Today, I'll be talking to you about safe consumption spaces and the extensive evidence to support their existence. Before I begin, I'd like to go over the outline of my presentation. First, I'll set the stage with the epidemiology of overdoses, opioid prescriptions, and the rising adulteration of heroin supplies with fentanyl and it's analogs. Second, I'll be talking about safe consumption spaces. I'll define it, talk about the various names that are used to refer to safe consumption spaces, which indicate how drugs are consumed within. I'll describe a few different models, talk about Insite, the first safe consumption space that is sanctioned in North America, located in Vancouver, Canada. Lastly, I'll talk about efforts to establish safe consumption spaces in the US, including focusing on work that I'm involved with in Baltimore. Now, I'm going to talk about the opioid epidemic, prescription pills, fentanyl, and overdose. Opioids, which include prescription opioids and heroin, killed more than 74,000 people in the US in 2017, more than any year on record. This is more than the total number of people, around 54,000, who were killed during the entirety of the Vietnam War. This slide reflects opioid overdose trends by death rate, separated by opioid type, from 2000-2014 in the US. Overdose deaths rate involving opioids has more than quadrupled since 1999. In 2014, for the first time in recorded history, more people died of drug overdoses than car accidents, and in 2015, drug overdoses became the leading cause of death in the United States, ahead of car accidents, surpassing fatalities from gun homicides as well. About half of those deaths were caused by opiates, such as OxyContin and heroin, which cost approximately 29,000 lives. Although prescription opioid overdoses had been on the rise since the turn of the century, the most recent concerns centers on the surge of heroin use and heroin overdoses, and that largely is related to the increasing number of people that are using heroin because of their becoming addicted to pills, and I'll talk about that a little bit. Heroin and prescription opioids share essentially the same mechanism of action. Both act on several types of endogenous opioid receptors in the central nervous system, which in turn relieves pains, cause euphoria, and manipulates the reward system. So, heroine opioids have a purpose. In the medical world, they stop people from having pain. Unfortunately, they've been overprescribed, and pain that could have been avoided in other ways were treated with these heavy, heavy drugs. Most important differences between heroin and prescription pills is purity. Prescription opiates are much more pure than heroin, and by consuming them in unintended ways, such as crushing them, smoking, snorting, or injecting them, the euphoria is much more immediate and intense, so there's a high addiction liability with adulterated pills. Even though prescription opiates are better drugs, so to speak, several factors have contributed to the increase in heroin abuse in the last five years and subsequent spike in heroin overdoses. Doctors became more cautious in the face of increasing prescription opioid overdoses. Drug companies developed new pills to counter opioid abuse, such as pills that had extended release, pills that when they were crushed no longer had any kind of potency, and legislations were introduced to curb the prescription of pills through pain clinics and established standards for pain clinics which had previously not existed. These regulatory factors limited access to legal opiates for everyone but subsequently people still wanted to get their high. Individuals with substance use disorders started buying heroin on the black market where prices had dramatically decreased by 80 percent since the '90s, while at the same time, the relative purity of heroin has increased by 60 percent, and these are data from the DEA, the Drug Enforcement Agency. Another influence on the rising rates of opioid-related deaths in the past several years is that of fentanyl. Fentanyl-related opioids have become an urgent concern in many countries throughout the United States, particularly on the East Coast, with dramatic increases in overdose deaths in the past five years. Fentanyl is a synthetic opioid and it's clinically used in anesthesia for the management of chronic pain. Fentanyl is 50-100 times more potent than heroin or morphine. The DEA actually recently declared fentanyl and its analogs as a global threat and then it noted that in the US, we're in the middle of a fentanyl crisis. The fentanyl challenge is not just the chemical itself but also 15 or more DEA-identified analog chemicals that are involved in current overdose outbreaks throughout the US. The dose and type of fentanyl in the street is typically unknown, in heroin and other drugs, placing individuals at a high risk because they don't know what they're putting in their body. This slide shows several licit formulations of fentanyl. A lot of people know a fentanyl patch, which is used oftentimes during treatment, fentanyl swab, that's sucked and devolved in your mouth, and then a fentanyl injection. The next several slides show increases of fentanyl found in drugs that had been seized by law enforcement in the US. You can see the darker the red, the highest concentrations of fentanyl. If you've been following overdoses in the US, these are states that have been particularly hard hit. You can see that only in a period of three years, rates have increased significantly, particularly in Kentucky, Ohio, West Virginia, Pennsylvania, Virginia. You can see that fentanyl is concentrated on the East Coast. A big difference between the heroin supply, although fentanyl has been found in other drugs, it's largely on the illicit drug market and heroin. On the East Coast of the US, heroin is in a white powder form versus black tar heroin which is a West Coast phenomenon. That is different drug cartels, different countries actually, sell drugs it different formularies. So, on the West Coast, in California, HIV actually has been lower. A lot of people attribute that the virus isn't as easily transmissible through drugs of a black tar substance, which needs to be prepared in a different way than a white powder substance. There have recently been several cases on the West Coast of fentanyl-adulterated tar heroin. I want to bring us back to the prime focus of this lecture which is safe consumption spaces, and talk a little bit about where people often inject unsafe consumption spaces or public spaces, parks, stairwells, cars, alleys, streets, et cetera, compared to private spaces like a home and enclosed area. Several studies have shown the risks associated with public injection, the risk of overdose, the risk of increased rates of hepatitis and HIV. One recent study in New York among people who inject drugs found that people who reported primarily in public spaces compared to those who reported injecting primarily in private spaces had twice the odds of reporting a non-fatal overdose in the past year. They also had four times the odds of reusing injection equipment and syringes, so that's reusing tainted equipment whether it be the syringe itself or the cooker that's used to cook up white powdered heroin into a solution that can then be injected. Half of the people that were interviewed had injected in public places and 60 percent had recently injected in a public place like a bathroom or a restaurant. People who work in the world of injection drug users and people who use drugs know that many McDonald's bathrooms function secondarily as a place for people to safely inject. But, of course, if they're alone in that space, they're not safely injecting. If they're alone in that space, there's no one else around for them to hear when they fall out from an overdose, and that's why overdose rates are often higher when people are injecting in public spaces, granted that is a bathroom but it's a public space because it's not a bathroom that's familiar to them, if that makes sense.