This commentary is by Jeremy Morrison, a family physician who lives and practices in Windham County and is board-certified in family medicine and in addiction medicine. He says his patients are mostly insured under Medicaid and Medicare, and many either suffer from addiction or have had it impact their lives, so he is biased on their behalf.

I have followed with interest the reactions to the governor's veto of H.728 based on its proposed feasibility study of supervised injection sites. 

We absolutely need to do more to address the opioid and overdose crises in Vermont, but convincing those who hold the pursestrings that people troubled by addiction are as worth saving as people with cancer or diabetes is hard enough without fighting for interventions that are controversial and of unknown utility.

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Supervised injection sites are one way of increasing the safety of substance use, but the data on their efficacy are varied, mostly showing a small decrease in mortality for people living within walking distance of the site. 

There are few official safe injection sites in North America: one that opened last year in New York City and three dozen in large cities across Canada. There are also supervised injection sites in some large European cities. Cohort studies in this population are difficult — studying an illegal activity through interviews and questionnaires introduces a lot of potential confounding.

The ubiquity of fentanyl in the illegal drug supply has also changed what preventing death by overdose looks like. Just like heroin or oxycodone, fentanyl can produce unconsciousness and respiratory failure — even more quickly because of its easy passage across the blood-brain barrier and its more selective action. 

This can be reversed with naloxone, though more may be required than for other drugs. However, fentanyl and its analogs are unique, in that they can also produce muscle rigidity and laryngospasm (termed “wooden chest syndrome”) in minutes, resulting in rapid death. Treating this often requires the administration of paralytics and rapid-sequence intubation. 

A supervised injection site would have to have a stronger ambulance or medical presence than would have been needed when fentanyl was the exception rather than the rule.

Supervised injection sites are problematic legally, as well: 21 U.S.C. Sec. 856 prohibits renting or maintaining any premises for the purpose of using a controlled substance. Aside from local opposition like we see with methadone clinics, such a site would have trouble evading the political winds of changing attorneys general and federal prosecutors. To this point, while Chittenden County State’s Attorney Sarah George promoted the possibility, Christina Nolan, when she was the U.S. attorney for Vermont, vowed to prosecute such endeavors.

The opioid crisis and the overdose crisis are at their worst, exacerbated by the Covid-19 pandemic and our efforts to mitigate that virus. Homelessness is up, mental health is down, and our society is losing substantial stability and cohesion on a national scale. 

If not on supervised injection sites, then where should we focus our efforts at the state level? There are several things that we can do now to slow both deaths from overdose and the damage to people's lives from substance use.

One incredibly valuable thing Vermont does is to provide funding for counselors and nurse care coordinators through its Hub and Spoke program. However, although all of Vermont's payers pay into the Blueprint program, Hub and Spoke currently excludes patients with Medicare and most with private insurance. 

It should certainly be extended to people who are Medicare patients with Medicaid as secondary insurance, as this group includes the physically and mentally disabled and those over 65 living in poverty. It could easily be extended as well to all Vermonters who are troubled by substance use. One team of a nurse care coordinator and counselor covers 100 Spoke patients, giving a lot of bang for the buck.

Managing drug use can be aided by amplifying efforts already in use: more liberal and widespread provision of naloxone and clean injection supplies and free testing for HIV and Hepatitis C.

Rather than establishing officially sanctioned supervised injection sites, wide distribution of safe supplies, education and naloxone could mean that anyplace people use drugs together might be safer. 

There are already unsanctioned supervised injection sites run by concerned advocates and former and current drug users, and most people who inject drugs would be happy to use safe injection supplies and have naloxone. 

Rather than just using nonprofits to distribute these in the limited way they can afford to (once a week for limited hours in my neck of the woods), the state could bundle supplies, naloxone and education into single kits and make them broadly available for free with no strings attached. 

We spend hundreds of thousands of dollars on cancer treatments that don’t decrease mortality, and on medically unnecessary testing. Surely we can direct some of that money to a disease that continues to kill our teens and young adults at rates outstripping Covid-19, cancer and car accidents.

There are plenty of areas that offer opportunity for intervention: better reimbursement for individual and family therapy, better reimbursement for primary and psychiatric care of people with complex needs like homelessness and addiction, increasing access to medication-assisted treatment, training youth in life and coping skills, ensuring adequate nutrition, helping people to find and afford safe housing. 

We need to start identifying meaningful interventions and committing to them as if the next person who dies of overdose could be someone we love.

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