implemented in public

hospital emergency departments and private hospitals throughout the city.

2013: DOHMH employed public health detailing methods—delivering judicious

prescribing, overdose prevention, and door-to-door treatment messaging to health care

providers—to reach nearly 900 health care providers on Staten Island.

2015-2017: DOHMH expanded its door-to-door health care provider detailing efforts to

over 1,000 providers in the Bronx and nearly 1,000 providers in Brooklyn.

2016-2017: The City ran the “I Am Living Proof,” “Save a Life, Carry Naloxone,” and “I Saved

a Life” public awareness campaigns, its largest drug treatment and overdose prevention

public education campaigns to date.

2017: DOHMH launched Relay, a peer-based crisis intervention and overose prevention

service for individuals in emergency rooms following a nonfatal overdose event. At the

time of HealingNYC’s launch, the program was operational in four hospitals across the city.

As part of HealingNYC, New York City committed to:

 Create mental health clinics in high-need schools to address youth substance use

and intervene early to prevent misuse and addiction before it starts

 Deliver targeted prevention and treatment messaging in primary care settings to

communities at high risk of overdose

 Train 1,500 clinicians annually in judicious opioid prescribing to reduce

overprescribing

 Expand Relay to 15 emergency departments citywide

Public health detailing in New York City

Public health “detailing” campaigns deliver critical education and prevention

messaging directly to health care providers. Providers engage in one-on-one visits

with DOHMH representatives during which they receive educational messages

about the judicious prescription of opioid analgesic and benzodiazepine

medications and means to reduce patient risk of overdose. Judicious prescribing

messages recommend that prescribers utilize the lowest effective dose for the

shortest duration necessary to reduce the risk of overdose or other harms. Detailing

is a key component of the City’s prevention strategy, reaching providers to help

prevent substance misuse before it starts.

3. Connect New Yorkers to effective treatment

2007: Correctional Health Services, which operates the oldest jail-based methadone

maintenance treatment program in the nation (since 1987), first introduced

buprenorphine treatment to individuals detained at Rikers Island as part of a research

study. Rikers Island now offers access to both methadone and buprenorphine.

methadone, buprenorphine is a medication that is highly effective in treating opioid use

disorder.

2016: DOHMH funded an innovative buprenorphine treatment model that supports nurse

care managers (NCM) in seven primary care organizations that run federally qualified

health centers. These NCM programs support primary care clinics and their clinicians to

provide comprehensive substance use care for patients with buprenorphine treatment.

As part of HealingNYC, New York City committed to:

 Train an additional 1,500 health care providers in buprenorphine prescribing, with

a focus on engaging nurse practitioners and physician assistants, who are newly

eligible to prescribe buprenorphine under federal law

 Expand the City’s nurse care manager for buprenorphine treatment model to

provide case management services and increased patient adherence to an additional

seven federally qualified health centers

 Start addiction treatment and care management with buprenorphine prescribing in

all New York City H+H primary care clinics

 Establish buprenorphine induction, the first phase of maintenance, in at least 10

New York City emergency departments

 Embed buprenorphine maintenance treatment in up to seven harm reduction

programs

 Transform the New York City H+H substance use care network into a system of

excellence in addressing harmful opioid use

 Increase the daily number of patients in the New York City jail system receiving

methadone to 600 and buprenorphine to 150, and offer individualized treatment

plans and connections to care for these patients upon release

 Engage health professional training programs and health systems leadership to

cultivate workforce readiness and optimize responses to treatment needs

 Connect New Yorkers involved with the criminal justice system to substance use

services through the HOPE (Heroin Overdose Prevention and Education) Program

Connect New Yorkers with substance use and mental health problems to necessary

treatment services through by establishing Health Engagement and Assessment

Teams (HEAT)

4. Reduce the supply of dangerous opioids

2012: DOHMH and the New York/New Jersey High Intensity Drug Trafficking Area

launched New York City RxStat, a public health and safety working group comprised of

over 25 City, State, and federal agencies that share information about overdose and

strategize collaborative policies and interventions to reduce overdose death. RxStat has

been hailed as a leading national model by Former President Obama’s White House Office

of National Drug Control Policy and the United States Department of Justice.

2015: NYPD increased heroin seizures by 32% citywide.

2016: NYPD and the Staten Island District Attorney’s Office launched the Overdose

Response Initiative to investigate overdose deaths to rapidly identify dealers, dismantle

distribution operations, and provide assistance to families and friends of overdose victims.

As part of HealingNYC, NYC committed to:

 Increase laboratory and technology capacity at the NYPD and Office of the Chief

Medical Examiner narcotics testing labs to identify new dangerous synthetic drugs

and target supply reduction operations

 Expand the Overdose Response Initiative to more neighborhoods

 Add NYPD personnel to New York City airports, highways, and ports to disrupt the

opioid supply at the level of trafficking

The continuum of care for people who use drugs

The identification, diagnosis, care, and treatment of substance misuse and substance

use disorders are part of a range of services available to people who use drugs.

Termed the continuum of care, these services span multiple health care settings,

from specific programs for substance use, like overdose prevention programs and

opioid treatment programs, to medical settings such as hospitals, emergency care,

and primary care that address individuals’ general health needs. Providing a range

of services with complementary goals and capabilities allows people who use drugs

to enter this continuum and receive care that matches their needs.

Primary care, emergency medical systems, and hospitals can effectively leverage their

high volumes of patient contact to identify substance use disorders and initiate

treatment—particularly medication for addiction treatment—among patients at

risk of overdose or other negative health outcomes. Practitioners in these settings

can treat the complications of substance use disorders and provide connections and

referrals to other parts of the continuum of care that would meet an individual

patient’s needs.

Treatment for opioid use disorder is most effective when it includes the use of

medication, termed medications for addiction treatment (MATs). The best-studied

medications are methadone and buprenorphine. Both medications have been shown

to decrease the risk of death from overdose and increase the likelihood of

individuals reducing or ceasing their drug use and improving their social and

economic lives. These medications can be used as long-term treatment depending

on individual need. Medications for addiction treatment also reduce the risk of

HIV/AIDS, chronic hepatitis C infection, other health problems, and even

engagement in criminal activity.

Harm reduction programs provide services and programing for people who use and

inject drugs. These programs may include but are not limited to syringe exchange

programs, support groups, and treatment services. Harm reduction programs aim to

serve people who use drugs by providing connections to support services, such as

housing, public benefits, education, or workforce programs.

Supervised injection facilities provide a space for people who use and inject drugs to

do so safely, in private settings with medical staff who can readily respond to an

overdose. SIFs reduce other risks associated with injection, such as bloodborne

disease transmission, and alleviate the threat of arrest and incarceration. On-site

medical, substance use treatment, and social services allow individuals to receive an

appropriate level of support.

A Legacy of Public Health Innovation

in New York City

The current opioid overdose epidemic is not the first drug-driven health epidemic to

necessitate an innovative public health response in New York City. New Yorkers have a

recognized history of national leadership in responding to substance use and associated

harms with scientifically grounded innovative approaches that protect public health.

1960s and 1970s

New York City experienced its first large-scale increase in injection heroin use in the

decades following World War II. By the 1960s, heroin-involved overdose was the leading

cause of death among New Yorkers between the ages of 15 and 35, with 75% of deaths in

this age group attributed to heroin overdose.

In response, the world’s first methadone

maintenance treatment program (MMTP) was established as a research pilot at Rockefeller

University in 1964. Methadone is a medication that prevents withdrawal symptoms and

reduces cravings for people with opioid use disorder. This groundbreaking pilot

demonstrated the efficacy and safety of methadone as a long-term maintenance therapy.

Over the next decade, MMTPs were institutionalized across the New York City health care

system and prescribed to approximately 34,000 patients. Scientific evidence and rigorous

evaluations indicating MMTPs’ association with decreases in overdose, drug-related crime,

and hepatitis transmission helped to push forward public and governmental acceptance

and propel the treatment toward wider use.

By the close of the 1970s, the heroin

overdose epidemic declined in large part due to the expansion of methadone maintenance

treatment.

While methadone maintenance is now widely accepted as the standard of care

for treating opioid use disorder, the intervention initially faced significant opposition.

However, the combined efforts of scientists, health care professionals, advocates, and

government led to the program that exists today. Approximately 30,000 people are

currently enrolled in methadone maintenance treatment in New York City.

1980s and 1990s

The second drug-driven epidemic New York City faced was the catastrophic rise of

HIV/AIDS in the 1980s and early 1990s. By 1984, an estimated 100,000 people who

injected drugs were infected with HIV in New York City, the highest disease concentration

among people who injected drugs in the United States.

Without access to sterile syringes,

HIV was spreading and people were dying at alarming rates, as sharing injection equipment

and paraphernalia greatly increases the risk of bloodborne disease transmission.

Advocates and health researchers identified lack of access to sterile syringes as a risk factor

in disease transmission and advocated for increased access to sterile syringes.

This collaboration resulted in the founding of syringe exchange programs (SEPs), now an

accepted public health intervention despite initially vehement opposition in the 1980s.

Opponents charged that syringe exchange programs condoned drug use and would lead to

increased drug use and crime in communities. However, evaluations of SEPs in Europe

indicated the contrary: SEPs led to reductions in community drug use and crime and, most

importantly, reductions in HIV transmission.

Despite the strength of this scientific

evidence, governmental opposition to syringe exchange continued in the United States.

Health advocates, unable to obtain licensure or approval to open a formalized service,

distributed syringes underground to quell the HIV epidemic.

By the early 1990s, the scientific evidence was overwhelming that syringe exchange

reduced HIV transmission. Proven effectiveness along with the mounting toll of AIDS,

which took so many lives, spurred government to action. In May 1992, after a decade of

advocacy by scientists and activists,

the New York State Department of Health adopted

emergency regulations to authorize the possession and distribution of syringes without a

prescription. This emergency regulation was adopted into law in October 1993, and the

first formal and legal syringe exchange pilot began in New York City, supported by a grant

from the Foundation for AIDS Research (amfAR). An evaluation confirmed the pilot’s

effectiveness in reducing risk behavior and HIV infection, with no documented increases in

injection drug use or negative impacts at the community level.

As evidence of the health

benefits of SEPs in New York City grew, more sites opened across the city and the scope of

SEPs expanded to offer a broad range of essential services, such as on-site medical care,

substance use treatment, and housing placements. By the late 1990s, these programs were

attributed with driving down the prevalence of HIV infection among people who inject

drugs, and further, reducing HIV transmission to sexual partners.

This momentum has

continued; in 2001 New York State implemented the expanded syringe access program to

make syringes available without a prescription in pharmacies and medical settings

statewide. Syringe exchange programs remain a significant contibutor to the overall

reduction in HIV cases in New York City.

Although syringe exchange has become institutionalized in New York City, the intervention

remains contested in some jurisdictions across the United States and to date remains illegal

in 23 states. Indiana—one state where syringe exchange is illegal—experienced an

outbreak of HIV infections in 2015 in rural communities of people who inject drugs.

Researchers quickly linked the outbreak directly to unsafe and unhygienic injection

practices. Deeply held opposition to syringe exchange among Indiana government officials

and national coverage of the outbreak reopened a public debate about the intervention.

Proponents urged state leaders to lift the ban on syringe exchange. Opponents eventually

permitted the practice temporarily on an emergency order from the governor. In the year

between detection of the outbreak and the opening of syringe exchange, nearly 200

individuals in Scott County tested positive for HIV, compared with only five HIV diagnoses

in the county between 2004 and 2013. Following the implementation of syringe exchange

in the affected counties, the pace of infection slowed and the outbreak was contained.

2000s and 2010s

The current opioid epidemic in the United States began more than 15 years ago, driven by

the aggressive marketing of opioid analgesic medications by the pharmaceutical industry.

The epidemic has escalated since 2010, particularly due to demand for heroin and more

recently the introduction of fentanyl into the illicit drug supply. As a result of fentanyl, drug

overdose deaths are at unprecedented levels nationally and in New York City. While new

health and safety resources have been devoted to overdose prevention at the local, state,

and federal levels, the sheer magnitude of this epidemic has compelled scientists, health

experts, professional societies, and advocates in the United States to reassess how to

address substance use. Among the range of additional strategies under discussion are SIFs,

which have been shown to reduce overdose deaths in people who are most vulnerable,

including people who are unstably housed.

Supervised injection facilities were established in Europe in 1992. This model has been

adopted widely in Europe—initially in Switzerland, Germany, and the Netherlands—as

well as more recently in Australia and Canada. Supervised injection facilities now operate

in more than 10 countries. Abundant scientific evidence supports the effectiveness of SIFs

to reduce deaths and other health consequences of injection drug use while facilitating

access to the continuum of care. At the same time, the data refutes concerns that SIFs

would cause increases in drug use or crime. Based on this information, many advocates and

professional health bodies publicly support the establishment of SIFs and ask that local and

state governments implement this strategy as a lifesaving measure. In response, legislation,

new policy, or studies are in progress in Colorado, Maryland, Maine, Massachusetts, New

York City and Ithaca, Philadelphia, San Francisco, and Seattle.

WHY SUPERVISED INJECTION

FACILITIES?

A Review of the Evidence

Supervised injection facilities are one of many overdose prevention strategies available to

public heath authorities. They have been shown to improve individual and community

health, increase public safety, and reduce the health and social consequences of injection

drug use through medically supervised use of injected substances. Supervised injection

facilities offer hygienic spaces where people who inject drugs can inject pre-obtained

substances with sterile equipment. Medically trained staff are on-site to respond to

potential overdose events, although these staff do not assist with injection. Most

established SIFs refer or provide access to a host of on-site health, mental health, substance

use, and social services that supplement existing harm reduction and syringe exchange

services through increased opportunities for engagement, education, and treatment.

Approximately 100 SIFs operate in 10 countries and 67 cities worldwide, with six

additional facilities scheduled to open across Europe and Canada over the next two years.

Although no SIFs exist in the United States, a number of jurisdictions have announced

intentions to open or explore the possibility of opening these facilities, including Colorado,

Maryland, Maine, Massachusetts, Seattle, San Francisco, and Ithaca, New York.

A growing body of scientific evidence, generated primarily though evaluations of existing

facilities, suggests the safety and effectiveness of SIFs. To date, no fatal overdose has been

documented in a SIF anywhere in the world.

Supervised injection facilities reduce overdose mortality and associated harms

Community impact studies conducted in Vancouver, Canada, have found reductions in fatal

overdose of up to 35% in communities where SIFs are located.

Evaluations of a SIF in

Sydney, Australia, have demonstrated reductions of up to 80% in overdose-related

emergency medical service calls in areas surrounding SIFs.

The safe and “low-threshold”

access to safer injection, overdose prevention, health care, and drug treatment services

provided by SIFs are associated with decreases in risk-taking behavior among consistent

SIF visitors and reductions in the harms associated with public injection.

Supervised injection facilities improve access to health care and social services

People who use drugs may face stigma that can create barriers to accessing medical and

mental health care and social services.

By offering on-site medical services, SIFs increase

access to routine primary care for people who inject drugs and facilitates linkages to

ancillary services.

Evaluation of Vancouver’s SIF found that on-site and referred

That is, minimal barriers to entry, free, and with few or no demands on the individual in exchange for the

service.

medical services provided to SIF visitors reduced the length of their hospital stays and

improved overall health.

Supervised injection facilities reduce injection-related health risks

By providing sterile injection equipment and a safe space to inject, SIFs can further reduce

transmission of bloodborne infections, including HIV and hepatitis C (HCV). Conservative

estimates from Vancouver suggest that a single SIF can prevent up to 35 new cases of HIV

per year.

Supervised injection facilities also have been shown to reduce bacterial

infections associated with non-sterile injection equipment.

Supervised injection facilities,

as well as syringe exchange programs, educate clients about safer injection techniques and

proper syringe disposal, which disseminate through networks of people who inject drugs

and can lead to increased community use of safe and hygiene techniques.

Research

indicates that individuals who inject in public or semi-public locations are at heightened

risk of injection-related health complications since their injection is often rushed out of fear

of being sighted, interrupted or arrested. Rushed injections increase risks of using non-

sterile equipment, developing and spreading infections, and overdosing. As the majority of

individuals who inject publicly are homeless or unstably housed,

SIFs are particularly

well-suited to meet the needs of this high-risk and underserved population.

Supervised injection facilities increase referrals to drug treatment

Supervised injection facilities, like other harm reduction services, have been shown to

increase referrals to and uptake of drug treatment and detoxification and, over time, are

associated with drug use cessation.

These findings serve as an important reminder that

SIFs, harm reduction, and treatment are all points along a continuum of care for people

who use drugs.

Supervised injection facilities provide outreach, engagement, and care to

marginalized populations

Supervised injection facilities function as spaces to engage and connect marginalized or

disconnected populations with health care, harm reduction, and other social services.

Research has demonstrated that SIFs may function as safe havens for women who inject

drugs, thereby reducing violence against women associated with street-based drug use.

Similar findings have shown increased engagement with homeless or unstably housed

young adults, a group at elevated risk of overdose and infectious disease transmission.

Supervised injection facilities reduce health care expenditures

Evaluations of SIF sites worldwide have demonstrated annual savings of up to $3.5 million

per site in averted HIV and HCV treatment costs.

Other estimates suggest savings of up to

$18 million over a 10-year period based on the number of averted overdose deaths.

Supervised injection facilities do not increase crime or drug use

A number of studies, reviewed below, have examined whether SIFs have negative effects on

communities, including increased crime, drug use, or concentrations of people who use

drugs in the neighborhood in which a SIF is located. The potential for SIFs to have negative

effects on communities is one of the most frequent concerns raised.

Some opponents of supervised injection have suggested that SIFs increase drug-related

crime in areas where they are located. While this may seem like an intuitive conclusion

given that drug use remains illegal in the United States, research from Vancouver, Canada,

observed decreases in a range of drug-related crimes following the establishment of a SIF,

including decreases in drug sales, drug solicitations, and public injection.

Research from

Sydney, Australia, demonstated decreases in public perception of public injection,

discarded syringes, and drug-related crime.

Other studies evaluating the effects of SIFs on

their surrounding communities in Sydney have shown declines in vehicle break-ins and

auto theft and neutral effects on levels of drug trafficking, assault, or robbery in

communities with SIFs.

Opponents of SIFs have also suggested that these services promote drug use and

discourage treatment. However, evidence from Vancouver, Canada, suggests that SIFs

reduce drug use in neighborhoods where they are located, by providing engagement and

connections to harm reduction and drug treatment services.

SIFs can serve as an entry

point into the continuum of care and lead to reductions in drug use and drug-related health

and social consequences.

As reported above, SIFs increase participation in drug

treatment and are associated with long-term drug use cessation.

Additionally, some opponents of supervised injection facilities have suggested that these

services may facilitate initiation into substance use or substance use injection, particularly

among youth. Like syringe exchange programs, most SIFs are not accessible to individuals

under age 18. Research has shown, however, that the majority of SIF clients are long-term

injectors, with an estimated average injecting history of 16 years.

Additionally, SIFs

reduce the number of publicly-discarded syringes in communities where they are located

and thus reduce community exposure to injection drug use.

This reduced community

exposure to drug use can function as a prevention measure, particularly as SIFs are often

situated in areas with high concentrations of public drug use, drug-related activity, and

crime.

Opponents of SIFs have expressed concerns that these services may draw large numbers of

people who use drugs into communities where they don’t live. However, research has

shown that the majority of individuals who use SIF services are not likely to travel more

than 20 minutes to a given facility.

Existing SIFs have been located in areas with high

densities of drug use and overdose and function as a targeted health intervention for these

communities. Furthermore, this same concern arose in reaction to the early

implementation of syringe exchange programs and was disproved through evaluation of

SEPs.

WOULD NEW YORKERS SUPPORT

SUPERVISED INJECTION FACILTIES?

