Safe Injection Facilities: Are They Effective?
November 08, 2017
The United States is currently facing a massive opioid crisis. Over half a million people have died from overdose since 2000, and almost 800,000 people are addicted to opioids (43% of whom have Hepatitis C and 2% of whom suffer from HIV). President Trump recently declared a national emergency on the opioid crisis, and created the President’s Commission on Combating Drug Addiction and the Opioid Crisis. Although the Commission recommended many policies to reduce addiction and prevent overdose, more can be done. One policy currently being researched and pushed in several cities throughout the United States is the implementation of Safe Injection Facilities (SIFs). An SIF is a safe, environment where people who inject drugs are provided with a sterile equipment, medical oversight, and overdose-reversal medication immediately on hand in case of emergency.
In the status quo, harm reduction programs constitute a large portion of the United States’ policy to combat the opioid crisis. Such programs include sterile syringe access programs and expanding provision of naloxone, an opioid overdose-reversal medication. However, the growing state of this national emergency means the status quo of policies are not wholly effective in curbing the opioid crisis sweeping through the country. Safe Injection Facilities (SIFs) provide addicts with a safe place to inject drugs and dispose of sterilize needles, and they reduce the amount of drug-related deaths while building relationships with addicts who can move towards rehabilitation when ready.
There are no legally sanctioned SIFs in the United States currently, though 66 cities in 10 countries including Vancouver, Canada; Sydney, Australia; and Geneva, Switzerland have legalized and encouraged the use of SIFs. International success suggests that the use of supervised injections sites is a viable strategy that the United States could consider to combat the growing opioid crisis.
Current Domestic Success of SIFs
A Case Study
Although SIFs in the US are still illegal, one site in an undisclosed urban area has been providing unsanctioned medical care to opiate addicts since September 2014. Coined as an “underground,” grassroots-style movement, this SIF has been providing extremely effective care to its patients over the last few years. The facility is made of one large room dedicated to injection and one adjoining room for monitoring patients post-injection. The site is open 5 days a week for 4-6 hours a day and is accessible via invitation only (with less than 60 people carrying active privileges at a time). From 2014 to 2016, over 2,574 injections were carried out by approximately 100 people (the exact number is unknown, due to the nature of the SIF). In these 2,574 injections, there were two overdoses, both of which were safely reversed by naloxone, preventing deaths.
In addition, a survey taken by each patient before injection, revealed that 67.4% of the users at this site had disposed of used syringes unsafely in the past 30 days; however, at the facility, all syringes are disposed of safely and cleanly. Thus, the SIF prevented 1,725 public disposals of syringes (67.4% of the 2,574 different injections over the 2 years). In addition, the facility prevented 92.2% of injections which would have otherwise occurred in a public bathroom or on a street, thus levering significant positive externalities on the public by preventing thousands of cases of public injections and potential police arrests. The results of this case study prove that SIFs in the US could prevent overdoses, reduce infection rates, and save the public from encountering injections and used needles.
A cost-benefit analysis of cities where SIFs are legal and cities in the US where SIF legislation is being discussed proves that SIFs are not only theoretically helpful, but economically efficient as well. According to one study performed in 2010 using data gathered from the Insite facility in Vancouver in 2008, SIFs operated at an extremely cost effective rate. The Vancouver Insite facility prevented roughly 35 cases of HIV and three deaths a year, saving the city around $1.6 million a year: a cost-benefit ratio of 1:5.12.
Another study examining Vancouver’s Insite facility found net savings of $14 million and 920 life-years gained over 10 years–just based on the effect of reducing needle sharing. However, factoring in the increase of general health practices and increased referral to methadone (an opioid used to taper down an addict’s dependence of stronger opioids like heroin) brings the net savings to roughly $18 million and 1175 life-years gained over 10 years of running the SIF. There were also significant benefits to other health outcomes, such as the rates of HIV infection and Hepatitis C virus infection.
