Massachusetts Medical Society: Testimony in Support of An Act Relative to Preventing Overdose Deaths and Increasing Access to Treatment

Testimony in Support of An Act Relative to Preventing Overdose Deaths and Increasing Access to Treatment

The Massachusetts Medical Society (MMS) wishes to be recorded in strong support of the H.1712, An Act relative to preventing overdose deaths and increasing access to treatment, filed by Representatives Fernandes and Gouveia. This legislation directs the Department of Public Health (DPH) to promulgate regulations to authorize a pilot program for harm reductions sites, also known as supervises consumption sites (SCS) or safe injection facilities (SIF). A pilot program was recommended in a recent report by the Massachusetts Harm Reduction Commission, established by Section 100 of Chapter 208 of the Acts of 2018. MMS was involved in this report through the important contributions of Dr. Jessie Gaeta, Chief Medical Officer of the Boston Health Care for the Homeless Program, who was appointed to the Commission to represent the Medical Society. The Commission was charged with reviewing the evidence base and experiences of other states/countries that have established harm reduction strategies and making recommendations regarding harm reduction opportunities to address substance use disorder in the Commonwealth. Among other important findings, the Commission recommended that, to continue fighting the opioid crisis and to effectively foster a culture of harm reduction throughout the state, Massachusetts should adopt a pilot program of one or more supervised consumption sites.

The Medical Society has been active in supporting harm reduction efforts in the Commonwealth, which are public health interventions aimed at reducing the harms associated with drug use. As the Commission notes, existing harm reduction efforts in the state are primarily focused on increasing access to naloxone and the expansion of needle exchange programs, implementing promising practice pilots, and public awareness campaigns. MMS policy supports increasing public access to needle exchange programs, as well as increasing affordable access to naloxone, as these are proven, effective harm reduction strategies. We believe that real public health promise lies when these harm reduction initiatives are matched with continued expansion of access to low-barrier medication treatment for

substance use disorder, a second key priority of the Medical Society’s approach to the current fentanyl-driven opioid crisis.

SCSs are legally approved public health facilities where people who use drugs (PWUD) can consume pre-obtained substances in a hygienic environment in the presence of trained staff who provide clinical monitoring. Services offered at SCSs/SIFs vary and can be tailored to reflect the particular characteristics and needs of their communities. SCSs typically offer the following services: health services including education, distribution and disposal of drug using equipment; a variety of medical, nursing, and social work services; access to medical care and emergency services in case of overdose; hygiene services including laundry, showers and bathrooms; and drug treatment referrals including medication treatment for substance use disorder such as methadone maintenance therapy, detoxification, and rehabilitation.

The primary goal and effect of SIFs is to decrease the number of overdose deaths. Addiction is a chronic disease and the reality we must face is that there will always be some people with addiction who are still using and who at any given time are simply not able or ready to stop. With more than 2,000 estimated overdose deaths each of the last 3 years, preventing these deaths is a top priority for physicians and should be a top priority of the Commonwealth. To date, there have been no reported overdose deaths in the more than 100 SCSs located in 11 countries outside the United States. In addition to decreasing overdose deaths, SIFs are designed to reduce other harms associated with illicit drug use, including reducing the transmission of human immunodeficiency virus (HIV), hepatitis B and C (HCV) and other blood-borne infections by providing minimize public order problems (including public drug use); and improve access to health and social services, including drug treatment and recovery services.

