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Am Fam Physician. 2022;105(5):454-455

Related Curbside Consultation: Harm Reduction for Patients With Substance Use Disorders

Author disclosure: No relevant financial relationships.

The opioid epidemic continues to ravage the nation, and overdose deaths in the United States are increasing every year. The ongoing COVID-19 pandemic has exacerbated this public health emergency. As a result, the number of annual overdose deaths increased by 37% to more than 96,000 from 2020 to 2021.1,2 Overdose deaths are so high that the U.S. Department of Health and Human Services has introduced harm reduction initiatives that have historically been controversial: needle exchange programs to slow the spread of bloodborne diseases and provision of fentanyl test strips to help people who inject drugs identify contaminated street drugs.3 However, the U.S. Department of Health and Human Services stopped short of supporting supervised injection sites, a harm reduction strategy that has been proven to save lives in other countries.4 Supervised injection sites have been legally operating in Europe, Canada, and Australia since 1986.4

With the 2021 opening of the nation's first supervised injection sites in New York City and a growing movement advocating for expanding them to other U.S. cities, family physicians should be knowledgeable about the potential impacts of these sites.5,6 These facilities are over-seen by health care personnel who provide sterile injection supplies, counseling on safe injection techniques, emergency care in the event of an overdose, primary medical care, and referrals to appropriate social and addiction services.7 The personnel in the facilities are able to offer services to people who would otherwise inject drugs in public spaces.8 Unfortunately, because of legal considerations, the U.S. Justice Department has fought to prevent the opening of supervised injection sites despite evidence that they lower death rates and decrease disease transmission.3

Supervised injection sites improve health outcomes. One study found a 26% net reduction in overdose deaths in the area surrounding a supervised injection site in Vancouver, Canada, compared with the rest of the city.9 A supervised injection site in Barcelona, Spain, was associated with a 50% reduction in overdose mortality from 1991 to 2008.4 People who inject drugs are significantly less likely to share needles if they regularly use supervised injection sites.10 These sites could be effective in reducing the rates of HIV and hepatitis C in people who inject drugs.11 Supervised injection sites can also reduce the number of publicly discarded syringes, and they improve public safety.7 A 2019 article from American Family Physician discusses ways that physicians can counsel patients who inject drugs about safer injection practices.12

Concerns about these sites leading to increased criminal activity or drug use are not supported by the evidence. One study in Vancouver, Canada, observed an abrupt, persistent decrease in crime after the opening of a supervised injection site.9 These sites reduce public nuisance because patients can inject drugs and discard used needles safely rather than in public spaces.9 In a study of an unsanctioned supervised injection site in the United States, 90% of people using the site reported that they would otherwise be injecting in a public restroom, street, park, or parking lot.11

Several modeling studies predict that legally sanctioning supervised injection sites in the United States would reduce health care costs by preventing HIV, hepatitis C, hospitalizations for skin and soft-tissue infections, overdose deaths, ambulance calls, and emergency department visits and by increasing uptake of addiction treatment.13,14 A cost-benefit analysis of a hypothetical site in Baltimore, Md., predicted that it would generate $7.8 million in savings at an annual cost of $1.8 million.13 Another estimate in New York City predicted that one supervised injection site could save $800,000 to $1.6 million in annual health care costs from opioid overdoses.14

Supervised injection sites effectively reduce overdose deaths, and many of the fears about them are unfounded. The American Academy of Family Physicians issued a policy statement supporting these facilities.15 Although federal support is lacking, individual cities and states are leading the efforts to increase harm reduction strategies to prevent overdose deaths. In 2021, Rhode Island became the first state to legalize supervised injection sites, with locations to be decided in 2022.16 Family physicians have several opportunities to promote this needed change, including speaking in support of the sites at town halls, working with local advocacy groups to promote efforts to create the sites, and working with physician organizations such as the American Academy of Family Physicians to develop supportive policies. Even something as simple as writing a letter to your senator or representative could be hugely impactful.

Overall, supervised injection sites reduce overdose deaths, infectious diseases, and public nuisance crimes. Patients who have opioid use disorder deserve access to safe, effective harm reduction interventions that save lives and connect them to treatment. These facilities are already saving lives in other countries, and the United States should follow suit by supporting supervised injection sites to reduce overdose deaths.

Editor's Note: Dr. Finke is the medical editing fellow for American Family Physician.

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