The Prevention Puzzle: How Safe Injection Facilities Could Be The Missing Piece

Posted on November 2, 2017 by

Last Thursday, Trump declared the current opioid crisis a “national public health emergency” under the Public Health services Act, an important distinction to note. The President could have declared the crisis an emergency through the Stafford Disaster Relief and Emergency Assistance Act instead.

Trump’s announcement may not be the “head on” approach we were promised. The President’s decision to affirm opioid dependency and abuse as a “national public health emergency” was a decision that in will provide less money to the reform effort.

Federal agencies can direct grant money to combat the epidemic. If Trump had used the Stafford Act to declare the emergency, however, the government would have been able to use more substantial funds from the Federal Emergency Management Agency’s Disaster Relief Fund.

In his wide-ranging speech, seemingly more focused on fanfare than commitment to ending a devastating epidemic, the President emphasized law enforcement and education as the administration’s main focuses on combating opioid addiction and overdoses.

The press conference offered little detail as to how funds will be allocated or even ideas about what the money will do. In his speech, Trump mentioned “cracking down” on those who are buying illegal drugs, as well as focusing efforts to stop the flow of traffic into the U.S.

What would happen though, if the administration treated addicts as medical patients and not criminals? If the preventative strategies were seen as methods of treatment and not punishment?

A preventive measure, referred to as Safe Injection Facilities (SIFs) could do just that. Similar to needle exchange programs, SIFs may actually save lives by providing addicts a safe and clean space to use. Through the SIF approach, people who are already struggling with addiction have access to the help they may need.

The Insite Safe Injection Facility

Other cities around the world have already implemented SIFs into communities. Insite, in Vancouver, Canada has been open since 2003 and is one example of how SIFs are changing thousands of lives.

In the article, “If Philly is serious about saving drug users’ lives it will open a supervised inject site,” former Insite employee, Sara Evans details her experience working for the nonprofit. “…I’ve seen the benefits firsthand,” she said of her experience, “At Insite, we tried to meet people wherever they were in the cycle of addiction and recovery and give them the options to make choices.”

In 2006, the British Medical Journal published a “before and after” study on the impact of medically supervised SIFs on the community and its drugs use patterns. This study measured the rates of relapse among former drug users and of the rates of current drug users who stopped using drugs.

The study found that “the reported benefits of supervised injecting facilities on drug users’ high risk behaviors and on public order do not seem to have been offset by negative community impacts.” Referencing Vancouver’s Insite, the study further discussed its findings, “Our study indicates that the opening of North America’s first supervised injection facility was not associated with measurable negative changes… indeed, we found a substantial reduction in the starting of binge drug use after the opening of the facility.”

The study went on to say that the “evaluation of the Vancouver facility Insite has shown that its opening has been associated with reductions in public drug uses and publicly discarded syringes… [as well as] reductions in syringe sharing among local injecting drug users.”

The study ultimately concludes by reiterating that the data suggests that positive benefits were not offset by any negative changes in community drug use. Safe Injection Facilities evolved from the idea of needle sharing and offering limited medical guidance to the idea of people who are struggling being given direct access to a wider array of opportunities

“If they [addicts] wanted detox, they could go right upstairs,” says Ms. Evans, “If they wanted treatment, we could keep them safe and help them find it. And if they relapsed along the way, they knew that they could come back to us and we’d be there to support them.”

Some might worry that safe sites add to using or increased drug use. But Evans says these concerns “ are unfounded.”

Reminiscent of Nancy Reagan’s, “Just Say No” campaign, is the idea that we aren’t talking about SIFs because there seems to be something scandalous about them when they could be (and are in some cases) a viable harm reduction perspective.

In our Good Law | Bad Law podcast, Number 46, we discuss this idea with Scott Burris, a Temple University law professor and a leading expert on public health law. “Values are really important,” Burris said, “[but] it’s a fantasy to think just affirming those values, you prevent people from doing those things. Let alone, help them once they’ve started to hurt themselves.”

