Implementing Safe Injection Facilities to Combat the Opioid Crisis

According to the Centers for Disease Control and Prevention (CDC), an average of 130 Americans die every day from an opioid overdose (“Understanding the Epidemic”). This alarming statistic is a product of the United States’ opioid crisis, which involves the misuse of and addiction to prescription pain relievers and illicit drugs. Understanding the escalating urgency of the opioid crisis, physicians, scientists, and politicians have searched for and proposed numerous solutions to help combat the issue. One of the most recent, yet perhaps the most controversial, seemingly defies all logic; the solution could actually allow drug users to inject opioids legally. Legal and safe drug use could be made possible with the implementation of safe injection facilities (SIFs), which would permit Americans to lawfully consume and inject drugs like heroin under the supervision of trained medical staff. While SIFs might appear counterproductive, these sites have been extremely successful at combating opioid-related issues in other countries. If implemented in the United States, SIFs would be instrumental in combating the opioid crisis due to their abilities to prevent overdose deaths, to encourage addicts to seek help, and to save on healthcare costs. Therefore, the United States government should allow for the gradual implementation of safe injection facilities in conjunction with current solutions to better fight opioid abuse, starting with a pilot program. 

In this essay I will discuss the ways in which SIFs would be a vital tool to help combat the opioid crisis. First, I will provide a brief history and background by discussing the role of SIFs in other countries, clarifying why they are not yet implemented in the U.S, and identifying the major proponents and critics of the proposal. Throughout, I will explain what the American government is currently doing about the opioid crisis, why those steps alone are not enough, and how safe injection facilities could fill those gaps. I will be sure to address common counter arguments and opinions held by government officials and concerned Americans about SIFs and will work to appease these apprehensions. My argument will be supported by peer-reviewed studies of SIFs in other countries and research predicting how the implementation of such measures would impact the U.S. I will conclude by discussing the limitations of SIFs and how they can be overcome.  

    Although other countries have already opened their own SIFs, the U.S has yet to open their own facilities because of opposition from the federal government. There are about 100 SIFs in North America, Europe, and Asia, the first of which opened in Vancouver in 2003 (Schatz and Nougier). The main goal of these facilities is to prevent and reduce issues associated with the opioid crisis, including overdose deaths, public drug use, and disease transmission through unhygienic injection practice. These goals are achieved through the provision of an enclosed facility where users can consume drugs away from the public eye; utilize sterile needles and other injecting equipment; and access emergency overdose care, counseling services, and addiction treatment services (“Drug Consumption Rooms”). However, as reported by the New York Times, several cities, including Philadelphia, San Francisco, and New York, and Boston, have expressed their desire to open SIFs, but there are currently none in America (Goodnough). According to an analysis published in the American Journal of Public Health, even though states can authorize SIFs, federal authorities can and have interfered with these facilities because of their interpretation of the Controlled Substances Act, which makes it illegal to operate a drug-involved premises (Beletsky et al. 234). Therefore, the authorization of SIFs ultimately lies in the hands of federal authorities and their interpretation of the laws. This authority, combined with the U.S federal government’s strong opposition to such facilities, has halted the construction of SIFs. 

    Although the federal government is heavily opposed to implementing SIFs, their current solutions to the opioid epidemic are clearly falling short. According to a U.S government brief, the Trump administration’s strategy in the fight against opioid use mainly targets suppliers, increases enforcement of drug laws, and emphasizes opioid education through advertisements. As detailed by a 2019 White House briefing, he has also increased funding for addiction treatment centers (“President Donald J. Trump's Fight”). While these strategies are partially effective, they ignore one of the key elements of the opioid crisis –– overdose deaths. Henry L. Dorkin, doctor and President of the Massachusetts Medical Society, explains the situation perfectly, saying, “we must remember that in order to get people into recovery, they must first stay alive” (Dornkin). In order for the U.S government’s allocation of resources to be effective, it must also ensure that opioid addicts are not only surviving, but willing to receive treatment. The United States’ effort to focus opioid-related funding on treatment is like putting a bandaid on a broken leg; it does not solve the underlying source of the problem. 

