Evaluation of an Unsanctioned Safe Consumption Site in the United States

To the Editor:

Nearly 70,000 people in the United States die each year from a drug overdose.¹ Opioid-involved overdose deaths may be preventable by the timely administration of naloxone. Eleven countries have responded to health concerns regarding people who use drugs by opening sanctioned safe consumption sites; however, no such sites exist yet in the United States. Safe consumption sites provide a space for people to bring preobtained drugs and use them with sterile supplies under clean conditions and with safe disposal of used drug equipment. These sites provide monitoring by staff equipped and trained in the use of naloxone to reverse overdose. Most sanctioned sites can also provide related services, including voluntary screening for infectious diseases, peer counseling, wound care, and referral to other social and medical services, such as substance use treatment. Observational studies from sites outside the United States show that sanctioned safe consumption sites improve the health of people who use the sites by reducing overdose mortality,² infectious disease risk, and drug use³ and by facilitating access to health and social services.⁴

In September 2014, in response to a local opioid overdose crisis, an organization in an undisclosed U.S. city opened an unsanctioned safe consumption site.⁵ Injections by people who came to this site were monitored by trained staff and were conducted with sterile equipment on stainless-steel tables disinfected before each use, thereby limiting the risk of transmission of human immunodeficiency virus or hepatitis C virus. All syringes were used only once, after which they were disposed of safely at the site. Site staff used an online data-collection system to document every drug injection, type of drug used, opioid-involved overdose, and related death that occurred during injections at the site, and we used that information to evaluate the first 5 years of operation of this unsanctioned site. (The methods are described in the Supplementary Appendix, available with the full text of this letter at NEJM.org.)

Table 1. Table 1. Injections, Opioid-Involved Overdoses, and Overdose Deaths at an Unsanctioned Safe Consumption Site, 2014 through 2019.

In total, there were 10,514 injections and 33 opioid-involved overdoses over 5 years, all of which were reversed by naloxone administered by trained staff (Table 1). No person who overdosed was transferred to an outside medical institution, and there were no deaths. The number of overdoses increased over the years of operation, due partially to the number of injections increasing over the same period of time (Fig. S1 in the Supplementary Appendix). The types of drugs used at the site changed over the 5 years of operation, with a steady increase in the proportion of injections involving the combination of opioids and stimulants, from 5% in 2014 to 60% in 2019 (Fig. S2).

Although this evaluation was limited to one city and one site that is unsanctioned, and therefore the findings cannot be generalized, our results suggest that implementing sanctioned safe consumption sites in the United States could reduce mortality from opioid-involved overdose. Sanctioning sites could allow persons to link to other medical and social services, including treatment for substance use, and facilitate rigorous evaluation of their implementation and effect on reducing problems such as public injection of drugs and improperly discarded syringes.

Alex H. Kral, Ph.D.
Barrot H. Lambdin, Ph.D.
Lynn D. Wenger, M.S.W., M.P.H.
RTI International, Berkeley, CA
[email protected]

Pete J. Davidson, Ph.D.
University of California, San Diego, San Diego, CA

This letter was published on July 8, 2020, at NEJM.org.