Community Support for and Concerns about Supervised

Injection

To assess the opinions of key stakeholders regarding the feasibility of opening a supervised

injection facility in New York City, the New York Academy of Medicine (NYAM) and the

New York City Department of Health and Mental Hygiene (DOHMH) jointly conducted a

community assessment. The assessment included focus groups and interviews with a range

of key stakeholders across the city. Findings are limited to those who agreed to participate

in the focus groups and interviews; several key stakeholders who have been vocal critics of

supervised injection were unavailable at the time of the study. Additional engagement is

need to best capture all community perspectives. An Expert Advisory Panel comprised of

national and international experts in supervised injection—including leading

epidemiologic and economic researchers, experts in drug policy and law, and advocates—

drew on research and implementation exertise to help identify stakeholder groups and

provide input into the study design and interview materials. A list of Expert Advisory Panel

members can be found in the Acknowledgments.

The assessment occurred in two parts. First, focus groups were conducted with a total of 52

people who use drugs to investigate if and how a SIF could meet the needs of this unique

and at-risk population in New York City. These focus group participants were asked about

their willingness to use a SIF, preferences regarding the types of services offered,

suggestions about the operational components of a facility, and perceived benefits and

concerns about SIFs.

Second, focus groups and individual interviews were conducted with a range of

stakeholders across New York City, including:

 Elected officials

 Law enforcement officials

 Health care providers

 Community leaders

 Faith leaders

 Business community representatives

 Harm reduction program staff and management

The interviews and focus groups with the above stakeholder groups—which captured the

perspectives of 71 individuals separate from the sample of people who use drugs—aimed

to solicit opinions regarding community need for supervised injection services, gather

concerns about possible health or safety consequences that may be associated with a SIF,

and identify operational components of a SIF that communities consider essential.

Findings from both sets of focus groups and interviews are presented below.

People who use drugs: Perspectives on supervised injection

Between December 2016 and March 2017, researchers from NYAM conducted six focus

groups with a total of 52 people who use drugs. Participants were recruited from harm

reduction programs in the Bronx, Brooklyn, and Manhattan. Researchers obtained

informed consent from all individuals prior to participation. Focus groups were conducted

anonymously and confidentially; no identifying information was obtained. Focus groups

were audio-recorded and fully transcribed for analysis. Participants received a $25

honorarium for their time.

At the beginning of each focus group, participants completed a short written demographic

questionnaire—the results of which are presented in Figure 6. Following the demographic

survey, researchers provided an overview of SIFs, including photographs and/or videos of

existing facilities to demonstrate what SIFs look like in practice. Researchers utilized an

open-ended interview schedule to guide the remainder of the focus group. Interviews

broadly probed: participant perceptions on supervised injection facilities, including

individuals’ willingness to attend or consider attending such a facility; operational aspects

of supervised injection facilities, including facilitators and barriers to access; and perceived

benefits and concerns about SIFs that might affect people who use drugs.

Figure 6: People who use drugs, demographic characteristics (n=52)

Total

100%

Age

18-30

15%

31-40

27%

41-50

37%

51-60

15%

60 & older

Gender

Male

67%

Female

29%

Transgender

Gender non-conforming

Race/Ethnicity

White

21%

Black/African American

14%

Latino/a

42%

Multi-racial

19%

Other

Housing status

Own home

27%

Other’s home

25%

Unstably housed

33%

Street homeless

15%

Could include: shelter, single room occupancy (SRO) facility, drug treatment facilty, supportive/transitional/three-quarter housing, or

hospital

Figure 7: Supervised injection facility, Vancouver, Canada

Photo courtesy New York Academy of Medicine

Three themes emerged during analysis of the focus group data: health and safety benefits;

site design and service integration; and community stigma.

Health and safety benefits

A number of participants discussed the fear they experience while injecting in public: fears

of being seen, interrupted, or arrested; and notably the fear of death due to injection alone

or in a clandestine location. Many participants considered supervised injection a viable

means of alleviating that fear.

“You have staff there that’s going to look out for you and make sure that you don’t overdose.

In your own car, you can overdose and nobody is there.”

—Person who uses drugs

Participants also described SIFs as potential safe spaces for people at risk of victimization,

including women and homeless people. This function of SIFs was of particular importance,

as some participants had experienced victimization as a result of high-risk public use. The

covert nature of public injection demands that individuals rush the injection process, which

can lead to injury or further harm. Participants perceived supervised injection facilities as

one means to prevent rushed injection.

“I think supervised injection is excellent for people that are homeless don’t have nowhere to

go. They’re constantly going to bathrooms and going, you know, places where they’re not

welcome. People don’t make them welcome. People barging in, and sometimes it’ll hurt. There

are injuries to your arm or something.”

—Person who uses drugs

Additionally, participants emphasized that, contrary to popular perception, people who use

drugs care very much about their health and share information regarding health issues

within their drug-using social networks. Many participants framed SIFs as a means of

bringing together a community striving toward health.

“It gets very macabre and lonely to be alone and shooting up, drinking. . . Having a place to go

where there's others around me, it could be uplifting and not only save my life if I were to

overdose, but save my life in other ways.”

—Person who uses drugs

Service integration and site design

Participants overwhelmingly emphasized the need for any supervised injection facility to

offer on-site or linkages to health care and supportive social services. Noting that SIFs

would target people who inject drugs publicly, participants—many of whom were street

homeless or precariously sheltered—described access to housing and basic medical and

psychiatric services as a critical component of a SIF.

“Safe injection, safe needles, doctors, psychiatrists, case workers, housing. The SIF has to

incorporate those in, you know, to make things work.”

—Person who uses drugs

Regarding site design, participants discussed a need for consistent operational hours to

engage and build rapport with clients as well as encourage regular service use. Early

morning operating hours were presented as necessary to facilitate withdrawal

management for people who use opioids. Late night hours were suggested as preventive

safeguards against sexual assault and other forms of violence—particularly violence

against women—that may more likely occur at night.

“Being a female, I would personally prefer something with middle of the night hours, that

would be the ultimate safe place for me. I don’t know how strong it is what I’m using. I don’t

know how my body is going to react to that particular shot. I really would like to be

somewhere totally safe, specifically within the you know timeframe of like, you know, 12 to

five, 12 to four. “

—Person who uses drugs

Community stigma and resistance

Most participants anticipated opposition to supervised injection facilities within their

communities, with many individuals linking this perceived opposition to pervasive stigma

against people who use drugs. Most participants recounted personal experiences of stigma

associated with their drug use from family members, medical providers, community

members, or even strangers. The stigma these marginalized individuals described led them

to a reflexive assumption that the community would be opposed.

“Stigma is life. Stigma is real. We stigmatize each other and we don’t even realize it. And

that’s a shame, because we get enough from society, you know what I’m saying. We really

need to be very mindful about the words that we use and the way that we refer to somebody

who is just as human as the next person. Whether I use or not is irrelevant.”

—Person who uses drugs

New York City stakeholders: Perspectives on supervised injection

Between January and December of 2017, six focus groups and 39 individual interviews

were conducted with a total of 71 stakeholders representing the following disciplines,

backgrounds, and interests: State and local elected officials; law enforcement officials;

health care providers specializing in psychiatry, primary care, emergency medicine,

correctional health, addiction medicine, infectious disease, and pharmacy; faith leaders

representing the Buddhist, Christian, Islamic, and Jewish traditions; business leaders and

small business owners; harm reduction program staff and management; and local

community leaders. A breakdown of stakeholders by category is presented in Figure 8.

Figure 8: New York City stakeholders (n=71)

Business leaders and small business owners

Elected officials

Faith leaders

Harm reduction staff and management

Health care providers

Law enforcement officials

Local community leaders

Stakeholders were solicited for interviews by representatives from DOHMH and/or NYAM,

and all interviewees were assured of both organizational and personal confidentiality.

Focus groups and interviews were conducted using a structured interview guide that

probed perceived benefits and harms to communities and individuals that may result from

SIFs, as well as opinions on what features or services would be crucial to include in a

potential SIF. Consistent with the interviews with people who use drugs, at the start of the

interviews stakeholders were presented with background information about SIFs, which

included a fact sheet with results from studies and evaluations of SIFs worldwide and

photographs and/or videos of existing facilities. Audio recording was used at the

researchers’ discretion. At every interview, a designated scribe took detailed notes.

Demographic information was not collected at stakeholder interviews, and stakeholders

did not receive compensation.

Figure 9: Supervised injection facility, Sydney, Australia

Photo courtesy New York Academy of Medicine

Four themes emerged during analysis: health benefits; safety benefits; safety and

community concerns; and site design and community integration.

Health benefits

Across all stakeholders, there was broad agreement that reducing fatal overdose was a

critical need for their communities and New York City. Stakeholders generally

acknowledged the seriousness of the overdose crisis and the need for new solutions.

Regardless of whether stakeholders felt that SIFs were right for New York City, they nearly

all acknowledged that supervised injection is one evidence-based public health strategy

that could help avert overdose deaths.

“The idea of SIFs is creative but scary. A part of me says this is the wrong direction, but not

really, because there are so many people dying and in need.”

—Elected official

Some stakeholders—health care providers and harm reduction program staff, in

particular—viewed SIFs as an important step along the continuum of care for people who

use drugs and believed that engagement with these services could help individuals move

toward stability, health, and well-being. A number of health care providers considered SIFs

particularly important for individuals who might not be ready to fully curtail their drug use

and would otherwise be excluded from programs for which abstinence is a requirement.

Stakeholders who expressed this opinion generally viewed SIFs as an effective form of

overdose prevention and patient engagement—a way to keep people who use drugs alive

so that they may one day access treatment

“I think what people find the most challenging about caring for people who use drugs, is that

our [health care facility’s] model doesn't allow for continued drug use to be in care with us.

And so, we have to sometimes coerce or force a model onto a patient that isn't where they're

at in order for us to stay in a relationship.”

—Health care provider

Safety benefits

A number of stakeholders described a need for services that would reduce public injection

and publicly discarded syringes, which they viewed as hazards to public safety. Most

agreed that SIFs were one strategy to achieve these goals. The issue of community safety

was particularly salient among members of the business community, a number of whom

described some of the prior problems they had experienced with public injection and

public overdose in local places of business. These individuals were primarily interested in

whether SIFs would reduce high-risk drug use occurring in public and semi-public settings,

with many expressing the belief that moving public use into a private setting under medical

supervision would benefit both the community and the individual using the drugs.

“Often, a barista will be [at the café] by themselves at night, and [a person who injects drugs]

will use the bathroom, and then they'll sit down in the café and usually just be falling asleep or

nodding out. It's of concern because the staff isn't equipped to deal with that, and it's

upsetting to other customers, but it's also a concern to the person's health. I think that [a SIF]

is the best possible solution.”

—Small business owner

Some law enforcement officials viewed SIFs as potential cost-saving tools. When provided

with the evidence demonstrating localized decreases in both public drug use and

associated nuisance crimes following the establishment of a SIF, these stakeholders framed

the intervention in pragmatic, monetary terms. Even if they held reservations about

supervised injection, the possibility of reduced crime and criminal justice expenditures

functioned as a convincing argument for support.

“If SIFs give us less crime, less public drug use, and less vulnerability among drug users, police

will save enforcement resources. We need to enforce the law, but we also need to try things we

haven’t before.”

—Law enforcement official

“At the end of the day, it’s about serving the people. People who use drugs are real people with

real needs.”

—Elected official

Safety and community concerns

While concerns about SIFs were most frequently offered by law enforcement, all

stakeholders highlighted potential community concerns. First was the concern that

supervised injection could be perceived as condoning injection drug use, which remains

illegal in New York State. Some stakeholders framed the implementation of SIFs as

potentially negligent, given the increased overdose risks posed by fentanyl.

“I’m concerned that we’re arming people with the potential to kill themselves. The X factor is

what’s in the needle.”

—Law enforcement official

“We spend a lot of time trying to convince people that addiction is an illness. SIFs are almost a

bridge too far. It could have a terrible backlash.”

—Law enforcement official

Other stakeholders raised the concern that areas around a SIF might create new drug

markets in known locations and create geographic concentrations of people who inject

drugs. This perception could lead to challenges with SIF placement and generate pushback

from community members on the grounds that SIFs might bring new people who inject

drugs into their neighborhoods.

“Automatically you’ll have a fear issue. ‘Don’t you dare put that in my backyard.’ Needles?

They’ll say, ‘Oh my god, they’re bad people.’ Not that ‘people who use drugs are suffering.’”

—Local community leader

A handful of stakeholders raised the concern that their communities feel overburdened by

services for vulnerable populations and noted that community members were likely to

oppose a SIF on that basis. These stakeholders emphasized that their communities had

entrenched problems with regard to affordable housing, homelessness, workforce

development, and education that, for some individuals in their neighborhoods, might

supersede the needs of people who use drugs. Stakeholders emphasized that SIFs could

garner support in some communities by addressing some of these needs in addition to

offering overdose prevention and drug use services.

“It’s going to be hard to convince people that it works. We can’t even put supportive housing

in the neighborhood, because of the stigma surrounding the people who might occupy it.”

—Elected official

Some stakeholders, particularly more experienced elected officials and harm reduction

professionals, connected the current national debate about supervised injection with the

history of syringe exchange programs. These stakeholders recollected that similar concerns

were discussed widely in advance of the formal implementation of SEPs in the 1990s. They

noted that the political risk taken to implement SEPs ultimately benefitted the health and

safety of both individuals who use SEPs and their broader communities by reducing HIV

transmission.

“We don’t want to replicate the battle we fought about needle exchange. We need to educate

the public about the benefits: HIV reduction and overdose prevention.”

—Elected official

Site design and community integration

The majority of stakeholders suggested integrating supervised injection into established

harm reduction facilities rather than launching new facilities. They described a number of

perceived benefits of co-location within harm reduction programs: established credibility,

relationships, and trust with the surrounding communities and law enforcement; existing

on-site buprenorphine treatment services; existing on-site health and social services to

provide care and expedite and ease referrals; and existing expertise about injection drug

use and compassion for people who use drugs. Some stakeholders also suggested that

integration into harm reduction services could help assuage the concern that SIFs would

draw new people who use drugs to their neighborhood, as there is a substantial anticipated

overlap in use between syringe exchange and supervised injection.

“It’s a perfect idea to have the SIFs in the back and have the rest of the services out front.

Whatever people need they can just get.”

—Harm reduction professional

Stakeholders overwhelmingly agreed that a successful SIF ought to include co-located

health and social services. Individuals who are homeless and people who inject drugs in

public often are disconnected from health care, substance use treatment, housing, and

broader social services. Co-locating these services within SIFs would allow immediate

connections to be made. In particular, as SIFs sit at the early engagement end of the

continuum of care for people who use drugs, on-site or immediate access to drug treatment

services would allow individuals who feel ready to reduce or cease drug use to do so

immediately.

“We can’t just say over and over what a tragedy overdose is and do nothing about it. I like the

idea of a holistic approach to help people try to get better.”

—Law enforcement official

Nearly all stakeholders agreed that the success of a SIF was predicated on proactive

relationship-building between harm reduction program staff, medical providers, law

enforcement, and local community groups. This would involve preparatory outreach with

local police precincts to provide education on basic tenets of harm reduction and the

intended function and goals of the planned SIF. A successful model for this outreach exists

as part of the trust-building that has occurred between SEPs and local law enforcement.

Likewise, the SIF planning process must acknowledge, consider, and incorporate the needs

of police working with people who use drugs. A broad coalition of the stakeholders in this

assessment should be involved early in the planning and implementation processes for

establishing a SIF.

“I would welcome this in my district, but the community engagement piece is critical. You

need to start laying the groundwork now, because this will be contentious.”

—Elected official

“Are you going to find resistance? Yes. Are you going to need to educate? Absolutely. It will be

important to emphasize SIFs as one of many approaches to prevent overdose deaths.”

—Local community leader

WHAT WOULD NEW YORK CITY GAIN

FROM SUPERVISED INJECTION

FACILITIES?

Estimating the Health and Fiscal Impacts of Supervised

Injection in New York City

Weill Cornell Medical College conducted a study to estimate the overdose prevention and

public cost saving impacts of supervised injection in New York City. The study aimed to

develop neighborhood-specific estimates for overdose deaths prevented, given the wide

variation in mortality among different neighborhoods. Short-term cost savings estimates

were developed by identifying key areas of public health care expenditures that could

experience reductions from SIFs, including emergency medical services, emergency

departments, and inpatient hospitalizations. A brief review of the estimated impact is

presented below. Full text of the report prepared by Weill Cornell, including the methods

and results, can be found in Appendix B.

As part of the planning and execution of this impact analysis, a Technical Advisory Group of

five global experts in supervised injection provided guidance to Weill Cornell on methods,

analysis, and findings at key intervals across the life of the study between March and June

2017. Members of the Technical Advisory Group contributed a range of expertise across

economics, policy analysis, and the clinical and behavioral sciences. All members have

extensive experience in the evaluation of SIFs internationally.

To generate the the number of overdoses avoided, researchers developed a model that

accounted for the neighborhood-level number of death and the proportion of people who

inject drugs who are willing to travel to and use a SIF, drawn from the New York City

Injection Drug User Health Alliance Survey, 2013-2014 and 2014-2015. They used this

model to estimate the impact of up to four supervised injection facilities on opioid

overdose fatalities, assuming unrestricted hours of operation and capacity. Additionally,

researchers estimated the direct health care cost savings in New York City. Using New York

City data of emergency department visits and hospitalizations, and emergency services

costs, researchers developed a model of direct health care costs saved by implementation

of a SIF. Where data was unavailable, best estimates from the literature were used.

Findings from the study suggest that implementing supervised injection would contribute

to reductions in overdose mortality and savings in direct health care expenses.

Supervised injection facilities could prevent between 67 and 130 overdose

deaths annually in New York City

Conservative estimates indicate that establishing supervised injection services in four of

the neighborhoods with the highest rates of overdose death would prevent between 67 and

130 overdoses annually, dependent on the number and location of SIFs established.

Opening a single SIF in the neighborhood with the highest rate of overdose death citywide

is projected to prevent between 19 and 37 opioid overdoses annually. These lives saved

would represent a substantial reduction in the overall impact on citywide overdose. Given

that the estimates presented here are conservative, it is possible that reductions in

overdose will exceed these estimates.

Supervised injection facilities are designed to serve individuals most in need. Individuals

who are homeless or unstably housed may be most likely to inject in public or semi-public

settings. In New York City, people who are homeless die of overdose at a rate more than six

times that of the general population.

As SIFs directly target this group, it is likely that the

projected reductions in overdose would in large part benefit people who inject drugs, are

homeless, and are marginalized for other reasons.

Supervised injection facilities could save between $1 and $7 million annually in

New York City direct health care expenditures

Opioid overdose costs the New York City health care system an estimated $50 million

annually on emergency medical service calls, emergency department visits, and

hospitalizations. Establishing a single SIF in a neighborhood heavily affected by opioid

overdose could save the City $1 million annually in direct health care expenses.

Establishing four SIFs in the most impacted neighborhoods could save up to $7 million

annually in avoidable acute health care costs. Acute health care is short-term treatment of

severe or brief illnesses and injuries, as opposed to chronic care which involves long-term

treatment of ongoing conditions. Estimates suggest that SIFs could generate $4 to $6

million in annual net savings.

The above estimated cost savings to the health care system are conservative, as additional

areas of substantial anticipated cost saving were not included due to limitations in New

York City-specific health data. However, evaluations of SIFs from other jurisdictions have

shown additional savings drawn from the following public benefits:

 Supervised injection facilities reduce HIV and HCV treatment costs by preventing

transmission through access to safe and sterile injection services.

 Supervised injection facilities connect individuals to cost-effective addiction

treatments.

Treatment with methadone or buprenorphine has been demonstrated

to reduce overdose and the financial burden of overdose.

 Supervised injection facilities reduce the high cost of treating skin and soft tissue

infections associated with unsafe injection practices. Skin and soft tissue infections

are prone to complications and often require lengthy and costly hospital admissions

to treat successfully.

