Ten countries have authorized injection facilities in about 66 cities around the world
by Miranda Gottlieb and Jessica Williams
During the rise of the HIV/AIDS epidemic in the 1980s, injection drug use prompted public health responses to reduce blood borne disease transmission and improperly disposed syringes. In 1986, in Bern, Switzerland, syringe exchange programs expanded services to address rising opioid-related overdose by legally authorizing facilities to supervise injection drug users for signs of overdose. Thus, trained clinical staff began monitoring clients while they injected pre-obtained drugs on the site’s premises where social support services were provided to high need populations.
Supervised Injection Facilities (SIFs; also known as supervised consumption sites, safe injection facilities, and a number of other names) are health care settings that take a harm reduction approach to injection drug use by providing an alternative space for people who would otherwise use drugs in public, solitary, or unhygienic spaces. SIF staff monitor clients for overdose, provide access to sterile injection materials, and offer referrals to social supports, including drug treatment services. Some facilities permit users to smoke or snort substances, in addition to injecting them.
A Global Public Health Response
Ten countries have authorized SIFs with about 66 cities around the world hosting over 90 sites. SIFs have been scrupulously evaluated throughout Europe, but the most-studied facilities are from Vancouver, Canada and Sydney, Australia. Numerous research studies have been conducted to determine the health benefits and cost-effectiveness of SIFs.
A systematic review of 75 relevant articles concluded that SIFs are fulfilling their public health objectives. They have reduced needle-sharing known to be associated with disease transmission, increased access to primary care, and reduced fatal overdose. The review also concluded that–contrary to many opponents’ fears–SIFs have not had been shown to increase injection drug use or crime in surrounding areas.
SIFs are also shown to be cost-effective. In the United States, the Centers for Disease Control and Prevention estimates that the opioid epidemic costs roughly $75 billion per year in health care and emergency response costs. In San Francisco, it is estimated that for each dollar spent on SIFs, a $2.33 savings will be generated, producing a yearly net savings of $3.5 million.
Rules of SIFs
Operational policies for SIFs vary greatly in their admission criteria, hours of operation, social support services, etc. Across the board, however, staff do not administer illicit drugs to clients, but rather educate clients and observe their behavior in order to revive the person with naloxone (the opioid overdose antidote) should an overdose occur. Clients are prohibited from procuring, selling, or sharing drugs on site.
2017 Will Be a Major Year for SIFs in Canada
Like the United States, Canada has seen a dramatic rise in deaths from opioid overdose. In that context, last year, the City of Toronto overwhelmingly approved the creation of three SIFs within the city limits. The three sites should open in 2017.
In addition to public concern about overdose, an impetus for the new SIFs was a 2012 cost-effectiveness analysis of safe consumption facilities in the city of Toronto. The researchers looked at some of the costs of injection drug use in Toronto (primarily the transmission of HIV and hepatitis and associated health costs), projected how people who inject drugs would do so in a supervised facility, and considered the costs of running a facility. The report recommended three sites within the Toronto city limits, and the the city will implement those suggestions.
Montreal is also looking to establish multiple SIFs in 2017, as are as many as ten other Canadian cities.
In the US, Federal Drug Policy Does Not Pave the Road for SIFs
SIFs have never before been established in the United States and current rhetoric from the Department of Justice creates additional uncertainty about how they would fare.
Numerous research studies have been conducted to determine the health benefits and cost-effectiveness of SIFs.
Although states and localities can legally authorize SIFs, programs and clients are vulnerable to prosecution under the federal Controlled Substances Act, which prohibits possession of illegal drugs and knowingly maintaining a property where illegal drugs are used. Program staff may also be at risk for disciplinary actions by professional licensing authorities, which could jeopardize their professional futures.
Under Jeff Sessions, the Department of Justice’s tone does not appear to be aligned with structural policy changes needed to reduce the harms of injection drug use through alternatives to criminalization. Even creating and maintaining less-controversial programs such as syringe exchange and medical cannabis clinics may be increasingly challenging if federal enforcement priorities come to fruition.
Moving Forward Amid Uncertainty
In 2016, Seattle-King County, Washington was the first local government in the nation to approve the development of SIFs (which they refer to as Community Health Engagement Locations) based on the recommendation of the county’s Heroin and Prescription Opiate Addiction Task Force. The three-year pilot project will host one site in Seattle and one outside the city. The pilot has the support of the King County Prosecuting Attorney, King County Executive, and the mayor of Seattle.
In spite of the federal climate, cities all over the country are considering SIFs, including San Francisco, Philadelphia, and Baltimore. State-level authorization would provide some (although not total) legal protection for these SIFs. Strategies that could be used to drive development of SIFs at the state level include: gubernatorial executive orders, recommendations from state medical societies, and rule making authorities by state public health agencies.
Miranda Gottlieb works for the State of Florida to reduce opioid-related overdose.
Jessica Williams is the Director of Communication and Health Promotion at IRETA.