1.Establish, on a pilot program basis, at least two Community Health Engagement Locations* (CHEL sites) where supervised consumption occurs for adults with substance use disorders in the Seattle and King County region. One site should be located outside of Seattle, reflecting the geographic distribution of drug use in other King County areas. The CHEL pilot program should have a provisional time limit of three years. Continuation of the program beyond that time should be based on evidence of positive outcomes.

* The Task Force will refer to sites that provide harm reduction services where supervised consumption occurs as Community Health Engagement Locations for individuals with substance use disorders (CHEL sites). This terminology recognizes that the primary purpose of these sites is to engage individuals experiencing opioid use disorder using multiple strategies to reduce harm and promote health, including, but not limited to, overdose prevention through promoting safe consumption of substances and treatment of overdose.

The Task Force’s equity and social justice (ESJ) charge emphases the importance of providing support and services to the most marginalized individuals in the County experiencing substance use disorders. The Task Force asserts that the designation CHEL sites is a non-stigmatizing term that recognizes that these sites provide multiple health interventions to decrease risks associated with substance use disorder and promote improved health outcomes.

Goals:

• Reduce drug-related health risks and harms including overdose death, transmission of HIV and hepatitis B and C viruses, and other drug-associated adverse health effects.
• Provide access to substance use disorder treatment and related health and social services, provide a safe and trusting environment where people who use drugs can engage with services to improve their health and reduce criminal justice system involvement and reduce emergency medical services utilization.
• Improve public safety and the community environment by reducing public drug use and discarding of drug using equipment.

Rationale:

• CHEL sites (aka supervised or safe consumption sites in other jurisdictions) offer a supervised place for hygienic consumption of drugs in a non-judgmental environment free from stigma, while providing low-barrier access to on-site health services and screenings, referrals, and linkages to behavioral health and other supportive services (for example, housing).
  • Supervised consumption sites (SCS) have been operating in Europe since 1988. Sites in Sydney, Australia, and Vancouver, Canada, began operating in 2001 and 2003, respectively. As of 2014, there are 90 SCSs operating across the globe on three continents. (See Attachment O for Community Health Engagement Location [akaSupervised Consumption Site] Bibliography, and see Attachment P for World Overview of Supervised Consumption Sites.)

• Published evaluations from existing SCSs show that SCSs can reduce overdose deaths and behaviors that cause HIV and hepatitis C infection (such as sharing of injection equipment and supplies), reduce unsafe injection practices, increase use of detox and substance use disorder treatment services, reduce public drug use and the amounts of publically discarded injection equipment; and, do not increase drug use, crime, or other negative impacts in the area of the SCS.  SCSs can also be cost-effective. (See Attachment O for Community Health Engagement Location [aka Supervised Consumption Site] Bibliography.)
  • SCSs are intended to engage individuals in substance use disorder treatment and other supportive services (physical and behavioral health care, housing, social services) who may not engage in traditional treatment related to substance use. The King County Board of Health previously endorsed and adopted the HIV/AIDS Committee’s 2007 strategic and operational plan for HIV prevention in King County that included a recommendation to promote the use of a ”safe injection site” within King County. (See Attachment O for Community Health Engagement Location [aka Supervised Consumption Site] Bibliography.)
  • In July, 2016 the City Council of Toronto, Canada, approved the implementation of three SCSs for the downtown area of Toronto. In their decision making process, the City Council of Toronto considered data published in the 2012 Report of the Toronto and Ottawa Supervised Consumption Assessment Study (TOSCA), funded by the Ontario HIV Treatment Network and the Canadian Institutes of Health Research, and the Supervised Injection Services Toolkit prepared by the Toronto Drug Strategy Implementation Panel in 2013. (See Attachment O for Community Health Engagement Location [aka Supervised Consumption Site] Bibliography.)
  • Published studies support the effectiveness of the services provided at SCSs in reducing drug-related health risks and overdose mortality for individuals utilizing the SCSs. Research of established SCSs also did not reveal an increase in criminal activity or negative impacts on the communities following the implementation of SCSs in those areas.

