Study: Safe Injection Site Reduces ED Use, Hospitalization

People using an unsanctioned safe consumption site (SCS) for injection drug use had a reduced chance of emergency department (ED) visits and hospitalization, researchers found.

According to a study in the Journal of General Internal Medicine, at one unsanctioned SCS — which quietly opened in an undisclosed urban neighborhood in 2014 — facility users had:

• 27% less likelihood to visit the ED (95% CI 12%-46%)
• 54% fewer ED visits (95% CI 33%-71%)
• 32% lower likelihood of hospitalization (95% CI 4%-57%)
• 50% fewer nights in a hospital (95% CI 1%-85%)

During each 6-month period, those who visited the site used it a median of 18 times, reported Barrot Lambdin, PhD, of RTI International in Berkeley, California, and colleagues.

New York City opened two such overdose prevention centers on Nov. 31, 2021, and several other cities are taking steps toward launching their own facilities where people who inject drugs can bring pre-obtained drugs to inject under the supervision of staff trained in the use of naloxone (Narcan), the opioid overdose reversal drug.

Lambdin, a senior epidemiologist and implementation scientist at RTI, acknowledged the study’s small sample size as a byproduct of the site’s unsanctioned nature.

“The unsanctioned environment is one of the most challenging implementation climates to really try to deliver any sort of evidence-based intervention,” he said. “But despite that environment, what we have seen in this study … is incredibly positive results” related to the use of emergency medical care.

The site’s users gain access “by invitation only” in order not to draw attention from law enforcement. Of the 494 study participants, 59 (12%) used the SCS at least once during the study period, and only about 8% of those individuals’ drug injection events happened at the SCS (median 4%, IQR 2%-10%). Thirteen of the 111 participants lost to follow-up died, and 11 of the 13 deaths were opioid overdoses.

While not statistically significant, the researchers observed trends toward lower risk of overdose, a greater risk of skin and soft tissue infections, and a lower rate of non-fatal overdose for people using the injection sites.

The unsanctioned site, which opened in September 2014, operates 5 days a week and provides access to approximately 50 people at one time.

All injections there are monitored by community health workers with lived experiences of substance use who are trained in the use of naloxone to help reverse overdoses. Formal connections to health and social service agencies aren’t possible given the site’s unsanctioned nature.

Study Design

For this study, researchers recruited 494 people who inject drugs from the neighborhood surrounding the unsanctioned site between 2018 and 2019 using data from health and social service agencies to identify the geographic distribution of people who inject drugs in the study area.

Outreach workers canvassed “recruitment areas,” described the study process to potential participants. Anyone interested was invited to meet with a study coordinator at a community field site. Eligible candidates were over 18, able to provide informed consent, and said they had injected illicit drugs in the last 30 days.

Drug use was confirmed by visually inspecting for “recent venipuncture.” Participants were interviewed at baseline and then 6 and 12 months later, with 405 (82%) completing their 6-month visits and 385 (78%) completing their 12-month visit. They were asked about sociodemographic characteristics, substance use and injection routines, use of the SCS, overdoses, HIV status, hepatitis C, healthcare use, substance use treatment, and interaction with the law.

Participants were given $20 to complete the first survey and $30 for follow-up surveys. To prevent attrition, study staff scheduled monthly visits to the field sites between survey visits for which participants were given $10.

Researchers used a “unique identifier based on non-identifying but easily reproducible information about the individual” to track use of the SCS among study participants in the 6 months preceding each survey.

Researchers also traced the 111 participants lost to follow-up and, by providing identifiers and the last date seen to the medical examiner’s officer, were able to learn which study participants had died and their cause of death, which was most frequently related to opioids.

The authors concluded that the study’s overall findings “support the use of SCS to reduce the growing burden of acute care service utilisation related to injection drug use in the USA.”

Lambdin told MedPage Today that SCSs provide guaranteed access to two evidence-based interventions that already have broad federal support: sterile syringes and naloxone. The only difference is in how they’re delivered, he said.

He also argued that implementation of a site that is sanctioned, fully funded, and supported by an engaged community will have a far greater chance of success: “Let’s see how it operates there.”