King County may become home to the first publicly supervised site in the U.S. where addicts could use illegal drugs such as heroin. The proposal is modeled on Insite, a center in Vancouver, B.C., that says it’s prevented nearly 5,000 overdoses in 13 years.
VANCOUVER, B.C. — It’s still quiet and calm here at Insite, North America’s first supervised drug-injection center, but that’s just because it’s 7:45 a.m. on a Thursday and the doors haven’t opened yet.
In less than an hour, the first of the day’s 376 clients will be lined up, clutching hidden stashes of heroin and other drugs, anxious to slide into one of more than a dozen mirrored, lighted booths and shoot up. Some come by more than once. Visits for the day will total 610. Three addicts will overdose — and be revived.
But that’s the point of the 13-year-old center that offers sterile supplies and a watchful eye: Reduce the risks for addicts, and worry less — or, at least, later — about helping them get clean.
Insite by the numbers
Vancouver’s Insite supervised injection center opened in 2003 and has seen nearly 3.5 million visits since then. Here are statistics for use in 2015:
• 263,713 visits by 6,532 individuals
• Average 722 visits per day
• 768 overdoses
• 5,368 referrals to social and health services
• 464 referrals to Onsite detox center
• 262 completed drug treatment.
Vancouver Coastal Health
“The more they come, the more supervision they get,” said Dr. Ronald Joe, associate medical director of addiction services for Vancouver Coastal Health, the public-health agency that runs Insite. “Some come three or four times a day.”
Such a scene could soon be a reality in Seattle and King County — albeit on a much smaller scale. A local task force in September recommended opening what could be the first public sites in the U.S. where drug addicts can inject and smoke hard drugs under supervision, and Seattle Mayor Ed Murray went to Vancouver to take a look.
“We need to do something. We have watched this epidemic grow year after year across this nation,” Murray said. “What we’re doing is not working. We need to figure out what we’re going to do.”
Murray, Dr. Jeff Duchin, who is the King County health officer, and King County Executive Dow Constantine are among those who say a safe injection site could help address an opioid-overdose problem, which claimed nearly 29,000 lives in the U.S. in 2014, according to the Centers for Disease Control and Prevention (CDC).
In King County, overdose deaths tied to heroin more than tripled from 49 in 2009 to 156 in 2014. The number dropped to 132 last year, but local experts say that doesn’t mean the problem is waning, especially among hard-core users.
Statistics show Insite has saved lives, proponents say, reversing nearly 5,000 overdoses since 2003, with no deaths. At the same time, studies show the center has prevented the spread of diseases such as HIV and hepatitis C, and reduced dangerous litter including needles strewn on local streets.
“This is not rocket science,” said Dr. Thomas Kerr, co-director of the Addiction and Urban Health Research Initiative at the British Columbia Centre for Excellence in HIV/AIDS, who has extensively studied Insite.
“We’re asking people to do something they do every day, but to do it in a health-care facility where we can minimize the harms.”
Critics, however — including supporters of the Conservative Canadian government leadership who battled for years to shut down the center — contend the effort doesn’t address underlying problems and simply enables addicts to continue to use.
“The problem is that it’s based on an ideological assumption that addicts can never get better,” said David Berner, executive director of the Drug Prevention Network of Canada, which promotes abstinence-based drug treatment. “Would you knowingly cross the street to give a drunk a clean shot glass?”
Although Insite is paired with a drug-treatment center, called Onsite, Berner and other critics point out that completion rates are low. Of the 6,500 people who visited Insite last year, 464 were referred to Onsite’s detox center. Of those, 252 finished treatment.
But that doesn’t count the 4,000 people whose addictions were managed through methadone and other medication-assisted methods, Insite officials noted.
“Why not more treatment? Treatment doesn’t work for everybody,” said Joe, the center’s addictions expert.
“Proper thing to do”
Insite was started in 2003, originally a three-year experiment aimed at curbing a spike in overdose deaths in Vancouver’s notoriously gritty Downtown Eastside neighborhood. On a recent morning, just outside the center, a man in a dark hoodie slumped over unconscious next to a trash can while a woman with wild blue eyes begged a visitor for cash. Nearby, another woman slept under a cardboard cover, and a thin young man, clearly drugged, writhed and wailed against a brick wall.
Since its founding, the center has been hotly contested but allowed to continue, and over the years Insite has seen nearly 3.5 million visits. Its work is supported by an annual budget of about $3 million a year, with an additional $1.4 million for detox treatment.
