Safe Injection Sites: The Case for Harm Reduction

As humanity currently deals with the Coronavirus pandemic, it concurrently must deal with another, more subtle, yet equally sinister health crisis: the opioid pandemic. Since the mid-2010’s, there has been exponential growth in both opioid addiction and fatality that has yet to be dampened, this crisis has come to be known as the opioid epidemic. According to the Center for Disease Control in 2019, it was estimated that in the United States 128 people died per day due to opioid overdose, and that opioid misuse cost Americans $78.5 billion ("Opioid Overdose Crisis"). The effects of the crisis are overwhelming and unmatched by any other prescription addiction in world history, therefore, innovative approaches must be taken to combat its prevalence. One solution is the implementation of safe injection sites, where opioid users can inject in sterilized sites with hygienic supplies and healthcare professionals on duty. Potier et. al has indicated that a large portion of the relevant, peer-reviewed and published scientific studies show that sanctioned safe injection sites in Vancouver and Sydney have shown to significantly reduce the overall economic and health burden of opioid misuse (64-65). Opponents of safe injection sites typically characterize safe injection sites as promoting opiate usage and negatively affecting surrounding communities. However, greater policing of drug usage has yet to show effective results in reducing the harm done to opiate users themselves. The “success” of opiate policing stems from the believed societal benefit of punishing opiate addicts and removing them from communities. In contrast, safe injection sites attempt to benefit society by aiding both the opiate users, as well as the communities. To counteract the opioid epidemic holistically, governments must take action that benefits both communities and opiate users in both the long term and short term, a goal that can only be achieved through the establishment of safe injection sites.

The establishment of safe injection sites must now be considered due to the failure of the status quo. From 1999 to 2018, there has been an estimated 450,000 deaths in America directly involving opioid usage ("Opioid Data Analysis And Resources | Drug Overdose | CDC Injury Center"). This time has historically been categorized into three separate waves, 1990-1999, 2010-2013, and 2013- the present. Each of these waves have had their own set of circumstances: the first resulting from increased prescription of opioids, the second from the rising popularity of heroin, and the present wave from the use of fentanyl as an ingredient in illicit drugs ("Opioid Data Analysis And Resources | Drug Overdose | CDC Injury Center"). Previous waves did significantly impact communities across the world, however they pale in comparison to the present wave . From 2013 to 2017 the amount of deaths attributed to drug overdose rose from 43,982 to 70,237 respectively. The 2017 total was approximately 412% greater than the amount of deaths recorded in 1999 from drug overdose ("Products - Vital Statistics Rapid Release - Provisional Drug Overdose Data"). From these deaths, the percentage attributed to opiate overdose is also significant. From 2013 to 2017, this percentage has increased from 57.0% to 67.8% respectively, with the 1999 percentage being recorded at 47.7% ("Products - Vital Statistics Rapid Release - Provisional Drug Overdose Data"). What these increases indicate is that the opiate crisis is entering a period of growth and in current measures such as increased naloxone production and administration training have yet to translate to successful mitigation. Therefore, implementation of more significant, community based measures must be implemented in order to avoid future repercussions of the current opiate wave.

A public policy response that has garnered momentum both internationally and locally has been that of sanctioned safe injection sites. They are typically defined as medically supervised safe spaces that provide information, sterile syringes, referrals to primary health services, as well as emergency care in the form of oxygen, naloxone, and ambulance calls for drug users, all without consequence (Marshall et al. 1431). The benefits of safe injection sites have been identified through experimental sites such as in Vancouver, where a safe injection site was granted permission to operate and collect data for a term of three years, which has since been renewed. According to Wood et. al, within a year there were 5,000 individual visitors of whom 1,280 were referred for substance addiction and 1,920 for other health issues (1400-1402). Of these visitors, 40% injected heroin, 30% used cocaine, and the rest of the rest utilized unspecified drug combinations (1402). This indicates that safe injection sites can act as a stepping stone in helping people find treatment not only for opiates, but other highly addictive illicit substances as well. Thus, safe injection sites are able to help local communities cope with the effects of the opioid crisis as they act as safe, central locations where all members of the community could receive treatment from its effects, as well as other substance and health issues.