The implementation of SIFs would be a valuable contribution to, not replacement of, the current fight against opioids, because SIFs would decrease the total number of overdose deaths. Upon review of SIFs across the world, the Massachusetts Medical Society found that “no deaths by overdose have been reported” (Fitzgerald 14). Not only do SIFs have a 100% survival rate, these facilities have actually been shown to decrease overdose-related death rates outside of the sites. According to a study examining a SIF in Vancouver called Insite, published in medical journal The Lancet, there were 35% less overdose deaths within 500 meters of the facility 3 years after its establishment, while areas outside that radius only reduced by 9% (Marshall 1424). So while these sites certainly save lives of those who inject inside the facilities, they also have an effect on overdose rates in the surrounding area, both of which would be beneficial to communities most impacted by opioid addiction. While SIFs should not completely replace the current methods, they would be an additional, valuable tool in helping prevent deaths, considering there are no other current methods that can boast a 100% survival rate. In conjunction with the programs in place, SIFs would cater to addicts directly, allowing them to survive another day and seek long term rehabilitation. 

However, it is understandable that the federal government and American citizens would be concerned that SIFs would be harmful to society and would prefer to stick with safer solutions that do not target addicts directly. To many, the idea of allowing drug users to legally use drugs seems counterproductive, and some argue that SIFs would only encourage increased drug usage and crime, not fix it. In fact, Colleen L. Barry and her colleagues at Johns Hopkins Bloomberg School of Public Health conducted a study to assess the public’s opinion on legalizing SIFs. Their findings reflect this concern for legal SIFs, determining that 51% of U.S. adults surveyed believed these facilities should be illegal because “they would lead to more illegal activities in the neighborhoods where they are located” (20). However, research suggests that current SIFs have had no impact on crime and increased drug usage. According to a systematic literature review published in the medical journal Drug and Alcohol Dependence, current SIFs were “not found to increase drug injecting, drug trafficking or crime in the surrounding environments” (Potier et al. 48). While the perception that SIFs contribute to an increase of illegal activities is understandable, these apprehensions have no basis in reality. 

However, opponents argue that even if drug use and crime do not increase, SIFs still do not address or solve rehabilitation efforts. In an opinion piece written for the New York Times, U.S. deputy attorney general Rod J. Rosenstein states that he believes that “Injection sites do not help drug users overcome addiction. Most visitors simply walk in, get high and stumble out” (Rosenstein). However, one of the crucial aspects of SIFs is their dedication to helping current addicts find treatment. SIFs are equipped with professionals who offer medical advice and referrals to drug treatment and other social support programs to addicts. These tools are valuable in convincing addicts to seek treatment for their opioid abuse. In fact, research conducted on a Vancouver SIF called Insite has actually shown an increased enrollment in addiction treatment. 517 drug addicts were referred to treatment, and over one third of them actually completed it (“Safe Injection Facilities Save Lives”). Moreover, individuals who inject at Insite weekly were nearly 2 times as likely to enroll in a detox program than those who visited less frequently (Wood et al.). So not only can SIFs prevent deaths, current research suggests that they could actually encourage drug users who use these facilities to seek help. This would be a valuable contribution for the United States, as more addicts might enter into life-saving treatment and rehabilitation centers, which is key to ending opioid addiction. Therefore, SIFs fill an important gap in the current opioid policies that strongly emphasize treatment, but not how to get addicts there in the first place. 

Furthermore, SIFs could help reduce another facet of the opioid epidemic that deserves attention –– the consequences of addiction stigma. According to a study published in the Current Opinion in Psychiatry, the stigma surrounding substance abuse disorders can “reduce the willingness of policy-makers to allocate addiction-related resources”, as well as deter providers to screen for and address substance abuse issues. The researchers argue not only do stigmas affect the quality of treatment addicts receive, they can discourage individuals with substance use disorders to seek treatment (Yang et al.). SIFs can help combat the consequences of drug use stigmas because they encourage addicts to receive ongoing medical treatment in a caring environment, rather than shame them for their condition. 