The anticipated $1 to $7 million saved excludes the law enforcement and criminal justice

costs associated with overdose response.

Operating a supervised injection facility could cost a minimum of $250,000

annually

DOHMH estimated the operating costs of a supervised injection facility, considering

staffing, supplies, and siting. Locating a SIF within an existing harm reduction service

Up to

$7 million

Up to

130 overdose

deaths

would require substantially lower costs than a freestanding facility, given that this

configuration could eliminate the majority of new overhead and leverage existing and

funded on-site services, treatment, and referral networks. In this estimate, a SIF would

require annual costs between $250,000 and $500,000, depending on hours of operation,

and service and staffing models.

Opening a new, freestanding facility would demand substantially higher operating costs. In

this estimate, a SIF could require annual operating expenses of up to $2 to $3 million, most

of which are associated with infrastructure and capital costs.

HOW COULD NEW YORK CITY

IMPLEMENT SUPERVISED INJECTION

FACILITIES?

Viable Legal Frameworks for Supervised Injection Facilities

in New York City

To evaluate potential legal pathways and challenges to SIFs in New York City, Columbia

Law School Associate Professor Kristen Underhill conducted a review of relevant federal,

state, and municipal criminal and civil laws and regulations. A summary of legal issues

relevant to the establishment or operation of SIFs in New York City is presented below. Full

text of the legal review can found in Appendix C.

Despite the growing recognition and support in public health for the need for expanded

harm reduction services to help reverse the course of the opioid epidemic, federal and state

criminal laws present significant risks to the operators of SIFs. The clearest avenue for

establishing SIFs would be to changes federal law to allow SIFs to operate and provide SIF

clients, staff, and owners with exemptions from federal criminal law. Nevertheless, state

legislation or administrative action would also offer some protection, but still leave clients,

staff, operators and landlords of SIFs vulnerable to federal prosecution.

Existing Federal legislation

The Federal Controlled Substances Act (CSA) poses a number of constraints to operating a

SIF, including its prohibitions on individual drug possession and on organizations or spaces

that facilitate drug use (colloquially known as the “crack house statute”).

Supervised

injection facility clients, operators, and staff could be at risk of arrest and prosecution

under the CSA, although the enforcement of these statutes are at the discretion of federal

authorities. Penalties may include fines of up to $500,000 for individuals, $2 million for

institutions, and imprisonment. In addition, any property used to commit a CSA violation is

subject to forfeiture, that is, the property could be transferred to the U.S. Attorney General,

who may then sell it or transfer it. Professional staff licensed by the state are also at risk of

disciplinary proceedings if convicted of a federal or state felony. No federal prosecutions of

harm reduction facilities on the basis of participants’ on-site drug use have occurred under

the CSA to date.

A state or locally sanctioned program that explicitly supervises drug consumption would be

a legal first in the United States, and it is difficult to predict how federal prosecutors might

respond. Additionally, federal agencies and Congress have the authority to prevent the use

of federal funding to support SIFs, although no such restrictions exist currently.

State legislation

The New York State Legislature has the authority to authorize SIFs by statute, and could do

so either with a freestanding law, or with an extension to the current state law authorizing

SEPs.

†85

Although state legislation would not safeguard SIFs against the Federal CSA, the

state legislative pathway provides the greatest legal security with respect to state and local

law. Legislation authorizing a SIF could simultaneously amend or provide exemptions from

state laws on possession, paraphernalia, criminal injection, criminal nuisance, and

professional misconduct to protect SIF staff, owners, and clients from arrest, prosecution

and disciplinary proceedings in the state. Even if the authorizing legislation did not

explicitly amend existing criminal laws, statutory support for a SIF ought to deter arrest

and support strong defenses for SIF clients, personnel, and owners who might be criminally

charged.

Statutory authorization under state law could also provide some protection

from local efforts to declare SIFs a public nuisance, or to find SIF clients in violation of local

laws such as Administrative Code § 10-203.

Recognizing this potential, New York State Assembly bill A.8534 was introduced in June

2017 to authorize SIFs statewide.

The proposed legislation—currently under health

committee consideration—would permit local health authorities to set and maintain SIF

operating and reporting standards. In addition to New York, several other states have

considered or are considering legislation authorizing SIFs, including California,

Colorado,

Maryland,

Maine,

and Massachusetts.

No bill has passed both houses of

any state legislature to date.

State administrative action

The New York State Governor or New York State Commissioner of Health could establish

SIFs through executive authority. Provisions in New York State law grant administrative

authority to the Governor to direct funds for programming in the event of a disaster.

Similarly, the New York State Commissioner of Health holds the authority to provide

treatment, supplies, and services to residents in the event of a statewide medical

emergency.

The scope of the opioid overdose epidemic in New York and the recent

acceleration of mortality caused by the introduction of fentanyl likely would justify the

declaration of a disaster or state of emergency and initiate SIFs. There is historical

precendent for such an approach in New York State, as the State Department of Health used

such a emergency regulation in 1992 to successfully establish syringe exchange programs

in response to the HIV/AIDS crisis.

Executive or agency action would be open to the risk of challenge as contrary to state

criminal laws, and it is unknown how New York State and federal legislators and

prosecutors might respond to such an administrative directive. However, the emergency

health action taken by New York State to establish SEPs went unchallenged by federal

†

Although possession of controlled substances remains illegal in New York State, syringe

exchange program participants are allowed to possess trace amounts of illegal drugs in

used syringes, an exception to the law established to facilitate SEP use and reduce

transmission of HIV and other bloodborne diseases.

authorities in the 1990s; ultimately syringe exchange programs were authorized by state

law in 1993.

As with SEPs, State administrative action to establish SIFs may also go

unchallenged.

Local legislation or administrative action

The New York City Council could establish a SIF through City law.

A city law authorizing

SIFs may be found by the courts to conflict with state criminal laws leaving SIFs established

by it vulnerable to state prosecutions. The local law option would also leave providers

uncertain about professional disciplinary proceedings which are also governed by state

law.

Local legislative action would need to consider local nuisance codes that criminalize

individuals or organizations that “knowingly allow” drug use in a given location.

Enforcement of these codes is at the discretion of state prosecutors, and establishment of a

SIF through City ordinance may be vulnerable to challenge by state and federal law

enforcement. However, evidence from other jurisdictions indicates that SIFs reduce

nuisances associated with public injection and overdose, reducing the likelihood of

prosecution on nuisance grounds.

Additionally, the New York City Charter grants the New York City Mayor and DOHMH the

authority to establish emergency services during short-term crises.

Should the City define

the overdose epidemic in these terms, DOHMH could establish one or more SIFs.

Coordination with the New York State Deparment of Health would be essential so as not to

interfere with State health waivers authorizing SEPs. As with local legislative efforts, local

administrative actions may draw challenges under state law, depending on state

prosecutors’ enforcement decisions. Some other cities, including Baltimore, Philadelphia,

and San Francisco are using local authority to study SIF feasibility. Seattle and Ithaca, New

York have announced intentions or decisions to authorize the establishment of SIFs as part

of a larger strategy to reverse the opioid overdose epidemic. However, all are grappling

with the potential impact of state and federal criminal laws.

Research study with federal and state authorization

A supervised injection facility could be implemented as a research study, with the goal of

evaluating the acceptability and feasibility of a SIF in New York City. There are established

legal procedures for conducting research that involves the use of controlled substances,

which insulate researchers and participants from prosecution under federal and state drug

laws. Either the New York State Department of Health or DOHMH could establish a SIF as a

research pilot under a two-year state license. Although licensure can be granted by the

state, all research licenses of this nature would require review and approval from several

federal authorities, including the National Institute on Drug Abuse, the US Department of

Justice and the Drug Enforcement Administration.

To date, no American city has attempted to establish a SIF through a research program,

although successful SIFs in Vancouver, Canada and Sydney, Australia began as research

pilots. Federally approved research licenses provide several advantages, including

certainty on the part of SIF staff and clients that they are not violating federal or state laws.

The evidence generated from a pilot also may help garner public support for SIFs as a

prelude to New York State legislative or administrative efforts. However, sustaining

services beyond the two-year license is contingent on reapproval, which may be uncertain

in a given political climate, and, as experienced in both Sydney and Vancouver, expansion

from a demonstration pilot program has been restricted because of limitations in the

research license even after years of operation and proven program benefits.

Conclusion on legal challenges and opportunities

State legislative action offers the greatest certainty under state and local laws for a New

York City SIF. However, the risk of federal prosecution under the Controlled Substances

Act would not be diminished by state legislative action. In the absence of state legislation,

state administrative action would provide some security, but would not protect against

state or federal prosecution. The City could also use legislative power, executive power, or

both to authorize SIFs; however, SIFs so established would be vulnerable to possible

contravening powers of both the state and federal government. Regardless of the pathway

by which supervised injection is implemented, viability will depend on law enforcement

bodies recognizing SIFs as an extension of health services for individuals most vulnerable

to illness and death from opioid use.

CASE STUDIES: SUPERVISED

INJECTION FACILITIES AT THE

MUNICIPAL LEVEL

Update from Seattle, San Francisco, and Philadelphia

Although no supervised injection facilities exist currently in the United States, Seattle, San

Francisco, and Philadelphia are moving toward implementing SIFs as a strategy to respond

to increasing overdose deaths.

Seattle

In January 2017, the Seattle City Council and King County Board of Public Health approved

a measure to authorize two SIFs, slated to open in 2018.

‡

The proposal originated from the

formal recommendations of the King County Heroin and Prescription Opiate Addiction

Task Force, and formal approval followed two years of coalition building and sustained,

broad-based support.

In November 2017, the Seattle City Council voted to allocate $1.3

million to fund a community health engagement location (CHEL) that would include

supervised injection and post-consumption drop-in space in conjunction with syringe

exchange, overdose prevention, sexual health, peer education, and referrals to medical,

mental health, and social services.

Since the Task Force released its recommendations, the proposal to establish SIFs has

received public endorsement from King County Prosecutor Dan Satterberg. The

endorsement from Satterberg, in particular, was critical in shoring up support among the

law enforcement community. Satterberg has spoken publicly about his evolution from self-

professed “drug warrior” during the crack cocaine epidemic of the 1980s to his current

stance that drugs are an issue of public health. His support for supervised injection is

emblematic of the multidisciplinary nature of contemporary drug reform once

stakeholders examine the evidence and best practice options. In all jurisdictions with

operational SIFs, cooperation between law enforcement and health authorities has been

crucial to the advancement, establishment, and sustainability of SIFs.

However, there is opposition to supervised injection in Seattle. Washington State Senator

Mark Miloscia introduced a bill that effectively would ban SIFs in Washington State, shortly

after the measure was approved by the City Council and Board of Public Health.

The bill

passed the Washington State Senate in March 2017 but has not yet advanced in the State

House. Senator Miloscia also drafted an open letter to the United States Attorney General in

February 2017 requesting federal intervention to prevent the City of Seattle from opening

the scheduled SIF pilot sites.

While the US Department of Justice has not yet responded to

the letter, any federal movement to prohibit SIFs could collaterally affect New York City.

Finally, the community group Citizens for Safe King County introduced a public ballot

‡

Seattle is the county seat of King County.

initiative, Initiative 27, to ban supervised injection in King County. The initiative garnered

over 70,000 signatures and was scheduled for a February 2018 vote before the King County

Superior Court invalidated the initiative in October 2017 on the grounds that matters of

public health could not be voted on by referendum. King County intends to use public funds

toward the operation of supervised injection sites.

San Francisco

In April 2017, California State Assembly Member Susan Talamantes Eggman introduced a

bill to authorize eight California counties, including San Francisco, to open SIFs in response

to increased overdose and public injection across California.

100

While the bill passed the

Assembly and received broad public support, it ultimately was voted down in the State

Senate in September 2017.

Simultaneously, the San Francisco Board of Supervisors passed a resolution in April 2017

urging the San Francisco Department of Public Health to convene the San Francisco Safe

Injection Services Task Force. The Task Force was commissioned between April and

September 2017 and was composed of experts in public health, law enforcement, social

services, and drug policy, as well as community members representing the interests of

small businesses and people who use drugs. As part of the Task Force’s recommendations

development process, surveys and focus groups were conducted with small business

owners, neighborhood groups, people who inject drugs, and people engaged in treatment

for substance use disorder. Task Force meetings included sessions for public comment, and

feedback from the public about supervised injection was received and incorporated into

the recommendations.

In September 2017, the Task Force released its recommendations, which broadly endorsed

supervised injection as a public health intervention.

101

The recommendations detailed

suggestions for planning, implementation, and sustainability and were presented before

the Board of Supervisors’ Public Safety and Neighborhood Services Committee for

consideration in October 2017. In February 2018, the Director of the San Francisco

Department of Public Health announced that San Francisco would seek to pilot two

supervised injection sites as early as July 2018, funded through private sources. San

Francisco intends to co-locate supervised injection services within existing community-

based programs that provide syringe access and other health and social services to people

who use drugs.

Philadelphia

In January 2018, the Philadelphia Task Force to Combat the Opioid Epidemic released a

report recommending supervised injection as a strategy to reduce opioid overdose.

102

Shortly thereafter, Philadelphia Mayor Jim Kenney, District Attorney Larry Krasner, and

Health Commissioner Thomas Farley announced their joint public support for supervised

injection. The Kenney Administration intends to pilot “comprehensive drug user

engagement sites,” holistic health care, and social services for people who use drugs in

which supervised injection services would be available. While the details of these pilot

programs are in development, the City of Philadelphia has expressed that any supervised

injection pilots will operate with private funding in partnership with existing harm

reduction organizations to oversee site operations.

RECOMMENDATIONS

New York City has experienced a 166% increase in overdose death since 2010, reaching an

all-time high in 2017 with a provisional 1,441 confirmed fatalities. Over 80% of these

deaths involved opioids. Nearly half (44%) of all overdose deaths in 2016 involved non-

pharmaceutical fentanyl—a synthetic opioid 50 to 100 times more potent than morphine—

and the drug’s impact on overdose cannot be overstated. Non-pharmaceutical fentanyl

greatly increases the risk of overdose among people who inject drugs due to its potency,

short-acting effect, and inability to be detected by sight or smell. Projections suggest that

non-pharmaceutical fentanyl’s presence in the drug supply will continue to expand, thus

requiring that public health actors deploy new responses.

Like syringe exchange before it, supervised injection is an evidence-based public health

strategy to prevent and reduce overdose and overdose death, curtail the transmission of

bloodborne disease, and facilitate access to care, treatment, and health for individuals at

highest risk of overdose. Despite concerns about increases in drug-related crime or

substance misuse in communities following the establishment of a SIF, evidence indicates

that supervised injection facilities may be an effective measure to reduce crime and

prevent community exposure to harmful substance use.

Results from the three studies presented in this report, in conjunction with the broad

scientific evidence from other jurisdictions, suggest that supervised injection is one

possible intervention to combat opioid overdose in New York City in alignment with the

goals of HealingNYC and ThriveNYC. Supervised injection facilities can fit into New York

City’s comprehensive overdose prevention agenda as a targeted strategy to reduce the risk

of overdose and disease transmission among people who inject drugs, as well as offering

the community-wide benefit of decreasing public injection. Guided by this evidence, we

offer the following recommendations to address the planning and implementation of

supervised injection services in New York City.

Support the creation of supervised injection services in New York City

 Our overarching recommendation is to support the piloting of four supervised

injection facilities in New York City, despite the risk of criminal prosecution for

clients, staff, and operators, as well as the risk of loss of licensure of clinical staff and

the forfeiture of property for facility operators and landlords. Supervised injection is

congruent with New York City’s comprehensive health and safety strategy to reduce

overdose. Establishing SIFs in neighborhoods highly affected by opioid overdose

death and in which public injection is a growing concern could maximize the

number of lives saved. Findings suggest that piloting four sites could prevent up to

130 overdose deaths and save up to $7 million annually while connecting

individuals at risk of overdose to a host of harm reduction, drug treatment, and

health care services.

Planning and implementation

Implement pilot supervised injection facilities by December 2018 in response to New York

City’s fentanyl-driven public health emergency

 All available data demonstrate that the increases in overdose death—47% citywide

from 2015 to 2016—and the toxicity associated with non-pharmaceutical fentanyl

constitute a public health emergency in New York City. Non-pharmaceutical fentanyl

was identified in 44% of overdose decedents in 2016, indicating the tremendous

risk of overdose posed by the current drug supply. Individuals residing in shelters

represent less than 1% of the New York City population but account for 7% of all

overdose deaths. Supervised injection facilities would directly serve the population

of people who inject drugs publicly due to lack of housing or private space.

Supervised injection facilities also would link individuals to needed medical care,

drug treatment, and housing services.

Locate pilot supervised injection facilities within existing syringe exchange programs

 Co-locating pilot SIFs within existing syringe exchange programs would leverage the

strong community relations and extensive on-site treatment and service referral

networks that SEPs have built over nearly three decades. Given the long-standing

history of collaboration and mutual respect between harm reduction services, law

enforcement, and local communities in New York City, locating SIF services within

an existing harm reduction facility will facilitate the acceptance of supervised

injection by law enforcement and local community members.

 The concerns identified through the community assessment presented in this

report—such as the generation of concentrations of people who use drugs and

public injection—would be assuaged by the co-location of SIFs in SEPs. Evaluations

of existing SIFs suggest that, like SEPs, these services are highly localized; people

who use drugs generally do not travel more than 20 minutes to use either SIFs or

SEPs. Additionally, evaluations of existing SIFs have shown significant declines in

public injection and improperly discarded syringes in neighborhoods following the

opening of a SIF site.

 Co-location of SIFs in SEPs would be cost-effective. It would eliminate the siting

expenses associated with developing a new facility, save startup and development

costs, and make co-location a fiscally responsible option.

Pilot sites should reflect where the burden of overdose is severe and the need for resources is

great

 The burden of overdose is spread disproportionately across the city, with the

poorest neighborhoods—including Hunts Point-Mott Haven in the Bronx and East

Harlem in Manhattan—experiencing extremely high fentanyl-involved overdose

rates. In order to address endemic disparities in risk and harm, pilot SIFs should be

located in areas of New York City that have borne a disproportionate burden of

overdose deaths.

Support New York State administrative action as a realistic legal possibility in the absence of

legislation

 While State legislative change could eliminate risk of prosecution under State law

and of loss of licensure and aid with defense in a federal criminal prosecution, State-

level administrative action may be more readily achievable. The current fentanyl

crisis and continued increases in overdose deaths constitute a public health

emergency, through which the New York State Department of Health could establish

a pilot SIF.

 There is precedent for the New York State Department of Health to take progressive

administrative action. In response to the HIV/AIDS epidemic, the New York State

Department of Health used administrative action to issue an emergency health

waiver to authorize syringe exchange programming, which was being run

underground by activists at the time.

Build out and collaborate with coalitions of nongovernmental support to operate supervised

injection pilots

 Widespread nongovernmental support exists for supervised injection, with 41

independent advocacy and community organizations endorsing the establishment of

supervised injection services nationally or in New York City. See Appendix A for the

full list of supporting organizations.

 One organization in particular, amfAR, wrote an open letter to New York Governor

Andrew Cuomo in September 2017 urging him to take New York State

administrative action authorizing SIFs and offering to fund a pilot site, as the

organization did during the first NYS syringe exchange pilot in the 1990s. History

has proved the success of allowing scientific experts such as amfAR to operate high-

risk, high-reward pilot health programs. Without amfAR’s funding and operational

support, the institutionalization of syringe exchange in New York State would not

have been possible. See Appendix B for the full text of amfAR’s letter to Governor

Cuomo.

