Supervised injection sites must focus on facilitating drug treatment

As the opioid epidemic and drug overdose fatalities continue to plague America, the opening of supervised injection sites —where addicts can use drugs in a safe environment —is again on the agenda. A federal court ruling last month removed a legal obstacle to opening the first such U.S. facility, in Philadelphia, and other cities are considering a similar move. While it’s not certain when this might happen, questions remain regarding how such sites will help move users into drug treatment.

Supervised sites do not provide drugs to addicts, but rather offer access to clean needles, and health professionals are on hand to administer anti-overdose drugs as well as provide counseling. Studies indicate such harm reduction strategies can reduce overdose fatalities as well as the transmission of infectious diseases through injection and drug-related criminality. 

Yet, while these sites might save lives, they fall short when it comes to motivating users to opt for treatment. My experience suggests that after a user injects drugs or is rescued from an overdose at a safe site, there is usually insufficient engagement to end the cycle of drug abuse. 

Safehouse, the Philadelphia nonprofit that wants to sponsor the supervised site, intends to do this by counseling users on rehabilitation options and promoting on-site medication-assisted treatment (MAT). This combines withdrawal drugs and behavioral therapy, buut it leaves the final decision up to the patient. It believes that by establishing a trusting relationship with the user, he or she will more likely agree to give treatment a try.  

Most addicts, however — especially the most vulnerable high-use, high-risk users — are likely to say “no” to treatment. How can we improve the odds?

What is so often missing from supervised sites is the mindset that all patients can be helped to enter treatment. An alternative approach would be to limit access to the facility to 100 days to discourage continued drug use without agreeing to treatment.

By the end of this time — and after extensive interaction with peer-based counselors and other addiction professionals — there would be an expectation that the patient is ready to start treatment to become drug free.  

Such incentives can and do work. For example, drug courts that offer individuals arrested on drug charges the choice between a trial with possible incarceration and treatment have brought thousands into treatment and has reduced drug-use relapse. In a similar way, private companies are experimenting with initiatives in which job candidates who fail a drug test can nevertheless start working if they enter a drug treatment program and stay clean.  

Opening America’s first supervised injection site in Philadelphia with a research protocol would be an opportunity to assess impact in a city where the overdose death rate since 2009 has risen nearly 200 percent. At the same time, conduct a pilot project with a safe site, along the lines I have proposed, that transforms a supervised injection center into a treatment induction center. 

We need to know what will work best and prove to be more beneficial as part of a comprehensive anti-opioid strategy.  

Mitchell S. Rosenthal, M.D., is the founder and former president of Phoenix House, the national drug treatment organization, and president of the Rosenthal Center for Addiction Studies.