Is Delaware ready for safe drug injection sites?

Imagine a place where people in the throes of heroin addiction could safely and legally shoot up. 

With few questions, they could have their drugs tested for levels of fentanyl and other potentially fatal add-ins. They could receive clean needles to stop the spread of HIV and hepatitis C. And they could receive information about how to get treatment and other help, should they decide they're ready.

They would inject themselves in a sterile room filled with cubiclelike spaces – not hidden in the shadows of a train overpass or in the bathroom of their home – and under the watchful eye of someone who could reverse an overdose.

Now imagine a place like that in Delaware.

It may be difficult to imagine after decades of the militaristic "war on drugs" mentality, but for a war most local and national leaders say the country has already lost, radical alternatives to treating addiction may be exactly what is needed.

A so-called safe injection site has already been approved in Philadelphia, though a host of legal challenges have stopped it from opening.

"The city is now just in the stage of saying we've concluded we can benefit from it," said Dr. Tom Farley, Philadelphia's health commissioner, at a recent panel on opioids at the University of Pennsylvania. Later, he added: "But it does save lives."

The chance of a safe injection site opening soon in Delaware is unlikely, according to Dr. Karyl Rattay, director of the state Division of Public Health. In December, she said at a Health Care Commission meeting that the state is in the early stages of discussing how these safe sites could be brought here.

Those discussions have remained in the preliminary stage, she said last week, noting that Delaware will likely wait to see how other cities and states implement safe drug consumption site amid the many legal and ethical challenges.

"We have a lot of work on our plate that we are working so hard to implement," Rattay said in reference to the state's new Centers of Excellence initiative, which looks to bolster the system of care for those struggling with addiction.

"I do hope in the interim that we do see some more openness to people thinking about whether this (safe injection sites) could be a good strategy for Delaware."

Obstacles to opening these sites include where in communities to put them, how to get around federal and state laws that ban operating a place to use illegal drugs and who should be held responsible should someone die at one of these sites. None of these issues have been tackled yet in America.

But the science behind safe consumption locations, which have successfully operated in Europe and Canada for years, backs the harm-reduction model that could show success with the support of federal and state laws.

"In terms of the data, they're incredibly well studied of their positive impact on a number of fronts," said Dr. Susan Sherman, a professor in the department of health, behavior, and society at Johns Hopkins Bloomberg School of Public Health. "By virtue of bringing people inside, connecting them with services when they're ready for services, you're treating them with dignity and respect. It's not just the space they inject; it's the services around it."

Philadelphia's Fairhill and West Kensington neighborhoods supply Delawareans with some of the most potent heroin on the East Coast.

Traveling from Delaware to Philadelphia to purchase heroin is a common story told by those who use locally, and until recently, heroin users would camp out along the Conrail tracks running through this section of Philadelphia. Some overdosed and died, only to be found days or weeks later by another person looking for a place to use and spend the night.

But in an attempt to clean up Kensington and turn around overdose numbers that far surpass any other U.S. city, Philadelphia closed off the tracks with fencing and signed off on opening safe or supervised injection sites. 

The city has dubbed them "Comprehensive User Engagement Sites" and will contract out these locations to medical providers, as has been done in Vancouver, Canada, and Europe. 

“We are facing an epidemic of historic proportions,” Farley said. “The people in the city of Philadelphia, our brothers, our sisters, our parents, our children, are dying. And they don’t need to die. And we have an obligation to do everything we can to prevent those people from dying.”

'Incredibly controversial'

Three hundred and forty-five people died last year from overdoses in Delaware.

That's a 12 percent increase over 2016's total of 308 deaths, according to the state Division of Forensic Science, which will produce a more detailed report on the fatalities later this month.

The state also saw a 105 percent spike in opioid overdose-related visits to emergency departments between late 2016 and mid-summer 2017, numbers that indicate Delaware's battle with heroin and opioid addiction is growing.

