Is The U.S. Finally Ready For A Supervised Heroin Injection Site?

Kathleen Errico's eulogy for her 23-year-old daughter, Kelsey, went viral last week. After a long battle with heroin addiction and nearly 10 months of sobriety, Kelsey overdosed on April 2. “To the person who doesn’t understand addiction she is just another statistic who chose to make a bad decision,” Errico writes. “I don’t care though because for the people who do understand, this was our baby, our youngest, our child, our daughter and as a mother; my everything.” The U.S. has been waging its broad “war on drugs” for several decades now. But with heroin use skyrocketing (and doubling among women like Kelsey in the past 10 years), some experts have a more controversial idea in mind for managing the epidemic: supervised injection sites (SISs). Essentially, these are places where people can do their drugs with clean equipment and under the supervision of trained staff — so that, should there be an overdose, they can get help quickly. There aren't any sites like this currently in the U.S., but cities such as NYC and Seattle are now considering implementing them in the next few years. "It's the natural next step in harm reduction," says Joshua Lee, MD, an addiction expert at NYU Langone Medical Center. "Wear a condom, use clean needles, and use your heroin in a safer way." Indeed, many of the objections to the sites mirror those initially lobbied at the idea of needle exchanges, explains Laura Thomas of the Drug Policy Alliance. "But the arguments evaporated when we had these programs up and running," she says. "There’s an epidemic right now; it’s a leading cause of totally avoidable death," says Sarah Evans of the Open Society Foundations. "There is no reason why anyone should be dying of an overdose when we have things like [the overdose-reversal drug] naloxone and when places like this are possible." But there’s no doubt that the sites have come up against some serious skepticism. Ahead, we talked to a few experts and proponents of SISs about how the facilities work — and how they might keep people alive. How would these even work?
An SIS is simply a government-funded space in which it is legal to use drugs. People come in, grab clean equipment (e.g. needles, swabs for their arms), and do their drugs under the supervision of staff who are trained to intervene if there’s a problem (e.g. administering naloxone). In some countries, people are even provided with medical-grade heroin. In addition, staff can easily refer people to treatment or detox programs as well as other government services, such as housing.

It may sound radical, but Sarah Evans estimates there are already about 100 safe injection sites in around 30 countries. Insite, the only SIS in North America, was founded in 2003 in Vancouver, British Columbia. “It's important to recognize that this is not a new idea,” she says. “It might be new to people in the U.S., but that’s a bit like Columbus saying he discovered America.” In the U.S., these facilities would work similarly, but it would be up to each city to decide exactly what sites will look like. There are only a few cities in the U.S. seriously talking about creating facilities: The Drug Policy Alliance is specifically advocating for sites in San Francisco and NYC, and Seattle is also looking into one. And Svante Myrick, the mayor of Ithaca, NY, just put together a proposal that includes a SIS (among many other harm reduction programs). Although each program would have, essentially, all the same ingredients, they may operate differently in different cities. For instance, "one thing we're arguing for [in NYC] is to just allow syringe exchanges to incorporate [supervised injection] into the work they’re already doing," explains Matt Curtis, the program and policy director for Vocal NY. But that would be alongside new spaces specifically designed for supervised injection. Ideally, there would be a facility anywhere there's currently outdoor drug use, wherever that may be. But even in areas where there’s support, those working to get an SIS up and running in America face considerable legal hurdles. Because heroin is illegal, federal and state governments would need to agree to some kind of exemption to allow people inside the facility to legally use the drug. "It'll be a heavy lift to do this in the United States," says Dr. Lee, "and it would be many times that difficulty to make it routinely available." Still, Ithaca's mayor is firmly behind the proposal despite some opposition. And Curtis says he's been pleasantly surprised at how quickly things are moving in NYC; Vocal NY introduced the idea to the public just seven months ago, and the team is already getting support from Manhattan State Assemblywoman Linda Rosenthal. So, although a SIS in the U.S. may still look very unlikely, it has also never been more likely than it is now. How do we know they’ll actually help?
One of the benefits of facing so much criticism is that the sites that do exist have been extensively researched and monitored. Insite, for example, has been the subject of over 50 published studies. And what do they show? The facility has more than proven itself: It's reduced overdose deaths by 35% in the surrounding neighborhood and by 9% in the whole city. In 2012 alone, the staff referred more than 4,500 people to other health and social programs.

"Even the most hardcore, broken drug user has the potential to live a healthier life and have a better quality of life," says Liz Evans, a nurse and one of the founders of Insite, "but we have to create the circumstances in which they can choose that." She says the changes the facility provided were monumental, especially because the people that the site attracts are those most at risk for overdoses and HIV transmission via needle sharing. Insite provides an accessible, trustworthy point of contact for drug users who otherwise would not have one. The result? Those who come to Insite are twice as likely to enter treatment as those who don't. "The bottom line is there’s really no downside," Thomas says. "Drug use does not go up, crime does not go up, and what we’ve been doing [so far] hasn’t worked." But don’t we want people to stop using drugs?
This might be the most common argument against SISs. Ithaca’s Mayor Myrick had his own doubts, telling the New York Times that his original thoughts were along the lines of, “Heroin is bad, and injecting heroin is bad, so how could supervised heroin injection be a good thing?” So, yes, in an ideal world, people would not be addicted to heroin. But proponents of harm reduction techniques like this would rather have someone alive and using than dead. "At the very least, we can come together and agree that if you’re dead, you’re not going into detox," Liz Evans says. "Our first objective has to be keeping them alive; then we can see at least one role for harm reduction and supervised injection sites as part of that.”