Ensure that supervised injection facilities are supportive and safe spaces for marginalized

communities at increased risk of overdose and associated harm

 Supervised injection services can serve as targeted interventions to aid the city’s

most vulnerable populations. Shelter residents and undomiciled individuals

represent less than 1% of the New York City population, yet account for 7% of all

overdose deaths with an unprecedented mortality rate over six times that of the

general population. Women who use drugs are at heightened risk of experiencing

street-based violence. Supervised injection facilities can position themselves as

supportive and safe spaces for these and other groups at high risk of overdose to

access a variety of services and referrals given SIFs’ demonstrated ability to function

as holistic health care and social service centers.

Evaluate the health, safety, and fiscal impacts of a supervised injection pilot

 While with clear proven value globally, given that no comparable services currently

exist in New York City or the United States, pilot supervised injection facilities in

New York City will be evaluated to assess their health, safety, and fiscal impacts. To

accomplish this, we recommend sustained engagement with the scientific

community coupled with ongoing quality improvement to ensure that pilot SIFs are

accountable and successful in meeting the aims for which they are established, and

contribute to the body of knowledge for use by other jurisdictions nationally and

internationally. As was the case with the first syringe exchange programs,

evaluation by independent academic experts should be conducted and required to

ensure that the highest possible scientific standards are met.

Public engagement and education

Leverage the support of county prosecutors to facilitate supervised injection pilot

implementation

 The support of prosecutors has been integral to the success of drug reforms in New

York City and nationally. In Seattle, the public support for supervised injection of

King County District Attorney, Dan Satterberg, was a key link in building the

coalition between public health and law enforcement that has brought Seattle closer

to opening a SIF.

 In New York City, prosecutors have been at the cutting edge of drug reform in the

law enforcement community. The late Brooklyn District Attorney, Kenneth

Thompson, ceased prosecuting low-level marijuana possession offenses in 2014,

which paved the way for the New York City Police Department to revise their

marijuana arrest policy. The Manhattan District Attorney, Cyrus Vance, Jr., is a

leader in restructuring drug diversion procedures, allowing the use of evidence-

based medications for addiction treatments in drug courts. The Staten Island

District Attorney, Michael McMahon, led the design and implementation of the HOPE

Program, a post-arrest drug diversion program. The Bronx District Attorney, Darcel

Clark, leads the Bronx Heroin Enforcement and Access to Treatment workgroup,

which aims to coordinate a comprehensive and collaborating public health and

safety response to increasing rates of opioid overdose in the Bronx. We recommend

engaging one or more New York City prosecutors in the planning and development

process of any supervised injection pilot to ensure that these front-line leaders in

law enforcement are able to provide their expertise and input into the development

of a SIF pilot.

Engage key perspectives as part of a collaborative planning process

 Incorporating the complementary perspectives of public health, public safety, law

enforcement, social services, and local communities in the planning process is

critical to maximize the potential benefits of SIFs with respect to all groups.

Responsiveness to a range of interests will ensure that SIFs can most effectively help

the New Yorkers who need them most.

Hold public planning sessions for the communities most impacted by overdose

 Public and community support are critical to the successful implementation of

supervised injection services. We recommend establishing planning consortiums of

key community stakeholders and advocates in target neighborhoods highly affected

by overdose mortality, with an anchor harm reduction provider in each. Planning

meetings would provide a structured space for members of the public to learn about

SIFs from recognized experts, provide feedback throughout the implementation

process, and raise concerns. An advisory committee comprised of health, safety,

community leaders, and advocates would guide the public discussion process in the

selected neighborhoods and ensure that public feedback is adequately incorporated

into the implementation plan. New Yorkers support the City’s ongoing mental health

and overdose prevention efforts. Sustained community engagement and procedural

transparency are essential to ensuring that SIFs are successfully integrated into the

existing landscape of harm reduction services. Including professional organizations

and expert bodies (e.g., the New York State Medical Society and New York State

Nursing Association) in the planning and feedback processes could garner support

and educate members who are New York City residents.

Work with law enforcement officials

 Law enforcement agencies are key partners of the public health and social service

communities citywide and it is important that they remain engaged throughout the

planning and implementation processes of any pilot supervised injection facility.

Strengthening the coalition through NYC RxStat that exists in New York City

between public health, public safety, and community-based social services will

cultivate cooperation and accountability between groups, allow groups to identify

clear roles and responsibilities, and ensure that all voices are heard.

Develop public resources and education about supervised injection facilities to inform local

stakeholders about the continuum of care and discuss stigma toward people who use drugs

 Opportunities for education about supervised injection and the substance use

continuum of care can be developed through collaboration between advocates,

public health professionals, and health care providers to both inform and receive

feedback from community stakeholders as part of a pilot implementation process.

Engaging community stakeholders early and often as part of a design and

implementation plan would help facilitate referrals between a pilot SIF and other

critical services—including housing, public benefits, re-entry, and victim services—

as well as address community drug use stigma. Additionally, advocates and health

professionals can offer training and education to public safety and law enforcement

professionals as part of pilot implementation to ensure collaboration between

multiple groups.

ACKNOWLEDGMENTS

Columbia Law School

Kristen Underhill, DPhil, JD

New York Academy of Medicine

Michele Calvo, MPH

Peter Schafer

New York City Department of Health and Mental Hygiene

Bennett Allen

Gary Belkin, MD, PhD, MPH

Stephanie Buhle

Holly Catania, JD

Cody Colon-Berezin, MPH

Rebecca Giglio, MPH

Alex Harocopos, PhD, MS

Amy Hecker, MPA

Maura Kennelly, MPH

Jacob Kraemer

Hillary Kunins, MD, MPH

Sam Miller, MPA

Michelle Nolan, MPH

Denise Paone, EdD

Maibe Ponet

Emily Winkelstein, MSW

Ricky Wong

Weill Cornell Medical College

Czarina Behrends, PhD, MPH

Bruce Schackman, PhD, MBA

Expert Advisory Panel

Ahmed Bayoumi, MD, MSc

Scientist at the Centre for Research on Inner City Health at the Li Ka Shing Knowledge Institute, general

internist and HIV physician at St. Michael's Hospital, and professor in the Department of Medicine at the

Institute of Health Policy, Management and Evaluation at the University of Toronto

Czarina N. Behrends, PhD, MPH

Postdoctoral Associate in the Division of Comparative Effectiveness and Outcomes Research in the

Department of Health care Policy and Research at Weill Cornell Medicine

Richard Elliott, LLM

Executive Director of the Canadian HIV/AIDS Legal Network

Liz Evans

Nurse, Co-founder of InSite, a supervised injection facility in Vancouver, founder and former director of PHS

Community Services Society, Executive Director of New York Harm Reduction Educators (NYHRE) and

Washington Heights Corner Project, and fellow with Open Society Foundation

Sarah Evans, MA

Senior Program Officer for the Open Society Foundation’s International Harm Reduction Development

Program

Brad Finegood, MA, LMHC

Assistant Division Director and Alcohol and Drug Treatment and Prevention Coordinator for the Behavioral

Health and Recovery Division of King County, Seattle and Co-Chair of the King County Heroin and Prescription

Opiate Task Force

Kassandra Frederique, MS

New York State Director at the Drug Policy Alliance, Co-author of Blueprint for a Public Health and Safety

Approach to Drug Policy and as Technical Advisor to Ithaca Mayor Svante Myrick’s The Ithaca Plan

Terrell Jones

Education and Advocacy Program Manager at New York Harm Reduction Educators

Thomas Kerr, PhD

Co-director of the Addiction and Urban Health Research Initiative at the British Columbia Centre for

Excellence in HIV/AIDS and professor in the Department of Medicine, University of British Columbia (Division

of AIDS)

Alex Kral, PhD, MS

Director of the Behavioral and Urban Health Program, San Francisco Regional Office of RTI International

Daniel Raymond

Policy Director at the Harm Reduction Coalition and member of the steering committee of the National Viral

Hepatitis Roundtable

Bruce Schackman, PhD, MBA

Professor of Health care Policy and Research, Weill Cornell Medical College.

Kristen Underhill, DPhil, JD

Associate Professor of Law at Columbia Law School

Technical Advisory Group

Ahmed Bayoumi, MD, MSc (Chair)

Scientist at the Centre for Research on Inner City Health at the Li Ka Shing Knowledge Institute, general

internist and HIV physician at St. Michael's Hospital, and professor in the Department of Medicine at the

Institute of Health Policy, Management and Evaluation at the University of Toronto

Eva Enns, PhD

Assistant Professor in the Division of Health Policy and Management at the School of Public Health, University

of Minnesota

Bohdan Nosyk, PhD, MA

Associate Professor and Endowed Chair of Economics of HIV/AIDS at the Faculty of Health Sciences, Simon

Fraser University and research scientist at the British Columbia Centre for Excellence in HIV/AIDS

Carol Strike, PhD, MSc

Division Head of Social & Behavioural Health Sciences at the Dalla Lana School of Public Health, University of

Toronto

Greg Zaric, PhD, MS, MASc

Professor and Chair in Management Science at Ivey Business School in Western University Canada

Report prepared by:

Bennett Allen

New York City Department of Health and Mental Hygiene

REFERENCES

New York City Department of Health and Mental Hygiene. Unintentional drug poisoning (overdose) deaths in

New York City, Quarters 1-3, 2017. Provisional Data Report. New York, NY: DOHMH; 2018.

DOHMH, 2018.

Blakeman D, Lewine E. HealingNYC: Preventing overdoses, saving lives. New York, NY: Office of the Mayor of

the City of New York; 2017.

AMA wants new approaches to combat synthetic and injectable drugs. American Medical Association

https://www.ama-assn.org/ama-wants-new-approaches-combat-synthetic-and-injectable-drugs. Accessed

July 18, 2017.

Defining and implementing a public health response to drug use and misuse. American Public Health

Association https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-

database/2014/07/08/08/04/defining-and-implementing-a-public-health-response-to-drug-use-and-

misuse. Updated November 5, 2013. Accessed July 18, 2017.

Schatz E, Nougier M. Drug consumption rooms: Evidence and practice. IDPC Briefing Paper. London, UK:

International Drug Policy Consortium; 2012.

European Monitoring Centre for Drugs and Drug Addiction. Drug consumption rooms: An overview of

provision and evidence. EMCDDA Perspectives on Drugs. Lisbon, Portugal: EMCDDA; 2017.

Seth P, Scholl L, Rudd RA, Bacon S. Overdose Deaths Involving Opioids, Cocaine, and Psychostimulants —

United States, 2015–2016. MMWR Morb Mortal Wkly Rep 2018;67:349–358.

Paone et al., 2017.

Paone D, Tuazon E, Nolan ML, Mantha S. Unintentional drug poisoning (overdose) deaths involving heroin

and/or fentanyl in New York City, 2000-2015. Epi Data Brief: 74. New York, NY: New York City Department of

Health and Mental Hygiene; 2016.

Paone et al., 2017.

Drug Enforcement Administration. 2016 National Drug Threat Assessment summary. Washington, DC: US

Department of Justice; 2016.

Drug Policy Alliance. Fact sheet: Fentanyl and synthetic opioids. New York, NY: Drug Policy Alliance; 2016.

Paone et al., 2017.

New York City Department of Health and Mental Hygiene. Unpublished data, 2016.

Carroll JJ, Marshall BDL, Rich JD, Green TC. Exposure to fentanyl-contaminated heroin and overdose risk

among illicit opioid users in Rhode Island: A mixed methods study. Int J Drug Policy. 2017.

Ciccarone D, Ondocsin J, Mars SG. Heroin uncertainties: Exploring users’ perceptions of fentanyl-

adulterated and –substituted ‘heroin’. Int J Drug Policy. 2017.

Paone et al., 2017.

Department of Homeless Services. Daily Report Census, October 2, 2017. Published October 3, 2017.

New York City Department of Health and Mental Hygiene. Unpublished data; 2017.

Kral AH, Bluthenthal RN, Booth RE, Watters JK. HIV seroprevalence among street-recruited injection drug

and crack cocaine users in 16 US municipalities. Am J Public Health. 1998;88(1):108-13.

Holtzman D, Barry V, Ouellet LJ, et al. The influence of needle exchange programs on injection risk

behaviors and infection with hepatitis C virus among young injection drug users in select cities in the United

States, 1994-2004. Prev Med. 2009;49(1):68-73.

Office of the Mayor of the City of New York. (2018, March 19). HealingNYC: Mayor and First Lady announce

$22 million expansion of City’s plan to combat opioid epidemic. [Press release]. Retrieved from:

http://www1.nyc.gov/office-of-the-mayor/news/143-18/healingnyc-mayor-first-lady-22-million-expansion-

city-s-plan-combat-opioid

Magura, S., Lee, J. D., Hershberger, J., Joseph, H., Marsch, L., Shropshire, C., & Rosenblum, A. (2009).

Buprenorphine and methadone maintenance in jail and post-release: a randomized clinical trial. Drug and

alcohol dependence, 99(1), 222-230.

Halpern M, Rho YM. Deaths from narcotism in New York City: Incidence, circumstances and postmortem

findings. NY State J Med 1966; 66(12):2391 – 2408.

Joseph H, Stancliff S, Langrod J. Methadone maintanence treatment (MMT): a review of historical and

clinical issues. Mt Sinai J Med. 2000;67(5-6): 347-64.

Joseph et al., 2000.

Des Jarlais DC, Friedman SR, Sotheran JL, et al. Continuity and change within an HIV epidemic. Injecting

drug users in New York City, 1984 through 1992. JAMA. 1994;271(2):121-7.

Stimson GV, Alldritt L, Dolan K, Donoghoe M. Syringe exchange schemes for drug users in England and

Scotland. Br Med J. 1988;296(6638):1717-9.

Tsai R, Goh EH, Webeck P, Mullins J. Prevention of human immunodeficiency virus infection among

intravenous drug users in New South Wales, Australia: the needles and syringes distribution programme

through retail pharmacies. Asia Pac J Public Health. 1988;2(4):245-51.

Anderson W. The New York Needle Trial: the politics of public health in the age of AIDS. Am J Public Health.

1991;81(11):1506-17.

Comprehensive Harm Reduction Reverses the Trend in New HIV Infections. New York State Department of

Health, AIDS Institute https://www.health.ny.gov/diseases/aids/providers/reports/docs/sep_report.pdf.

Updated 2014. Accessed October 15, 2017.

Paone D, Des jarlais DC, Gangloff R, Milliken J, Friedman SR. Syringe exchange: HIV prevention, key findings,

and future directions. Int J Addict. 1995;30(12):1647-83.

Des jarlais DC, Marmor M, Paone D, et al. HIV incidence among injecting drug users in New York City

syringe-exchange programmes. Lancet. 1996;348(9033):987-91.

Comprehensive Harm Reduction Reverses the Trend in New HIV Infections. New York State Department of

Health, AIDS Institute https://www.health.ny.gov/diseases/aids/providers/reports/docs/sep_report.pdf.

Updated 2014. Accessed October 15, 2017.

Peters PJ, Pontones P, Hoover KW, et al. HIV Infection Linked to Injection Use of Oxymorphone in Indiana,

2014-2015. N Engl J Med. 2016;375(3):229-39.

Hadland SE, DeBeck K, Kerr T, et al. Use of a medically supervised injection facility among street youth. J

Adolesc Health. 2014;55(5):684-9.

Drug Policy Alliance. Supervised consumption facilities. New York, NY: Drug Policy Alliance; 2017.

Potier C, Laprévote V, Dubois-arber F, Cottencin O, Rolland B. Supervised injection services: what has been

demonstrated? A systematic literature review. Drug Alcohol Depend. 2014;145:48-68.

Hedrich, D, Kerr T, Dubois-Arber F. 2010. “Drug Consumption Facilities in Europe and Beyond.” Chap. 11. In

Harm Reduction: Evidence, Impacts, and Challenges, edited by T. Rhodes and D. Hedrich, 305–331. Lisbon,

Portugal: European Monitoring Centre for Drugs and Drug Addiction.

Marshall BD, Milloy MJ, Wood E, Montaner JS, Kerr T. Reduction in overdose mortality after the opening of

North America's first medically supervised safer injecting facility: a retrospective population-based study.

Lancet. 2011;377(9775):1429-37.

Salmon AM, Van Beek I, Amin J, Kaldor J, Maher L. The impact of a supervised injecting facility on

ambulance call-outs in Sydney, Australia. Addiction. 2010;105(4):676-83.

Stoltz JA, Wood E, Small W, et al. Changes in injecting practices associated with the use of a medically

supervised safer injection facility. J Public Health. 2007;29(1):35-9.

Van Boekel LC, Brouwers EP, Van Weeghel J, Garretsen HF. Stigma among health professionals towards

patients with substance use disorders and its consequences for healthcare delivery: Systematic review. Drug

Alcohol Depend. 2013;131(1-2):23-35.

Small W, Van Borek N, Fairbairn N, Wood E, Kerr T. Access to health and social services for IDU: The impact

of a medically supervised injection facility. Drug Alcohol Rev. 2009;28(4):341-6.

Small W, Wood E, Lloyd-Smith E, Tyndall M, Kerr T. Accessing care for injection-related infections through a

medically supervised injecting facility: A qualitative study. Drug Alcohol Depend. 2008;98(1-2):159-62.

Lloyd-Smith E, Wood E, Zhang R, et al. Determinants of hospitalization for a cutaneous injection-related

infection among injection drug users: A cohort study. BMC Public Health. 2010;10:327.

Andresen MA, Boyd N. A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection

facility. Int J Drug Policy. 2010;21(1):70-6.

Milloy MJ, Wood E. Emerging role of supervised injecting facilities in human immunodeficiency virus

prevention. Addiction. 2009;104(4):620-1.

Bravo MJ, Royuela L, De La Fuente L, et al. Use of supervised injection facilities and injection risk

behaviours among young drug injectors. Addiction. 2009;104(4):614-9.

Stoltz et al., 2007.

Kral et al., 1998.

Holtzman et al., 2009.

Kimber J, Mattick RP, Kaldor J, Van Beek I, Gilmour S, Rance JA. Process and predictors of drug treatment

referral and referral uptake at the Sydney Medically Supervised Injecting Centre. Drug Alcohol Rev.

2008;27(6):602-12.

Wood E, Tyndall MW, Zhang R, et al. Attendance at supervised injecting facilities and use of detoxification

services. N Engl J Med. 2006;354(23):2512-4.

Debeck K, Kerr T, Bird L, et al. Injection drug use cessation and use of North America's first medically

supervised safer injecting facility. Drug Alcohol Depend. 2011;113(2-3):172-6.

Fairbairn N, Small W, Shannon K, Wood E, Kerr T. Seeking refuge from violence in street-based drug scenes:

Women's experiences in North America's first supervised injection facility. Soc Sci Med. 2008;67(5):817-23.

Hadland SE, DeBeck K, Kerr T, et al. Use of a medically supervised injection facility among street youth. J

Adolesc Health. 2014;55(5):684-9.

Andresen MA, Boyd N. A cost-benefit and cost-effectiveness analysis of Vancouver's supervised injection

facility. Int J Drug Policy. 2010;21(1):70-6.

Bayoumi AM, Zaric GS. The cost-effectiveness of Vancouver's supervised injection facility. CMAJ.

2008;179(11):1143-51.

Wood E, Tyndall MW, Lai C, Montaner JS, Kerr T. Impact of a medically supervised safer injecting facility on

drug dealing and other drug-related crime. Subst Abuse Treat Prev Policy. 2006;1:13.

Salmon AM, Thein HH, Kimber J, Kaldor JM, Maher L. Five years on: what are the community perceptions of

drug-related public amenity following the establishment of the Sydney Medically Supervised Injecting

Centre?. Int J Drug Policy. 2007;18(1):46-53

Freeman K, Jones CG, Weatherburn DJ, Rutter S, Spooner CJ, Donnelly N. The impact of the Sydney Medically

Supervised Injecting Centre (MSIC) on crime. Drug Alcohol Rev. 2005;24(2):173-84.

Snowball L, Burgess M, Price B. Trends in property and illicit drug-related crime in Kings Cross: An update.