Even with those who see the value of safe injection sites, some may question their cost-effectiveness compared to other preventative strategies. Simply put, the opioid epidemic has a major economic impact on the United States. Researchers Curtis Florence and others at the CDC estimate that the opioid epidemic has cost the United States a total of $78.5 billion, so it is important that the U.S. carefully consider the economic costs of proposed solutions (Florence et al.). Opponents argue that, with these limited resources, it would be more beneficial to spend money on proven effective strategies like prevention or advertisements. However, research on proposed SIFs estimate only economic benefits for U.S. cities. Martin A. Andresen and Neil Boyd, professors at Simon Fraser University’s School of Criminology, conducted a study to investigate Insite’s cost-effectiveness. After examining the facility’s prevention of HIV infections and deaths, the authors estimate that SIFs provide a “social-benefit” of around $6 million per year, which they believe is an “efficient use of public health-care resources” (Andresen and Neil). Although this is only one facility, it is not a sweeping conclusion; other studies predict similar cost-benefits to specific cities in America. In a study published in the Journal of Drug Issues, researchers considered the potential savings from establishing a potential SIFs in San Francisco, California, estimating a total savings of $3.5 million dollars. The researchers suggest that the facility would be a “significant boost to the public health system” (Irwin et al.). 

Moreover, a different study published by the same authors in the Harm Reduction Journal has similar findings; it is estimated that the implementation of a single SIF in Baltimore, Maryland would generate an annual net savings of about $6 million, which is equivalent to 28% of the Baltimore’s harm reduction and disease prevention budget. The predicted savings are due to SIFs estimated ability to decrease the amount of overdoses and infections, as well as ambulance calls, emergency visits, and hospital stays (Irwin et al. 9). These statistics show that, if implemented, SIFs could be a cost-effective strategy for the United States. Furthermore, the money saved by these sites could then be reallocated to other areas of the opioid epidemic that need funding, including preventative measures and treatment facilities. In the end, not only would SIFs benefit the economy, the money saved could be further used to fight the epidemic. 

Although there are some limitations when it comes to SIFs, they can easily be overcome. One might argue that just because SIFs are effective in other countries does not mean they will be beneficial to the United States. While it is true that the only research is based on facilities outside of the U.S and cannot be applied with certainty, this is only because there has not been any opportunity to study their effects on America. Simply put, the only way to know how SIFs will affect the United States is to actually implement them. The data collected from existing SIFs indicate economic and health benefits for addicts and communities affected by the opioid epidemic, and this research cannot not be ignored any longer. Introducing a pilot SIF would allow the United States to safely extend the study of how SIFs benefit the surrounding community, and this information could be assessessed for the consideration of more widespread implementation.

In an interview for a study conducted by Simon Fraser University School of Criminology, a Canadian safe injection site user had this to say about the facility he attends:
 

They teach us how to properly inject … It’s changed my way of thinking, the way I use drugs, the amount I use … Now I am starting to care about myself more, I have more self respect …  Now that I’ve somewhere to go and someone to talk to about it, I don’t use as much (Jozaghi 11).
 

While it is easy to It is important to remember that those who suffer from opioid addictions are real people who require compassion and care. Although there may be resistance from the federal government, SIFs are worthy of consideration because they have shown to be successful in preventing overdose deaths, encouraging users to seek treatment, providing economic benefits . While there will never be one definitive solution to the opioid crisis, the incorporation of SIFs could bring the United States one step closer to ending one of the most tragic epidemics the country has ever faced. 

 

Works Cited

Andresen, Martin A., and Neil Boyd. "A Cost-benefit and Cost-effectiveness Analysis of Vancouver's Supervised Injection Facility." International Journal of Drug Policy, vol. 21, no. 1, Jan. 2010, pp. 70-76, doi.org/10.1016/j.drugpo.2009.03.004.

Barry, Colleen L., et al. "Arguments Supporting and Opposing Legalization of Safe Consumption Sites in the U.S." International Journal of Drug Policy, vol. 63, Jan. 2019, pp. 18-22, www.sciencedirect.com/science/article/pii/S0955395918302706.

Becker, Deborah, and Chris Citorik. "'Supervised Injection Sites Are a Terrible Idea,' U.S. Attorney Lelling Says." Radio Boston, 20 July 2018, www.wbur.org/radioboston/2018/07/20/lelling-supervised-injection-marijuana-enforcement.

Beletsky, Leo et al. “The Law (and Politics) of Safe Injection Facilities in the United States.”
    American Journal of Public Health vol. 98, 2 (2008): 231-7.

            doi:10.2105/AJPH.2006.103747

Centers for Disease Control and Prevention. "Understanding the Epidemic." 19 Dec. 2018, www.cdc.gov/drugoverdose/epidemic/index.html.

