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MGH

Published On November 21, 2019

POLICY

A Safe and Controversial Place

Physician Mark Eisenberg discusses the furor over (and the desperate need for) safer injection sites.

The opioid epidemic may have moved from the headlines, but in most states overdoses actually increased by about a third between 2017 and 2018. The enduring state of the crisis has led many health officials to rethink their strategies. One controversial approach is the safe injection facility, or SIF, where users are invited to inject their illicit drugs—safely and without judgment—under the supervision of medical staff.

Physicians in Massachusetts, a state with one of the highest rates of opioid overdose deaths, have been particularly vocal about trying this approach. Mark Eisenberg is a primary care physician at Massachusetts General Hospital and has been demonstrating a mock injection facility at sites around Boston, most recently at the MGH Charlestown HealthCare Center.

Whereas approximately 100 SIFs exist in Switzerland, Australia and Canada, efforts to establish them in the United States face considerable opposition, most notably from the U.S. Department of Justice. While a state bill calling for a SIF pilot program is currently pending, the path toward full implementation is rocky at best, and Massachusetts Governor Charlie Baker contends that these facilities violate federal law. But the sites are in the news again, as an October ruling by a Pennsylvania district court judge could open the doors to the first such U.S. sites operating soon in Philadelphia.

Q: Is there any clear evidence that safe injection facilities reduce harm?

A: There are more than 100 SIFs around the world, at which millions and millions of injections have taken place. None has seen a single death. When an overdose happens—in one Vancouver location that happens about once in every 1,000 injections—medical staff is able to step in quickly. A study found that the site reduced overdose mortality by 35%. A comprehensive review of more than 20 studies on these 100 facilities found that they enhance access to primary health care and reduce the frequency of overdoses.

Mark Eisenberg, primary care physician at Massachusetts General Hospital.

Q: So the goal is to reduce overdose deaths?

A: Yes, but this approach also helps us head off other terrible complications from injecting drugs, too. Clean equipment helps users avoid transmitting HIV, which is rising among this population, and hepatitis C, which is endemic. We can also offer medical care to a population that desperately needs it. Many of my young patients have strokes, experience chronic pain from bone infections or need cardiac surgery to treat an infection of the heart valves or heart lining. All of these conditions can develop from injection drug use, and all of them are preventable.

Q: Are there other ways to achieve the same result without a dedicated injection site?

A: Believe me, we have tried. My health center in Charlestown has developed a remarkable addiction team—with a full-time addiction nurse, social workers, addiction psychiatrists and many providers. Despite this advantage, we still have patients who continue to use drugs, overdose and die. You can put in a great system of care and treatment, but for some people that's not enough. I'm tired of losing my patients.

Q: Many contend that these facilities are illegal.

A: Yes. And many people think that these facilities will enable drug use. But if drug users are going to keep using regardless of the care and treatment options available, I’d rather have them do it safely and with the least amount of risk to themselves and others. Lacking a better option, they inject themselves unsafely—in alleyways, alone in their bedrooms, in parked cars and in fast food restrooms.

This comes back to the perennial debate about any kind of harm reduction, whether that means needle exchanges, relaxing naloxone prescription laws or offering safe injection sites. The opioid crisis is a public health emergency and states have the right to do something about it. And they have the right to listen to the medical community. SIFs have gotten support from the Massachusetts Medical Society, the Massachusetts Hospital Association and the American Medical Association, which is traditionally a conservative organization.

Q: You recently publicized safe injection by setting up a mock facility. What was the reaction?

A: We had an information booth in our lobby and set up a mock safe injection site on our second floor. We also held a public meeting attended by state legislators and people from the District Attorney’s office. One speaker was a man named Michael whose son overdosed and died three years ago. He is a very prominent member of the Charlestown community and said that his son was alone that final, fatal time he used drugs. If he had gone to a safe injection facility, he might still be alive today. One of the attendees heard this and said, “I came here today thinking that SIFs are a bad idea, but if they could have saved Michael’s son, maybe I need to rethink my opinion.”

Q: Why is this particular issue so important to you?

A: I'm a primary care doctor in Charlestown, which was one of the first communities in Massachusetts and New England to be hit really hard with Oxycontin in the late nineties, and then with heroin and fentanyl. I’ve gone to too many wakes and have comforted too many people. Our group, SIF MA Now, has been working on this for three years and I've testified multiple times in front of the state legislature. In just those three years, 6,000 people have died in Massachusetts. And so, every day we wait, there is a cost in human life.