Safe Injection Sites: A Step Forward

From recent lawsuit settlements to rising overdose rates, the opioid epidemic is as pressing an issue as ever. The United States’ opioid epidemic currently has a higher body count than the Vietnam War, claiming 106,000 lives in 2021 alone (“Drug Death Overdose Rates”). A public health crisis only exacerbated by the recent pandemic, drug addiction is a problem America has tried to solve since she started her War on Drugs in 1971. A strategy that started with mass incarceration is shifting its focus to other methods. Of the various tools that could be used to address the epidemic, few are more hotly debated or controversial than safe injection sites (SISs). SISs are facilities where drug users can inject their own drugs in a safe, sterile environment under the supervision of trained staff positioned to intervene in the case of an overdose. It must be noted that these sites do not actually provide drugs nor do their employees actively inject drugs into the site’s users although SISs do typically provide access to medical treatment, social workers, counselors, and addiction treatment (Interlandi). Opponents claim that these sites are, at best, a poor substitute for other means of addiction treatment and overdose death mitigation and, at worse, a way to glorify or even encourage drug use (Rosen). However, as these opponents point to other alternatives for overdose mitigation and addiction treatment, they often fail to address the barriers that accompany such alternatives, barriers that SISs might actually help substance abusers overcome. While SISs are not a panacea, they are a valuable tool for responding to the opioid epidemic as they patch the cracks left by other treatment options, connecting drug users to treatment options and enabling them to stay alive long enough to use them.

SISs are not anything new. From Vancouver to France and Spain, SISs have been around since 1989 and exist in more than 60 cities (Kreit 415). Insite, Canada’s most well-known SIS, for example, was established in Vancouver in 2003. It was such a success that the Supreme Court of Canada explicitly recognized the benefits of SISs by ruling that the federal Minister of Health had to continue exempting InSite from criminal drug laws because closing Insite would undermine the people’s health and safety (Gordon). The justices are not alone in their appreciation for SISs. Business leaders in downtown Vancouver also acknowledged the value of Insite by actually requesting the implementation of another SIS near their businesses to decrease drug users from overdosing in their bathrooms and alleyways (Gordon). The New South Wales Health Department in Sydney, Australia also reported benefitting from SISs, as their analysis of opioid-overdose ambulance calls from 36 months before the opening of an SIS to 60 months after revealed a reduction in the number of opioid-related overdose events near the SIS (Ambrecht, et al.). The time and resources opioid-related calls typically required could be diverted to other people in need, while drug users benefitted by having fewer medical emergencies, displaying the positive impact SISs can have. Australia is not alone in experiencing such benefits as, throughout other countries, SISs are associated with decreased hospital utilization, decreased mortality and infectious disease rates, and increased access to treatment (Gray). By reducing infection transmissions, preventing overdoses, and increasing public safety, SISs benefit all members of a community from small business owners to the drug users themselves.

Unlike other countries, the United States has been resistant to opening SISs. When it comes to addiction in the United States, most Americans probably think of the ‘War on Drugs.’ The United States’ initial response to drug possession and addiction resulted in one-fifth of all incarcerated people in the United States being put behind bars because of a drug-crime (Ptucha). This response, however, has not worked as both drug-related crimes and overdose fatalities have continued to rise, increasing still in 2020 (Ptucha). While government officials are shifting their response to rehabilitation over incarceration, many remain hesitant to support SISs, preferring medication-assisted treatment (MAT) instead (Rosen). MAT, however, is not a perfect solution. Due to federal restrictions on methadone and buprenorphine, the most popular of the three FDA-approved medications used in MAT, people in treatment must travel to their doctor’s office daily to get the necessary injections, a drain on time and resources that not everyone can afford (Mancher and Leshner). Inflexible working hours or lack of transportation can prevent MAT from being a viable option. Before drug users seeking treatment need to worry about keeping daily appointments, they have to find a doctor, which can be a difficult task due to the necessary qualifications doctors must have to administer the medication. Estimates suggest that, even if all the doctors with the necessary qualifications were prescribing and administering the MAT at full capacity, they would barely be able to serve half the current drug-using population (Mancher and Leshner). Not to mention, not all forms of insurance cover MAT, forcing many seeking treatment to pay out of pocket, which few can afford (Mancher and Leshner). That is not to say that MAT is not a valuable form of addiction treatment. It is. It simply has some barriers to access. SISs are not a replacement for MAT; rather, they are a much needed gateway to it, helping users find the doctors and funds they need to access the treatment.

