A CHEL site is a public health service for people with substance use disorders that provides access to medical, behavioral health and social services, either directly on-site or through referrals.

CHEL sites also provide space for hygienic consumption of drugs under the supervision of a healthcare professional trained in overdose response and safer drug consumption practices. Similar sites around the world are commonly referred to as supervised consumption sites (SCS) and other similar names. The term “CHEL” is specific to Seattle and King County.

CHEL sites are designed to improve the health of persons with substance use disorders by decreasing the risk of transmission of blood borne viruses like HIV and hepatitis C, preventing overdose deaths, providing needed medical care and social and behavioral health services, and importantly, providing an access point for treatment of drug use disorders (addiction).

Additional health services provided at CHELs include education on safer consumption practices, needle exchange, wound care and medical consultation, counseling and case management, and referral to treatment and other services.

There are approximately 90 sites around the world that, for public health reasons, provide supervised, safe locations for consumption of drugs. Most of these sites are in European countries and Australia and many have been operating since the late 1980’s. Vancouver, BC, Canada, has a site that has been operating for over 12 years.  

CHEL sites are intended to achieve the following three main goals:

• Reduce drug-related health risks and harms, including: overdose deaths, transmission of viral infections such as HIV and hepatitis C, and other adverse drug-associated health effects.
• Provide access to substance use disorder treatment and related health and social services to improve health, reduce criminal justice 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 in the area near the CHEL site.

Published studies support the effectiveness of the services provided at supervised consumption sites (SCS) in reducing drug-related health risks and overdose mortality for individuals utilizing the SCSs. Available studies do not reveal an increase in criminal activity or negative impacts on the communities where these sites are located.

CHEL sites are part of a network of services to address complex health and social needs of the most vulnerable and marginalized members of our community with substance use disorders, many of whom are also experiencing homelessness.

Other names used for these services include: “supervised/safer consumption site” (SCS); supervised/safer injection facility” (SIF);  “supervised/safer injection service” (SIS); and “drug consumption room” (DCR).

While the names vary, the underlying idea is the same: to reduce the harms associated with drug use by providing a hygienic, supervised space and ready access to treatment as well as other social and health services.

While a safe space to consume drugs under the supervision of a health care provider can reduce overdose deaths and transmission of infections like HIV, the King County Heroin and Prescription Opiate Task Force (Task Force) recommended a greater goal: providing more comprehensive services to help people with substance use disorder return to heath and ultimately, to productive lives.  Therefore, a number of other key health services are included in the CHEL site, such as access to medical and behavioral health care, social services (such as housing assistance) and, importantly, access to treatment for substance use disorder.

When individuals who are suffering from substance use disorder are engaged in health and social services, their likelihood for positive health outcomes increases.  Therefore, the Task Force recommended a more comprehensive health engagement through services like wound and abscess care, social service assistance, and access to treatment for substance use disorder as the best strategy for long term success.

This terminology – “Community Health Engagement Location” – recognizes the need to use multiple approaches to reduce harm and promote health for individuals experiencing substance use disorder. Promoting safer consumption of substances and immediate treatment of overdoses are two ways to promote health. CHEL sites will utilize several additional of several approaches to further promote the health and well-being of people with substance use disorder. 

Equity and social justice considerations emphasize the importance of providing readily accessible support and services to the most marginalized individuals experiencing substance use disorders in King County. 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. 