Crime and Just Statistics. 2010;51:1-6.

Kerr T, Stoltz JA, Tyndall M, et al. Impact of a medically supervised safer injection facility on community

drug use patterns: A before and after study. BMJ. 2006;332(7535):220-2.

Tyndall MW, Kerr T, Zhang R, King E, Montaner JG, Wood E. Attendance, drug use patterns, and referrals

made from North America's first supervised injection facility. Drug Alcohol Depend. 2006;83(3):193-8.

Kimber et al., 2008.

Debeck et al., 2011.

Kerr T, Tyndall MW, Zhang R, Lai C, Montaner JS, Wood E. Circumstances of first injection among illicit drug

users accessing a medically supervised safer injection facility. Am J Public Health. 2007;97(7):1228-30.

Wood E, Kerr T, Small W, et al. Changes in public order after the opening of a medically supervised safer

injecting facility for illicit injection drug users. CMAJ. 2004;171(7):731-4.

Vecino C, Villalbí JR, Guitart A, et al. Safe injection rooms and police crackdowns in areas with heavy drug

dealing: Evaluation by counting discarded syringes collected from the public space. Adicciones.

2013;25(4):333-8.

Bayoumi AM, Strike C, Brandeau M, et al. Report of the Toronto and Ottawa Supervised Consumption

Assessment Study, 2012. Toronto, Ontario: St. Michael's Hospital and the Dalla Lana School of Public Health,

University of Toronto;2012.

Kral AH, Wenger L, Carpenter L, Wood E, Kerr T, Bourgois P. Acceptability of a Safer Injection Facility

among Injection Drug Users in San Francisco. Drug Alcohol Depend. 2010;110(1-2):160-163.

Fischer B, Allard C. Feasibility Study on ‘Supervised Drug Consumption’ Options in the City of Victoria Victoria,

British Columbia: Centre for Addictions Research of British Columbia, University of Victoria;2007.

Bouvier BA, Elston B, Hadland SE, Green TC, Marshall BDL. Willingness to use a supervised injection facility

among young adults who use prescription opioids non-medically: a cross-sectional study. Harm Reduct J.

2017;14:13.

Joshi M, Sorenson SB. Intimate partner violence at the scene: incident characteristics and implications for

public health surveillance. Eval Rev. 2010;34(2):116-36.

New York City Department of Health and Mental Hygiene. Unpublished data; 2017.

Milloy MJ, Wood E. Emerging role of supervised injecting facilities in human immunodeficiency virus

prevention. Addiction. 2009;104(4):620-1.

Kimber J, Mattick RP, Kaldor J, Van Beek I, Gilmour S, Rance JA. Process and predictors of drug treatment

referral and referral uptake at the Sydney Medically Supervised Injecting Centre. Drug Alcohol Rev.

2008;27(6):602-12.

Kenworthy J, Yi Y, Wright A, Brown J, Maria madrigal A, Dunlop WCN. Use of opioid substitution therapies

in the treatment of opioid use disorder: results of a UK cost-effectiveness modelling study. J Med Econ.

2017;20(7):740-748.

Irwin A, Jozaghi E, Weir BW, Allen ST, Lindsay A, Sherman SG. Mitigating the heroin crisis in Baltimore, MD,

USA: a cost-benefit analysis of a hypothetical supervised injection facility. Harm Reduct J. 2017;14(1):29.

21 U.S.C. §§ 801 et seq. (2017).

See Burris et al., supra note 18, at 1146-47 (noting that Congress could, in theory, limit federal funds to

programs or jurisdictions that operate SIFs, and describing an unsuccessful prior legislative effort to do so).

N.Y. Public Health Law § 3381 (2017).

See Roe v. City of New York, 232 F. Supp. 2d 240 (S.D.N.Y. 2002) (finding an exception to the law

criminalizing possession of trace amounts of drug in syringes, as applied to clients of legally authorized SEPs).

A.8534, 2017-2018 Reg. Sess. (N.Y. 2017) (introduced June 21, 2017, in the Committee on Health).

AB-186, 2017-2018 Reg. Sess. (Cal. 2017) (passed the House as of June 2017).

https://leg.colorado.gov/sites/default/files/summary_report_to_legislative_council_-

_opioid_and_other_substance_use_disorders.pdf

H.B. 519, 2017 Reg. Sess. (Md. 2017) (in the House as of June 2017).

L.D. 1375, 128th Legisl. (Me. 2017) (rejected in the House and Senate as of June 2017).

S.1081, 190th Gen. Court. (Mass. 2017) (in the Joint Committee on Mental Health, Substance Use and

Recovery as of June 2017).

NY Public Health Law § 201 (2017).

N.Y. Comp. Codes R. & Regs. 10, § 80.135

NY Constitution, art. IX § 2(c)(10).

New York City Charter § 556.

King County Heroin and Prescription Opiate Addiction Task Force. Final report and recommendations.

Seattle, WA: King County Department of Community and Human Services; 2016.

SB 5223, 65

Legisl. (Wfa. 2017).

Sessions, Jeff. Sen. Miloscia Letter to U.S Attorney General Jeff Sessions. Senate Republican Caucus. 2017.

100

AB-186, 2017-2018 Reg. Sess. (Cal. 2017)

101

San Francisco Safe Injection Services Task Force. (2017). 2017 final report. San Francisco, CA: San

Francisco Department of Public Health.

102

Mayor of Philadelphia’s Task Force to Combat the Opioid Epidemic. Final report and recommendations,

Philadelphia, PA: Philadelphia Department of Public Health; 2017.

APPENDIX A

Institutional Support for Supervised Injection

Supervised injection as a health strategy is supported by a wide range of professional

organizations, advocacy groups, community-based social services, and policy institutes.

Below is a list of local, national, and selected international organizations that have publicly

endorsed the establishment or pilot of supervised injection facilities.

New York City Organizations

ACT UP New York

After Hours Project

AIDS United

BOOM! Health

Bronx Defenders

Callen-Lorde Community Health Center

Community Access

Family Services Network of New York

Harlem United

Harm Reduction Coalition

Hepatitis C Mentor and Support Group

Hispanic Health Coalition

Housing Works

Injection Drug User Health Alliance

Lower East Side Harm Reduction Center

Metropolitan Community Church of New York

New York City Anti-Violence Project

New York Harm Reduction Educators

Peer Network of New York

Positive Health Project

St. Anne’s Corner of Harm Reduction

Sex Workers Project, Urban Justice Center

VOCAL New York

Washington Heights CORNER Project

National and International Policy and Advocacy Organizations

ACRIA

amfAR, the Foundation for AIDS Research

Center for Constitutional Rights

Clinton Foundation

Criminal Justice Policy Foundation

Drug Policy Alliance

European Monitoring Centre for Drugs and Drug Addiction

International Drug Policy Consortium

Katal Center for Health, Equity, and Justice

Latino Commission on AIDS

LatinoJustice PRLDEF (Puerto Rican Legal Defense and Education Fund)

Treatment Action Group

National and International Professional Organizations

American Medical Association

American Public Health Association

Australian Medical Association

Massachusetts Medical Society

National Association of State and Territorial AIDS Directors

New York Academy of Medicine

APPENDIX B

Statement of Support for Supervised Injection from the

American Medical Association

American Medical Association wants new approaches to combat synthetic and

injectable drugs

Responding to the health and safety threat posed by the abuse of new designer drugs that

are synthesized and marketed to circumvent drug laws, the American Medical Association

(AMA) today voted to support a comprehensive, multidisciplinary effort to close a gap in

the nation’s ability to identify, regulate, and mitigate the dangers posed by new

psychoactive substances.

New psychoactive substances – or NPS - mimic the effects of a wide range of substances,

including prescription opioids, cannabinoids, stimulants, hallucinogens, and central

nervous system depressants. NPS are sold as “legal highs” and alternatives to established

drugs of abuse. NPS have been increasingly associated with hospital emergencies, acute

adverse health consequences, and drug-induced death.

“Although Congress passed AMA-supported legislation in 2012 that placed 26 synthetic

drugs in Schedule 1 under the Controlled Substances Act (CSA), drug traffickers have

devised ways to circumvent federal drug laws by slightly altering the chemical structure of

their products and designing new synthetic drugs,” said Patrice A. Harris, MD, chair of the

AMA Board of Trustees and the AMA Task Force on Opioid Abuse. “These new products are

currently unregulated and are frequently marketed to young people as innocent products

like “bath salts,” plant food, or incense. They also include variations of the extremely

dangerous opioid fentanyl, which has been wreaking havoc across the country and

resulting in a sharp increase in drug overdoses and deaths due to such overdoses.”

Delegates at the AMA Annual Meeting voted to support multifaceted, collaborative

multiagency approach to combat NPS. Delegates also supported increased NPS surveillance

and early warning systems for more actionable information that can quickly aid law

enforcement, public health officials, emergency physicians, and vulnerable populations in

mitigating the growing NPS problem.

American Medical Association. AMA wants new approaches to combat synthetic and injectable drugs.

Available at: https://www.ama-assn.org/ama-wants-new-approaches-combat-synthetic-and-injectable-

drugs. Accessed December 29, 2017.

Public health approaches have been used to successfully address outbreaks of NPS

overdoses. When such approaches have been successful, pre-existing coordinated

relationships among multiple stakeholders have allowed for a rapid and comprehensive

response to a given outbreak.

In addition to the newly adopted policies for eliminating the NPS threat, the AMA is also

supporting the “Synthetic Drug Control Act of 2017” (H.R. 1732) that would require the

Attorney General of the United States to assign Schedule I classification to approximately

250 dangerous new synthetic substances identified by the Drug Enforcement

Administration since 2012.

In an effort to consider promising strategies that could reduce the health and societal

problems associated with injection drug use, the AMA today voted to support the

development of pilot facilities where people who use intravenous drugs can inject self-

provided drugs under medical supervision.

Studies from other countries have shown that supervised injection facilities reduce the

number of overdose deaths, reduce transmission rates of infectious disease, and increase

the number of individuals initiating treatment for substance use disorders without

increasing drug trafficking or crime in the areas where the facilities are located.

“State and local governments around the nation are currently involved in exploratory

efforts to create supervised injection facilities to help reduce public health and societal

impacts of illegal drug use,” said Dr. Harris. “Pilot facilities will help inform US

policymakers on the feasibility, effectiveness and legal aspects of supervised injection

facilities in reducing harms and health care costs associated with injection drug use.”

The examination of this issue by physicians at the AMA Annual Meeting was greatly

assisted by the Massachusetts Medical Society and its recently completed

comprehensive study of the literature associated with supervised injection facilities.

Fitzgerald TC, Abel B, Bates SR. Establishment of a pilot medically supervised injection facility in

Massachusetts: Report of the Task Force on Opioid Therapy and Physician Communication. Waltham, MA:

Massachusetts Medical Society; 2017.

APPENDIX C

Statement of Support for Supervised Injection from the

American Public Health Association

Defining and implementing a public health response to drug use and misuse

Problem Statement

As recognized in APHA policy 8817(PP), the current “war on drugs” is a “severely flawed”

approach based on “misplaced priorities and strategies.”

In the more than 40 years since

President Richard Nixon declared a war on drugs in 1971, the United States has spent an

estimated $1 trillion on drug war policies.

Yet national rates of drug use have remained

relatively stable, albeit with some minor fluctuations.

Meanwhile, drug-related harms,

such as the spread of bloodborne diseases and accidental overdose deaths, have grown

severely worse.

Overdose is second only to motor vehicle accidents as a leading cause of

injury-related death in the United States.

The war on drugs is a major driver of the HIV/AIDS pandemic among people who inject

drugs and their sexual partners. The criminalization of people who use illicit drugs, along

with the mass incarceration of people for nonviolent drug law violations, has restricted

American Public Health Association. Policy No. 201312. Available at: https://www.apha.org/policies-and-

advocacy/public-health-policy-statements/policy-database/2014/07/08/08/04/defining-and-

implementing-a-public-health-response-to-drug-use-and-misuse. Accessed December 29, 2017.

American Public Health Association. Policy No. 8817(PP). Available at:

http://www.apha.org/advocacy/policy/policysearch/default.htm?id=1179. Accessed December 12, 2013.

Lambert D. Drugs and receptors. Contin Educ Anaesth Crit Care Pain. 2004;4(6):181–184.

Ruiz P, Strain EC, eds. Substance Abuse: A Comprehensive Textbook. 5th ed. Philadelphia, PA: Wolters

Kluwer Health; 2011.

Mendoza M. US drug war has met none of its goals. Available at:

http://www.huffingtonpost.com/2010/05/13/us-war-on-drugs-has-met-n_n_575351.html#. Accessed

December 12, 2013.

Results from the 2011 National Survey on Drug Use and Health. Rockville, MD: Substance Abuse and Mental

Health Services Administration; 2012.

Johnston LD, O’Malley PM, Bachman JG, Schulenberg JE. Monitoring the Future, National Survey Results on

Drug Use, 1975–2012: Volume I, Secondary School Students. Ann Arbor, MI: Institute for Social Research,

University of Michigan; 2013.

World Drug Report 2013. New York, NY: United Nations; 2013.

The War on Drugs and HIV/AIDS: How the Criminalization of Drug Use Fuels the Global Pandemic. Rio de

Janeiro, Brazil: Global Commission on Drug Policy; 2012.

Compressed Mortality File 1999–2009. Atlanta, GA: Centers for Disease Control and Prevention; 2012.

Warner M, Chen LH, Makuc DM, Anderson RN, Miniño AM. Drug poisoning deaths in the United States,

1980–2008. NCHS Data Brief.2011;81:1–8.

US Department of Health and Human Services. Vital signs: overdoses of prescription opioid pain relievers—

United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–1492.

Compressed Mortality—Underlying Cause of Death, ICD-10 Codes X40-44. Washington, DC: US Department

of Health and Human Services; 2010.

access to sterile syringes and opioid substitution treatments, and aggressive law

enforcement practices have promoted risky practices that facilitate the spread of HIV/AIDS

and other diseases while creating barriers to drug and HIV treatment.

Failure to adopt proven harm reduction measures has significantly increased the public

health harms of drug misuse. For example, legal and bureaucratic barriers still prevent

people who inject drugs from accessing sterile syringes in the United States, despite

decades of evidence proving that syringe access programs help to reduce the spread of

diseases.

In fact, the US Congress recently reinstated a federal ban on funding of sterile

syringe programs, after finally lifting the 2-decade-long ban just 3 years ago. The federal

ban is estimated to have cost thousands of lives and hundreds of millions of dollars.

Perhaps not surprisingly, fewer than one-third of people who inject drugs surveyed by the

Centers for Disease Control and Prevention (CDC) had been reached by an HIV

intervention.

Furthermore, while the United States has relatively high HIV prevalence

rates among people who inject drugs (at roughly 14%), countries that have consistently

and comprehensively provided harm reduction and effective treatment options, such as

syringe access and opioid substitution therapies, have rates that are far lower; in some of

these nations, HIV prevalence among people who inject drugs is 1% or lower.

Public funds are routinely prioritized for drug law enforcement instead of proven HIV

prevention strategies. While drug war budgets have generally increased, effective

treatment programs are chronically under resourced, and in the United States practically

no federal funds are invested in programs that will reduce harms related to injection drug

Effectiveness of Sterile Needle and Syringe Programming in Reducing HIV/AIDS Among Injecting Drug

Users. Geneva, Switzerland: World Health Organization; 2004.

Tilson H, Aramrattana A, Bozzette S, Celentano D, Falco M, Hammett T. Preventing HIV Infection Among

Injecting Drug Users in High-Risk Countries: An Assessment of the Evidence. Washington, DC: Institute of

Medicine; 2007.

International Guidelines on HIV/AIDS and Human Rights: 2006 Consolidated Version. Geneva, Switzerland:

Joint United Nations Programme on HIV/AIDS; 2006.

Hurley SF, Jolley DJ, Kaldor JM. Effectiveness of needle-exchange programmes for prevention of HIV

infection. Lancet. 1997;349(9068):1797–1800.

Uuskula A, Des Jarlais DC, Kals M, et al. Expanded syringe exchange programs and reduced HIV infection

among new injection drug users in Tallinn, Estonia. BMC Public Health. 2011;11:517.

Lurie P, Drucker E. An opportunity lost: HIV infections associated with lack of a national needle-exchange

programme in the USA. Lancet. 1997;349(9052):604–608.

Centers for Disease Control and Prevention. HIV-associated behaviors among injecting-drug users—23

cities, United States, May 2005–February 2006. MMWR Morb Mortal Wkly Rep. 2009;58(13):329–332.

Mathers BM, Degenhardt L, Ali H, et al. HIV prevention, treatment, and care services for people who inject

drugs: a systematic review of global, regional, and national coverage. Lancet. 2010;375(9719):1014–1028.

use.

The stigma associated with seeking and accessing drug treatment is also a barrier.

Criminalization of substance use further stigmatizes people who use drugs, making it more

difficult to engage people in health care and other services, a tendency that is often

compounded by sociocultural factors associated with problematic drug-using populations,

such as fear, lack of information and education, general physical and mental health

problems, homelessness, and incarceration.

Criminalization also exacerbates social

marginalization and encourages high-risk behaviors such as poly-drug use, binging, and

injecting in unhygienic, unsupervised environments.

Aggressive campaigns to arrest and

incarcerate people who use drugs only increase drug-related deaths, primarily because

people are too afraid to call 911 if they witness an overdose.

Harsh mandatory

minimum sentencing laws have also led to increased overdose deaths, because the illicit

drug market encourages the sale of more potent forms of prohibited drugs.

Drug law

enforcement has been shown to increase overdose mortality, while the provision of

medication-assisted treatment has been found to have the opposite effect.

Moreover,

aggressive drug law enforcement has been shown to increase levels of violence related to

Office of National Drug Control Policy. 2013 National Drug Control Strategy. Washington, DC: Executive

Office of the President; 2013.

Lloyd C. The stigmatization of problem drug users: a narrative literature review. Drugs Educ Prev Policy.

2013;20(2):85–95.

Semple SJ, Grant I, Patterson TL. Utilization of drug treatment programs by methamphetamine users: the

role of social stigma. Am J Addict. 2005;14(4):367–380.

Lloyd C. Sinning and Sinned Against: The Stigmatisation of Problem Drug Users. York, England: University

of York; 2010.

Corrigan PW, Kuwabara SA, O’Shaughnessy J. The public stigma of mental illness and drug addiction:

findings from a stratified random sample. J Soc Work. 2009;9(2):139–147.

White WL. Long-Term Strategies to Reduce the Stigma Attached to Addiction, Treatment, and Recovery

Within the City of Philadelphia (With Particular Reference to Medication-Assisted Treatment/Recovery).

Philadelphia, PA: Department of Behavioral Health and Mental Retardation Services; 2009.

Friedman SR, Cooper HL, Tempalski B, et al. Relationships of deterrence and law enforcement to drug-

related harms among drug injectors in US metropolitan areas. AIDS. 2006;20(1):93–99.

Hughes CE, Stevens A. What can we learn from the Portuguese decriminalization of illicit drugs? Br J

Criminol. 2010;50(6):999–1022.

Darke S, Ross J, Hall W. Overdose among heroin users in Sydney, Australia: II. Responses to overdose.

Addiction. 1996;91(3):413–417.

Davidson PJ, Ochoa KC, Hahn JA, Evans JL, Moss AR. Witnessing heroin-related overdoses: the experiences

of young injectors in San Francisco. Addiction. 2002;97(12):1511–1516.

Ochoa KC, Hahn JA, Seal KH, Moss AR. Overdosing among young injection drug users in San Francisco.

Addict Behav. 2001;26(3):453–460.

Pollini RA, McCall L, Mehta SH, Celentano DD, Vlahov D, Strathdee SA. Response to overdose among

injection drug users. Am J Prev Med. 2006;31(3):261–264.