These issues do not only affect MAT. Ms. Corso, a counselor at OnPoint, the first SIS in New York City, notes that “‘It can be a full-time job getting just one person placed [in an addiction treatment program or rehabilitation center], and we are never dealing with just one person” (Interlandi). If Ms. Corso, a professionally trained counselor familiar with the system and with access to a plethora of resources, struggles to find treatment for drug users, then it is not hard to imagine how challenging it must be for a recovering addict, especially one who might be living on the streets or without easy access to various information gathering technologies like a computer, to find the treatment he or she needs. One of Ms. Corso’s preferred rehabilitation centers for her patients has only 16 beds (Interlandi), highlighting the scarcity. Barriers including accessibility, availability, and cost impede access to various forms of addiction. Therein lies the value of SISs, which offer users some safety and stability as they work to overcome barriers to treatment.

By providing support throughout a drug user's struggle with addiction, SISs serve as a valuable tool for decreasing overdoses and increasing access to addiction treatment. SISs assist those seeking treatment in the often time-intensive and confusing process of finding low-cost treatment (Interlandi). Ms. Corso started working at OnPoint after years of working for abstinence-based recovery programs, which often expelled people when they relapsed (Interlandi). She made the switch because she felt that abstinence-based programs missed “a lot of people” (Interlandi). SISs are able to meet drug users where they are and provide them with a way to get to somewhere better. According to the Centers for Disease Control and Prevention, “research shows that new users of SSPs [syringe service programs] are five times more likely to enter drug treatment and about three times more likely to stop using drugs than those who don’t use the programs” (“Summary of Information”). Although SISs differ from SSPs, most SISs include some kind of SSP, making it more than likely that that users of SISs will have a similar if not better chance of entering treatment, since sources agree that SISs typically amplify the benefits of SSPs (Gray). While a drug user is waiting to get into a treatment program, SISs provide them with a safe, sterile place to inject where they are surrounded by a support network of peers, counselors and social workers. Having a safe, sterile place to inject matters because, at the end of the day, in order to get treatment, a drug user must be alive. In the less than one year since OnPoint, the first official SIS in the United States, opened, it prevented almost 700 overdoses (Interlandi). Thanks to OnPoint, 700 mothers, brothers, friends, and loved ones are still alive. Looking only at the number of deaths prevented, SISs have a clear benefit. Insite, Canada’s foremost SIS, has prevented over 2,151 deaths and has never had a fatality within its facilities (Walks 176). A more general study shows that SISs prevent 88 fatal overdoses for every 100,000 person-years (Ng). Opposing SISs is like telling the people whose overdoses they have prevented that saving their lives was a mistake not worth continuing. By preventing overdoses, SISs offer a second chance at life along with the addiction treatment resources a drug user needs to take full advantage of it.

In addition to helping drug users navigate the addiction treatment process, SISs address an overarching issue with MAT and other forms of addiction treatment that people often overlook: a lack of trust. As Mr. Jones, one of OnPoint’s employees and a recovered addict himself, reflects, “Almost all the people he and his colleagues encountered were, at one point or another, treated terribly by the very institutions charged with helping them” (Interlandi).That should not be surprising considering that “stigmatizing attitudes among health professionals have been shown to be widespread, which has detrimental consequences for connecting persons with OUD to treatment” (Mancher and Leshner). After all, asking for help can be hard for anyone, but asking for help from someone who judges you for needing it is even harder. One study analyzed functional magnetic resonance imaging and ultimately revealed that, when thinking about drug addicts, participants’ cerebral activity revealed that the participants perceived them to be “‘less than human’” (Des Jarlais et al.). It makes sense that a drug addict might be wary of asking people who might view them as “less than human” for help. Dr. Emily Kauffman, a physician at The Ohio State University, identifies the crux of the issue perfectly. In the United States, she remarks that addiction “‘is seen as a disease of ‘choice’” when, in reality, it is a “complex and chronic brain condition that completely hijacks reward pathways’ (Gray). A glaring example of this view and the issues it brings occurs in a journal article where two doctors lament the “evil” of SISs, instead, supporting and expanding “places where they [drug addicts] are welcome but their addiction is not.” (Bozza and Berger 86). They hold up the Salvation Army’s rehabilitation program, which requires clean drug and breathalyzer tests to participate in as the paradigm of addiction treatment option (88). While the Salvation Army’s rehabilitation program certainly has its place as a treatment option, it is concerning that these doctors somehow expect someone in the throes of addiction–a disease they admit biologically alters neurological pathways and can eclipse a person’s drive to eat or sleep (87)—to pass the drug and breathalyzer tests necessary to enter into that program. To paraphrase Ms. Corso’s struggle with abstinence-based programs, it seems paradoxical to expect drug users to be sober to get help, when they need help to get sober (Interlandi). Others object to SISs on the grounds that they prevent drug users from reaching the “rock-bottom” circumstances necessary to seek treatment (Lofaro and Miller 48), displaying a distinct lack of sympathy for those suffering from addiction. In the face of such negative attitudes towards addiction, it is easy to see why a drug user might be hesitant to seek treatment, making more judgment-free zones like SISs a valuable access point and trust a valuable resource. The understanding that the peers–current and former drug users–SISs typically employ is a more valuable commodity than many realize.