Harm reduction – and saving lives – has subsequently become the mantra for state health officials.

"We know right now when individuals in our state overdose, our system isn't really built to engage them into treatment in a meaningful way," Rattay said. 

Moving forward, Rattay said the state wants people who have overdosed and are then discharged from the hospital to leave with resources on how to continue treatment, along with medication so they don't go into withdrawal.

Added Rattay: "This is an opportunity to say, 'You almost died. Now is your chance to find a different pathway for yourself.'"

But not everyone wants to quit, and not everyone is ready for treatment, Sherman said.

That's where harm reduction tactics like these sites in Europe and Canada could make a difference.

"People are so much more comfortable focusing on the kind of schemes for when people are ready to go into treatment," Sherman said, "but what about the people still actively using? That's what this is for."

The mission of harm reduction is relatively simple: Keep people alive so they have the option to seek treatment when they're ready.

It's the premise of the overdose-reversing medication naloxone, which has helped save thousands of lives in Delaware since first responders began carrying it. In 2016, emergency responders in Delaware administered naloxone 2,334 times.

It's also the driving factor behind the syringe exchange program, which allows those using IV drugs to trade dirty needles for clean ones free of charge. The program, which now extends statewide and is operated by Brandywine Counseling and Community Services, has reached thousands of drug users and diverted about 1,000 people into treatment, Rattay said.

It, too, was met with severe pushback when first introduced in the state, Rattay recalled. Delaware was one of the last two states to implement such a program.

Many viewed the syringe exchange as a way to further IV drug use because it gave people the tools. But drug users continued to use if they wanted to – and the public sentiment changed when the program began showing success. 

Delaware's needle exchange program gives consistency amid turmoil

Safe injection sites are seen as an extension of that. Some cities want to give those struggling with addiction a place to safely use their drugs, in addition to clean needles.

"Only in the U.S. do we have this morality criminal justice view," Sherman said. "It's what we have an appetite for."

Rattay said she believes other cities and states will have to demonstrate the benefits of the safe drug consumption sites before they make their way to the First State.

"It's so incredibly controversial," the health director said, "and certainly we know that's the case in Delaware, as well." 

That's largely why it has remained far from public discussions as state and local officials focus first on bringing Delaware's current addiction response system up to date with the latest medical practices. This includes broadening the availability of medication-assisted treatment, which helps to stave off withdrawal symptoms and replace the urge for heroin and other opioids.

Lt. Gov. Bethany Hall-Long, who chairs the statewide Behavioral Health Consortium, said talks about safe injection sites have not made their way into community forums. 

"It has not been an issue of priority for the consortium," Hall-Long said. "Once more data is there, if it's been successful in other cities or states, then we may look more at it."

Yet many say the research and results in Europe and Canada provide that data.

"There's a will or there's not a will," Sherman said. "European drug users are not that different. What's different is the rate at which people are dying here (in the United States). That's what's different."

'Safe heroin injection'

Philadelphia may have approved safe injection sites, but officials say implementing the sites has many more challenges.

In order for Canada to legally open sites, an exemption was created to keep health care companies from being prosecuted under federal drug laws.

To date, a similar exemption has not been created in the U.S., and President Donald Trump's administration has not indicated it would support these sites.

"As a threshold matter, it's illegal under federal law as well as state law," said Delaware Attorney General Matt Denn, who does not support the sites.

"I understand the benefit of them, but that's outweighed by the message it sends," Denn said. "The name itself is a misnomer. There is no such thing as a safe heroin injection."

Denn said the state lacks the treatment facilities. Even if the sites offered strong engagement into treatment, he said, the state would be without places to put patients.

That's why he is advocating for more treatment options.

Anti-addiction advocates are trying to encourage prosecutors to stop pursuing low-level drug crimes and offer treatment rather than incarceration.

In Delaware, some law enforcement agencies like the New Castle County Police Department and the Dover Police Department already take this tactic through programs like Hero Help and the Angel Program.