Tracy M, Piper TM, Ompad D, et al. Circumstances of witnessed drug overdose in New York City:

implications for intervention. Drug Alcohol Depend. 2005;79(2):181–190.

Davies RB. Mandatory minimum sentencing, drug purity and overdose rates. Econ Soc Rev.

2010;41(4):429–457.

Nordt C, Stohler R. Combined effects of law enforcement and substitution treatment on heroin mortality.

Drug Alcohol Rev. 2010;29(5):540–545.

drug markets: a systematic review revealed that “contrary to the conventional wisdom that

increasing drug law enforcement will reduce violence, the existing scientific evidence

strongly suggests that drug prohibition likely contributes to drug market violence and

higher homicide rates.”

The domestic drug war has also been an engine of mass incarceration. With less than 5% of

the world’s population but nearly 25% of its incarcerated population, the United States

imprisons more people (and at a higher rate) than any other nation in the world, largely as

a result of the war on drugs.

More than 1.5 million drug arrests occurred in the United

States in 2011. The vast majority—more than 80%—were for possession only, and half

were for marijuana law violations.

Seventeen percent (17%) of people in state prisons

and nearly half (48%) of those in federal prisons were incarcerated for a drug law violation

in 2011.

Roughly 500,000 Americans are behind bars on any given night for a drug law

violation, 10 times the total in 1980.

Misguided drug laws and disproportionate sentencing requirements have produced grossly

unequal outcomes for communities of color. Although rates of drug use and selling are

comparable across racial and ethnic lines, Blacks and Latinos are far more likely to be

criminalized for drug law violations than Whites.

People of color experience

discrimination at every stage of the judicial system.

This is particularly the case for drug

law violations. Blacks make up 13% of the US population and are consistently documented

by the US government to use drugs at rates similar to those among people of other races.

However, Blacks account for nearly one-third of drug arrests

and roughly 45% of those

Werb D, Rowell G, Guyatt G, Kerr T, Montaner J, Wood E. Effect of drug law enforcement on drug market

violence: a systematic review. IntJ Drug Policy. 2011;22(2):87–94.

Walmsley R. World Population List. 9th ed. London, England: International Centre for Prison Studies; 2011.

Crime in the United States, 2011. Washington, DC: Federal Bureau of Investigation; 2012.

Carson EA, Sabol WJ. Prisoners in 2011. Washington, DC: US Department of Justice, Bureau of Justice

Statistics; 2012.

The Sentencing Project. Trends in US corrections: state and federal prison population, 1925–2011.

Available at: http://sentencingproject.org/doc/publications/inc_Trends_in_Corrections_Fact_sheet.pdf.

Accessed December 12, 2013.

Beck AJ, Gilliard DK. Prisoners in 1994. Washington, DC: US Department of Justice, Bureau of Justice

Statistics; 1995.

Mauer M, King RS. A 25-year quagmire: the war on drugs and its impact on American society. Available at:

http://www.sentencingproject.org/detail/publication.cfm?publication_id=170. Accessed December 12, 2013.

Fellner J, Vinck P. Targeting Blacks: Drug Law Enforcement and Race in the United States. New York, NY:

Human Rights Watch; 2008.

Nguyen H, Reuter P. How risky is marijuana possession? Considering the role of age, race, and gender.

Crime Delinquency. 2012;58(6):879–910.

Tonry M. Punishing Race: A Continuing American Dilemma. New York, NY: Oxford University Press; 2011.

Alexander M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York, NY: New

Press; 2012.

Rastogi S, Johnson TD, Hoeffel EM Jr. The Black Population: 2010. Washington, DC: US Department of

Commerce; 2011.

incarcerated in state and federal prisons for drug law violations.

From 1980 to 2007,

Blacks were arrested for drug law violations nationwide at rates 3 to nearly 6 times higher

than Whites.

A recent report by the American Civil Liberties Union, for example, showed

that Blacks were arrested for marijuana possession offenses at roughly 4 times the rate of

Whites, although rates of use are essentially no different.

Furthermore, Blacks and

Latinos tend to be arrested for crimes that hold more serious punishments, such as selling

drugs rather than just possessing them.

Mass incarceration resulting from the war on drugs has devastated many families and

communities. A 2012 national study published in the American Journal of Public Health

showed that Black youths were less likely than Whites to use or sell drugs but more likely

to be arrested; the researchers concluded that “[r]acial disparities in adolescent arrest

appear to result from differential treatment of minority youths and to have long-term

negative effects on the lives of affected African American youths.”

Approximately 2.7

million children are growing up in US households in which one or more parents are

incarcerated. One in 9 Black children have an incarcerated parent, as compared with one in

28 Latino children and one in 57 White children.

Punishment for a drug law violation is not only meted out by the US criminal justice system

but also perpetuated by policies denying child custody, voting rights, employment, business

loans, trade licensing, student aid, and public housing and other public assistance to people

with criminal convictions. In addition, criminal records are cited as justification for

deporting legal residents and barring other noncitizens from visiting the United States.

Even if a person does not face jail or prison time, a drug conviction record—particularly a

felony—often imposes a lifelong ban on many aspects of social, economic, and political life.

Such exclusions create a permanent second-class status for millions of people and, as with

drug war enforcement itself, fall disproportionately on people of color. According to a 2008

article published in the American Journal of Public Health, “the popular war on drugs

translates to a war on people of color in terms of their overall health and well-being….

US Department of Justice. Federal Justice Statistics Program. Available at: http://bjs.ojp.usdoj.gov/fjsrc/.

Accessed December 12, 2013.

Fellner J. Decades of Disparity: Drug Arrests and Race in the United States. New York, NY: Human Rights

Watch; 2009.

The War on Marijuana in Black and White. Washington, DC: American Civil Liberties Union; 2013.

Beckett K. Race, drugs, and law enforcement. Criminology Public Policy. 2012;11(4):641–653.

Fellner J. Race, drugs, and law enforcement in the United States. Stanford Law Policy Rev. 2009;20:257.

Helms R, Costanza S. Race, politics, and drug law enforcement: an analysis of civil asset forfeiture patterns

across US counties. Policing Soc. 2009;19(1):1–19.

Kakade M, Duarte CS, Liu X, et al. Adolescent substance use and other illegal behaviors and racial disparities

in criminal justice system involvement: findings from a US national survey. Am J Public Health.

2012;102(7):1307–1310.

Western B, Pettit B. Collateral Costs: Incarceration's Effect on Economic Mobility. Washington, DC: Pew

Charitable Trusts; 2010.

Chesney-Lind M, Mauer M. Invisible Punishment: The Collateral Consequences of Mass Imprisonment. New

York, NY: New Press; 2011.

Communities of color face an escalating public health problem created by our society’s

solution to imprison those arrested for nonviolent drug offenses.”

APHA recognizes that the United States leads the world in incarceration and that the war

on drugs is a major driver of mass incarceration, particularly among people of color. APHA

policy 9123 (Social Practice of Mass Imprisonment) states that APHA has “a long history of

concern and activity aimed at correcting inadequacies in health conditions in correctional

institutions, and is aware that prison health and community health are intimately related

elements of public health in the US with…millions of individuals released annually from

custody to community.” It notes that “APHA has long-defined drug abuse as a public health

problem rather than a criminal justice problem and called for drug treatment to be

available for all who request it.” It further “condemns the social practice that sanctions

mass imprisonment rather than defining and changing those conditions that engender and

accompany criminal behavior, including drug addiction,” and calls for alternatives to

incarceration.

In 2009, in the wake of the XVIII International AIDS Conference in Vienna, Austria, the

international scientific and public health community issued the Vienna Declaration, a

statement seeking to improve community health and safety by calling for the incorporation

of scientific evidence into illicit drug policies. The Vienna Declaration calls for an

acknowledgment of the limits and harms of drug prohibition, for ending the criminalization

of people who use drugs, and for drug policy reform to remove barriers to effective HIV

prevention, treatment, and care.

Since then, an increasing number of prominent figures in and sectors of society have raised

their voices against policies that criminalize people who use drugs, in favor of robust,

health-centered alternatives. In 2011, former presidents Fernando Henrique Cardoso

(Brazil), Cesar Gaviria (Colombia), and Ernesto Zedillo (Mexico) joined with former UN

secretary general Kofi Annan, former US secretary of state George Shultz, former Federal

Reserve Board chairman Paul Volcker, former Swiss president Ruth Dreifuss, and other

members of the Global Commission on Drug Policy (GCDP) to launch a landmark report

calling for fundamental reforms to national and global drug policies, including (1)

acknowledging the failure of the “war on drugs” and its disastrous impact on human rights,

violence, and corruption; (2) replacing the criminalization and punishment of people who

use drugs with the offer of health and treatment services to those who need them; and (3)

encouraging governments to experiment with models of legal regulation to undermine the

power of organized crime and safeguard people’s health and security.

In advance of the

Moore LD, Elkavich A. Who’s using and who’s doing time: incarceration, the war on drugs, and public

health. Am J Public Health. 2008;98(5):782–786.

The Vienna Declaration. Available at: http://www.viennadeclaration.com/. Accessed December 12, 2013.

Report of the Global Commission on Drug Policy. Rio de Janeiro, Brazil: Global Commission on Drug Policy;

2011.

International AIDS Conference in Washington, DC, the GCDP issued a second report in June

2012, The War on Drugs and HIV/AIDS, which was successful in exposing the causal links

between the HIV pandemic and the criminalization of drug use.

The GCDP has since been joined by former presidents Jorge Sampaio (Portugal), Alexander

Kwasniewski (Poland), and Ricardo Lagos (Chile). Former US presidents Jimmy Carter and

Bill Clinton have echoed most or all of the commission’s recommendations, as has former

president Vicente Fox of Mexico. In 2013, the GCDP issued a third report, The Negative

Impact of the War on Drugs on Public Health: The Hidden Hepatitis C Epidemic, which

again called for the decriminalization of drug use and the expansion of proven, science-

based solutions to reduce hepatitis C, including sterile syringe access, supervised injection

facilities, and heroin prescription programs.

Against this backdrop, the Organization of American States issued a groundbreaking, 2-part

report in May 2013 in which it critically examined the current war on drugs and considered

new approaches for the future, giving equal weight to options such as decriminalization

and harm reduction.

Among the report’s conclusions is the urgent need for a “public

health approach” to address drug problems, and it specifies that “the decriminalization of

drug use needs to be considered as a core element in any public health strategy.”

In June 2013, Human Rights Watch publicly condemned “[n]ational drug control policies

that impose criminal penalties for personal drug use” as a violation of human rights, stating

that the “criminalization of drug use has undermined the right to health” because “fear of

criminal penalties deters people who use drugs from using health services and treatment,

and increases their risk of violence, discrimination, and serious illness.” Its statement

continues, “Criminal prohibitions have also impeded the use of drugs for legitimate medical

research, and have prevented patients from accessing drugs for palliative care and pain

treatment,” a harm well documented in the literature.

It concludes by urging governments

to “rely instead on non-penal regulatory and public health policies.”

And in November

2012, Colorado and Washington became the first political jurisdictions in the world to vote

to permit the legal regulation of marijuana sales, cultivation, and distribution among adults

21 years of age and older within their borders, and both states are in the process of

The Negative Impact of the War on Drugs on Public Health: The Hidden Hepatitis C Epidemic. Rio de

Janeiro, Brazil: Global Commission on Drug Policy; 2013.

Scenarios for the Drug Problem in the Americas: 2013–2025. Washington, DC: Organization of American

States; 2013.

The Drug Problem in the Americas: Analytical Report. Washington, DC: Organization of American States;

2013.

Nickerson JW, Attaran A. The inadequate treatment of pain: collateral damage from the war on drugs. PLoS

Med. 2012;9(1):e1001153.

Human Rights Watch. Americas: decriminalize personal use of drugs; reform policies to curb violence,

abuse. Available at: http://www.hrw.org/news/2013/06/04/americas-decriminalize-personal-use-drugs.

Accessed December 12, 2013.

implementing their new laws in such a way as to strengthen public safety and health to the

maximum extent possible.

Joining those distinguished colleagues and peers, APHA agrees that the criminalization of

people who use illicit drugs is fueling the HIV epidemic and has resulted in overwhelmingly

negative health and social consequences, and that a full policy reorientation is needed.

Proposed Recommendations Statement

APHA policies 7121 and 8817(PP) call for a reorientation of current US drug policies, and

APHA also has adopted longstanding policies that support several aspects of a health-based

response to drug misuse. Policy 8817(PP) urges a “redirection of current War on Drugs

policies, which are seriously flawed and have little chance of alleviating the serious drug

problems facing our society today.”

The present policy statement identifies the following proposals as vital elements of the

redirection in US drug policy envisioned by APHA’s existing policy statements, toward the

adoption and implementation of a truly public health approach to reducing the harms of

drug misuse.

End the criminalization of drug possession and people who use drugs: APHA’s policies

7121 and 8817(PP) recommend the removal of criminal penalties for drug use.

Policy 7121

first expressed APHA’s belief that people who use drugs should not be criminalized:

“because substance abuse is viewed primarily as a public health problem, this Association

recommends that no punitive measures be taken against the users of alcohol, marijuana, or

other substances when no other illegal act has been committed.”

APHA reiterated its belief that drug misuse must be primarily addressed as a public health

issue, resolving in policy 8817(PP) that “[s]trict punitive measures should not take priority

over drug treatment and prevention goals…punitive measures have only a limited impact

on drug use and problem rates and, in many cases, have been shown to have an underlying

purpose to discriminate against disadvantaged groups.” Policy 8817(PP) further

recommends that US drug policy give “high priority to prevention, treatment and recovery”

and that “punitive measures should be used with caution and should play a secondary

role.… Particular attention should be given to the special needs of young people and

disenfranchised groups and caution must be exercised to avoid discriminatory policies.”

Countries that have ended the criminalization of drug use and possession have generally

been better able to cope with injection drug–related HIV/AIDS. Decriminalizing drug

possession and investing in treatment and harm reduction services can provide several

major benefits for public health, including reducing the number of people incarcerated;

increasing uptake into drug treatment; reducing criminal justice costs and redirecting

resources from criminal justice to health systems; redirecting law enforcement resources

to prevent serious and violent crime; addressing racial disparities in drug law enforcement,

incarceration, and related health characteristics and outcomes; minimizing stigma and

creating a social, cultural, and policy climate in which people who use drugs are less fearful

of seeking and accessing treatment, using harm reduction services, and receiving HIV/AIDS

services; and protecting people from the wide-ranging and debilitating consequences of a

criminal conviction.

Some countries particularly stand out. In 2001, Portuguese legislators enacted a

comprehensive form of decriminalization of low-level possession and consumption of all

illicit drugs and reclassified these activities as administrative violations.

A person caught

with personal-use amounts of any drug in Portugal is no longer arrested but, rather,

ordered to appear before a local “dissuasion commission” composed of 3 officials (one from

the legal arena and a pair from the health arena) who determine whether and to what

extent the person is addicted to drugs. On the basis of these findings, the commission can

order someone to attend a treatment program, complete other monitoring activities, pay a

fine, or submit to other administrative sanctions. Drug trafficking and non-drug offenses

remain illegal and are still processed through the criminal justice system.

The decriminalization policy was part of a comprehensive health-oriented approach to

addressing problematic drug use, especially unsafe injecting drug use, that also included a

major expansion of treatment and harm reduction services. New diagnoses of HIV and AIDS

among people who inject drugs have also declined in Portugal. Between 2000 and 2008, the

number of cases of HIV among people who inject drugs declined from 907 to 267, and the

number of AIDS cases decreased from 506 to 108. These highly significant declines are

largely attributable to the increased provision of harm reduction services and efforts made

possible by decriminalization.

In addition, research has shown no significant increases in overall illicit drug use among

adults in Portugal, and any slight increases in lifetime use of some drugs appear to be part

of a regional trend. More importantly, adolescent drug use, as well as problematic drug

use—defined as use by people deemed to be dependent or addicted and by people who

inject drugs—has decreased overall since 2003.

The number of people arrested and sent to

criminal courts for drug law violations declined by more than half after decriminalization.

The percentage of people in Portugal’s prison system as a result of drug-related offenses

also decreased by about half, from 44% in 1999 to 21% in 2008.

These positive outcomes cannot be attributed to decriminalization alone. Alongside its

decriminalization law, Portugal significantly expanded its treatment and harm reduction

services, including access to sterile syringes as well as methadone maintenance therapy

and other medication-assisted treatments. Between 1998 and 2008, the number of people

Domoslawski A, Siemaszko H. Drug Policy in Portugal: The Benefits of Decriminalizing Drug Use.

Washington, DC: Open Society Institute; 2011.

in drug treatment increased by more than 60% (from 23,654 to 38,532 people). The

percentage of drug-related deaths in which opiates were the primary substance involved

declined from 95% in 1999 to 59% in 2008.

On the basis of such evidence and APHA’s longstanding policies, eliminating criminal

penalties for personal drug use and possession is an essential feature of a public health

response to drugs and drug misuse, and APHA calls on state and federal governments to

remove such criminal penalties.

Expand access to harm reduction interventions: Harm reduction programs including sterile

syringe access, supervised injection facilities, and medication-assisted treatment should be

scaled up to eliminate HIV and hepatitis C transmission among people who inject drugs.

Interventions that have proven effective in other countries should be evaluated for

implementation in the United States, and legal and political barriers to programs with

evidence of effectiveness should be removed. Treatment providers, health professionals

(including primary care physicians), community health workers (CHWs), and other

stakeholders should receive professional preparation and training with respect to proven

treatment and harm reduction interventions. CHWs play a critical role in making contact

and building trust with hard-to-reach, drug-using populations at high risk and connecting

them to health services or delivering those services to them. To expand access to these

harm reduction and treatment services to every person in need, CHWs must be empowered

to deliver cost-effective interventions such as syringe access programs, secondary syringe

exchange services, low-threshold methadone maintenance, peer education programs, and

HIV/AIDS testing, education, and links to treatment. Criminalization, by contrast, makes the

essential harm reduction functions of CHWs more difficult or even impossible.

Restricting access to sterile syringes among people who inject drugs has been proven to

lead to syringe sharing, a major cause of HIV infections. According to the CDC, people who

inject drugs represented 9% (4,500) of all estimated new HIV infections in 2009, an annual

figure that has not changed significantly since 2006.

Such restrictions persist despite

conclusive evidence from more than 200 studies conducted in the United States and abroad

showing that expanding sterile syringe access—through syringe exchange programs and

non-prescription sales of syringes—is a cost-effective means of reducing the spread of HIV

and viral hepatitis and that these programs do not contribute to increased drug use, drug

Estimates of New HIV Infections in the United States, 2006–2009. Atlanta, GA: Centers for Disease Control

and Prevention; 2011.

injection, crime, or unsafe discarding of syringes.

According to a CDC-funded study

published in the Journal of the American Medical Association, syringe access has helped

reduce HIV incidence among people who inject drugs in the United States by 80% in the

past decade.

Current APHA policy in this regard recognizes “the critical importance of

access to sterile syringes to prevent disease spread, and the effectiveness of increasing

sterile syringe access in reducing risk behavior”; it “urges states that criminalize possession

of prescribed syringes for injection of illicit substances to modify their laws or policies to

permit such possession.”

Sterile syringe access programs are integral elements of a

comprehensive health response to problematic drug use, are necessary to reach the goal of

an AIDS-free generation, and should be funded at the local, state, and national levels toward

the goal of providing a sterile syringe for every injection.

Medically supervised injection facilities (SIFs) are controlled health care settings where

people who use drugs can more safely do so under clinical supervision and receive health

care, counseling, and referral to health and social services, including drug treatment. There

are currently 92 SIFs operating in 62 cities around the world, but none in the United States.

SIFs are proven to reduce unsafe injecting practices and the transmission of bloodborne

viruses; prevent overdose fatalities; increase access or referrals to treatment programs,

including medication-assisted treatment and detoxification services; decrease societal

costs associated with emergency room visits and crime; and reduce the social harms

Belani HK, Muennig PA. Cost-effectiveness of needle and syringe exchange for the prevention of HIV in New

York City. J HIV/AIDS Soc Serv. 2008;7(3):229–240.

