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Safe injection site shows promise, tradeoffs

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Used hypodermic needles are seen among a pile of debris on Market Street on September 14, 2016.

As San Francisco develops plans for authorized safe injection sites for drug users, a study of an underground site already in operation released Wednesday suggests that there are potential tradeoffs in bringing such services out into the open.

A city task force, led by current acting Mayor London Breed, released a report in September endorsing the concept of supervised injection sites, which would provide safe spaces with clean needles and staff trained to respond to overdoses for The City’s estimated 22,000 injecting drug users.

The report received strong backing from members of the Board of Supervisors at a hearing in the fall.

The push for safe injecting spaces comes in response to a growing and highly visible drug crisis, which causes around 100 overdose deaths a year and public complaints about needle litter and people injecting drugs in public.

In places such as Canada and Europe, safe injecting sites have been shown to prevent overdose deaths, reduce the spread of diseases such as hepatitis C and HIV and help get users into services including drug treatment programs.

In addition, supporters say the sites can get drug use off the streets and out of public view, reduce needle litter and even save The City money. The task force estimated The City could save around $3.5 million a year by opening a safe injection site because of reduced health care costs and increased drug treatment uptake.

Since the release of the task force’s report, The City’s health department has been in talks with organizations that already provide health and social services to the homeless and injecting drug users about adding safe injecting services to their offerings, according to Barbara Garcia, director of the Department of Public Health.

Garcia said:

“I’m not going to open up a new site for this. … We have plenty of community organizations that have integrated care that can easily put one of these services into action in their programs.”

Health officials are now working on developing policies and procedures for the program and expect to report back to the Board of Supervisors in March, Garcia said.

Funding remains uncertain, however, and the health department is working closely with the city attorney’s office on legal issues, Garcia said.

Safe injecting sites remain illegal within the United States, although legislative efforts to legalize them at the state level are being made, and San Francisco looks likely to be among the first cities in the country to authorize them. Officials in the Seattle area have also taken steps toward opening two sites and cities such as New York are exploring the concept.

Unofficially, however, some safe injecting spaces are already operating on an underground level, according to a study of one such site released Wednesday.

Around the country, many organizations serving injecting drug users have recognized that their restrooms and facilities were being used for shooting up, and have installed informal measures ranging from staff monitoring to needle exchange and disposal facilities to doors that can be easily opened in the case of an overdose.

However, at least one organization decided to take things a step further.

In a study set to be published in the March issue of the International Journal of Drug Policy, a team of researchers described one organization in an undisclosed city that began in April of 2014 with a renovated restroom designated for injecting drug users.

By September of 2014, the organization had converted two rooms into a monitored injecting space equipped with clean needles and disposal facilities and a neighboring room for users to recuperate and rest.

An initial study of the underground site released in August found that even with limited word of mouth advertising it was used in its first two years more than 2,500 times by more than 100 individual users.

Around 80 percent of those using it were homeless and more than 90 percent said that if the space had not been available they would have shot up in a public space such as a street, park, parking lot or public bathroom.

Around 67 percent reported having disposed of needles unsafely in the recent past at other locations.

A second study of the site released Wednesday found that users of the unauthorized site said they felt safer, less rushed and less stigmatized, and reported better health outcomes and better hygiene and disposal practices.

Researcher Alex Kral, a San Francisco-based epidemiologist with RTI International who also served on The City’s safe injecting sites task force, said the study also found there were advantages as well as disadvantages to the site’s underground status.

The unsanctioned nature of the site required a high level of secrecy, limiting access to small groups of users, and also made it difficult to connect users to drug treatment or other health and social services.

Kral, who co-authored the study with Peter Davidson of the University of California at San Diego and Andrea Lopez of the University of Maryland, said:

“There’s tons of lost opportunities at the site because it’s not above ground. You can’t have licensed professionals because it’s illegal, they might lose their license.”

By the same token, however, the lack of government supervision meant that the site’s rules could be tailored to suit users.

For instance, at some authorized sites in other countries users are prohibited from helping each other to inject or from sharing drugs, due to official concerns around liability and limiting dealing on site.

However, such rules can limit the site’s usefulness to users, such as those who cannot inject themselves, and deter some of those who might otherwise take advantage of it. The underground site was able to take a more permissive approach adapted to the needs of its clients.

Kral said:

“I think there’s always this tension in terms of, if you have something aboveground and its run by a government agency or its contracted out to a community agency from the government, that maybe there are regulations that people don’t want to adhere to or that aren’t best practices.”

Similar issues have cropped up around needle exchange programs, which also began as underground movements in the 1980s staffed by volunteers seeking to prevent the spread of HIV by providing drug users with clean needles.

Much as it is preparing to do now with safe injecting sites, San Francisco defied state and federal law in 1992 by declaring a public health emergency and providing funding for needle exchange programs.

However that government support initially came with rules limiting the number of needles users could be given or requiring that exchanges operate only on a one-to-one basis, one clean needle for every dirty one turned in.

Kral said activists have had to work to relax such rules, which limit the access users have to clean needles and reduce the public health benefits of the program:

“We still have to fight that one to this day.”

Bringing sites out into the open also increases the risk of neighborhood backlash from residents concerned about an increase of drug activity in the neighborhood.

The City’s plan to contract for safe injecting services with existing service providers may help reduce that problem, by placing them in areas where the homeless and drug users are already being served. The task force report also calls for multiple sites to operate in different neighborhoods around The City, both to help distribute the impact and increase access.

Garcia, however, expressed optimism over the response of San Francisco residents to the new services, saying she has seen positive responses from neighborhood and business groups eager for solutions to the city’s highly visible drug crisis.

Garcia said:

“Business groups, providers who may not have last year been interested in this now see it as an opportunity for us to provide needed care for individuals.”

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