Professor Burris insists that once we understand this notion, we can understand the morality of SIFs. “So you have to say, we have other values… you know, we love our family members, and if they stumble we want to catch them, we want to bring them back.”

“As soon as you get into that realm of values, the proclamation here is very easy to make,” Burris said, “We know for a fact, from evidence, that offering needle exchange in a community doesn’t increase the uptake of drug use by kids. We know for a fact that if you have a safe injection facility in a community, more people don’t start using drugs…we know for a fact those interventions actually save lives.”

Despite this and the success of sites like Insite in Canada and others around the world, there are still no SIFs in the U.S. Unofficially, some are trying to help as best they can.

A recent CNN article, “Opioid addiction and the most controversial bathroom in New York,” explores the benefits of safe spaces for IV addicts.

The Corner Project In New York City

The Corner Project in New York, New York, began as a needle sharing initiative to battle the spread of communicable diseases, such as HIV. (Note: experts believe we have yet to reach the peak of opioid addiction and the death toll has already surpassed that of the peak HIV outbreak in the 90s.) Beginning as a community outreach program in 2005, the Corner Project established roots in an actual building in 2009. It was a move to stabilize the program and with it came windows, a door, and a bathroom.

Corner Project workers quickly found that clients would come for a clean needle and then promptly use the bathroom to shoot up, soon, there was an overdose, and then there was another, and so on and so on, until Corner Project employees saw an opportunity to help as a “moral obligation.”

At first blush, this bathroom is just a bathroom, but to Director Evans, it is much, much more. “People are dying in those bathrooms,” Evans said, “…and so there’s an acknowledgment that as a syringe exchange provider, we have a moral obligation to make sure that people don’t die in our building.”

Bathrooms are often a spot where people who are struggling with addiction use and administer drugs. We know this and this then becomes a safety concern for addicts and for other people using the bathrooms and public areas. Some argue that SIFs will solve both of these dilemmas.

At Corner Project, there is someone who will check in on a user via intercom every three minutes to make sure the user is still conscious. If someone doesn’t respond to a check-in, someone medically trained, will unlock the door and rush in ready with a syringe of naloxone. One worker, Hector Mata, has been with the program for more than seven years and has personally seen at least 25 overdoses, but zero deaths. He says he has never failed.

To the argument that these facilities are merely “consumption sites,” Corner Project and the liked-minded argue that if addicts don’t have access to SIFs, they will find other places to shoot up, just as they have done before, far away from people who might be able to help in the event of an overdose.

SIFs and Hesitation

Not everyone is as confident about Safe Injection Facilities. In an article published in, The Journal of Global Drug Policy and Practice, Garth Davies, a Canadian academic, scrutinizes the methodology of studies on SIFs, predominantly those overwhelmingly suggesting the success of such sites.

“Previous studies are comprised by an array of deficiencies, including a lack of baseline data, insufficient conceptual and operational clarity, inadequate evaluation criteria, absent statistical controls, dearth of longitudinal designs, and inattention to intrusive variation,” writes Davies. He purports that these studies are misguided and that they insufficiently disentangled “complicated causal mechanisms,” assuming then that these studies misidentified their shortcomings.

Davies concedes that “SIFs are but one part of a much larger systematic response to the problem of substance abuse and intravenous drug use,” but cautions that “they are too often credited with generating positive effects that are no borne out by solid empirical evidence.

It’s Time to Start Doing

No matter one’s stance on SIFs, it is important to consider all solutions. What is crucial however, is that we begin to implement these proposed strategies. “Ending the epidemic will require mobilization of government, local communities, and private organizations. Trump said last Thursday, “It will require the resolve of our entire country.”

Trump promises that approvals on his panel’s recommendations will come “very, very fast.” But what if the recommendations laid out by the commission omit critical ideas that are saving lives? How fast is “very, very fast”? We must keep asking questions and keep the discussion moving forward in order to help those struggling now, but also to help everyone in the future.