The Medical Society takes great pride in a 2017 report produced by its own Task Force on Opioid Therapy and Physician Communication (Task Force), which recommends support for a pilot supervised injection facility (SIF) program.1 A review and analysis of published literature on SIFs show that they reduce harms associated with drug use by: reducing overdose deaths; providing an alternative to unsafe injection practices that lead to HIV, HCV, and other diseases; and facilitating entry into drug treatment. The existing research is rigorous and has been endorsed by many experts and published in peer-reviewed journals, including the Lancet and the New England Journal of Medicine, providing evidence that SIFs achieve positive outcomes. For example, in Vancouver, British Columbia, SIF utilization reduced overdose mortality by 35% and significantly increased access to drug treatment.2 Studies further suggest that SIFs  are cost effective and the impact on the communities in the areas around the SIFs has been positive. After extensive research and review of data, ethical analysis, legal analysis, and professional liability analysis, the Task Force determined that SIFs constitute evidence-based medical interventions that offer a unique opportunity to target and engage some of the most at-risk and socially marginalized individuals. This focused intervention is key, as a Canadian survey of persons who inject drugs (PWIDs) found that those who were most likely to use a SIF were homeless, unsure of how to access clean drug equipment such as needles, had overdosed in the past, and tended to inject in public spaces. These findings suggest that SIFs are used by the most vulnerable of the drug-using population and should be located in an area where people are already using drugs in public spaces or are homeless.3 Establishing a non-judgmental healthcare setting that does not stigmatize drug use, and which accepts that people with addiction are people first and foremost, is essential to caring for this most vulnerable population. Importantly, SIFs are consistent with the Medical Society’s Code of Ethics, whereby physicians are obligated to provide compassionate and respectful medical care to all people, while respecting individual human dignity and rights.

The MMS Task Force’s findings are consistent with those of the Commission. Both reports address the peer-reviewed publications detailing decreased overdose rates and related clinical and public health successes of SIFs. Each report also details the legal barriers to establishing a SIF in Massachusetts, from federal, to state, to local laws, regulations and ordinances. The Medical Society commends the Commission for inclusion of recent legal scholarship and analysis that has continued to identify potential paths forward for federal legality, and for reference to the pending legal case in Philadelphia, which may soon shed light on the merits of some of these legal considerations. For these reasons, it is prudent to push forward a plan to remove state legal and regulatory barriers that present challenges to a pilot SIF program while the federal legal concerns continue to be addressed. We would like to underscore the recommendations related to Charges 7 and 8, wherein the Commission outlines specific legal issues to be addressed, including state criminal laws related to illegality of possession, distribution, aiding and abetting, and forfeiture of property, as well as protections for organizations and individuals who would staff a SCS, including licensed professionals and non-professionals.

Massachusetts is among the top ten states with the highest rates of opioid-related overdose deaths. Significant investments in Massachusetts have made positives strides in combatting the opioid crisis; while Massachusetts reported an estimated 4% decline in opioid-related overdose deaths from 2016 to 2018, certain trends remain alarming. Geographic disparities exist, with some communities seeing a significant increase in overdose deaths. While the vast majority of fatal overdoses are male, deaths  among women of all races increased from 2017 to 2018. In the Spring of 2018, the Department of Public Health (DPH) released a report finding that that more than a third (38.3%) of pregnancy-associated deaths among women between 2011 and 2015 were fatal opioid-related overdoses. This data underscores the need for further investment and expansion of comprehensive, coordinated harm reduction efforts in Massachusetts.

The current opioid epidemic represents the greatest public health crisis our state and the nation has faced in recent memory and it will take a variety of aggressive efforts to change its course and sustain progress. The Baker Administration has rightfully focused on using data to drive decision-making around programs and policies that are proven effective. The analysis and findings of both the Commission and the Medical’s Society’s report demonstrate that SCSs/SIFs are an important, evidence-based tool that should be incorporated into Commonwealth’s comprehensive approach. For these reasons, the Medical Society urges the committee to issue a favorable report to House bill 1712.

1 Establishment of a Pilot Medically Supervised Injection Facility in Massachusetts, Massachusetts Medical Society Task Force on Opioid Therapy and Physician Communication (April 2017), 
2 Marshall B, Milloy M, Wood E, Montaner J, 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;1429–37.
3 Toronto and Ottawa Supervised Consumption Assessment Study. Report of the Toronto and Ottawa Supervised Consumption Assessment Study, 2012. April 11, 2012. Retrieved from Accessed October 23, 2016.

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