The premise is simple. Addicts bring their own drugs to the center, which offers a supervised space and clean supplies — syringes and needles, tourniquets, alcohol swabs. Each booth has bright lighting and mirrors so addicts, nurses and other support staff can clearly see what’s going on. Nurses won’t inject anyone with drugs, but they can advise users about safer veins to minimize the damage to their bodies.
If clients overdose — and people do, multiple times a day — they’re revived immediately with naloxone, a drug that reverses the effects of opioids.
The key is offering addicts a safe place to use and a nonjudgmental atmosphere in which to do so, said Alex Kral, a San Francisco epidemiologist with RTI International, who has studied supervised injection sites.
“That’s what these places do, they decrease stigma and they increase trust, and from there comes all kinds of possibilities,” he said.
Stuart, an Insite client, first came to the center nearly three years ago. He’s a formerly successful Vancouver architect and father to two school-age children. He said his marriage, work and family life were destroyed almost three years ago by his alcoholism and drug use.
“I really don’t think I’d be here if it weren’t for this site,” Stuart said.
He’s been hospitalized eight times after overdoses and tried recovery programs three times. Until he can stop using heroin and crystal meth, Insite keeps him alive, he said.
“It’s a practical solution to the problem,” said Stuart. “It’s the proper thing to do. It’s not that you make it easy, but you make it safe.”
Although research appears to bear that out, many of the studies that attest to Insite’s success are small and limited to the years after the center opened. For instance, a 2011 study published in the journal The Lancet found a 35 percent reduction in overdose deaths in the blocks surrounding Insite, versus 9 percent in the rest of Vancouver.
But that often-cited study looked only at the period two years before and two years after the center opened, not the ensuing decade.
“It is old and it is skimpy, in that it’s only in Vancouver,” acknowledged Kral, the epidemiologist. “However, having done research and evaluation, I can tell you, there is no intervention that we’ve studied that is better researched and has better data than the center in Vancouver.”
King County proposal
Against that backdrop — and additional research from some 90 supervised drug sites around the world — members of King County’s Heroin and Prescription Opiate Addiction Task Force recommended starting the sites here as part of a broad effort to address substance abuse and decrease drug deaths.
“I think the public will understand,” said Duchin, the health officer. “They understand this is a horrible thing. It’s a health problem that needs a health solution.”
Under the proposal, King County would create two centers dubbed Community Health Engagement Locations, or CHEL sites.
The name is deliberate, Duchin said. The centers won’t simply be supervised drug- use sites, but rather places where users are offered multiple interventions, including education, health care and long-term treatment.
“They think we’re obfuscating, calling it a CHEL site, but the idea is not just to take people off the street,” he said.
No locations for the potential sites have been named, except to say that one center would be in Seattle, with another elsewhere in King County, both in places where public drug use already exists.
“The point is not to set up a site in a new area,” Duchin added.
The plan would establish small centers, likely only a few stalls, in buildings where health services already are offered. The sites could be operated directly under the jurisdiction of Public Health — Seattle & King County, or by an entity supervised by the local health district.
However, several key questions about creating and running the centers remain. There’s no estimated cost or funding source. And because such drug use is illegal, the centers could run afoul of state and federal laws — though that’s less likely if they’re operated as a public-health project, according to an analysis by the American Civil Liberties Union.
King County officials are expected to respond to the proposal by mid-December. If the plan is approved, the centers could open within a year, Duchin said.
“We’re ready to move,” added Brad Finegood, assistant director of the King County Behavioral Health and Recovery Division, who is co-chairman of the task force.
In addition to the drug-use sites, the plan calls for expanding existing drug-treatment and prevention programs, increasing access to naloxone and expanding the number of patients who can be treated at methadone clinics.
The proposal is likely to be a hard sell, however. Political and community resistance has slowed efforts in other U.S. cities, including New York City; Ithaca, N.Y.; San Francisco; and Baltimore, Kral noted.
But proponents are committed to listening to neighbors and addressing their concerns, Duchin and Finegood said.
“To say that there are not hurdles is not true,” Finegood added. “We want to be mindful of the community impact.”
Although the Insite center is a model, the Vancouver neighborhood surrounding it is nothing to emulate, advocates acknowledged.
“If I came from a city like Seattle and I went to that Insite place, it would scare the hell out of me,” Kral said. “I would think, ‘Are we going to create one of those?’ ”
The truth, he said, is that the injection center keeps people from dying, but it can’t change the illegality of drugs or other pervasive issuessuch as poverty or homelessness.
“It’s like the chicken and the egg, which came first?” Kral said. “I know the chicken and the egg, and it was worse than that before.”