These initiatives offer the dismissal of charges with the successful completion of a rehabilitation program, but only certain charges are eligible.

"The approach that we've taken with lower level cases, I think has been effective," Denn said. "If someone successfully goes through the diversion program, they aren't incarcerated and in some cases, don't have a conviction record, so I think that's been successful. But we can't do as much of those as we like because of the limitation of treatment resources."

The state aggressively pursues large-scale drug trafficking. In some ways, this is what Trump is calling for nationally. He wants to impose harsher sanctions against drug dealers, especially those trafficking highly addictive drugs like heroin and fentanyl.

"Toughness is the thing that they most fear," Trump told those gathered Monday in Manchester, New Hampshire – a state hit hard by the opioid epidemic. 

Trump said dealers who sell deadly batches of drugs to people should be handed the death penalty, which has been federally opposed by the courts and taken off the books in most states. 

"Drug traffickers kill so many thousands of our citizens every year," Trump said. "That's why my Department of Justice will be seeking so many tougher penalties than we've ever had, and we'll be focusing on the penalties that I talked about previously for big pushers, the ones that are killing so many people, and that penalty is going to be the death penalty."

Delaware Rep. Lisa Blunt Rochester, a member of the Bipartisan Heroin Task Force, voiced concern for the president's proposal, which she said focused too heavily on law enforcement and not enough on the public health crisis.

"This issue touches the lives of far too many and deserves immediate action,” she said in a statement. "Yet, I am deeply concerned that it will jeopardize the progress we’ve made by incarcerating those in desperate need of drug treatment."

'Everyone has an immediate reaction'

The proof is in the science when it comes to addiction. 

Last month, the New York Times editorial board wrote in support of safe injection sites, pointing out that because heroin use often occurs alone, dying from an overdose is often an incredibly lonely way to go. 

This week, New York City Council member Mark Levine took to Twitter to laud the city's health commissioner and her support for safe injection sites. He stressed that despite federal law, the city should move forward with the policy – and be prepared for the ramifications that may come with it. An official recommendation or decision by the city has not been reached.

In Philadelphia, city leaders are working to find a community to put a safe injection site, though the "not in my backyard" mentality has already begun to appear.

"It's a new idea," Farley said. "Everyone has an immediate reaction."

But he said the response of communities has been mostly encouragement to do whatever it takes to save lives.

Last year, researchers took on what a hypothetical safe injection site could do for Baltimore's drug overdose epidemic. The article, published in the Harm Reduction Journal, found that for a city with 260 recorded drug overdose deaths in 2016, a single safe injection site "would generate $7.8 million in savings, preventing 3.7 HIV infections, 21 Hepatitis C infections, 374 days in the hospital for skin and soft-tissue infection, 5.9 overdose deaths, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations, while bringing 121 additional people into treatment."

For every dollar spent, researchers estimated $4.35 would be saved. 

"We either continue to allow for unsafe facilities to exist, or we open our eyes and start to think about solutions," Johns Hopkins' Sherman said. "What's the political will?"

Though no legislation has been introduced in Delaware to implement supervised injection sites, the nationwide issue has already made its way to the local grassroots advocacy group atTAcK Addiction, which helps push legislation in support of those struggling with addiction.

"We keep our eyes on our neighbors," said Dave Humes, director of public policy for the nonprofit. "We know they're talking about it in Philadelphia. And we know we will be asked about it."

And what Philadelphia finds as they begin to work through the process of opening these centers may pave the way for Delaware and other major cities like New York and Seattle. 

"I feel like it's too new of a concept for people to really process," Rattay said. "It seems like the first time people hear it, they go, 'What? Why would we do that?' But with the science to back it, perhaps people will begin to open their minds to it."

Contact Brittany Horn at (302) 324-2771 or bhorn@delawareonline.com. Follow her on Twitter at @brittanyhorn.

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