Recently, the King County Heroin and Prescription Opiate Addiction Task Force recommended a comprehensive set of strategies to address the growing opioid epidemic. In today’s PH Insider, Dr. Jeff Duchin, Health Officer at Public Health and Task Force Co-Chair shares his thoughts about CHELs. Community Health Engagement Locations (or CHELs) are one of the eight Task Force recommendations. We talk to Dr. Duchin about how they fit in with the other main recommendations and their role as a bridge to treatment access.
Q: We’ve been hearing that heroin and opioid drug use is at crisis levels in King County. How bad is the problem?
Approximately every 36 hours, someone dies from a heroin or opioid drug overdose in King County, and overdoses from these drugs have surpassed automobile accidents as the leading cause of preventable deaths. Each of these deaths is a personal tragedy for the individual and their families and loved ones, and together, they represent a collective tragedy for our community. The impact is particularly striking for youth and young adults – we know from national data that the peak age for initiating opiate misuse is fourteen years.
Q: What can we do about the problem?
To combat this crisis, the Task Force recommended a multi-pronged public health approach. Let’s take a look at the three main categories of recommendations:
Expanding treatment availability is the Task Force’s top priority recommendation so that people can have “treatment on demand.” This means that when someone is ready to start treatment, they can meet with a provider to start treatment as close to where they are located as possible. We also need to ensure everyone has this access regardless of income, race, ethnicity, ability to navigate the health system, housing status, or where the person lives in the County.
Preventing all people, but particularly youth from developing opioid use disorder in the first place is another central focus of the plan. We must raise awareness of the harmful effects of opioid misuse, increase screening for signs of opioid misuse in schools and healthcare settings, and ensure safe storage and disposal of prescription medications because most people who misuse prescription medications access them from a friend or relative’s medicine cabinet.
Third, the Community Health Engagement Locations are one part of the overall strategy that focuses on preventing overdose deaths and improving the health of heroin and opioid drug users, including those that are not yet ready or able to enter treatment.
The complete set of Task Force Recommendations, including CHEL sites, has been approved by the King County Executive, the Mayor of Seattle, the King County Board of Health, the King County Prosecuting Attorney’s Office, and the King County Sheriff’s Office.
Q: What is a CHEL site?
Our approach to fighting the heroin and opioid crisis recognizes not only the priority areas of prevention and treatment expansion, but also the need to reduce the harms of addiction for people who are currently not ready or able to enter treatment – we know from the 2015 Washington State Syringe Exchange Survey that a third of injecting drug users not currently in treatment were not yet ready to start it.
CHEL sites (sometimes referred to as supervised injection facilities) are an extension of the public health harm reduction approach widely used by needle exchange programs. Needle exchange reduced the harms of injection drug use by preventing blood borne infections like HIV. Early adoption of syringe exchange programs in Washington state prevented the HIV epidemic from taking hold among injecting drug user’s like it did in other areas of the country.
CHEL sites provide a safe and hygienic space for consumption of drugs under the supervision of a healthcare professional trained in overdose response and safer drug consumption practices. In addition to treatment for drug overdoses, a CHEL provides access to addiction treatment, and medical, behavioral health, and social services (such as housing assistance), either directly on-site or through referrals.
CHEL services are targeted towards caring for the most marginalized and vulnerable persons in our community, including persons who are homeless and those who may have mental health problems such as depression or anxiety disorders. CHEL sites do not provide drugs, staff will not administer illicit drugs, and clients are not allowed to buy, sell or exchange drugs.
Q: What are the main goals of the CHELs?
There are three main goals.
First, to prevent overdose deaths among people who are using drugs but who are not yet ready for treatment so that they may enter treatment in the future. We believe that no one should have a family member, loved one or friend overdose and die, cutting off any future chance for treatment and recovery, when there could have been access to life-saving help available.
Second, we want to reduce the public safety hazards associated with public drug injecting. Currently, drug users are injecting on our streets or in other public places including parks, business and public restrooms, which creates a public safety risk from discarded syringes and needles. CHEL sites help move this unsafe behavior that is already occurring into a medically supervised environment.
The third goal is to help those struggling with addiction access treatment and recovery support, when they are ready and able to do so. We know that each person with addiction has their own set of complex health and social challenges and struggles, and that many people who are not ready to enter treatment immediately may do so in the future, given additional time and a connection to a supportive caregiver at a CHEL.
CHEL sites also provide other health and medical services such as testing for HIV and other infections, education about safe injection practices and access to social services such as housing assistance.
Q: Are CHEL sites effective?
CHEL sites are not expected to solve our heroin and opioid drug crisis alone, but we do expect they will reduce overdose deaths and increase access to treatment. They are a sound part of a larger response strategy.
Supervised injection facilities have been operating in Europe since the mid-1980s. The Task Force reviewed the available evidence about these sites, and several Task Force members visited multiple sites in other countries.
The sum of the evidence we reviewed suggests these sites provide meaningful health benefits to users and improve indicators of public safety, without increasing drug use or attracting additional users to the community in which the site is located. For this reason, they are sanctioned in British Columbia, Toronto and Ottawa, Canada; Australia; Ireland; the Netherlands; Switzerland; Germany; Spain; Norway; Luxembourg; France; the United Kingdom (Glasgow) and, Denmark. The American Public Health Association, Aids United, the European Monitoring Center for Drugs and Drug Addiction, and the International Drug Policy Consortium have endorsed CHEL sites. The Infectious Diseases Society of America and the HIV Medical Association support demonstration projects and further research to evaluate the effectiveness of safe consumption sites at reducing overdose deaths and transmission of HIV, hepatitis C and other infections at the discretion of local jurisdictions without legal consequences.
Learn more about the evidence behind CHELs at the Task Force FAQ web page.
Q: Do CHELs encourage drug use?
Approximately 90 sites across the globe have been operating successfully, reversing overdoses, decreasing injecting in public spaces, and connecting users to treatment. The available evidence does not show that these sites encourage initiation of drug use or cause an increase in the frequency of heroin or opioid drug use. We have no reason to believe this will be any different for CHELs locally.
A similar argument took place several decades ago when needle exchanges were being established, yet this concern was never realized. To the contrary, needle exchanges reduced the prevalence of HIV in our community, saved lives and connected hundreds of drug users to treatment.
Q: Where will CHELs be located?
CHEL sites will work best if they are located where there is a concentration of people who use heroin and other opioids. In addition, we surveyed local people who inject drugs who reported that they would not travel far to use a CHEL site, underscoring the need to locate the site where public drug use is already occurring. We will be working over the next several months to identify potential sites and engage community members prior to opening a CHEL.
Q: How will we know if CHELs are working?
Although the evidence in support of CHELs is promising, we are not taking for granted that this strategy will be successful locally. It’s important to know that the Task Force recommended CHEL sites on a pilot program basis. This means we will be carefully evaluating the CHEL sites to determine how well they are achieving their goals and for impacts on the community. Based on these evaluations, we will have a better idea about how well CHELs will work in our area, and can take steps to modify the approach as needed.
To learn more about the Task Force and CHELs, visit the frequently asked questions webpage.
Originally posted on February 28, 2017.