Lurie P, Gorsky R, Jones TS, Shomphe L. An economic analysis of needle exchange and pharmacy-based

programs to increase sterile syringe availability for injection drug users. J Acquir Immune Defic Syndr Hum

Retrovirol. 1998;18(suppl 1):S126–S132.

Schackman BR, Gebo KA, Walensky RP, et al. The lifetime cost of current human immunodeficiency virus

care in the United States. Med Care. 2006;44(11):990–997.

Centers for Disease Control and Prevention. Syringe exchange programs—United States, 2008. MMWR

Morb Mortal Wkly Rep. 2010;59(45):1488–1491.

Lambert EY, Cesari HK, Stein JB. Principles of HIV Prevention in Drug-Using Populations: A Research-Based

Guide. Bethesda, MD: National Institute on Drug Abuse; 2002.

Marx MA, Crape B, Brookmeyer RS, et al. Trends in crime and the introduction of a needle exchange

program. Am J Public Health. 2000;90(12):1933–1936.

Palmateer N, Kimber J, Hickman M, Hutchinson S, Rhodes T, Goldberg D. Evidence for the effectiveness of

sterile injecting equipment provision in preventing hepatitis C and human immunodeficiency virus

transmission among injecting drug users: a review of reviews. Addiction. 2010;105(5):844–859.

Des Jarlais DC, Perlis T, Arasteh K, et al. Reductions in hepatitis C virus and HIV infections among injecting

drug users in New York City, 1990–2001. AIDS. 2005;19(suppl 3):S20–S25.

Hall HI, Song R, Rhodes P, et al. Estimation of HIV incidence in the United States. JAMA. 2008;300(5):520–

529.

associated with injection drug use, such as public disorder, public intoxication, public

injecting, and publicly discarded syringes.

Medication-assisted treatments, most commonly opioid-substitution programs (also called

narcotic replacement therapies), have demonstrated success in improving the lives and the

health of people who use heroin and other opioids. Such therapies include methadone and

buprenorphine,

as well as pharmaceutical heroin treatment, and they have proven

successful in many countries.

Denial of these treatments can result in untreated

addiction, preventable HIV risk behaviors, and heightened vulnerability to fatal

overdose.

APHA took a leading position in 1970 when it supported “further experimentation with

organized maintenance programs using methadone and similar compounds, subject to

appropriate supervision and evaluation,” in policy 7015. One year earlier, policy 6907 had

resolved:

“The American Public Health Association believes that the illicit profit incentive involved in

the sale of drugs to drug addicts not only contributes to their misery but puts at risk entire

communities in the United States, unnecessarily submitting its citizens to muggings,

robberies, injuries and in some instances murder, while constantly contributing to the

profits of gangsters and Mafia-like organizations. APHA…declares that it will seek and

support state and federal legislation to eliminate the profit motive in the illicit sale of

drugs…by making medically approved drugs and regimens of the most suitable and

clinically evaluated methods readily available to known drug addicts at specially

designated health centers equipped with professional staffs competent to deal with the

comprehensive rehabilitation of the addict by means of: Medical care…psychological and

Kerr T, Wood E, Montaner J, Tyndall M. Findings from the Evaluation of Vancouver’s Pilot Medically

Supervised Safer Injection Facility—Insite. Vancouver, British Columbia, Canada: Centre for Excellence in

HIV/AIDS; 2009.

Schatz E, Nougier M. Drug Consumption Rooms: Evidence and Practice. London, England: International

Drug Policy Consortium; 2012.

Semaan S, Fleming P, Worrell C, Stolp H, Baack B, Miller M. Potential role of safer injection facilities in

reducing HIV and hepatitis C infections and overdose mortality in the United States. Drug Alcohol Depend.

2011;118(2–3):100–110.

Maher L, Salmon A. Supervised injecting facilities: how much evidence is enough? Drug Alcohol Rev.

2007;26(4):351–353.

Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement

therapy for opioid dependence. Cochrane Database Syst Rev. 2009;3:CD002209.

Gowing L, Farrell M, Bornemann R, Sullivan L, Ali R. Substitution treatment of injecting opioid users for

prevention of HIV infection. Cochrane Database Syst Rev. 2008;2:CD004145.

Gowing L, Ali R, White JM. Buprenorphine for the management of opioid withdrawal. Cochrane Database

Syst Rev. 2009;3:CD002025.

McKenzie M, Zaller N, Dickman SL, et al. A randomized trial of methadone initiation prior to release from

incarceration. Substance Abuse. 2011;33(1):19–29.

Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Prevention.

Geneva, Switzerland: World Health Organization; 2004.

psychiatric counseling; social, economic, and welfare counseling aimed at increased

employability [and] provision of the necessary funding to enable states, communities, and

consumer action groups to give priority and coordinated action to implement

establishment of such centers.”

Since that time the CDC,

the Institute of Medicine,

the National Institutes of Health,

the

Substance Abuse and Mental Health Services Administration (SAMHSA),

the National

Institute on Drug Abuse,

the World Health Organization (WHO),

and more than 4

decades of government-funded, peer-reviewed medical research have unequivocally and

repeatedly proven that substitution therapies such as methadone maintenance are the

most effective treatments for opioid dependence.

Methadone, buprenorphine, and

other existing medication-assisted treatments should be expanded to serve all who need

them. Indeed, according to the National Institutes of Health, “all opiate-dependent persons

under legal supervision should have access to methadone maintenance therapy.” Yet, few

opioid-dependent people in the United States have access to these treatments; according to

SAMHSA, only 9% of substance abuse treatment facilities in the country offer specialized

treatment of opioid dependence with methadone or buprenorphine.

Publicly funded

treatment programs are far less likely than privately funded programs to offer opioid

replacement therapies.

100

Centers for Disease Control and Prevention. Methadone maintenance treatment. Available at:

http://www.cdc.gov/idu/facts/Methadone.htm. Accessed December 12, 2013.

Rettig RA, Yarmolinsky A. Federal Regulation of Methadone Treatment. Washington, DC: National Academy

Press; 1995.

Effective Medical Treatment of Opiate Addiction. Bethesda, MD: National Institutes of Health; 1997.

Medication-Assisted Treatment for Opioid Addiction in Opioid Treatment Programs. Rockville, MD: Center

for Substance Abuse Treatment; 2005.

National Institute on Drug Abuse. Research report: heroin abuse and addiction. Available at:

http://www.drugabuse.gov/ResearchReports/heroin/heroin.html. Accessed December 12, 2013.

Methadone Research Web Guide. Bethesda, MD: National Institute on Drug Abuse; 2007.

Substitution Maintenance Therapy in the Management of Opioid Dependence and HIV/AIDS Prevention.

Geneva, Switzerland: World Health Organization; 2004.

Ball JC, Ross A. The Effectiveness of Methadone Maintenance Treatment: Patients, Programs, Services, and

Outcome. New York, NY: Springer-Verlag; 1991.

Fiellin DA, O’Connor PG, Chawarski M, Pakes JP, Pantalon MV, Schottenfeld RS. Methadone maintenance in

primary care: a randomized controlled trial. JAMA. 2001;286(14):1724–1731.

Novick DM, Joseph H. Medical maintenance: the treatment of chronic opiate dependence in general medical

practice. J Subst Abuse Treat. 1991;8(4):233–239.

Hser YI, Hoffman V, Grella CE, Anglin MD. A 33-year follow-up of narcotics addicts. Arch Gen Psychiatry.

2001;58(5):503–508.

Ward J, Hall W, Mattick RP. Role of maintenance treatment in opioid dependence. Lancet.

1999;353(9148):221–226.

Catania H. About Methadone and Buprenorphine. Revised 2nd ed. New York, NY: Drug Policy Alliance;

2006.

National Survey of Substance Abuse Treatment Services: 2011 Data. Rockville, MD: Substance Abuse and

Mental Health Services Administration; 2013.

100

Abraham AJ, Knudsen HK, Rieckmann T, Roman PM. Disparities in access to physicians and medications

for the treatment of substance use disorders between publicly and privately funded treatment programs in

the United States. J Stud Alcohol Drugs. 2013;74(2):258.

Medication-assisted treatment models for opioid dependence using diacetylmorphine

(heroin) have been safely and successfully implemented in several countries and are now

well supported in the academic literature as one tool in an effective, health-based response

to problematic drug use, especially among those who have not responded to conventional

treatments.

101

115

A systematic review of all published studies to date on heroin-assisted

treatment (HAT) showed significant reductions in illicit drug use and crime and

improvements in the health of participants. An important article in the New England

Journal of Medicine on the success of the North American Opioid Medication Initiative in

Canada, which provided heroin by prescription to a select group of people who had not

responded to other forms of treatment, reported a two-thirds (67%) reduction in illicit

drug use and other illegal activity.

Similar reductions in illicit heroin use were reported

from HAT trials in the United Kingdom (72%) and Germany (69%). HAT is not only more

101

Blanken P, Hendriks VM, Koeter MW, van Ree JM, van den Brink W. Craving and illicit heroin use among

patients in heroin-assisted treatment. Drug Alcohol Depend. 2012;120(1–3):74–80.

102

Blanken P, van den Brink W, Hendriks VM, et al. Heroin-assisted treatment in the Netherlands: history,

findings, and international context. Eur Neuropsychopharmacol. 2010;20:S105–S158.

103

Ferri M, Davoli M, Perucci CA. Heroin maintenance for chronic heroin-dependent individuals. Cochrane

Database Syst Rev. 2011;12:CD003410.

104

Fischer B, Oviedo-Joekes E, Blanken P, et al. Heroin-assisted treatment (HAT) a decade later: a brief update

on science and politics. J Urban Health. 2007;84(4):552–562.

105

Haasen C, Verthein U, Degkwitz P, Berger J, Krausz M, Naber D. Heroin-assisted treatment for opioid

dependence: randomised controlled trial. Br J Psychiatry. 2007;191:55–62.

106

Oviedo-Joekes E, Brissette S, Marsh DC, et al. Diacetylmorphine versus methadone for the treatment of

opioid addiction. N Engl J Med. 2009;361(8):777–786.

107

Oviedo-Joekes E, March JC, Romero M, Perea-Milla E. The Andalusian trial on heroin-assisted treatment: a

2 year follow-up. Drug Alcohol Rev. 2010;29(1):75–80.

108

Petrushevska T. Heroin maintenance treatment—are further investigations needed? Macedonian J Med

Sci. 2012;5(4):453–461.

109

Strang J, Groshkova T, Metrebian N. New heroin-assisted treatment: recent evidence and current practices

of supervised injectable heroin treatment in Europe and beyond. Available at:

http://www.emcdda.europa.eu/attachements.cfm/att_154996_EN_Heroin%20Insight.pdf. Accessed

December 12, 2013.

110

Strang J, Metrebian N, Lintzeris N, et al. Supervised injectable heroin or injectable methadone versus

optimised oral methadone as treatment for chronic heroin addicts in England after persistent failure in

orthodox treatment (RIOTT): a randomised trial. Lancet. 2010;375(9729):1885–1895.

111

Uchtenhagen A. Heroin-assisted treatment in Switzerland: a case study in policy change. Addiction.

2010;105(1):29–37.

112

Killias M, Aebi MF, Jurist K. The impact of heroin prescription on heroin markets in Switzerland. Crime

Prev Stud. 2000;11:83–100.

113

Nordt C, Stohler R. Incidence of heroin use in Zurich, Switzerland: a treatment case register analysis.

Lancet. 2006;367(9525):1830–1834.

114

Verthein U, Bonorden-Kleij K, Degkwitz P, et al. Long-term effects of heroin-assisted treatment in

Germany. Addiction. 2008;103(6):960–966.

115

Reuter P. Can Heroin Maintenance Help Baltimore? Baltimore, MD: Abell Foundation; 2009.

effective in reducing street heroin (and other drug) use than methadone, but it has also

proven to be more cost-effective.

116

117

Emerging literature on treating stimulant dependence with the administration of agonists

or partial agonists, such as dextroamphetamine,

118

120

methylphenidate,

121

and

modafinil,

122

123

has shown favorable results. Such treatments utilizing opioid and

stimulant agonist and/or partial agonist substitution clearly merit research into their

feasibility in the United States and should be adopted as part of the US treatment response

if evaluations prove favorable.

124

Opposing Arguments/Evidence

Opponents of the health-based drug policies called for in the present policy statement often

claim that the criminalization of people who use drugs is effective in reducing drug use. As

a corollary, it is often argued that reducing or eliminating criminal penalties for drug

possession or expanding access to harm reduction services such as syringe exchanges,

supervised injection facilities, or medication-assisted treatments enables problematic drug

use; promotes the initiation of drug use; increases rates of drug misuse, crime, and related

problems; and worsens public health and public safety.

Yet, available evidence does not support these assertions. Not only has the dominant drug

war paradigm completely failed to curb drug use or supply, but the evidence consistently

shows that this approach has significantly amplified the harms of drug misuse and

addiction. A recent evaluation by the Government Accountability Office (GAO) issued in

March 2013 showed that the Office of National Drug Control Policy (ONDCP) and the

federal government “have not made progress toward achieving most of the goals

116

Verthein U, Haasen C, Reimer J. Switching from methadone to diamorphine: 2-year results of the German

heroin-assisted treatment trial. Subst Use Misuse. 2011;46(8):980–991.

117

Nosyk B, Guh DP, Bansback NJ, et al. Cost-effectiveness of diacetylmorphine versus methadone for chronic

opioid dependence refractory to treatment. CMAJ. 2012;184(6):E317–E328.

118

Longo M, Wickes W, Smout M, Harrison S, Cahill S, White JM. Randomized controlled trial of

dexamphetamine maintenance for the treatment of methamphetamine dependence. Addiction.

2010;105(1):146–154.

119

White R. Dexamphetamine substitution in the treatment of amphetamine abuse: an initial investigation.

Addiction. 2000;95(2):229–238.

120

Grabowski J, Rhoades H, Schmitz J, et al. Dextroamphetamine for cocaine-dependence treatment: a double-

blind randomized clinical trial. J Clin Psychopharmacol. 2001;21(5):522.

121

Vansickel AR, Fillmorex MT, Hays LR, Rush CR. Effects of potential agonist-replacement therapies for

stimulant dependence on inhibitory control in cocaine abusers. Am J Drug Alcohol Abuse. 2008;34(3):293–

305.

122

Dackis CA, Kampman KM, Lynch KG, Pettinati HM, O’Brien CP. A double-blind, placebo-controlled trial of

modafinil for cocaine dependence. Neuropsychopharmacology. 2005;30(1):205–211.

123

Hart CL, Haney M, Vosburg SK, Rubin E, Foltin RW. Smoked cocaine self-administration is decreased by

modafinil. Neuropsychopharmacology. 2008;33(4):761–768.

124

Reuter P. Can heroin maintenance help Baltimore? What Baltimore can learn from the experience of other

countries. Available at: http://www.abell.org/pubsitems/cja_HeroinMaintenance_0209.pdf Accessed

December 12, 2013.

articulated in the 2010 National Drug Control Strategy.” The GAO concluded that, in terms

of reducing youth drug use, overdose fatalities, and HIV caused by injection drug use, the

ONDCP not only has been unsuccessful but in fact has lost ground.

125

Aggressive drug law enforcement practices—and the resulting fear of arrest—drive many

people who inject drugs into environments where HIV risks are greatly elevated and away

from HIV testing, prevention, and other public health services.

126

127

Two studies published

in the American Journal of Public Health further demonstrate that aggressive drug law

enforcement exacerbates public health risks among people who use drugs. The first, a 2012

analysis of the relationship between arrest rates for heroin and cocaine offenses and the

prevalence of injection drug use from 1992 to 2002, revealed that “deterrence-based

approaches to reducing drug use seem not to reduce IDU prevalence” and that “alternative

approaches such as harm reduction, which prevents HIV transmission and increases

referrals to treatment, may be a better foundation for policy.”

128

The second, a 2005 study

of intense street-level enforcement near syringe exchange program sites in Philadelphia,

showed that utilization of such programs fell significantly as a result of increased drug law

enforcement.

129

After studying nearly a hundred metropolitan areas in the United States, researchers found

that repressive drug law enforcement was correlated with increased HIV prevalence

among people who inject drugs. The researchers concluded: “This may be because fear of

arrest and/or punishment leads drug injectors to avoid using syringe exchanges, or to

inject hurriedly or to inject in shooting galleries or other multi-person injection settings to

escape detection.” Criminalization also erects multiple barriers to both HIV and drug

treatment.

130

131

Research demonstrates that people who use drugs tend to have lower

rates of antiretroviral therapy utilization and higher rates of death due to HIV/AIDS. What

is more, these factors also seriously interfere with the front-line work of CHWs to reach out

to, engage, recruit, and retain hard-to-reach people in health programs, especially low-

threshold and secondary harm reduction services.

125

Office of National Drug Control Policy: Office Could Better Identify Opportunities to Increase Program

Coordination. Washington, DC: US Government Accountability Office; 2013.

126

Kerr T, Small W, Wood E. The public health and social impacts of drug market enforcement: a review of the

evidence. Int J Drug Policy. 2005;16(4):210–220.

127

Strathdee SA, Hallett TB, Bobrova N, et al. HIV and risk environment for injecting drug users: the past,

present, and future. Lancet. 2010;376(9737):268–284.

128

Friedman SR, Pouget ER, Chatterjee S, et al. Drug arrests and injection drug deterrence. Am J Public Health.

2011;101(2):344–349.

129

Davis CS, Burris S, Kraut-Becher J, Lynch KG, Metzger D. Effects of an intensive street-level police

intervention on syringe exchange program use in Philadelphia, Pa. Am J Public Health. 2005;95(2):233–236.

130

Wolfe D, Carrieri MP, Shepard D. Treatment and care for injecting drug users with HIV infection: a review

of barriers and ways forward. Lancet. 2010;376(9738):355–366.

131

Wood E, Kerr T, Tyndall MW, Montaner JS. A review of barriers and facilitators of HIV treatment among

injection drug users. AIDS. 2008;22(11):1247–1256.

Moreover, empirical evidence from jurisdictions around the world has demonstrated

rather conclusively that policies that eliminate criminal penalties for drug possession or

allow limited drug availability do not increase drug use to any appreciable degree.

Specifically, jurisdictions that have legalized medical marijuana, decriminalized possession

of marijuana and/or other drugs, or tolerated limited, retail sales (e.g., recreational

marijuana “coffee shops” in the Netherlands) have not experienced significant, if any,

increases in marijuana or other drug use.

132

143

A new study published in the American

Journal of Public Health, for instance, revealed that adolescent marijuana has not increased

in states with medical marijuana laws.

144

Empirical evidence from countries that have

adopted less punitive policies toward drug possession shows that these countries have not

experienced any significant increases in drug use, drug-related harm, or drug-related crime

relative to more punitive countries.

145

A WHO study of lifetime drug use rates among 17

countries showed that the United States had the highest drug use rates by a wide margin,

despite its punitive drug policies, noting that the US, which has been driving much of the

world’s drug research and drug policy agenda, stands out with higher levels of use of

alcohol, cocaine, and cannabis, despite more punitive illegal drug policies…than many

comparable developed countries. Clearly, by itself, a punitive policy towards possession

and use accounts for limited variation in nation-level rates of drug use.”

132

Degenhardt L, Chiu W-T, Sampson N, et al. Toward a global view of alcohol, tobacco, cannabis, and cocaine

use: findings from the WHO World Mental Health Surveys. PLoS Med. 2008;5(7):e141.

133

Room R. Cannabis Policy: Moving Beyond Stalemate. New York, NY: Oxford University Press; 2010.