The impacts of supervised consumption sites (SCSs) have been studied in Canada, Europe, and Australia. The SCS in Vancouver, BC, has been studied most extensively and the results of evaluations are available online at http://uhri.cfenet.ubc.ca/content/view/57/92/

Although the specific impacts of a CHEL site may vary from community to community, papers published in scientific journals show that SCSs have positive outcomes, not only for people who use the services, but also for the surrounding community. The findings of these studies show that SCSs:

1. Prevent overdose deaths in the facility
   • Over nearly 30 years of operation, tens of millions of drug consumptions have occurred in SCSs around the world, but no overdose related deaths have occurred.¹
   • The SCS in Vancouver, BC prevents an estimated 2-12 overdose deaths every year and has had no reported deaths in over 12 years.²

      

2. Reduce overdose deaths in the community
   • Over 4 years, overdose fatalities within 500 meters of a supervised injection facility in Vancouver, BC, dropped 35% compared to a 9% reduction for the rest of the city.³
   • A study of German drug consumption rooms showed a close statistical relationship between the opening of consumption rooms and a long term reduction in the number of drug-related deaths. In Hamburg, the association wasn’t seen until the opening of the third consumption room. In Frankfurt, the relationship wasn’t seen until a fourth consumption room was opened.⁴

      

3. Reduce demand for emergency services related to overdoses
   • A study in Sydney, Australia found that the number of ambulance call-outs for opioid-related overdoses declined significantly in the vicinity of the SCS after it opened, compared to the rest of NSW. This effect was greatest during operating hours and in the immediate SCS area, suggesting that SCSs may be most effective in reducing the impact of opioid-related overdose in their immediate vicinity.⁵

      

4. Reduce high-risk injection behaviors linked to negative health consequences
   • People who consistently used Vancouver’s SCS were less likely to share syringes, reuse syringes, rush injections, and inject in public spaces. They were more likely to use sterile water, clean the injection site with alcohol, and safely dispose of used syringes.^6,7
   • Interviews of visitors to SCSs in Copenhagen, Denmark found: 75% reported reduced high-risk injection behavior, 56% no longer shared syringes, 54% cleaned injection sites more often, and 63% reported fewer outdoor injections.⁸

      

5. Increase use of detoxification services and substance use disorder treatment
   • After the SCS in Vancouver opened, there was a 30% increase in use of detoxification services.⁹
   • Clients who regularly used the Vancouver SCS were 33% more likely to have initiated addiction treatment than those without regular SCS use and those having any contact with an addiction counselor in the SCS were 54% more likely to have initiated treatment than those without such contact. ¹⁰
   • Weekly use of the Vancouver SCS and any contact with the facility’s addiction counselors were both associated with more rapid entry into a detoxification program.¹¹
   • A Health Canada report concluded that “INSITE encourages users to seek counseling, detoxification and treatment. Such activities have contributed to an increased use of detoxification services and increased engagement in treatment.”¹²
   • A study comparing community drug use patterns before and after the opening of the SCS found no substantial increase in relapse rates and no substantial decrease in the rate of stopping drug injecting.¹³

      

6. Reduce drug use in public spaces
   • Numbers of people injecting in public in the vicinity of Vancouver’s SCS were counted before and 12 weeks after the opening of the facility. The opening of the service was associated with a reduction in the number of people injecting in public spaces.¹⁴
   • Multiple studies European have found reduced public drug use as the result of drug consumption rooms.¹⁵

      

7. Reduce the amount of improperly discarded syringes and injection related litter
   • A study measured the amount of discarded syringes and injection related litter in the vicinity of an SCS before and after it opened. There was a significant relationship between the opening of the SCS and a reduction in syringes and other drug related litter found in the area.¹⁴
   • A survey of SCS visitors found that 71% reported less outdoor injecting as a result of the availability of the SCS.¹⁶
   • Multiple studies in Europe have found a reduction in syringes and injection related litter result of drug consumption rooms.¹⁵

      

8. Do not contribute to an increase in crime, violence, or drug dealing
   • A study in Sydney, Australia concluded that trends in property crime and drug-related offenses were the same in the area around the SCS and the rest of the city.¹⁷
   • Following the opening of Vancouver, BC’s, SCS, there was no increase in drug trafficking or assaults/robberies. There was a decline in the number of break-ins and vehicle theft in the area.¹⁸

      

9. Are cost effective
   • The Vancouver SCS saves $5 for every $1 spent. This is based on a conservative estimate that the Vancouver SCS prevents 35 new cases of HIV and 3 overdose deaths per year.¹⁹
   • Another study estimated that the Vancouver, BC, SCS saves between $14 million and $20 million over a 10-year period.²⁰

In multivariate analyses with the use of Cox regression, an average of at least weekly use of the supervised injecting facility and any contact with the facility's addictions counselor were both independently associated with more rapid entry into a detoxification program (relative hazards, 1.72 [95 percent confidence interval, 1.25 to 2.38] and 1.98 [95 percent confidence interval, 1.26 to 3.10], respectively).