Aside from Vancouver (where SIFs are legal), a theoretical cost-benefit analysis was performed in San Francisco, a city in the US where SIF legislation is currently being discussed. Using four factors (averted HIV and Hepatitis C infections, reduced skin and soft tissue infection, averted overdose deaths, and increased medication-assisted treatment uptake), the 2017 study found that for every dollar spent on an SIF, $2.33 was generated in savings from medical costs, netting an annual saving of $3.5 million for a SIF in San Francisco. Another study performed in 2017, this time on Maryland, also found positive data regarding the implementation of SIFs. This study factored in HIV transmission prevention, Hepatitis C transmission prevention, skin and soft-tissue infection prevention, overdose mortality reduction, overdose-related medical care reduction, and increased medication-assisted treatment for opioid dependence. The study predicted that a single SIF, while costing $1.8 million to run, would generate $7.8 million in savings; prevent 3.7 HIV infections, 21 Hepatitis C infections, and 5.9 overdose deaths; reduce 374 days hospitalized for skin and soft-tissue infections, 108 overdose-related ambulance calls, 78 emergency room visits, and 27 hospitalizations; and would bring in 121 additional people to treatment (all per year). Based off the studies of Vancouver and potential US-based SIFs, the legalization of SIFs could bring economic benefits to cities where they are implemented.
Several counterarguments to Safe Injection Facilities have been put forth by a variety of sources. They raise ethical considerations, unintended consequences, and concerns that this is not the best method of treatment. However, most of these concerns have been refuted in academic literature.
First, both religious and nonreligious groups have raised ethical considerations, both on the provider and patient side. They argue that it is unethical for doctors to be involved in the administration of illegal substances, and that this tacit social approval of risky, potentially “immoral” behaviors is harmful. However, some, like John Kleinig of Charles Sturt University in Australia, argued have stated that although effectiveness considerations do not necessarily outweigh ethical ones, there is also a duty towards drug users, as they too have the normative and legal rights to reasonable personal safety.Therefore, not providing means for safe injection may in fact not meet the required standard of care and be unethical itself. A 2000 survey on physician/pharmacist’s opinions of the ethics of prescribing sterile injection equipment found a substantial majority of those studied had a reasonable basis and legal backing in all 50 states to prescribe such measures.
There are also practical concerns about potential negative externalities of SIFs on the neighboring community. For instance, critics have hypothesized increased crime levels; however, studies have found that the opening of Insite in Vancouver led to no visible effect on drug trafficking, assaults, or robbery - indeed, breaking and entering of vehicles and vehicle theft diminished in its surrounding neighborhood. Analysis on SIFs in Australia found similar results, and in a 2005 survey, 90% of the Australian public believe there’s at least one substantial benefit of SIFs.
A third counterargument is that SIFs are “social Band-Aids, not cures,” and that the money should instead be used on prevention, education, treatment, law enforcement and supply prohibition” . Indeed, studies have found that SIFs do not actually decrease usage - Insite’s needle exchange program has actually increased tenfold in the last decade , and the risk of infection rises with each injection, suggesting that abstinence should be the solution. Furthermore, there have been concerns that the presence of medical personnel creates a sense of security, leading to moral hazards if individuals increase their dosage. However, these claims draw a false dichotomy between treatment and harm reduction, when in reality SIFs can do both. Moreover, the increase in needle provision does not necessarily mean an increase in overall injections if more people are injecting at SIFs rather than alone. Studies have verified this, showing a significant reduction in the amount of public injections . Finally, while the moral hazards may still persist, there have been no deaths from overdose in the unsanctioned SIF in the US.
In June of 2017, the American Medical Association (AMA), the largest body of physicians in the United States, declared their full support of the legalization of SIF. In its announcement, the AMA pointed to findings that SIFs lead to fewer overdose deaths, reduced transmission of infectious disease associated with injection, and promote long-term treatment and rehabilitation.
In tandem, there are currently strides being made to legalize SIFs or at least propel a positive discussion in several cities including San Francisco, where legislation has cleared one chamber of state lawmaking; Ithaca, where some New York lawmakers are fighting for opening a facility despite being stalled at the capitol; and Seattle, where legislation is being passed but opponents to SIFs are collecting signatures to pass a countermeasure which would ban the use of government spending toward SIFs.
The effectiveness of SIFs is clear. They provide economic benefits, demonstrated by numerous studies on the Vancouver facility as well as other studies on several American cities. They have been successful at reducing overdose rates, infection rates, and public exposure to dangerous, drug-related materials, as indicated by the success of the “underground” site in the US, and legalized sites in other countries. Furthermore, the AMA has endorsed their effectiveness, which may help lawmakers to pass legislation in multiple American cities despite backlash.
In order to effectively combat the opioid crisis ravaging our country, new avenues must be explored, and Safe Injection Facilities are one of many concepts that can be discussed by legislators.
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