134

Reinarman C, Cohen PDA, Kaal HL. The limited relevance of drug policy: cannabis in Amsterdam and in San

Francisco. Am J Public Health. 2004;94(5):836–842.

135

Harper S, Strumpf EC, Kaufman JS. Do medical marijuana laws increase marijuana use? Replication study

and extension. Ann Epidemiol. 2012;22(3):207–212.

136

Single EW. The impact of marijuana decriminalization: an update. J Public Health Policy. 1989;10(4):456–

466.

137

MacCoun RJ, Reuter P. Drug War Heresies: Learning From Other Vices, Times, and Places. Cambridge,

England: Cambridge University Press; 2001.

138

Reuter P. Marijuana Legalization: What Can Be Learned From Other Countries. Santa Monica, CA: RAND;

2010.

139

MacCoun RJ. What can we learn from the Dutch cannabis coffeeshop system? Addiction.

2011;106(11):1899–1910.

140

Vuolo M. National-level drug policy and young people’s illicit drug use: a multilevel analysis of the

European Union. Drug Alcohol Depend. 2013;131(1–2):149–156.

141

Joy JE, Watson SJ, Benson JA. Marijuana and Medicine: Assessing the Science Base. Washington, DC:

Institute of Medicine; 1999.

142

Gorman DM, Huber CJ Jr. Do medical cannabis laws encourage cannabis use? Int J Drug Policy.

2007;18(3):160–167.

143

O’Keefe K, Earleywine M. Marijuana Use by Young People: The Impact of State Medical Marijuana Laws.

Washington, DC: Marijuana Policy Project; 2011.

144

Lynne-Landsman SD, Livingston MD, Wagenaar AC. Effects of state medical marijuana laws on adolescent

marijuana use. Am J Public Health. 2013;103(8):1500–1506.

145

Johnston L, Bachman J, O’Malley P. Marijuana Decriminalization: The Impact on Youth 1975–1980. Ann

Arbor, MI: University of Michigan; 1981.

The Portuguese experience is particularly noteworthy; as described above, it has not

resulted in any significant increases in overall illicit drug use among adults.

In fact,

Portugal’s drug use rates remain below the European average and are far lower than those

in the United States.

Overall, evidence after 10 years shows that none of the fears of drug

war proponents have come to pass. According to the United Nations Office on Drugs and

Crime, “Portugal’s policy has reportedly not led to an increase in drug tourism. It also

appears that a number of drug-related problems have decreased.”

146

A new study of

European Union countries showed that countries such as Portugal that have decriminalized

the use and possession of all drugs have not experienced increases in rates of monthly drug

use and, in fact, have lower rates of use than countries with punitive policies.

Nor have harm reduction interventions such as syringe access, SIFs, and medication-

assisted treatments been shown to increase drug use. Syringe access programs, on the

contrary, have been proven not to contribute to increased drug use, drug injection, crime,

or unsafe discarding of syringes.

SIFs reduce the social harms associated with injection

drug use, such as public disorder, public intoxication, public injecting, and publicly

discarded syringes. Several dozen published articles in peer-reviewed journals have

confirmed the positive public health impact of SIFs, including 2 articles published in the

American Journal of Public Health showing that the SIF located in Vancouver, Canada, has

succeeded in attracting and retaining a population of injection drug users who are at

heightened risk for infectious disease and overdose without increasing initiation into

injection drug use.

147

148

The evidence is similarly (and uniformly) positive for HAT

programs: far from enabling drug use, these programs reduce illicit drug use and crime. In

fact, many HAT participants freely choose to move on to another form of treatment (such as

methadone) or to become abstinent, while others continue to receive HAT treatment on a

long-term basis, with lasting positive results.

149

150

Alternative Strategies

Some policymakers, academics, and commentators have suggested that, rather than

removing or reducing criminal penalties or investing in harm reduction services, US drug

policies should focus on delivering drug treatment through the criminal justice system,

146

World Drug Report 2009. Vienna, Austria: United Nations Office on Drugs and Crime; 2009.

147

Wood E, Tyndall MW, Qui Z, Zhang R, Montaner JSG, Kerr T. Service uptake and characteristics of injection

drug users utilizing North America’s first medically supervised safer injecting facility. Am J Public Health.

2006;96(5):770–773.

148

Kerr T, Tyndall MW, Zhang R, Lai C, Montaner JS, Wood E. Circumstances of first injection among illicit

drug users accessing a medically supervised safer injection facility. Am J Public Health. 2007;97(7):1228–

1230.

149

Rehm J, Gschwend P, Steffen T, Gutzwiller F, Dobler-Mikola A, Uchtenhagen A. Feasibility, safety, and

efficacy of injectable heroin prescription for refractory opioid addicts: a follow-up study. Lancet.

2001;358(9291):1417–1420.

150

Blanken P, Hendriks VM, van Ree JM, van den Brink W. Outcome of long-term heroin-assisted treatment

offered to chronic, treatment-resistant heroin addicts in the Netherlands. Addiction. 2010;105(2):300–308.

mainly in the form of an ever-growing number of drug court programs. The 2013 National

Drug Control Strategy, for example, “supports alternatives to incarceration such as drug

courts, diversion programs, enhanced probation and parole programs, and other

supervision strategies” and calls for an increase in the country’s already significant

investment in drug courts. Some evaluations have shown reductions in drug use and

recidivism for the duration of time that people are sentenced to drug court.

151

However, available evidence shows that coerced treatment programs, such as drug courts,

are costly, are no more effective than voluntary treatment, serve very few people, and often

deny proven treatment modalities such as methadone and buprenorphine.

152

156

A recent

survey of drug courts revealed that while nearly every drug court in the country serves

participants who are opioid dependent, fewer than half offer medication-assisted

treatments such as methadone. Most drug courts have not significantly reduced

participants’ chances of incarceration either.

In fact, one study showed that because of drug

courts’ nearly exclusive focus on low-level drug (especially marijuana) possession offenses,

their strict eligibility requirements, and underlying sentencing laws (e.g., mandatory

minimums) that render many individuals ineligible for any type of diversion, such

programs are highly unlikely to reduce the number of people incarcerated. That study also

suggested that drug courts may have a “net-widening” effect; that is, they may actually

increase the number of people incarcerated. Such criminal justice programs, moreover,

have absorbed scarce resources that could have been better spent on bolstering

demonstrated, health-centered approaches such as community-based treatment.

157

Finally, coerced treatment for any health condition, especially for mere drug possession,

raises serious ethical concerns; a recent commentary argued that coercive treatment for

people who use or possess drugs is unethical and runs counter to accepted health

principles; it is also “unlikely to have large effects on population levels of drug use and

crime.”

158

For these reasons, drug courts should be reserved for individuals charged with

151

Rossman SB, Roman J, Zweig JM. The Multisite Adult Drug Court Evaluation: The Impact of Drug Courts.

Washington, DC: Urban Institute; 2011.

152

Sevigny EL, Pollack HA, Reuter P. Can drug courts help to reduce prison and jail populations? Ann Am Acad

Polit Soc Sci. 2013;647(1):190–212.

153

Rossman SB, Roman JK, Zweig JM, et al. The Multi-Site Adult Drug Court Evaluation: Study Overview and

Design. Washington, DC: Urban Institute; 2011.

154

Pollack H, Sevigny E, Reuter P. If Drug Treatment Works So Well, Why Are So Many Drug Users

Incarcerated? Chicago, IL: University of Chicago Press; 2011.

155

Matusow H, Dickman SL, Rich JD, et al. Medication assisted treatment in US drug courts: results from a

nationwide survey of availability, barriers and attitudes. J Subst Abuse Treat. 2013;44(5):473–480.

156

Friedmann PD, Hoskinson R, Gordon M, et al. Medication-assisted treatment in criminal justice agencies

affiliated with the Criminal Justice-Drug Abuse Treatment Studies (CJ-DATS): availability, barriers, and

intentions. Subst Abuse. 2011;33(1):9–18.

157

Drug Courts Are Not the Answer: Toward a Health-Centered Approach to Drug Use. New York, NY: Drug

Policy Alliance; 2011.

158

Stevens A. The ethics and effectiveness of coerced treatment of people who use drugs. Hum Rights Drugs.

2012;2(1):7–16.

more serious (non-drug) offenses but whose behavior was motivated by an underlying

drug problem; they should never be used (as they currently are) for individuals charged

with mere drug possession offenses, who can be better served outside of the criminal

justice system. Coerced treatment is ethically unjustifiable, especially when voluntary

treatment can yield equal or more positive outcomes.

159

More alternative strategies are emerging in various localities. Seattle recently instituted a

pilot program known as “Law Enforcement Assisted Diversion,” or LEAD, the first pre-

booking diversion program; it aims to bypass the criminal justice system entirely. Instead

of arresting and booking people for certain drug law violations, including drug possession

and low-level sales, police in a pair of Seattle neighborhoods will immediately direct them

to drug treatment or other supportive services. LEAD allows law enforcement to focus on

serious crime but to still play a key role in linking people with certain drug law violations

to services before they enter the justice system.

160

162

In doing so, it has the potential to

reshape law enforcement practices and culture.

Seattle’s policy resembles aspects of the health focus that many European countries, as well

as Canada and others, have adopted: a public health policy orientation often termed a “4

pillars approach.” This comprehensive strategy is based on 4 principles—harm reduction,

prevention, treatment, and enforcement—and it has demonstrated dramatic reductions in

public drug consumption, overdose deaths, and HIV and hepatitis infection rates.

163

164

Programs such as LEAD, however, still rely on law enforcement as the primary point of

contact with people who misuse substances. To be most successful, local, state, and

national drug policies must empower health professionals to assess and deliver services to

each individual. CHWs, for example, should be enabled (and given adequate resources) to

serve as the point of contact, source of referrals and information, and service provider for

certain low-threshold services directly.

Ultimately, the removal of criminal sanctions in favor of optional, non-punitive,

proportionate, administrative sanctions—alongside a major expansion of proven,

evidence-based harm reduction, treatment, and prevention services—offers more promise

in achieving a health-centered approach to drug misuse. Some commentators hope that

159

Stevens A. The ethics and effectiveness of coerced treatment of people who use drugs. Hum Rights Drugs.

2012;2(1):7–16.

160

King County Government. Law Enforcement Assisted Diversion (LEAD) program. Available at:

http://leadkingcounty.org/. Accessed December 12, 2013.

161

Fan M. Street diversion and decarceration. Am Crim Law Rev. 2012;50:1.

162

Learning for Action Group L. LEAD program and evaluation plan narrative. Available at:

http://leadwa.squarespace.com/storage/LFA%20Evaluation%20Narrative%20-%20February%202012.pdf.

Accessed December 12, 2013.

163

Alexander BK. Beyond Vancouver’s “four pillars.” Int J Drug Policy. 2006;17(2):118–123.

164

Savary J-F, Hallam C, Bewley-Taylor D. The Swiss Four Pillars Policy: An Evolution From Local

Experimentation to Federal Law. Oxford, England: Beckley Foundation Drug Policy Programme; 2009.

various legislative changes—notably the Affordable Care Act of 2010—will expand

treatment availability and resources, potentially making it possible to deliver treatment

and harm reduction services through the health care, rather than the criminal justice,

system.

165

167

Action Steps

APHA believes that national and state governments and health agencies must reorient drug

policies to embrace health-centered, evidence-based approaches that reduce the individual

and community harms deriving from current policies and from illicit drug misuse, respect

the human rights of people who use drugs, and allow for the redirection of financial

resources toward where they are needed most. Therefore, APHA:

 Urges Congress, the administration, and federal health agencies to convene relevant

experts and stakeholders in the fields of public health, drug treatment, medicine,

harm reduction, education and prevention, social work, and law enforcement, as

well as people who currently use (or formerly used) drugs and affected

communities, to critically review the effectiveness of current drug policies; to

examine the potential public health gains of a range of new drug policies, including

the decriminalization of personal drug possession and use; to open a public debate

about regulatory alternatives to drug prohibition in order to address the public

health and safety harms of illicit drug markets; and to produce a policy environment

that will be most conducive to significantly expanding US treatment, education, and

harm reduction programs.

 Urges federal, state, and local elected officials and agency staff to implement

evidence-based and culturally appropriate prevention, regulatory, treatment, and

harm reduction interventions, including (but not limited to):

 Expanding proven, life-saving public health interventions and harm

reduction and treatment programs, including medication-assisted treatment,

and strengthening professional preparation and training in these

interventions for health care providers, CHWs, and public health, allied

health, health education, and health communication professionals.

 Investigating (and, if results are favorable, implementing) new innovative

agonist and partial agonist replacement treatments and medically supervised

165

Kilmer B, Caulkins JP, Pacula RL, Reuter PH. The US Drug Policy Landscape. Santa Monica, CA: RAND; 2012.

166

Croft B, Parish S. Care integration in the Patient Protection and Affordable Care Act: implications for

behavioral health. Adm Policy Ment Health. 2013;40(4):258–263.

167

Saloner B, Cook BL. Blacks and Hispanics are less likely than whites to complete addiction treatment,

largely due to socioeconomic factors. Health Aff. 2013;32(1):135–145.

injection facilities, which have demonstrated their safety and efficacy in

several countries around the world but have not yet been attempted in the

United States.

 Increasing funding for existing treatment modalities and ensuring they are

available to all people who need them, including those who are incarcerated

or under criminal justice supervision.

 Deprioritizing the use (and funding) of non-health agencies—such as drug

courts and other court-based diversion programs—to deal with people who

use drugs and redirecting resources from criminal justice programs toward

public health interventions to improve the health of such individuals.

 Calls on Congress to permanently repeal the federal ban on syringe access funding,

to fund such programs to the maximum extent possible, and to remove other

detrimental barriers to proven interventions.

 Encourages state governments to leverage resources potentially available through

the Affordable Care Act toward effective community-based drug treatment, harm

reduction, and physical and mental health services.

 Urges Congress and state governments to eliminate federal and state criminal

penalties and collateral sanctions for personal drug use and possession offenses and

to avoid unduly harsh administrative penalties, such as civil asset forfeiture, and

acknowledges that proportionate criminal penalties may be appropriate—

consistent with principles of public health and human rights—for behavior that

occurs in conjunction with drug use if that behavior causes or seriously risks harm

to others, such as driving under the influence; however, such penalties should not be

imposed solely for personal drug possession and use.

APPENDIX D

Letter of Support for Supervised Injection from amfAR to

New York State Governor Andrew Cuomo

APPENDIX E

New York City Supervised Injection Facility Feasibility

Impact Report

Prepared by:

Czarina Behrends, PhD, MPH

Postdoctoral Associate, Weill Cornell Medical College

Bruce Schackman, PhD, MBA

Professor of Health Policy, Weill Cornell Medical College

Researchers from the Weill Cornell Medicine Department of Health care Policy and

Research analyzed the potential health impacts and health care cost impacts of

implementing supervised injection facility (SIFs) in New York City. SIFs provide a clean,

safe environment in which pre-obtained drugs can be consumed under clinical supervision

with purpose of quickly reversing overdoses, providing medical care, and connecting

people who inject drugs (PWID) with substance use treatment and care. This research was

done in collaboration with DOHMH and with input from a technical advisory group made

up of experts in SIF evaluation. We present a summary of the results below.

SIF Impact on preventing opioid overdose fatalities

 Based on 2015-2016 NYC opioid overdose mortality data, implementing one SIF in

the neighborhood with the most opioid overdose fatalities could prevent 19 to

37 opioid overdose fatalities per year, assuming no operational constraints on

SIF hours or capacity.

 Based on 2015-2016 data, up to 67 to 130 opioid overdose fatalities per year

could be saved if 4 SIFs were placed in four neighborhoods with the most

overdose fatalities.

 The estimate of opioid overdose fatalities prevented in the highest priority

neighborhood is within the range of the estimated opioid overdose fatalities

prevented annually by Vancouver’s SIF (23 per year) and exceeds projected

annual opioid overdoses prevented for proposed SIFs in San Francisco and

Baltimore (0.24 and 5.9, respectively).

 Because of the recent upward trend of overdose fatalities in NYC, increasing 46%

from 2015 to 2016, this forecast likely underestimates the impact of SIFs on

overdose mortality in 2017.

Short-term cost impact to the health care system

 Opioid overdoses cost the NYC health care system an estimated $50 million per

year for EMS calls, ED visits, hospitalizations. Approximately $6 million of these

costs are associated with fatal opioid overdoses.

 If one SIF was optimally placed, $1.0 million in health care system costs would

be saved if all onsite opioid overdoses were avoided in the base case scenario.

In an alternative scenario, $2.0 million in health care system costs would be

saved if all opioid overdoses were avoided. If overdoses continued to occur at SIFs

but EMS response and ED rates were at similar rates to those observed in Vancouver,

$860,600 in health care system costs would be avoided in the base case scenario.

 If four SIFs were optimally placed, $3.6 million in health care system costs

would be saved ($905,000 per SIF) if all onsite opioid overdoses were avoided

in the base case scenario. If opioid overdoses continued to occur at SIFs but EMS

response and ED rates were at similar rates to those observed in Vancouver, $2.7

million in health care system costs would be avoided in the base case scenario.

Recommendations for future analyses to evaluate SIF impact on other health and cost

outcomes

 Recommend additional analyses of fatal, non-fatal and averted opioid overdose

estimates that take into account fentanyl use trends and the potential impact of

synthetic opioids on opioid overdose estimates.

 Recommend analyses of SIF impact on reducing hepatitis C infections, reducing

high cost medical care services (i.e., need for treatment of skin and soft tissue

infections and endocarditis), and increasing opioid agonist treatment and other

addiction treatment uptake.

 Recommend economic analyses of cost-effectiveness and net monetary benefit of

SIFs that also consider non-health care economic impacts, including law

enforcement resource utilization and community impacts such as crime, public

injection, and public disposal of syringes

Background: Supervised injection facilities (SIFs) provide a clean, safe environment in

which pre-obtained drugs can be consumed under clinical supervision with purpose of

quickly reversing opioid overdoses, providing medical care, and connecting people who

inject drugs (PWID) with substance use treatment and care. Given the rising rates of

overdose fatalities in New York City reaching its all-time peak in 2016, SIFs may be one

strategy to reduce opioid overdose mortality in NYC, and the cost of implementing SIFs may

be offset in part by savings in health care system costs.

Purpose: Researchers from the Weill Cornell Medicine Department of Health care Policy &

Research, in collaboration with DOHMH, analyzed the potential opioid overdose-related

health and health care system cost impacts of implementing SIFs in New York City, with

input from a technical advisory group made up of experts in SIF evaluation.

Limitations: While our estimates are based on the best NYC data sources available, we

relied on the literature for several estimates. We received feedback on the face validity of

those assumptions and assistance in identifying additional relevant sources from the

technical advisory group and DOHMH. Base and alternate case estimates for fatal opioid

overdoses prevented under different scenarios were estimated. For costs, we provide a

range of estimates to account for different assumptions of SIF impact.

Summary of Findings:

1) SIF Impact on preventing opioid overdose fatalities

 Based on 2015-2016 NYC opioid overdose mortality data, implementing one SIF in

the neighborhood with the most opioid overdose fatalities could prevent 19 to

37 opioid overdose fatalities per year, assuming no operational constraints on

SIF hours or capacity.

 Based on 2015-2016 data, up to 67 to 130 opioid overdose fatalities per year

could be saved if 4 SIFs were placed in four neighborhoods with the highest

overdose fatalities.

 The estimate of opioid overdose fatalities prevented in the highest priority

neighborhood is within the range of the estimated opioid overdose fatalities

prevented annually by Vancouver’s SIF (23 per year) and exceeds projected

annual opioid overdoses prevented for proposed SIFs in San Francisco and

Baltimore (0.24 and 5.9, respectively).

 Because of the recent upward trend of overdose fatalities in NYC, increasing 46%

from 2015 to 2016, this forecast likely underestimates the impact of SIFs on

overdose mortality in 2017.

2) Short-term cost impact to the health care system