Support for establishing safe injection facilities (SIFs) — places where people can use their own illicit drugs under medical supervision — is growing in the United States, but the backlash against the model has been fierce.
An SIF is a facility that provides a hygienic space for people to inject, and sometime smoke, their own illicit drugs in the presence of trained medical staff who can intervene if an emergency occurs.
Proponents of these sites, also called “safe consumption spaces” argue the facilities reduce the risk of dying from an overdose, prevent needles and other drug-related litter, and, in some instances, connect the substance users with treatment. Critics charge that the facilities are a form of government-sanctioned heroin addiction that do little to improve substance users’ quality of life.
To date, there are no legally sanctioned SIFs in the United States; however, a recent study suggests the presence of at least one unsanctioned facility in an undisclosed urban area in the U.S., according to the American Journal of Preventive Medicine (AJPM).
History of Safe Injection Sites
SIFs are legal in 10 countries, including Australia, Canada, France, Germany, and the Netherlands. Roughly 98 sites are currently operating in 66 cities, according to the AJPM study.
“Implementation of supervised injection sites has been shown to improve individual health, such as overdose mortality rates, drug use and enrollment in drug treatment, HIV and viral hepatitis risk, and access to health and social services,” the authors noted.
Research also suggests these facilities may reduce healthcare costs.
A May 2017 study from John Hopkins Bloomberg School of Public Health, published in the Harm Reduction Journal, estimated the city could save $6 million in opioid-related costs by opening one SIF in Baltimore. The site’s total cost at $1.8 million each year was based on the model of a 1, 000 square-foot facility with 13 booths, providing 18-hour access.
Their projections were rooted in studies conducted at Insite, the first SIF in North America. Insite opened in downtown Vancouver in 2003, when the city’s HIV rate was among the highest in the industrial world, Anna Marie D’Angelo, senior media relations officer for Vancouver Coastal Health, told MedPage Today in a phone call.
Government actions, including ending funding from Health Canada for the research being conducted at Insite, led to a protracted legal battle and the publication of dueling research reports, noted CMAJ.
Ultimately, in 2011 Canada’s Supreme Court voted unanimously to order the Canadian government to exempt the clinic from any prosecution for its activities.
“During its eight years of operation, Insite has been proven to save lives with no discernible negative impact on the public safety and health objectives of Canada,” the Court said, according to The Globe and Mail. The Court further noted that its concern for denying clients services and the “correlative increase in the risk of death and disease” outweighed the symbolic benefits of Canada upholding “a uniform stance on the possession of narcotics.”
How SIFs Work
Each individual who enters the SIF undergoes a screening process in order to exclude those under the age of 19, pregnant women, and first-time users. They are given an alias or a handle as a secure means of keeping a record of each individual, said D’Angelo.
Those who pass the screening test give a staff member their alias and are assigned a booth where they can inject their own self-obtained drugs under the supervision of a nurse. Nurses will sometimes show the individual how to use a tourniquet and how to properly clean the injection site, D’Angelo noted.
Afterwards, the individual will dispose of the needle in the available biohazard and Sharps containers, and be sent to a “chill room” where juice and coffee are available. Individuals can stay for 10 -15 minutes, again under a nurse’s supervision, she explained.
“You do leave the site walking out under the influence of drugs,” D’Angelo said.
The organization’s goals are to reduce harm and connect people with care, she said. “At Insite, there’s been over 3.5 million injections of illicit substances and there’s not been one death.”
“Hospice Care” for Substance Users
Brianne Fitzgerald, RN, a nurse practitioner in Boston, who has been working in addiction for 40 years and “cut her teeth on the AIDS epidemic” is outspoken in her opposition to these facilities.
She supports most “harm reduction” services. Fitzgerald favors needle exchanges and medication assisted treatment (MAT), when treatment is time-limited, but she does not support safe injection facilities.
“The emperor has no clothes … There’s no more talk of recovery. There’s no more talk of improving someone’s life. This is end-stage care. It’s hospice care,” she said.
There’s one exception to her criticism of SIFs — Fitzgerald said she would endorse safe injection services if they were given in a van and not one fixed location. If services were offered from a mobile unit, communities could be engaged, she said. There could be HIV testing and clients could share coffee with people in recovery and with parents who’ve lost loved ones to addiction. “The van shows you the opioid mess is more than just the addicts,” Fitzgerald said.
Although some critics have noted that the overdose rate hasn’t changed much in Vancouver since Insite came along, looking at that number isn’t really “meaningful,” said Thomas Kerr, PhD, associate director of the BC Centre on Substance Use at the British Columbia Centre for Excellence in HIV/AIDS, and a professor in the Department of Medicine at the University of British Columbia in Vancouver.
The surge in the supply of fentanyl across the U.S. and Canada, a synthetic opioid roughly 100 times more potent than heroin, has hit Vancouver hard, Kerr said, which accounts for some of the rise in overdose deaths.
Also, Insite is a small facility serving only a fraction of the city’s substance users, and cannot be expected to save the lives of those 30 miles away, he continued.
The real question, according to Kerr, is “How much greater would [that rate] have been if there hadn’t been a supervised injection site?”
The opening of a SIF was linked to a 30% increase in detoxification service use, according to a study Kerr and colleagues published in Addiction in May 2007. That study also noted that, “this behaviour was associated with increased rates of long-term addiction treatment initiation and reduced injecting at the SIF.”
“I think there is a lot of good data out there, but people are often immune to evidence,” he concluded.
What Matters for Drug Users
D’Angelo noted that Insite’s primary goal is to save lives.
However, just by entering the facility clients are expressing, to a small degree, concern for their well-being, she said. “They’re taking a tiny step to better their health. Somebody who’s done that is more likely to go into detox than not.”
And while it may seem counterintuitive, supporters say there is an outreach and engagement strategy focused on the path to health and recovery embedded within SIFs.
“I think people tend to react viscerally to the concept, but what they have to do is look at the results,” said Henry Dorkin, MD, director of the Pulmonary Clinical Research Program at Boston Children’s Hospital and president of the Massachusetts Medical Society, which has endorsed SIFs.
If the sites are so bad, so ineffective, he asked why have Australia and Canada and Europe done it for years?, Dorkin added. “People don’t persevere in things that aren’t working.”
In June, the American Medical Association announced its support for piloting safe injection facilities, WBUR reported.
“There are legal issues that need to be addressed, but the AMA certainly came out in support of pilot projects on these facilities so that we can collect the evidence and do a full evaluation of their effectiveness,” said Dr. Patrice Harris, who chairs the AMA’s task force on opioid abuse.
Advocates in three cities — San Francisco, Seattle, and New York — are trying to get the facilities off the ground, and state governments also are looking at the issue. For instance, members of the New York State legislature have introduced legislation to allow for safe injection sites.