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MDUSA (Make Drug Use Safe Again): Safe Spaces for Addicts

Opioid epidemic and drug abuse concept with a heroin syringe or other narcotic substances next to a bottle of prescription opioids. Oxycodone is the generic name for a range of opioid painkillers

The opioid crisis is one of the worst public health emergencies ever to plague the United States. In 2017, 72,000 people died from drug overdoses, up from 63,600 in 2016. In addition to the devastating social and cultural effects of opioid misuse, the economic cost of prescription-opioid abuse specifically is estimated to be $78.5 billion annually. This number represents the billions of dollars lost due to healthcare and treatment costs, lost productivity, and legal expenses.

Despite the overwhelming scale of opioid abuse, studies suggest that safe injection sites could alleviate some of the public health burden with minimal negative externalities. Safe injection sites, or supervised consumption services, are spaces where people can legally consume drugs with clean equipment in the presence of staff who are professionally trained to respond to medical emergencies. Staff members, in addition to providing medical care, can also provide referrals to treatment services and other programs to aid in recovery. Given the relationships of trust that are established in SIFs, and the perceived absence of judgement at the sites, these referrals are particularly poignant.

13 US cities are considering opening safe-injection sites, but deputy Attorney General Rod Rosenstein has promised swift legal action if any of these sites were to open. Because these legally sanctioned facilities would violate federal drug laws, supervised injection sites face legal as well as cultural obstacles.

As demonstrated by the debates in the 1990s about the establishment of Clean Needle Exchanges and the contemporary debate over marijuana legalization, tension between local governments and the federal government about drug policy is nothing new. In order to effectively address this epidemic, however, local governments should be able to make decisions for their own communities–a one-size-fits-all federal prevention program has failed thus far, and locally-run treatment facilities promise to reduce the rates of fatal drug use.

The efficacy of supervised injection sites is indubitable: no one has ever died of an overdose at any of the 120 safe injection facilities that exist globally. These facilities also provide access to critical health services and treatments such as naloxone and methadone.

Insite, North America’s first and only supervised consumption facility, opened in 2003 in Vancouver. The facility provides clean equipment, a cohort of on-hand nurses to intervene should an overdose occur, and addiction treatment. The site also facilitates an easy path from injecting illegal drugs at Insite to detoxing and managing withdrawal at the partner facility, Onsite. Over the past 15 years, 3.6 million people have utilized the injection facility and successful overdose interventions have saved 6,440 lives. Additional studies suggest that people at safe injection facilities are less likely to engage in needle-sharing that could lead to HIV and Hepatitis C infections. By reducing the number of people who become infected with HIV, SIFs are cost-effective. A Vancouver-based study, using conservative estimates, found that these facilities prevent 35 new cases of HIV from developing each year, resulting in net savings of $6 million. People who used Insite’s facility were also 30% more likely to initiate detoxification services, which was associated with “increased rates of long‐term addiction treatment initiation and reduced injecting at the SIF.”

Despite the robust evidence that safe injection facilities and the harm-reduction model significantly reduce the number of overdose-related deaths and increase the number of drug-users seeking treatment, there are staunch opponents to these facilities. The harm-reduction model, a humanizing principle based on respect for the rights of drug users, acknowledges that people are using drugs regardless of legality. Given this reality, proponents of the model seek to reduce the associated risks. Critics of this model invoke moral hazard arguments, despite the evidence demonstrating the unequivocal efficacy of safe injection sites.  

Some people fear that opening safe injection facilities will lead to an influx of drug users in their communities, and subsequently spikes in violent crime. Research suggests, however, areas with supervised consumption services experience less outdoor drug use, and the presence of such facilities does not seem to increase or encourage drug use.

Some cite fears that normalizing drug-use would enable and exacerbate the crisis. John P. Walters, director of drug control policy under George W. Bush, argues that the only “safe” way to manage opioids is to stop taking them, and that any site that legitimizes the use of illegal drugs perpetuates harm. Additional opposition cites the legal quandaries associated with safe injection facilities. It is a federal crime to have and use heroin, and it is also illegal to operate spaces for the purpose of narcotics use.  

In Canada, Insite faced its own legal issues, but achieved success in 2011 when the Supreme Court granted an exemption to the facility from the Controlled Drugs and Substances Act. The court ruled on the basis that “the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs on Insite’s premises.”

It is time for a similar cultural and legal shift in the United States. Unofficial safe injection sites already exist in Manhattan, Brooklyn, Philadelphia, and Boston. But grass-roots activism can only go so far: in order to have the maximum influence on reducing harmful and often-fatal drug use, these spaces need to be legally sanctioned.

In an August Op-Ed in the New York Times, deputy Attorney General Rod J. Rosenstein said that safe injection facilities violate federal law, and therefore would be met with “aggressive action” if they were to open. He cites in his opposition to such facilities that the surrounding communities would be harmed by the presence of such sites, and future generations would be encouraged to start using harmful drugs if the government seemed to approve of supervised injection. In the last sentence of the article, Rosenstein appeals to “cities and counties” to “join [the federal government] and fight drug abuse, not subsidize it.” Rosenstein’s plea mirrors Nixon’s persisting War on Drugs policies that have failed to stop this epidemic and have had destructive effects on the most marginalized communities.

Rosenstein’s comments emphasize the divide between federal and local governments. Ed Rendell, the former governor of Pennsylvania, recently joined the board of Safehouse, a non-profit safe injection site. To Rosenstein, Rendell said, “come and arrest me first.”

The federal government’s prevention through education program has not worked, as opioid related deaths continue to rise. Communities plagued by drug use are already suffering. Needle Exchange Programs (NEPs) in the 1990s faced harsh cultural opposition, but the presence of NEPs has drastically reduced the risk of HIV transmission. NEPs are also associated with more referrals to drug abuse treatment. Safe injection facilities could have similar effects.

By creating local facilities run by trained, non-judgmental professionals, drug addicts will have access to life-saving services. While the current federal administration has advocated for expanded education programs and increased reprisals against drug dealers, both of these programs fail to address the deadly and pressing crisis at hand. Prevention has not worked: it is therefore essential to address the growing issue with treatment and harm-reduction services.

Local officials are uniquely positioned to understand where supervised consumption sites will have the most impact, in order to best serve a population that faces severe social stigma and marginalization. Syringe Exchange Programs are community-based and may apply  for federal funding for specific and limited services. SIFs could similarly be funded by local and state governments, with federal funds being reserved for non-injection related services. The model also mirrors Planned Parenthood, where federal funds are not used for abortion services, but do cover other preventative care costs. Applying this system to SIFs would allow local and state governments to fund essential programs to respond to needs in their community, with monetary support from the federal government only being used for certain, approved purchases.

If the federal government wants to reduce the number of opioid related deaths in this country, it needs to stop denying the reality of drug use and abuse. Granting exemptions from federal drug law is essential in sanctioning safe injection facilities. Once these spaces can operate openly, they will be able to provide life-saving physical and emotional support to addicts.

Photo: “Pills and a Needle”

About the Author

Annie Lehman-Ludwig '20 is a Staff Writer for the World Section of the Brown Political Review. Annie can be reached at anna_lehman-ludwig@brown.edu

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