John Metcalfe was CityLab’s Bay Area bureau chief, covering climate change and the science of cities.
Cities across the U.S. are pondering legalized, sterile street-drug injection sites to fight the overdose epidemic.
A 35-year-old man with a history of mental illness found cold on the sidewalk.
A 38-year-old man cocooned in a blanket on the street, who neighbors heard “moaning” before going silent.
A 56-year-old woman discovered in an open lot near an underpass. Another woman, age 50, found unresponsive at a friend’s home. A 32-year-old man who security guards caught passed out in an upscale shopping mall’s toilets.
These are just a few of the homeless people who recently died from drug-related causes in San Francisco. They are not the first and won't be the last unhoused drug users to perish here. Of the 41 homeless deaths the city recorded from December 2014 to November 2015, the number one cause was accidental drug deaths.
The enduring problems of addiction—not just fatal overdoses, but diseases from dirty needles and the burden on hospitals, first responders, and families—has more and more city leaders considering a somewhat radical intervention. It’s called a supervised-injection facility (SIF), and it has a promising track record in preventing overdose deaths, reducing public blight, and getting addicts to treatment.
There are already about 100 such sites operating around the globe, from Vancouver to Sydney to Barcelona. To the best of anyone’s knowledge, there’s never been a single overdose fatality at any of them. The basic idea at each is the same: Provide a safe, sterile environment for addicts to inject their own drugs while connecting them to resources like addiction doctors, peer counselors, and housing specialists. If a supervised site were to open in California it would be the first in the U.S., and that possibility has drug-policy experts, some politicians, and even the San Francisco Drug Users Union pumped.
“San Francisco’s open-air drug market is thriving and, with an exploding homeless population, public injection is in every neighborhood,” emails Hollis Cambodia of the drug-users union, which is a real organization and even has an address in the Tenderloin. “People are injecting drugs in the city’s streets and public bathrooms hundreds of times a day. There are overdoses, complaints, discarded syringes everywhere.”
Opening a supervised facility would slice a “huge percentage” off those problems, Hollis believes, and so is the morally correct thing to do. “Anyone who puts up barriers to SIFs is actively engaged in the death of drug users, actively a part of mothers losing their kids to overdose, and other terminal health-related issues that cause the deaths of people who use drugs.”
Any mention of SIFs inevitably needs to reference Insite, the first such facility in Canada and by many scientific measures a success. Insite is located in Downtown Eastside Vancouver behind an unguarded storefront—a highly visible security guard might deter drug users—and when it opens at 9 a.m. usually has a line around the block.
Serious, long-term users (novices are screened out) who've registered with Insite enter an “injection room” with mirror-equipped booths. They pick up clean gear from a nurse's station, go to a booth, and shoot up, usually with heroin, meth, or cocaine. Then they move to a “chill room” for 10 to 15 minutes, where they sip coffee and juice while staff members check for overdoses or delayed reactions. Scattered throughout the building are addiction specialists, nurses, and representatives from housing organizations they can chat with for potential help.
Since opening in 2003, Insite has had nearly 3.5 million visits among 18,000 registrants. While it’s seen many cardiac arrests and thousands of overdoses, on-location personnel who administer aid and opiate-blocking drugs like naloxone have kept OD deaths to zero, says Anna Marie D’Angelo, a spokeswoman for Vancouver Coastal Health.
“When we started this, HIV transmission rates were some of the highest in the industrial world,” she adds. “Now we have one of the lowest rates in Canada.”
Above Insite is a detox facility called Onsite. Addicts often live chaotic lives, especially if they're homeless; barriers to getting clean range from the serious (mental illness) to the tragically ridiculous (missing detox appointments because you don't have a clock.) But at Insite, all they have to do is walk up some stairs and they can be assigned a private room and bathroom where they can detox.
“We've had successes at Onsite where about 50 percent of people actually complete the program,” says D’Angelo. “These are people who’ve never been able to complete one drug-treatment program in their lives.” She pauses. “I thought it was low percentage, but apparently it’s really high for that kind of person.”
The facility’s various benefits are chronicled in dozens of peer-reviewed papers, many of them coauthored by Thomas Kerr. “We found there was a greater than 30 percent increase in the proportion of people entering abstinence-based treatments after Insite opened,” says Kerr, a professor at the University of British Columbia’s medical department. “We also found the site reduced overdose mortality. And in the neighborhood around the facility, overdose deaths went down by 35 percent.”
San Francisco, by the city’s own reckoning, has an estimated 6,600 people without stable housing and 22,000 who inject drugs. It’s unclear how much these groups overlap. In a study published in 2010, Kerr and others interviewed about 600 intravenous-drug users in San Francisco and found the “majority” were homeless. They were also nearly all in support of a place where they could legally inject. “Eighty-five percent of [users] reported that they would use a SIF,” according to the study, “three quarters of whom would use it at least three days per week.”
This finding backs up Kerr's belief that most addicts don’t enjoy shooting up in public. After all, it can be dangerous. “We know that people who are homeless often inject alone in secluded, hidden environments,” he says, “which makes them very difficult to reach with emergency response in the event of an overdose.”
People who inject in alleys, garages, and the like also tend to do it as quick as possible to avoid detection or arrest. That means they often skip steps like not filtering drugs and not rubbing their skin with alcohol swabs, allowing bacteria to get jammed into their bodies. The result are gruesome abscesses, sepsis, and infective endocarditis, a quite-deadly heart malady.
