Supervised Injection Facilities

Safe(r) Spaces
Supervised injection facilities could reduce HIV and HCV transmission in the U.S.
by Larry Buhl

Prepping rig at Insite. Photo courtesy InSite
Prepping rig at Insite. Photo courtesy InSite

[dropcap]T[/dropcap]he U.S. could have its first safer space—harm reduction advocates say injecting drugs is never completely safe—for IV drug users to pursue their habit as soon as the end of 2016.

Seattle, Boston and Ithaca, New York, are in various stages of development for bringing supervised injection facilities (SIF) to those cities. SIFs, also called drug consumption rooms (DCRs) or medically supervised injection sites (MSIS), are formal storefront locations for users to self-inject their own drugs in a hygienic environment under the supervision of medical staff.

There are approximately 100 SIFs in nine countries around the world, but right now there’s only one in North America, a place called InSite in Vancouver.

All but unthinkable in the U.S. a few years ago, SIFs are a reaction to the overdose crisis and the rise in heroin use in the U.S. They’re getting a boost from harm reduction advocates who point to statistics showing SIFs decrease the risk of fatal overdoses and can prevent new HIV and hepatitis C infections as well as the reinfection of hep C.

Daniel Raymond, policy director for the Harm Reduction Coalition, tells A&U that the interest in SIFs is part of the trend that led Congress to change its needle exchange policy last year.

“There is a crisis mentality to put all the options on the table now,” Raymond says. “Some proposals that were considered too radical or polarizing are getting a second hearing.”

SIFs could pull more of these risky injection situations out of public places where people might be rushed and might not be able to take safety procedures, Raymond says.

“The thinking is, if you start to pull a proportion of those into a supervised setting where people do have access to sterilized equipment, where people have a nurse or maybe a counselor to educate them about safer injecting, you’ll reduce the proportion of unsafe injections where HIV or hepatitis could be transmitted.”

Insight from InSite
Canada’s InSite facility shows that the harm reduction theory can work. InSite opened in 2003 in a poorer area of downtown Vancouver and accessed by up to 900 people per day, some access it more than once a day. Addicts find it by word of mouth.

Users register and get an unused syringe and paraphernalia, then are directed to sit at a mirrored booth. Nurses will watch users inject at these booths and if they see a reaction, from hives to cardiac arrest, they will intervene with Naloxone. After injecting, users go into the “chill room” for further observation for up to an hour.

There have been no deaths at the facility since it opened.

Anna Marie D’Angelo, a spokesperson for Vancouver Coastal Health, which operates InSite, says that in addition to offering safety, InSite can be a soft-sell for recovery.

“The second floor is called OnSite, and that’s a detox facility. If people will go to InSite [to shoot up] and express interest in getting off drugs, a peer counselor or nurse will send them upstairs immediately. The success rate for completing detox is around forty percent, which is actually pretty high for that group.”

A growing response in the U.S.
While harm reduction advocates have pointed out the benefits of supervised injection facilities for years, the recent opioid epidemic is making some public health officials and even lawmakers consider what was once politically untenable everywhere in the U.S.

In early February, Dan Morhaim, a physician who also serves in Maryland’s House of Delegates, introduced a bill including a version of heroin-assisted treatment.

In Boston, the city’s HealthCare for the Homeless Program is trying to raise $250,000 to open an SIF in early 2017. They plan to get around the legal issue by doing only post-injection supervision. Because patients would not be allowed to take illegal drugs in the room, skeptics question how many IV drug users would be helped by the program.

In Seattle, the nonprofit People’s Harm Reduction Alliance wants to have a mobile safe consumption space, probably in the form of a van, up and running sometime in 2016.

In an interview with Fox 13 News in Seattle in March, Shilo Murphy, executive director of the People’s Harm Reduction Alliance, said the program would be good for Seattle because it would dramatically reduce public drug consumption on the streets.

“We will be helping them do as little damage as possible to their bodies, whether they smoke drugs, snort drugs or inject drugs,” he said.

InSite's injection site. Photo courtesy InSite
InSite’s injection site. Photo courtesy InSite

Seattle’s mayor, Ed Murray, said last year that he was open to the idea of setting up safe injection sites. But he hasn’t given a prognosis on whether the city council would get on board with the idea.

Murphy said that he would operate the space even if Seattle didn’t grant him a permit, but that he believes the city wouldn’t crack down.

“Middle-class people are dying in the streets and if we don’t do something we are going to have a larger death toll and that is a city issue we can’t avoid.”

In February, the mayor of Ithaca, New York, Svante Myrick, said he will seek authorization or exemption from the state to make his proposed SIF legal. Like Ithaca, any city would need an exemption from the federal government for a facility that allows illegal drug use within its walls.

Myrick is also proposing other measures to combat the IV drug epidemic. He’s pushing for comprehensive heroin-assisted treatment, which would include a twenty-four-hour crisis center, an Office of Drug Policy to coordinate the city’s harm reduction efforts and a youth apprenticeship program to keep kids away from drug use.

Myrick’s plan would give cops the ability to direct heroin users to counseling, housing or other services instead of sending them to jail. Seattle has a similar program, called Law Enforcement Assisted Diversion.

In my backyard?
City leaders and health advocates in Ithaca, Boston, Seattle, and elsewhere will face another issue in setting up SIFs. They’ll have to get the larger community to accept the centers and assuage residents fearing that putting a center near where anyone lives could lead to unintended hazards.

Raymond says advocates of SIFs have some advance work to do, including outreach to stakeholders in the community, business owners, law enforcement (and from the municipal government which must legalize drug use in these facilities) to get buy-in before these centers open—if they open.

In local media, Shilo Murphy has been addressing the NIMBY (not in my backyard) concerns of Seattle residents. In his March interview on Fox 13 he said that people who access such facilities are unlikely to be coming from across town.

“All the studies show that consumption rooms, people are willing to go between five and ten blocks. They’re not coming to your neighborhood. They’re already in your neighborhood. They’re going to a place to make sure they don’t die.”

D’Angelo says it’s important to get the word out that an SIF will be safe space not just hygienically for injection, but a place where nobody will be arrested and nobody will be picketing.

In other words, though there’s increased awareness and interest in SIFs for harm reduction, groundwork still needs to be done to make these sites a reality throughout the U.S.


Larry Buhl writes A&U’s monthly Hep Talk column.