It’s only been a year since North Carolina legalized a program that provides clean syringes and needles to people with drug addictions.
Some public health advocates say the next step in dealing with the nation’s opioid epidemic – legalizing safe injection facilities – would face more opposition in North Carolina. At such sites, drug users would be able to shoot up illegal drugs in the presence of a medical supervisor, rather than picking up their clean syringes and going off to shoot up alone in a parking lot, public park, public bathroom or alleyway.
More than 100 such injection sites are in use, mostly in Europe, as well as Canada and Australia, but the concept is not widely known in North Carolina, even among public health officials. The facilities are set up to prevent drug overdose deaths, and to reduce the public health risks associated with drug users discarding dirty needles in public places. The on-site medical supervisors who oversee the injections are trained in administering antidote medicines that can reverse an overdose-in-progress before the drug user dies.
In this country, only one supervised injection site is known to exist. It is operating underground and of dubious legal status, its location unknown to but a few. The patient usage data produced at this location is the subject of a new report issued Tuesday by epidemiologist Alex Kral, the director of the Behavioral Urban Health Program at RTI International, a nonprofit organization in Research Triangle Park.
Kral said the data, published in the American Journal of Preventive Medicine, provides the first glimpse of how safe injection sites could operate if they were allowed in this country, based on U.S. data going back to 2014, rather than on extrapolations from foreign facilities.
“First and foremost is the fact that it’s been around so long and the sky hasn’t fallen,” Kral said. “It reduces crime in the neighborhoods. It reduces the number of needles in the streets. There’s less overdosing in the communities.”
According to Kral, who is based in San Francisco, there has never been an overdose death at a safe injection site anywhere in the world, because trained supervisors are on hand to intervene.
In his study, conducted and published with UC San Diego medical sociologist Peter Davidson, the secret injection house in this country oversaw 2,574 injections by more than 100 drug users over a two-year period. In that time, there were two overdoses, both reversed by staff using the medication naloxone.
Of the drug users in the facility, 80.5 percent were homeless, and more than 90 percent said they would otherwise have injected in a public restroom, park, street or parking lot. And 67.4 percent said they had disposed of a syringe in a public place in the previous 30 days.
North Carolina has seen opioid overdose deaths surge from 150 in 1999 to an all-time high of 1,110 in 2015, the most recent year for which data is available. Wake County had 62 deaths in 2015, and Johnston County was up to 23 deaths, highs for both counties. Durham County experienced 17 deaths in 2015, the third-highest annual total in 16 years.
Establishing an injection house in North Carolina and other states would run afoul “crack house statutes” passed in many states that make it illegal to operate a facility where illegal drugs are knowingly used or sold, said Corey Davis, deputy director of the Network for Public Health Law in Los Angeles, Calif. Local and state authorities could potentially decide not to enforce the law, but looking the other way does not confer legal status.
“The law doesn’t really care if you have good intentions,” Davis said. “It’s just a strict prohibition.”
A safe injection site would essentially decriminalize possession and use of illegal drugs, requiring cooperation from local law enforcement and acceptance from the public. The idea is gaining support in this country, most recently with the American Medical Association’s endorsement in June of developing pilot facilities to test the concept in this country. The AMA based its decision in part on a comprehensive study issued in April by the Massachusetts Medical Society, which concluded that injection sites help addicted people but would pose a legal risk to doctors and medical staff who oversaw people injecting illegal drugs, unless the medical professionals were granted a legal exemption.
Earlier this month, U.S. Surgeon General Jerome Adams embraced the concept in his Senate confirmation hearing. Adams said safe injection sites should be considered, as long as they have community support, but Adams noted such approaches lack the scientific evidence that is available to support the establishment of syringe exchange programs.
Legislative efforts to create injection sites are underway in California, Massachusetts, Vermont, Maryland, New York and Seattle, said Lisa Raville, executive director of the Harm Reduction Action Center, which is involved in a similar legislative push in Colorado. She said an injection site in her state would require creating a legal exemption to nuisance ordinances in order to let drug users arrive with illegal narcotics in their possession.
“It would be a safe space,” Raville said. “Law enforcement knows they can’t arrest their way out of this epidemic, or they would already have done so.”
One benefit in a rural state like North Carolina, which has spotty public transportation options, would be the prevention of drug users from shooting up and driving under the influence, said Loftin Wilson, the Hepatitis and Harm Reduction Program Coordinator at the N.C. Reduction Coalition, which administers the syringe exchange programs in Wake and Durham counties.
Lisa Harrison, director of the Granville Vance Public Health department, predicted it will be long time before North Carolina is ready for supervised injection sites. Several other county public health directors, including Wake’s director Sue Lynn Ledford, declined comment or referred the questions elsewhere.
Facilities set up to help the addicted use illegal drugs would meet greater resistance than syringe exchange programs, which are still questioned in some police departments, whose officers are concerned that providing free needles to drug users enables criminality, Harrison said. Some police departments opt not to carry naloxone to aid drug users during overdose, she added.
“In my opinion we have a long way to go to get to a supervised safe injection facility,” Harrison said. “It’s just a really sticky issue, especially in the South and the Bible Belt, where you’re going to have a different level of potential for judgment and blame of people with substance use disorder.”