Over nearly 30 years of operation, tens of millions of drug consumptions have occurred in SCSs around the world, but no overdose related deaths have occurred.

Similar concerns were raised in the past regarding the effect of needle exchange programs, but have not been borne out.  Fear that increased availability of sterile needle exchange programs might exacerbate illicit drug use was a major factor delaying adoption and expansion of these programs.

Research consistently shows that syringe exchange programs reduce transmission of HIV, are cost effective, can increase recruitment of drug users into treatment programs and provide needed medical care, and are not associated with major negative unintended consequences.  For example, studies have searched for and found no convincing evidence that needle exchange programs result in greater injection frequency, increased illicit drug use, recruitment of new users, less motivation to reduce drug use, or increased transition from non-injecting drug use to IDU.¹⁹

In addition to the substantial experience with syringe exchange programs, evaluation of existing sites where supervised drug consumption occurs has not shown an increase in drug use or major unintended consequences (see 6, above). 

The Task Force recommended the CHEL sites should be staffed by nurses, social workers, case managers, and peer support workers. Staff are trained in an overdose response protocol.

The first successful sanctioned drug consumption room (DCR) was established in Berne, Switzerland in 1988, though unofficial services had been operating across Europe since the 1970’s. More DCR’s were established in several European countries, including Germany, The Netherlands, Spain, Luxembourg, Norway, and Denmark, throughout the 1990’s and 2000’s. In 2001 a medically supervised injecting center (MSIC) was opened in Sydney, Australia. In 2003, InSite, currently North America’s only supervised injection facility (SIF) opened in Vancouver, BC. As of 2010, there were approximately 90 official safe SCSs in Europe, Australia, and Canada.²⁰ The first SCS in France opened in Paris in October 2016 and more are set to open in other French cities. 

Harm reduction is a set of practical strategies to reduce risks associated with substance use among people who are actively using substances and not ready to participate in treatment.  For example, harm reduction strategies reduce risks for HIV and other infectious diseases, prevent overdoses, and help engage substance users in treatment.  CHEL sites and other supervised consumption sites are considered a harm reduction intervention.

No. The heroin and opioid drug epidemic is a complex issue that requires a comprehensive, multi-strategy approach to prevent initiation of illicit substance use, expand access to medication-assisted and other types of treatment, reduce health and social harms associated with substance use disorders, and reducing the illicit drug supply.

The Heroin and Prescription Opiate Task Force made a number of recommendations to address the opiate epidemic in King County.  The recommendations focus on preventing people from developing opioid use disorders, identifying and treating people with opioid use disorders, expanding and enhancing treatment options for opioid use disorders, and improving the health of opioid drug users including through expanding the distribution of naloxone to prevent overdose deaths.

Another recommendation to improve the health of opioid drug users is to establish and evaluate two CHELs in King County on a 3-year trial basis.  The results of the evaluation are to help understand the effect and consequences of the CHEL sites, including how well they are meeting their goals and whether the sites should be continued or not.

The goals of CHEL sites as stated in the Task Force recommendations are to a) reduce drug-related harms and risks, including overdose death and transmission of HIV and hepatitis C, b) provide access to treatment and other health and social services, and reduce involvement with the criminal justice system, and c) to improve public safety by reducing drug use in public spaces and the discarding of syringes in public spaces. 