“In Vancouver, we’ve shown that the number-one cause of hospital use by people who inject drugs are these types of infections—abscesses, sepsis, and the like,” says Kerr. Needles that’ve been inside somebody’s infected skin are common on certain sidewalks of San Francisco. Could an SIF help with that nasty nuisance?
Kerr thinks it might. “If you're someone who’s concerned about discarded syringes in your kid’s schoolyard,” he says, “then what you actually want is a supervised-injecting site so people have a place to go instead of the schoolyard.”
The Zuckerberg San Francisco General Hospital and Trauma Center has a special clinic for treating wounds and infections in soft tissue, including a handful each day caused by shooting drugs (typically oozing abscesses). Will the city ever get a clinic that prevents these wounds in the first place?
It's not like it hasn't tried. In 2007, Laura Thomas and experts from Vancouver helped organize a symposium about how an SIF might assuage local drug woes. “Unfortunately, it got picked up on right-wing talk radio and sort of batted around as one of these crazy San Francisco stories,” says Thomas, a deputy state director for the national Drug Policy Alliance.
Soon after, South Carolina Republican Senator Jim DeMint announced he'd cut off federal funds for San Francisco if it proceeded with supervised injections. “He didn’t have the ability to do that—it’s the kind of idle threat that doesn’t actually go anywhere—but it certainly got people’s attention in San Francisco and led to a freeze on talking about it,” Thomas says. “No one wanted to court that kind of controversy, even if it was a well-researched public-health intervention.” (DeMint had an weird fixation on the Bay Area for someone 2,000 miles away; he later threatened to revoke millions in earmarks for Berkeley because it balked at opening a military-recruitment center.)
For proponents of supervised injections in San Francisco, 2016 started off looking like a year of possibility. First, California State Assembly member Susan Eggman introduced a bill giving local and state health jurisdictions the authority to permit legal injections. It failed in committee, but San Francisco Supervisor David Campos picked up the fight with a proposal to build homeless shelters where alcoholics could drink and drug users inject with medical supervision.
That also went nowhere, and earned a strong condemnation from Mayor Ed Lee. “We have a vigorous disagreement over allowing people to inject heroin and meth,” he chided, “to literally destroy their bodies and their minds, in a city-funded shelter, as some have proposed.” (A Campos staffer would not say if he intends to pursue the supervised-injection idea.)
But unlike a decade ago, the conversation isn't dying. These past few months have seen the mayor of Ithaca, New York, proposing a safe-injection site with clean needles and trained staff; Baltimore lawmakers backing a similar facility and vying to decriminalize small amounts of narcotics; and a city/county task force in the Seattle region taking on opiate-overdose deaths, which have tripled in King County since 2009. That task force might recommend not just an injection but “consumption” facility, where crack users could also go.
“We have focused on supervised-consumption spaces, as opposed to supervised injection,” says Patricia Sully, a staff attorney with Seattle’s Public Defender Association. “Some of that has to do with racial-justice implications. We know that crack-cocaine enforcement really goes with racial disparity in many ways.”
The shift in tone among policymakers comes hand in hand with America’s unparalleled overdose crisis. In California, for instance, drug overdose is now the main cause of accidental death. Here’s more from The Guardian:
Nationally, overdose deaths have more than doubled over the past decade and a half, driven largely by opioids—initially prescription painkillers, but increasingly heroin.
Today, more Americans die from drug overdoses than car crashes or gun fatalities. In all, drug overdoses killed 47,000 people in the US in 2014, the latest year for which data is available. That’s 130 deaths per day, on average. The majority of those deaths—29,000, or 80 per day—involved an opioid.
U.S. citizens taught that addicts deserve their fates might be able to ignore the situation, but from Canada the view is appalling.
“There’s such a strong history of prohibitionist, pro-enforcement drug policy that has brainwashed the general public and policymakers into thinking somehow you can criminalize your way out of addiction,” says Kerr.
“The data from the U.S. office of drug control itself shows that while expenditures on drug-law enforcement have increased in hundreds of billions of dollars over recent decades, the price of drugs has gone down, purity has gone up, nothing’s working,” he says. “Now you have a massive, massive overdose crisis and you desperately need interventions.”
“In some ways this is one of the easier issues I’ve ever worked on, because the evidence is so overwhelming and so clear,” says Thomas of the Drug Policy Alliance. “It’s also been one of the hardest issues because it is a new idea for many people and strikes them often as, ’What? We’re going to let people do what?’”
But she thinks the chances are “extremely high” a supervised-injection site will soon open somewhere in the U.S. It might not be authorized by city government but more of an underground thing, which in San Francisco would jibe well with a history of civil disobedience. After all, this was one of the first cities to attack the late-’80s HIV crisis with a needle-exchange program. That push wasn’t led by the government but impassioned street volunteers, who broke state law by handing out syringes in hard-hit neighborhoods, sometimes in a baby carriage to avoid detection.
“San Francisco already has a few models for what we do when there is strong public will and support for something not necessarily in line with the federal government,” says Thomas. That includes progressive causes like being a “sanctuary city” that doesn’t cooperate with ICE, medical marijuana, and same-sex marriage.
And the will for change does seem to exist. Nearly three-quarters of voters in the San Francisco region disagree with Mayor Lee, saying they’d support a supervised-injection service, according to a poll from David Binder Research commissioned by the drug alliance.
“We’ve got a long and proud history of doing what we think is right,” says Thomas, adding: “The alternative to supervised-injection services is people injecting on the street, people dying on the street.”