When it comes to SISs, there are actually a lot of things people do not realize or simply misunderstand, contributing to much of the contention around them. A common misconception is that SISs will increase crime or drug use rates in the surrounding community (Gordon). Analyses of Insite show that that is not the case. Neither drug-related arrests nor drug injection rates increased following the SIS’s opening (Ng; Ptucha), proving these fears to be unfounded. Although it is too soon to know for sure, it seems likely that OnPoint is not causing a spike in drug-related crime either as even the long-time director of the preschool near OnPoint admits that “a lot of the problems that get laid at their [OnPoint’s] feet are things we’ve been dealing with since long before they even existed’” (Interlandi). In other words, the drug-related crimes occurring around SISs are not caused by the SISs as much as they are a symptom of the problems SISs seek to address. The SISs are not the root of the problem, but they could be a solution.

Another common misconception is that there is little research that supports SISs’ efficacy. Critics often try to discredit the success of these sites using a 2018 RAND Corporation study that warns that “there is uncertainty about the size of the overall effect” of SISs (Kreit 423). However, they often leave out the caveat that even the 2018 RAND study admits that “there is evidence that supervised drug consumption ‘reduces the risk of disease transmission and other harms associated with unhygienic drug use practices’” (423), so even the RAND corporation acknowledges that SISs do have value. In reality, the difficulty with quantifying the overall effect of SISs is not a reflection on SIS efficacy as much as it is a sign of the limitations on researchers. As reviews of SIS research attest, modeling things like HIV transmission rates or wound infection rates is inherently difficult as it often relies on self-reporting, and the real-world environment can make it hard to account for all possible outside influences (Des Jarlais, et al.; Valencia, et al.). At the end of the day, studies do show that SISs leave a net-positive impact on their communities, and, just as there is a possibility that the effect could be smaller than expected, there is also the possibility that the effect could be greater than anticipated.

Finally, at the root of many people’s issues with SISs lies a fundamental misunderstanding of their purpose. SISs are not a “form of surrender” as some like to suggest (Kreit 416). Instead they are simply a new approach to an issue that San Francisco Mayor London Breed agrees is “too big” to “rule out any possible solutions” (Kreit 424-425). In an Op-Ed in the Philadelphia Inquirer, Former Attorney General Jeffrey A. Rosen contested SISs on the grounds that “enabling those suffering from addiction to go to the brink of death is a dubious treatment” (Rosen). SISs, however, do not provide those suffering from addiction with drugs. SIS employees do not administer injections. They simply provide drug users with a safe, sterile place to inject. It is highly likely that those suffering from substance abuse will be injecting regardless of the availability of SISs, since addiction is a disease that disrupts basic brain functioning to the point that the drive to inject becomes as primal as the drive to eat (Bozza and Berger 87). Its 40-60% relapse rate speaks to how hard it is to abstain (National Institute on Drug Abuse). Opioid addiction is called opioid addiction for a reason. Recovery does not occur overnight, nor is it a linear process (“Drug Overdose Rates”), which makes the supportive atmosphere of an SIS so valuable. The existence of SISs determines whether a drug user is injecting alone or in a safe, sterile environment surrounded by people willing to help them seek treatment if they so desire. SISs are not the thing bringing drug users to the brink of death, but they can bring them back by preventing overdoses and providing them with addiction treatment resources.

By preventing overdoses, helping those suffering from addiction find treatment options, and providing a variety of benefits to the surrounding community, SISs have the potential to be a valuable part of America’s solution to the opioid crisis. Other alternatives have been tried. Incarceration did not work. MAT and other addiction treatments have their own issues. Other countries have been benefiting from SISs for years. Statistically speaking, SISs make sense: they save lives, take strain off local responders, decrease infection transmission rates, take drug use off the streets, and act as a gateway to other forms of treatment. In the face of increasing deaths and bereft families and communities, SISs are a ray of hope that should not be shuttered.

Author

Kate Drab

Kate Drab is a chemical engineering major and member of the Class of 2026. Originally from Columbus, Ohio, Kate now lives in Howard Hall. She took this paper as an opportunity to explore and better understand the premise of SISs and the intense reactions they inspire on both sides. Kate would like to thank Dr. Schepers for his support and encouragement.