• Read the full Heroin and Prescription Opiate Task Force Final Report and Recommendations here.
• Read about information on drug consumption rooms provided by the European Monitoring Centre for Drugs and Drug Addiction
• Read about SCSs around the world and find links to publications under the Research link.
• Read about Vancouver’s supervised injection facility “InSite.”
• Read "Public Health and Public Order Outcomes Associated with Supervised Drug Consumption Facilities: a Systematic Review."

In 2014, opioid overdose deaths in King County were the highest ever recorded. In 2013, heroin overtook prescription opiates as the primary cause of those deaths. The 2015 report Drug Abuse Trends in the Seattle-King County Area (2014) noted that “heroin-involved deaths totaled 156 in 2014, their highest number since at least 1997 and a substantial increase since the lowest number recorded, 49, in 2009. Increases in heroin deaths from 2013 to 2014 were seen in all four regions of the County, with a total increase from 99 to 156.” Although prescription opioid-involved deaths have been dropping since 2008, many heroin users, and the majority of young adults, report being hooked on prescription-type opioids prior to using heroin. This reduction has been primarily attributed to changes in the formulation of prescription opioids, which have made them more difficult to misuse. 

King County Executive Dow Constantine and Seattle Mayor Ed Murray, along with Mayor Backus of Auburn and Mayor Law of Renton, created an action-oriented taskforce to rapidly address the epidemics of heroin and prescription opioid addiction and overdose. They instructed the Task Force to explore evidence-based tools and interventions that can be implemented in new ways and in new settings to dramatically increase service capacity and improve opioid use disorder outcomes, public health and safety. They directed the Task Force to facilitate collaboration, speed progress, and to develop a plan for responding to the need to address the growing crisis of heroin and opioids in King County.

1. All Home 
2. American Civil Liberties Union 
3. Auburn Police Department 
4. City of Bellevue Fire Department 
5. City of Seattle Mayor’s Office 
6. Department of Community and Human Services 
7. Department of Social and Health Services, Children’s Administration 
8. Downtown Emergency Services Center 
9. Evergreen Treatment Services
10. Harborview Medical Center 
11. Hepatitis Education Project 
12. Kelley-Ross Pharmacy 
13. King County Adult Drug Diversion Court 
14. King County Emergency Medical Services 
15. King County Needle Exchange 
16. King County Prosecuting Attorney’s Office 
17. King County Sheriff’s Office 
18. Muckleshoot Tribe 
19. Neighborcare Health 
20. People’s Harm Reduction Alliance 
21. Public Defender Association 
22. Public Health – Seattle & King County 
23. Puget Sound Educational Service District 
24. Recovery Community 
25. Renton Police Department 
26. Seattle Children’s 
27. Seattle Fire Department 
28. Swedish Hospital, Pregnant and Parenting Woman Program 
29. Seattle Human Services Department 
30. Seattle Police Department 
31. Seattle Public Schools 
32. Therapeutic Health Services 
33. United States Attorney for Western Washington’s Office 
34. United States Department of Veterans Affairs, Veterans Health Administration 
35. United States Substance Abuse and Mental Health Services Administration (SAMHSA) 
36. University of Washington Alcohol and Drug Abuse Institute (ADAI) 
37. Washington State Department of Social and Health Services, Behavioral Health Adm. 
38. Washington State Health Care Authority

The Task Force identified specific focus areas based on their potential to have the broadest and most meaningful public health impact on the region’s heroin epidemic. The specific areas of focus were:
 
A. Primary Prevention (of opioid use disorders) 

B. Treatment Expansion and Enhancement 

C. User Health Services and Overdose Prevention 

Yes. After the first full Task Force meeting a small group of Task Force members developed the following equity and social justice charge for the whole Task Force.  This was adopted at the second full meeting: 

