Anyone who passes by the sidewalks of some of the streets of Washington DC, might think that the vending machines that have been appearing installed near the White House and the Capitol are like those that offer soft drinks and water, so common in the capital of USA
But the shelves of these new machines are full of opioid overdose nasal sprays, rapid drug test strips, rapid HIV tests, female and male condoms, and basic hygiene and wound care kits.
All that is required to access the products it offers is to enter the required product number and then a code that is received immediately – and anonymously – when calling a number that is printed on the machine itself.
It’s all free and available 24 hours a day, seven days a week.
The seven automated harm reduction machines began being installed within a few blocks of the White House and Capitol Hill four months ago, and an eighth will come online in the coming weeks.
The strategy is a testament to the severity of the opioid overdose epidemic facing the US today, as well as an example of the creativity and agility on the part of the country’s public authorities when it comes to tackling a problem.
The crisis
While in 2015 the number of drug overdose deaths in Washington was 114 (or 17 per 100,000 population), in 2021 it had already reached 426 (or almost 62 per 100,000), more than double the homicide rate in the city, according to official data.
The trend in the escalation of deaths is similar throughout the country. According to information from the National Institute of Health, 52,400 people died in the US from overdoses in 2015. The number climbed to 106,700 in 2022.
Behind this increase in fatalities there is a specific drug: fentanyl .
This synthetic opioid is approximately one hundred times more potent than morphine and 50 times stronger than heroin.
Because of this, the consumption of just 2 milligrams of fentanyl by an adult can be fatal.
The obituaries leave no doubt. In 2016, fentanyl was behind 62% of overdose deaths in Washington. In 2022, it was the cause of 96% of deaths related to drug abuse.
Experts on the subject believe that at least some of the dead didn’t even know they were taking fentanyl.
a problem drug
“One of the biggest problems in the US is that fentanyl is mixed with other drugs in general. Thereforewhatever the substance that the person is going to consume, we must help them to know if it contains fentanyl”, explains to BBC News Angela Wood, head of Family and Medical Counseling services, a non-profit organization that offers harm reduction programs in Washington and operates five of the eight machines in the city.
“We try to educate everyone, even to people who only use marijuana, that if you are buying an illegal drug you should know that fentanyl can be mixed with anything and that just a single dose can be lethal.
According to Wood, since the machines were installed they have already distributed 1,700 of their items in the capital.
The most sought-after product was naloxone, the nasal antidote against opioid overdose, capable of saving a life if applied within 90 minutes of taking the drug.
Second, there were the tapes that immediately test any drug and identify if fentanyl is mixed with it.
For Wood, who coordinates face-to-face syringe distribution and drug user monitoring programs in the Washington metropolitan area, the advantages of the machines are that, on the one hand, they do not require any information from the user to guarantee access to protective items. staff. On the other hand, they ensure availability at any time of the day or night, any day of the week.
“Among those using the machines, we’ve seen both people we’ve followed through other harm reduction programs and people who are completely new to us,” Wood explains.
“There are both opioid users, who are looking to prevent and have a dose of naloxone on hand, as well as family members or friends of the users, who want to be able to care for their loved one in the event of an overdose.“.
According to the Centers for Disease Control and Prevention (CDC), more than 80% of overdose deaths occur indoors, and about 40% of the time, someone else is present at the time of death, a situation in which access to naloxone may be vital.
The rebirth of the machines
Experiments with “soda machines” to distribute products that help reduce harm to drug users are not necessarily new.
The strategy has been used for at least 30 years in countries such as Denmark and Norway.
But it was not until the covid-19 pandemic that this idea began to gain traction in the US.
One of the longest running initiatives of this type in the country was adopted in the city of Cincinnati, Ohio, in February 2021.
“When the covid-19 pandemic started, most user health services in our area were closed,” explains Suzane Bachmeyer, director of prevention at Caracole, an HIV prevention nonprofit that operates vending machines. harm reduction in Ohio, one of the five states with the highest opioid overdose death rates in the country: about 14 deaths a day.
“We needed to stay safe, but we didn’t want to stop taking action on HIV and overdose prevention, and we needed a solution that would eliminate contact but still be effective.”
What seemed like an emergency solution turned out to be successful in reaching a broader audience in need of harm reduction services.
“There is a trust component that is really important. Many of our users are people with social and economic vulnerabilities, who have faced stigma, racial issues, and who had every reason to be wary of being arrested while interacting with people to receive syringes.”, tells BBC News Daniel Arendt, a professor at the University of Cincinnati, who is part of the program as a researcher.
“When you remove the element of human interaction using a vending machine and guarantee anonymity, you really get a new population to achieve harm reduction that we otherwise never would have been able to achieve,” he said.
In Cincinnati, those who want to pick up a product from the machine can call the number on the machine and obtain a personal code valid for 90 days.
During this period, the person may check out one item of each type per week.
Products include: syringes, pipe kits, injectable and inhalable naloxone, fentanyl drug tests, pregnancy tests, condoms, among others.
If the person decides to continue using the machine after 90 days, they will need to call back to receive a new code.
It is at this moment that the researchers take advantage, without breaking the anonymity, to learn a little more about the consumer’s profile and about the use they make of the elements they take out of the machine.
