Medical Examiner

How Safe Injection Facilities Could Reduce Fentanyl Overdoses

Fentanyl has perhaps been the most intractable part of the opioid crisis, but new strategies being deployed in San Francisco and Philadelphia might help.

Man about to inject drugs with a syringe. Photo illustration by Slate. Photo by Thinkstock.
Photo illustration by Slate. Photo by Thinkstock.

America will soon have its first safe injection facilities—locations where drug users can shoot up under supervision and without fear of legal repercussions—thanks to newly greenlighted initiatives in Philadelphia and San Francisco. The model has a long and relatively successful history in Europe, Canada, and Australia, though it’s still controversial in the U.S. But there’s good reason for skeptics to give these programs a chance. Safe injection facilities might be uniquely suited to help address one of the most intractable aspects of the current opioid crisis: fentanyl.

Data from the Centers for Disease Control and Prevention show that deaths from fentanyl now outstrip those from common opioid painkillers or even heroin. Cheap to produce, easy to procure, and 50–100 times more potent than morphine, the drug’s proliferation has become one of the most concerning aspects of the crisis—particularly as fentanyl contamination of other substances has become increasingly widespread, with fatal consequences. Many are oblivious until it’s too late. In one study of 242 heroin users in British Columbia, 70 tested positive for fentanyl—and more than 50 of those hadn’t known they were using it.

In light of these hazards, one of the key advantages of safe-injection facilities is ready access to naloxone, a drug designed to reverse opioid overdoses. Access to the lifesaving antidote has been limited by its prescription requirement in some states, as well as cost and stigma. But it’s so essential and effective that in Vancouver—probably the leading city when it comes to harm-reduction—even bar staff are learning how to administer it. Given the pervasiveness of fentanyl poisoning and the challenges of procuring naloxone as an individual, the ability to inject drugs under the supervision of staff who have the tools and training to reverse the effects can be the difference between life and death.

And safe injections facilities might soon offer even more robust options for better managing fentanyl. While researching SIFs, representatives from both San Francisco and Philadelphia visited Vancouver’s Insite, the first legal SIF in North America. Since opening in 2003, the site has undoubtedly made an impact: It’s treated 6,900 overdoses, of which nearly half required reversal by naloxone, and has never had an overdose death. But the city is still battling to keep the opioid epidemic, and particularly fentanyl poisoning, in check. A report from British Columbia’s Ministry of Public Safety shows that in 2017 alone, fentanyl was detected in 1,156 illicit drug overdose deaths—representing more than 80 percent of all such fatalities.

To confront this, Vancouver Coastal Health undertook a nine-month pilot study in which Insite visitors were offered a testing strip that could determine whether their drugs contained fentanyl. Out of 1,000 drug samples tested, 80 percent turned up positive. Since participation was voluntary, it’s possible that people were more likely to take researchers up on their offer if they already had reason to believe their drugs were contaminated—but the ability to evaluate this before injecting can and does save lives, and it’s simple and inexpensive to implement.
The strips, originally devised to test for fentanyl in urine, cost about $1 each and work much like a pregnancy test: A colored band appears if the drugs are fentanyl-free, while a blank strip indicates contamination. According to Barbara Garcia, director of health at the San Francisco Department of Public Health and a member of the city’s Safe Injection Services Task Force, San Francisco is going to offer them at its test site.

Philadelphia’s task force also recognizes the dangers of the drug, but is so far less convinced about the merits of detection. “Fentanyl is probably the major reason we’ve had such a sharp spike [in overdoses] in the last 18 months,” said Dr. Thomas Farley, the city’s health commissioner. But he worries that testing strips might be used for the wrong reasons. “We hear—anecdotally but frequently—that drug users may be seeking out fentanyl because it gives a better high.”

Dr. Mark Lysyshyn, who oversaw the Insite pilot study, acknowledges that what we know so far is complicated. “Clients were just as likely to dispose of their drugs following a positive test as following a negative test,” he said. “Some of those clients might have been seeking fentanyl and disposing of their drugs if they did not contain it.” But his team’s more important finding was that those whose drugs tested positive for fentanyl were 10 times more likely to reduce their dose accordingly, and 25 percent less likely to overdose as a result. Paired with a paper published earlier this month, which found that 90 percent of drug users surveyed said they were willing to use test strips, and another in which 70 percent of respondents said knowing their drugs contained fentanyl would lead them to modify their behavior, there’s a compelling case for empowering those most at risk to make informed choices about their own safety.

Some Canadian cities are taking even more aggressive approaches, including providing clean drugs to reduce users’ reliance on contaminated street substances. Neither Philadelphia or San Francisco has any plans to do that. Still, in the U.S., the ability to test for contamination, to reverse an overdose when it occurs, and to do so under informed, compassionate supervision is plenty radical. Here’s hoping SIFs are soon acknowledged and implemented as a vital tool in curbing this devastating and difficult crisis.