The Task Force will apply an Equity and Social Justice (ESJ) lens to all of its work. We acknowledge that the “War on Drugs” has disproportionately adversely impacted some communities of color, and it is important that supportive interventions recommended now not inadvertently replicate that pattern. Interventions to address the King County heroin and opioid problem will or could affect the health and safety of diverse communities, directly and indirectly (through re-allocation of resources). Measures recommended by the Task Force to enhance the health and well-being of heroin and opioid users or to prevent heroin and opioid addiction must be intentionally planned to ensure that they serve marginalized individuals and communities. At the same time, the response to heroin and opioid use must not exacerbate inequities in the care and response provided among users of various drugs. All recommendations by the Task Force will be reviewed using a racial impact statement framework. The Task Force will not seek to advance recommendations that can be expected to widen racial or ethnic disparities in health, healthcare, other services and support, income, or justice system involvement. Whenever possible, these concerns should lead to broadening the recommendations of the Task Force, rather than leaving behind interventions that are predicted to enhance the health and well-being of heroin and opioid users.

Primary Prevention:

• Raise awareness and knowledge of the possible adverse effects of opioid use, including overdose and opioid use disorder;
• Promote safe storage and disposal of medications; and
• Leverage and augment existing screening practices in schools and health care settings to prevent and identify opioid use disorder.

Treatment Expansion and Enhancement: 

• Create access to buprenorphine in low-barrier modalities close to where individuals live for all people in need of services;
• Develop treatment on demand for all modalities of substance use disorder treatment services; and
• Alleviate barriers placed upon opioid treatment programs, including the number of clients served and siting of clinics.

User Health and Overdose Prevention: 

• Expand distribution of naloxone in King County; and
• 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. Given the distribution of drug use across King County, one of the CHEL sites should be located outside of Seattle. 

Medication-assisted treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders. A combination of medication and counseling and behavioral therapy is effective in treating alcohol and opioid dependency. (http://www.samhsa.gov/medication-assisted-treatment). The federal Food and Drug Administration (FDA) has approved several different medications to treat opioid addiction and alcohol dependence. A common misconception associated with MAT is that it substitutes one drug for another. Instead, these medications relieve the withdrawal symptoms and psychological cravings that cause chemical imbalances in the body. MAT programs provide a safe and controlled level of medication to overcome the use of an abused opioid. Research has shown that when provided at the proper dose, medications used in MAT have no adverse effects on a person’s intelligence, mental capability, physical functioning, or employability.

The ultimate goal of MAT is recovery, including the ability to live a self-directed life. This treatment approach has been shown to:

• Improve patient survival
• Increase retention in treatment
• Decrease illicit opiate use and other criminal activity among people with substance use disorders
• Increase patients’ ability to gain and maintain employment
• Improve birth outcomes among women who have substance use disorders and are pregnant

For more information about MAT please see: http://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat.

The Task Force recommends providing the full range of treatment options for individuals experiencing opioid use disorders. There are a range of substance use disorder treatment modalities, including detoxification/withdrawal management, outpatient therapy, residential treatment, and MAT. Not every individual experiencing opioid use disorder is interested in treatment with medications or is an appropriate recipient of MAT. Providing individuals seeking treatment with multiple treatment options supports the many pathways of recovery and respects client choice and autonomy. 

A “buprenorphine first” model of care aims to use buprenorphine treatment and overdose prevention induction and stabilization as the priority health intervention. A traditional approach to treatment has provided quality care to a subset of the overall population of individuals with opioid use disorder who are able to consistently and predictably engage in treatment and adhere to stringent treatment requirements (regular appointment attendance, urinalysis testing, etc.). However, individuals who 1) are experiencing homelessness, 2) have limited or no support systems, and/or 3) have complex medical and behavioral health needs may experience difficulty successfully engaging and receiving care at traditional opioid treatment programs. A “buprenorphine first” model of care is an alternative approach to opioid treatment that is client-centered, focused on harm reduction, and designed to engage a greater number of individuals experiencing opioid use disorder in effective opioid treatment.

Community Health Engagement Locations (CHEL sites) are sites where supervised consumption occurs for adults with substance use disorders in the Seattle and King County region. For more information about CHEL sites, click here.