The research revealed, for example, that almost one in five people using the machine’s products were doing so for the first time, meaning they had never before participated in face-to-face harm reduction services.
And, while the majority of those who consume harm reduction products – both from the machines and from personal interactions – are white people, the machine’s clientele is more diverse, with a more significant percentage of black people, for example.
What about overdoses?
“In two and a half years of operation, we have reversed 2,500 overdoses by distributing naloxone through an automated machine. And the test strips have been used to detect fentanyl in users’ drugs on at least 5,500 occasions.” reports Arendt.
“Of these, in 2,900 situations, users reported having changed their behavior as a result, discarding the drug or ingesting a smaller amount,” he adds.
These data were obtained thanks to the questions answered by more than 500 users who renew their passwords every 90 days.
“While nationally the number of overdoses increased by 15% in the first year of the machine’s operation, here in Hamilton County, where we are located, we reduced the number of deaths by approximately 10%.”
In the 1980s, when the concept of harm reduction emerged as an idea to facilitate injection drug users’ access to syringes and safe means of use to prevent contamination by viruses such as hepatitis and HIV, there was a fear that these non-repressive practices would end up stimulating an increase in drug use.
Decades of research have shown that this fear has not come true and that harm reduction programs have actually limited the number of infections among drug users.
But research published in mid-2019 by researcher Analisa Packham in the Journal of Public Economics suggested that the arrival of fentanyl on the market could have altered this calculus in favor of harm reduction.
Packham compared the results of the needle exchange program in certain US counties between 2008 and 2016.
He noted that HIV infection rates were originally similar in the selected locations.
However, the paths of the observed sites were divided when some began to implement damage reduction programs.
In those with needle exchange programs, HIV infections decreased by 15% compared to those without such programs.
But the deaths of opioid users did not decrease; in fact, on average, opioid deaths increased 22% in counties where harm reduction measures are in place.
Packham’s conclusion is that access to safe means of consumption may have increased the frequency of use of a highly lethal drug, hence the increased number of deaths.
The risks of the programs
In 2018, two other researchers, Jennifer Doleac and Anita Mukherjee, reached similar conclusions when they found that increased access to the antidote naloxone did not reduce the occurrence of opioid overdose-related medical emergencies.
“exists e concern that widespread access to naloxone, which reduces the risk of death from overdose, may inadvertently lead to increased or riskier use of opioids,” the authors wrote in the study.
In December 2022, that hitherto little-known study received a mention in a British journal article The Economist with the headline: “Needle exchange in the United States is killing drug users.”
The conclusions of the two studies (and also the report of The Economist) caused a stir in the scientific community.
In response, Helen Clark, former Prime Minister of New Zealand and one of the leaders of the Global Commission on Drug Policy, accused the British publication of exposing dark research on harm reduction programs with negative results among hundreds of papers with positive results that, moreover, have been widely reviewed by other scientists.
“The evidence is clear: needle and syringe exchanges do not encourage drug use. On the contrary, a long-standing literature shows that this approach has been effective in preventing the transmission of blood-borne diseases such as HIV and hepatitis C (and indeed other infections with serious complications such as abscesses).),” Clark wrote in his public response.
“New Zealand, which was an early adopter of needle and syringe exchange programs in the 1980s, has largely avoided endemic rates of HIV among people who inject drugs, a very different result to that seen in countries that did not implement such programs early”, he added.
Arendt acknowledges that harm reduction strategies may seem contradictory to most people, but argues that the scientific evidence shows that their concrete results defy common sense logic.
“People can imagine that someone receives a syringe and only then think about getting the drug to inject. It doesn’t happen like that. People want to use the drug, have it, and will use it, with or without a new syringe available.”, says the researcher from the University of Cincinnati.
Both Wood and Bachmeyer point out that their work doesn’t end with vending machines or handing out syringes to users in person.
Both institutions offer a broader range of medical care and chemical dependency treatment options, should the user so desire.
According to Arendt, the recurring users of the machine became more interested in delving into their personal care and eventually even seeking some kind of treatment.
“We are not here to tell the user: ‘enough, now you are not going to use anything and anything less than abstinence will not be a victory.’ The strategy is different. The machine is usually the first step”, says Arendt.
“Every time the user returns to the machine, their confidence in the service increases. Some begin to give us their names and their contacts, reduce one or two uses per week, little by little they accept other approaches, seek more health information, conditions improve. The next step is always easier than the last. It’s not all or nothing,” she points out.
There is an additional argument in favor of automatic harm reduction machines: the low cost of the program.
Although there is an initial investment of around $15,000 to pay for the device, its maintenance and replacement can be done cheaply.
In Washington, Wood estimates that each machine costs $1,300 per month to maintain, an amount that the City transferred to the organization.
In the case of Cincinnati, Caracole finances the program without public funds.
“In cost-benefit terms, it’s much cheaper to replace parts of the machine and keep it running than it is to hire an educator or social worker for 40 hours a week,” says Bachmeyer.
According to Caracole’s director of Prevention, at least 70 US cities have already consulted Cincinnati about its experience with automatic harm reduction machines, including New York, which recently installed models in Brooklyn.
In addition to Washington, New York and Ohio, there are experiences in Nevada and Puerto Rico.
In the midst of an overdose epidemic, at least part of the solution may lie in the old soda machine.
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See original article on BBC