Addictions Advisor: Supervised Injection Facilities — An Uphill Battle
As society’s understanding of substance use and addiction continues to evolve, those working in the field increasingly advocate for the implementation of harm reduction models—practices and services that look to decrease the negative consequences of substance use. One such intervention is the creation of supervised injection facilities (SIFs), also known as safer consumption spaces.
SIFs offer individuals a place to use preobtained drugs in a setting where health care professionals can monitor them and respond in case of overdose. SIFs allow access not only to a hygienic setting but also to sterile syringes and new injecting equipment. Staff at SIFs can include physicians, nurses, social workers, case managers, and, ideally, peers.
“SIFs have a really great role for peers,” says Sheila P. Vakharia, PhD, a researcher in the Office of Academic Engagement at the Drug Policy Alliance. She notes that having a peer on site—in whatever role they may take on—gives those coming in the opportunity to connect with someone who is not a professional, which can be invaluable.
“[Peers] are like the Uber of connecting people in a fragmented system,” agrees Nick Szubiak, LCSW, integrated health consultant and principal at NSI Strategies. “They can connect in a way that is uniquely different.”
As for the professional staff, they serve a supervisory role and are on hand to respond in case of emergency or overdose. They also provide referrals to available resources and services in the community. What they are not there to do is judge or force a treatment plan on anyone using the SIF.
“The whole model is a noncoercive model,” Vakharia emphasizes.
More than 100 SIFs exist around the world in almost a dozen nations, including Canada, parts of Europe, and Australia. Where implemented, it has been found that SIFs can help decrease overdose deaths, reduce high-risk practices such as the use of shared equipment, and increase access to physical health, behavioral health, and substance use–specific treatment. Studies also show that SIFs help increase public safety and reduce crime in the neighborhoods where they are located.
However, none of these benefits have been seen to date in the United States, because there are no sanctioned SIFs in the country.
In August 2018, for example, then Deputy Attorney General Rod Rosenstein wrote an op-ed for The New York Times condemning SIFs. In it, he stated, “injection sites destroy the surrounding community. When drug users flock to a site, drug dealers follow, bringing with them violence and despair, posing a danger to neighbors and law-abiding visitors.” He made clear in his piece that the federal government would not condone the existence of SIFs.
A little over a month later when then California governor Jerry Brown vetoed the bill that would allow San Francisco to open an SIF, he cited threats from the U.S. Department of Justice and echoed Rosenstein’s disbelief that such spaces would lessen substance use. The bill had passed in the state senate six days before Rosenstein’s article and in the assembly the day his op-ed was published.
Even more recently, in February 2019, United States Attorney William M. McSwain filed a civil lawsuit attempting to stop the opening of an SIF in Philadelphia. The proposed site would be run by the nonprofit organization Safehouse but has the support of city officials. Though this suit has not yet been decided, a similar one appears poised to be filed in Washington State, as well.
The federal government, however, is not the only opposition to the opening of SIFs. Among others, community members, too, have expressed reservations. In Philadelphia, the proposed SIF would be in the Kensington section of the city. There, residents are not all hoping for the facility to move forward.
“You can’t have the conversation about sanctioning illegal drug use without it touching on the community trauma,” says Brooke M. Feldman, MSW, center manager for CleanSlate in Philadelphia. She adds that decades of the War on Drugs have concentrated the unregulated open-air drug market and, in turn, open-air drug use in Kensington. This has led to a lot of unaddressed issues for the residents, who have concerns that need to be discussed. “You never tell a community what’s best for them,” she says. “You work alongside them.”
And Kensington isn’t the only neighborhood/area that objects to the idea of an SIF in their community.
“NIMBY-ism (not in my backyard) really gets kicked up when we talk about using these sites,” Vakharia says. However, she continues, “the research doesn’t show that [the presence of a SIF] increases crime. The research shows that crime rates go down, drug dealing and open-air public injecting decreases, and rates of HIV go down. This pushback against ‘having one in my neighborhood’ is not grounded in any evidence.”
Science of Addiction
“It comes from not understanding the science of addiction,” Szubiak says. “The people we’re talking about are not [using] to party. The parties ended years and years and years ago. It doesn’t mean a high, feeling good anymore. It means just not feeling awful or terrible. They have to have those opioids in their body just to function.
“People who truly have a substance use disorder are doing something that they don’t want to do anymore,” he says.
If more people were able to look at substance use disorders as a chronic health condition, rather than a moral failing, the conversation around how to treat and address substance use would shift, opening the door for more prevention, intervention, and harm reduction options, including SIFs. As it is, Szubiak says, only 10% to 20% of individuals with a substance use disorder in the United States get the treatment they need—a statistic that would spark outrage if linked to cancer or diabetes diagnoses.
However, given the misunderstanding of substance use, many approach the treatment of disorders in a black-and-white manner. “We want people to stop immediately on our terms,” Feldman says. “But it’s a process for every individual. It’s unique to every individual.” Best practice means meeting the individual where they are, she continues. “If somebody says, ‘I’m not ready to stop using drugs,’ traditionally we would say, ‘Okay, come back to us when you’re ready.’” Instead, it should be “Okay, what can I support you with?” Feldman says.
That’s where harm reduction would come in. But the stigma surrounding substance use extends to such models. “There is still drug user stigma that people struggle with and a misunderstanding that a harm-reduction approach that welcomes people where they’re at is somehow condoning, enabling, or encouraging use,” Vakharia says.
Rather, “SIFs can create an environment where people aren’t under that pressure to stop using,” Szubiak says. “It’s about reducing use. They reduce that risk of transmitting disease. It opens up an opportunity to bring the care to people where they are.”
Informing and Engaging
Szubiak often gives presentations in which he explains the science of addiction. “There are people in that room that have been affected by it themselves or there is someone in their family with a substance use disorder,” he says. “When people start to understand the science, there’s an incredible release for many in the audience. That understanding is the seat of compassion.”
When it comes to SIFs in particular, the key to working with the communities, Feldman says, is education, engagement, and listening. “Listen to what community members’ greatest concerns are, which may be different than what our concerns are,” she says. And work to help those residents understand exactly what the presence of a SIF means. “Demystify what these facilities are and what they do,” she continues.
Further, don’t limit the education and engagement to the areas where SIFs are proposed to be. Neighborhoods such as Kensington are not the only communities where substance use occurs. “We know that people live in recovery in your community,” Feldman says, speaking to more affluent neighborhoods that are rarely linked to substance use despite a presence. “Some Kensington community members have expressed, ‘If you were talking about putting this in Rittenhouse Square, it would be different,’” Rittenhouse Square is a part of Center City Philadelphia known to be wealthy.
As for the government’s position on SIFs, it appears that only time and a judge’s opinion will tell. Yet, Szubiak, Vakharia, and Feldman are confident that a sanctioned safer consumption space will one day exist in the United States—thanks to the work being done around SIFs and substance use, and in part to the recognition that what has been the standard for addressing substance use from treatment, law enforcement, and other systems isn’t working.
“This is one of the glasses of lemonade that has come from the lemon of the opioid epidemic,” Szubiak says. “There’s been a shift.”
But for Feldman, until that shift results in spaces such as SIFs, it is not enough. “Every day we don’t have them is another member of our community dying. We need this yesterday.”
— Sue Coyle, MSW, is a freelance writer and social worker in the Philadelphia suburbs.