Dorkin, Henry L. "As a Doctor, I Was Opposed to Supervised Injection Facilities. Now I'm Ready to Give Them a Try." The New York Times, 13 Dec. 2017, www.statnews.com/2017/12/13/supervised-injection-facilities-doctor/.

"Drug Consumption Rooms: An Overview of Provision and Evidence." European Monitoring Centre for Drugs and Drug Addiction, 6 July 2018, www.emcdda.europa.eu/system/files/publications/2734/POD_Drug%20consumption%20rooms.pdf.

Fitzgerald, Therese C. Establishment of a Pilot Medically Supervised Injection Facility in Massachusetts. Massachusetts Medical Society, Apr. 2017, www.massmed.org/advocacy/state-advocacy/sif-report-2017/.

Florence, Curtis, et al. "The Economic Burden of Prescription Opioid Overdose, Abuse and Dependence in the United States, 2013." Medical Care, vol. 54, no. 10, Oct. 2016, pp. 901-06, stacks.cdc.gov/view/cdc/55377.

Goodnough, Abby. "Safe Injection Site for Opioid Users Faces Trump Administration Crackdown." The New York Times, 6 Feb. 2019, www.nytimes.com/2019/02/06/health/safe-injection-opioids-overdose.html.

Irwin, Amos, et al. "A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA." Journal of Drug Issues, vol. 47, no. 2, 2016, pp. 164-84, journals.sagepub.com/doi/pdf/10.1177/0022042616679829. 

Irwin, Amos et al. "Mitigating the Heroin Crisis in Baltimore, MD, USA: A Cost-benefit Analysis of a Hypothetical Supervised Injection Facility." Harm Reduction Journal, digital ed., vol. 14, no. 29, 2017.

Jozaghi, Eshan, “‘A Little Heaven in Hell’: The Role of A Supervised Injection Facility in Transforming Place.” Urban Geography, 33:8, 1144-1162, DOI: 10.2747/0272-3638.33.8.1144

Marshall, Brandon DL, et al. "Reduction in Overdose Mortality after the Opening of North America's First Medically Supervised Safer Injecting Facility: A Retrospective Population-Based Study." The Lancet, vol. 377, no. 9775, Apr. 2011, pp. 1429-37, 

Potier, Chloe, et al. "Supervised Injection Services: What Has Been Demonstrated? A Systematic Literature Review." Drug and Alcohol Dependence, vol. 145, 1 Dec. 2014, pp. 48-68, reader.elsevier.com/reader/sd/pii/S0376871614018754?token=5A7CF2431A957D2194876CC1F707400079E12D595EBC896045809B0D27B60C90E55ADCF5BA44E082D4DA90FA2C1E7BE4.

Rosenstein, Rod J. "Fight Drug Abuse, Don't Subsidize It." The New York Times, 27 Aug. 2018, www.nytimes.com/2018/08/27/opinion/opioids-heroin-injection-sites.html.

“Safe Injection Facilities Save Lives.” Scientific American, vol. 319, no. 1, June 2018, p. 10. EBSCOhost, doi:10.1038/scientificamerican0718-10.

Schatz, Eberhard, and Marie Nougier. "Drug Consumption Rooms Evidence and Practice." International Drug Policy Consortium, June 2012, www.drugsandalcohol.ie/17898/1/IDPC-Briefing-Paper_Drug-consumption-rooms.pdf.

U.S Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. The Opioid Crisis and Economic Opportunity: Geographic and Economic Trends. By Robin Ghertner and Lincoln Groves, Ph.D., 11 Sept. 2018, aspe.hhs.gov/system/files/pdf/259261/ASPEEconomicOpportunityOpioidCrisis.pdf.

The White House, Trump Administration. President Donald J. Trump's Fight Against the Opioid Epidemic Continues to Help Americans Around the Country. 9 Mar. 2019, www.whitehouse.gov/briefings-statements/president-donald-j-trumps-fight-opioid-epidemic-continues-help-americans-around-country/.

Wood, E., Tyndall, M.W., Zhang, R., Stoltz, J., Lai, C., Montaner, J., & Kerr, T. “Attendance at Supervised Injecting Facilities and Use of Detoxification Services”. New England Journal of Medicine 354(23), 2512-2514. 

Yang, Lawrence H et al. “Stigma and substance use disorders: an international phenomenon.” Current opinion in psychiatry vol. 30,5 (2017): 378-388. doi:10.1097/YCO.0000000000000351