The Massachusetts Medical Society appreciates the opportunity to provide comment to the Joint Committee on Mental Health, Substance Use, & Recovery regarding SB 1081. The Medical Society applauds Senator Brownsberger for taking this important step to recognize Supervised
Injection Facilities (SIFs) as an essential element of the continuum of healthcare necessary to stem the tide of opioid-related death and disease in the Commonwealth.
A SIF is a legally approved public health facility that offers a safe environment where people can inject illicit drugs under the supervision of trained staff. Importantly, SIFs do NOT supply illicit drugs to persons who inject drugs. SIFs should also encourage and facilitate referrals to drug treatment and recovery
programs upon patient request. Evidence indicates that SIFs can reduce risks related to drug use, including: overdose; the transmission of blood-borne infections such as HIV and hepatitis; and public safety issues such as violence and public drug use.
The Medical Society recognizes that SIFs, despite their current illegality and controversy in the U.S., provide a gateway to treatment and recovery to those suffering from substance use disorder and other life-threatening chronic illnesses and are a crucial source of health care for some of our most
marginalized citizens. Our position is in keeping with the following decision made by the Canadian Supreme Court of British Columbia:
“While users do not use Insite [Vancouver’s SIF] directly to treat addiction, they receive services and assistance at Insite which reduce the risk of overdose that is a feature of their illness, they avoid risk of being infected or of infecting others by
injection and they gain access to counseling and consultation that may lead to abstinence and rehabilitation. All of this is healthcare.”
We therefore wish to emphasize the strong evidence basis for implementing SIFs as part of the fight against the opioid crisis in the Commonwealth, in particular for the most vulnerable population of persons who inject drugs, which includes persons who are homeless, poor, uninsured, and suffering from other co-morbid
psychiatric illnesses. In April of 2017, the Massachusetts Medical Society Task Force on Opioid Therapy and Physician Communication published a report containing “an internal evidence-based study of the ethical, legal, and liability considerations and feasibility of a medically-supervised injection
facility (MSIF) in Massachusetts.”[i]
We found a clear, evidence-based argument in support of SIFs as a harm reduction approach. Specifically, SIFs reduced harms associated with drug use by: reducing overdose deaths by 35% at the Insite facility in Vancouver; provide providing an alternative to unsafe injection practices that lead to HIV, HCV, and other
diseases; and facilitating entry into drug treatment, including a 30% increase in detoxification and an increase in methadone maintenance initiation. SIFs can also protect persons who inject drugs, especially women, from street violence associated with public injectable drug use.
Before SIFs opened in other countries across the globe decades ago, there were concerns of negative consequences within the communities they served, but the reality has not borne these concerns out. There has been a reduction in public injection and related litter, crime has not increased, and zero deaths have
been reported in SIFs despite the recent increase in the potency of drugs being used, including fentanyl and carfentanil. In fact, after initial reticence, both business leaders and law enforcement in Vancouver have expressed support for that city’s SIF, and police and Vancouver SIF staff maintain a productive
and positive relationship as they continue to combat the disease of addiction and improve public order in their community.
SIFs not only save lives and improve health, they save money. Johns Hopkins University estimates demonstrate that “at an annual cost of $1.8 million, a single SIF would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue
infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment.” Recently, San Francisco researchers published findings indicating that a 13-booth SIF could save $3.5 million annually in that
city.
National interest in this issue is growing as other states confront the same epidemic. The American Medical Association has voted to support the development of pilot facilities in the U.S. where people who use intravenous drugs can inject self-provided drugs under medical supervision. Cities such as Seattle,
Baltimore, San Francisco, and New York are working on establishing SIFs, and a paper on the successful unsanctioned implementation of a Supervised Injection Site within the United States was published in the American Journal of Preventive Medicine in August.[ii]
In contemplating the challenges that would need to be addressed to establish a SIF in Massachusetts—including amendments to state and federal drug laws, state health care facility licensure regulations, local support from the community, government officials, and law enforcement, and professional licensure and
liability matters—the Medical Society crafted its policy to promote SIFs in the context of a strategy that would most effectively address these issues and concerns.
The Medical Society strongly supports SIFs as an evidence-based harm reduction strategy to combat the opioid epidemic in Massachusetts; however, our official policy states: “that the MMS advocate for a pilot SIF program in Massachusetts under the direction and oversight of a state-led task force convened by a state
authority.” Therefore, the Medical Society cannot support this legislation as drafted, but strongly supports the efforts by its sponsors insofar as those efforts catalyze conversation about this worthwhile harm reduction strategy, and would enthusiastically strongly support a bill such as this if it were
amended to include a pilot phase with direct input from, rather than approval by, a state authority such as MA DPH.
MA DPH has a long history of providing harm reduction services to citizens in the Commonwealth, and has the expertise to convene and direct a task force to establish a pilot SIF program in Massachusetts. Therefore, we believe that any decisions about the logistics of such a program – including location(s) – ought to be
made by a collaborative task force led by MA DPH and representing the opinions and expertise of a variety of local stakeholders, including those engaged in public service and public health, and persons who inject drugs. The Medical Society has no preconceived opinion on where in the Commonwealth a pilot SIF
ought to be established, and we hold that a state-led stakeholder task force ought to make that decision.
Furthermore, our policy specifies a pilot SIF program because that model would facilitate rigorous scientific evaluation to demonstrate the efficacy of SIFs in Massachusetts.
We wish to emphasize that we do not view SIFs as a cure-all for the Commonwealth’s opioid epidemic; rather, SIFs are one vital piece of a larger, comprehensive continuum of healthcare to aid those struggling with substance use disorder. The Medical Society has implemented and will continue to develop a broad
spectrum of advocacy and education efforts in response to the opioid crisis in Massachusetts.
We are deeply troubled by the magnitude and severity of this epidemic, and we need to find new ways to fight it. A New York Times article published this past weekend on nationwide drug overdose deaths in 2016 shows a 540% increase in fentanyl-related deaths over the past three years, despite everything that we
are already doing to combat the opioid epidemic.[iii] And given the significantly more rapid and intense impact of fentanyl and carfentanil, simply increasing the supply of Narcan will not have the same effect it had when heroin and prescription narcotics were the principal agents.
These drugs are fast-acting and lethal, and unless we intervene quickly, the death rate will continue to rise.
We need to save lives, and we see SIFs as an essential means of doing so. We look forward to continuing this conversation, and to working with our fellow organizations and agencies to provide evidence-based interventions for persons who use drugs throughout Massachusetts.
[i]
http://www.massmed.org/advocacy/state-advocacy/sif-report-2017/
[ii] Addressing the Nation’s Opioid Epidemic: Lessons from an Unsanctioned Supervised Injection Site in the U.S. Kral, Alex H. et al. American Journal of Preventive Medicine
[iii] Katz, Josh. “Fentanyl Overtakes Heroin as Leading Cause of U.S. Drug Deaths.” The New York Times, The New York Times, 2 Sept. 2017,
www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html.