Approach:

• Evaluation

The Taskforce recommends a rigorous evaluation process be integrated into the planning and design of the CHEL program. Outcomes should include fatal overdose prevention, other health outcomes, community and environmental indicators (impact on public drug use/injection, community impact including neighborhood perceptions and public safety experiences, OD-related first responder calls, 911 calls, etc.), and impact of linkage to services. Evaluation should be performed by public agencies (Public Health – Seattle & King County and King County Department of Community Health Services) and/or by third-party evaluators. Potential third party evaluators include the University of Washington School of Public Health, the Alcohol and Drug Abuse Institute (ADAI), the Harm Reduction Research and Treatment Center (HaRRT), Cardea, and Battelle. To the extent feasible, selected indicators should be monitored in near real time in order to inform the need for any change in these recommendations during the pilot period.

• Planning and Implementation
  • Continue to engage members of the community (including civic and business stakeholders) and potential CHEL clients to inform the planning and implementation process and ensure the environment and services provided adequately and appropriately address the needs of the clients and the surrounding community.
  • Community partners and stakeholders (including persons who use drugs) should continue to be engaged in the CHEL planning and implementation process throughout the duration of the pilot program.
  • Conduct an Equity Impact Review in the planning process prior to implementation:  
  • Sponsorshiphttp://www.kingcounty.gov/~/media/elected/executive/equity-social-  justice/2016/The_Equity_Impact_Review_checklist_Mar2016.ashx?la=en

• Proposed CHEL program sponsorship options may include:
  • Public Health – Seattle & King County (PHSKC) in collaboration with King County Department of Community and Human Services (DCHS), or;
  • A public-private partnership between PHSKC/DCHS and other community- based service providers, or;
  • Another entity with oversight by PHSKC/DCHS.
  • See Attachment Q for Legal Framework Grid, and see Attachment R for Summary of Legal Considerations for CHEL sites in King County

• Siting
  • Consideration for siting CHELs should include the following priorities:
    • Geographic concentration of drug consumption and overdose.
    • Co-location with or in close geographic proximity to (if co-location not possible) existing services utilized by the target population.
    • Local governmental and community engagement.
    • Fixed locations are preferred over a mobile CHEL during the pilot period
    • Establish at least one site outside the city of Seattle.
    • Geographic areas that have been identified as drug use/OD “hotspots”, and that could potentially benefit from the services provided by a CHEL, should be prioritized for potential CHEL sites.

• Services Provided at a CHEL
  • The following services should be provided (essential services):
    • Hygienic space and sterile supplies
    • Overdose treatment: naloxone and oxygen administration
    • Overdose prevention: naloxone kit distribution
      • Syringe exchange services
      • Sexual health resources and supplies (including male and female condoms)
      • Drinking water; restrooms
      • Direct provision of (preferred), or linkage to, basic medical treatment (wound care), wraparound social services and case management
        • Peer support
        • Health education
        • Rapid linkage to medication-assisted treatment, detox services and outpatient/inpatient treatment services
        • Security and crisis response plan
        • Post-consumption observation space
          • Every effort is to be made to ensure that the provision of supplies and space for consuming illicit drugs (NOT tobacco-containing products or marijuana) via smoking (more precisely sublimation, meaning without combustion of the drug itself) and nasal inhalation be incorporated into the CHEL program design.
          • The following services are highly desirable (but not essential):
            • On site medication-assisted treatment (MAT, for example, buprenorphine treatment)
            • On site drug and alcohol assessment
            • Basic medical treatment and screening services
            • Linkage to legal services

• Staffing
  • CHEL staffing should include at minimum: one (1) licensed healthcare professional (for example registered nurse) and appropriate support staff for the size of facility and scope of services provided, such as social workers, peer support workers, site manager(s) and/or security workers.
  • Medical supervision by a licensed healthcare professional should be provided on site during all hours of operation.

• Funding

No current dedicated resources have been identified to support CHEL implementation and evaluation. Possible public and private resources for this purpose should be explored during the recommendation implementation phase.

• Partner Service Providers
  • A CHEL should be an integrated part of the wide array of services and programs available to the target population. The pilot program should work in close cooperation with:
    • Drug treatment services
    • Medical and behavioral healthcare services including primary health care providers
    • Social services case management
    • Housing assistance
    • Employment assistance
    • Legal Services
    • EMS
      • Law enforcement