The recent opening of the first US supervised consumption site (SCS) in New York City was big news (Mays JC, Newman A. Nation’s first supervised drug-injection sites open in New York. The New York Times. November 30, 2021.). But what exactly is an SCS, and can it help patients? In this article, we’ll review the purpose of these sites, the evidence behind them, and how to discuss them with your patients.

What is an SCS?
An SCS is a clinical setting with trained medical staff where clients come to use drugs, most commonly intravenous opioids. Clients bring their own drugs, and the clinic provides sterile injection equipment. Drugs are typically consumed in cubicles, which provide privacy while allowing staff to monitor for signs of overdose. Should an overdose occur, trained staff members with naloxone at the ready can quickly treat the patient and, if necessary, arrange for transport to the emergency room. An SCS usually includes other services as well, like food and clothing, mental health counseling, peer specialists, basic medical care, and referral to addiction treatment.

The approach fits within the tradition of harm reduction, a framework that prioritizes the survival and health of patients over complete abstinence (see the Carlat Addiction Treatment Report Jan/Feb 2020 for a primer on harm reduction). Various harm reduction services are already available in the US—needle exchanges and naloxone distribution are notable examples—but until recently, no SCS could open due to a federal law known as “the crack house statute.” The legal landscape changed in 2019 when a federal judge ruled that the statute does not apply to these sites, laying the groundwork for the New York City SCS.

What is the evidence for these sites?
Research (much of which comes from data collected at sanctioned sites in Vancouver, Canada and Sydney, Australia) has consistently shown that an SCS can reduce overdose-related harms, promote safer drug use, and connect clients to addiction treatment and other health services in a cost-effective manner. Furthermore, these sites have not been shown to increase crime or facilitate entry into drug use, and clients as well as surrounding communities view them positively. Here are some key research findings (Kennedy MC et al, Curr HIV/AIDS Rep 2017;14(5):161–183; Levengood TW et al, Am J Prev Med 2021;61(5):738–749):

Overdose-related morbidity and mortality

• Over a 2.5-year period after it opened, one SCS reported a 26% reduction in overdose deaths in the surrounding area when compared with the rest of the city.
• The opening of another SCS was associated with reductions in ­overdose-related ambulance activations, both city-wide (45%) and in the surrounding neighborhood (80%).

Drug-related risk behaviors

• Higher frequency of SCS use was associated with reductions in all of the following: needle sharing, needle reuse, outdoor injections, rushed injections, and improper syringe disposal.
• SCS openings did not impact population rates of relapse or initiation into injection drug use.

Access to other health and addiction services

• SCS attendance was associated with increases in all of the following: enrollment in addiction treatment, access to addiction services, and cessation of injection drug use.
• Those referred to medical services by an SCS were more likely to access medical treatment.
• Clients hospitalized with skin infections had shorter lengths of stay if referred by an SCS compared to those who self-presented.

Public drug use and crime

• Neighborhoods surrounding an SCS saw significant declines in both public injections and improper syringe disposal.
• No studies found an association between the presence of an SCS and increases in crime or arrests.

Cost-effectiveness

• Estimates place SCS costs on par with methadone and buprenorphine treatment (Caulkins JP et al, Addiction 2019;114(12):2109–2115).
• Simulation studies show a favorable cost-benefit analysis when taking into account the high value of preventing fatal overdoses and HIV or hepatitis infections.

Client satisfaction

• Clients reported that an SCS offers a safe and positive social environment by reducing drug-related harms and facilitating access to treatment (McNeil R and Small W, Soc Sci Med 2014;106:151–158).

How to discuss these sites with your patients

While there may not yet be an SCS in your area, one could soon be on the way; proposals for new sites are in the works across the country. The patients most likely to benefit from a referral are those using drugs who are not yet ready to engage in treatment. When introducing the concept of an SCS, frame the discussion in terms of harm reduction, and be sure patients understand that an SCS does not substitute for evidence-based treatment with medication. Here is an example of what you might say: “The safest option for you is to start treatment with a medication like buprenorphine or methadone. But even if you do continue to use drugs, there are ways of using that are safer than others. Taking drugs at an SCS ensures that you have access to sterile supplies, and staff are available if you need immediate medical attention. The staff there can also refer you to addiction treatment when you’re ready.”

It is also worth discussing these sites with your patients who are already engaged in treatment. For one, they might be able to pass the information on to someone they know who is actively using. But also, should they return to use themselves, doing so at an SCS could be life-saving. You might say: “Using drugs after a period of abstinence can be particularly dangerous since you’ll have less tolerance and you’ll be at higher risk for overdose. If you were to ever use drugs again, it would be safest if that happened at an SCS.”

Whether or not an SCS is available in your area, you can use the discussion of these sites as an opportunity to reinforce key principles of harm reduction and emphasize that these principles can be just as life-saving outside the confines of an SCS. Consider saying something like: “We don’t have an SCS in our area yet, but you can use the same principles to keep you safer when using drugs. For example, using clean needles lowers your risk of getting hepatitis and HIV [refer your patient to a needle exchange program if one is available]. Using when other people are around, even just with someone on the phone, and having naloxone on hand lowers your risk of dying by overdose. Do you have naloxone? If not, I can prescribe it to you now.”

Stay up to date about SCS developments in your area by contacting your state public health department and local harm reduction organizations, such as needle exchange programs. The scientific literature on these sites is growing, and you can learn about the latest evidence via the National Harm Reduction Coalition (www.harmreduction.org). And finally, if any of your patients have used a SCS themselves, use the opportunity to learn from their first-hand experience.

CARLAT VERDICT

An SCS provides a safe and hygienic setting for the consumption of drugs, and sanctioned sites are just starting to open in the US. If a site is available near you, consider referring your patients who are actively using drugs and declining your recommendation for buprenorphine or methadone. But even if your area does not have an SCS, discussing these sites with your patients can reinforce life-saving harm reduction principals.