As the opioid crisis continues, it is clear that one of the most important aspects to consider is the overdose rate, especially the rate at which fatalities occur due to opiate overdose. According to the center for disease control, 128 people die each day from opiate overdose, thus, any solution that could help curb overdoses and subsequent fatalities should be considered as significant potential solutions ("Opioid Data Analysis And Resources | Drug Overdose | CDC Injury Center"). Between the Sydney and Vancouver pilot safe injection site projects, the average overdose rate was about 1.25 per 1000 injections, with the majority of overdoses being handled successfully by the medical staff present on-site (Potier et al. 48-68). What is most impressive about the Vancouver pilot project was that over its initial three year lifespan with over 5000 unique individual users, they did not experience a single fatal overdose (Wood et al. 1399-1404). This can be best attributed to the timely and safe manner in which medical assistance and naloxone were provided to the few overdoses that did occur on site as 60% of overdoses were handled on site and 30% being handled using naloxone (Potier et al. 48-68). However, whatever this may be due to, the fact of the matter is that the safe injection site was able to save lives and limit overdose deaths. This provides evidence that safe injection sites are both feasible and effective solutions to the opioid epidemic. This achievement alone merits safe injection test sites across the globe, especially the United States.

It is commonly projected that communities will be negatively impacted by an influx of stray needles, public injections, and crime if safe injection sites were to be established. As the heart of the opioid epidemic are the communities and families affected by addiction, it is necessary that safe injection sites must not negatively impact the community that they serve in any manner, in order to be considered as a potential solution. This concern stems from the supposed increased amount of opiate abuse related litter found in communities that house needle exchange programs, as well as the stereotype of illicit drug dealers and users congregating in communities with safe injection sites for economic gain (Lelling). Critics of harm reduction measures such as safe injection sites typically cite this as evidence that greater punishment must be placed upon opiate abusers, rather than greater resources provided in aiding their recovery, as such resources potentially go on to harm community members (Lelling). However, according to Wood et al., within the lifespan of the pilot project in Vancouver, the amount of public injections were reduced by 1.9 per day and publicly discarded syringes by 6.1 per day (1402). The Sydney police reports also indicate that the establishment of the safe injection site neither increased, nor decreased crime in the surrounding communities over a period of 10 years (Wood et al.1402). This directly contradicts the narrative that safe injection sites are simply euphemisms for “drug dens” in local communities that encourage drug use and illicit drug dealing.

Inherent to community safety regarding opiate usage is infectious disease transmission. Due to the chronic pain associated with HIV, opiate prescriptions are very often prescribed to HIV patients. Estimates suggest that up to 53% of HIV patients are prescribed opiates in response to complaints of chronic pain. Reports also indicate that HIV patients are more likely to receive higher doses of opiate prescriptions in comparison to other patients. The combination of higher rates of prescription at higher dosages result in a greater possibility of addiction and overdose for HIV patients overall (Cunningham 143-146). It is thus significant to evaluate the performance of safe injections sites in limiting infectious disease transmission through shared needles, as is currently a common practice. The Vancouver safe injection site, in an effort to reduce infectious disease transmission, recruited 874 opiate users to share their injection experiences. Results indicated that medical staff present at the facility aided 30% of recruited users in learning about safer injection techniques (Potier et al. 48-68) . This is significant as lack of knowledge of safe injection practices is correlated to higher risk of HIV infection and transmission. Thus, safe injection site medical staff were potentially able to reduce the transmission of HIV, as well as other infectious diseases through the use of opiate usage education.

However, even with all the benefits of safe injection sites, they still are not widely sanctioned due to the narrative that they promote illicit drug usage. Rather than spending funding educating the youth on drug usage and other preventative measures, safe injection sites are seen as caving in to the opioid epidemic and blatantly breaking federal laws. According to Steven Johnson in Modern Healthcare, public perception views safe sites as unethical due to their normalization and possible promotion of opioid abuse (Johnson). In addition, top legal officials, such as former United States Deputy Attorney General Rod Rosentein, fundamentally disagree on the legal basis of safe injection sites. In an interview with National Public Radio, he acknowledged that communities across the United States are struggling to curb the opioid epidemic, yet he was “not aware of any valid basis for the argument that you can engage in criminal activity as long as you do it in the presence of someone with a medical license” (Allyn). The legal aspect of sanctioning safe injection sites is very difficult, as any attempt to legalize the use of illicit drugs, especially opiates, could very well push the opioid epidemic to horrific heights. Legalizing safe injection sites on a federal level would thus be an extremely difficult proposition, as although safe injection sites have proven to be useful, the risk for catastrophe is too plausible for such measures to be taken.

However, in regards to the legal aspect of safe injection sites, cities such as Philadelphia, San Francisco, and New York are all preparing plans to sanction safe injection sites, even though the justice department has issued strict warnings. This illustrates both the severity of the opiate epidemic in these communities, as well as the potential ability of public policy to utilize a variety of solutions in the fight against the opioid epidemic. If such actions were to be taken by these communities and legal ramifications were dismissed, public officials would also have to justify the issue regarding the potential promotion of drug usage. In order to address the critique that safe injection sites potentially promote illicit drug usage, such facilities would have to include prevention measures alongside their harm reduction measures. Although this is not currently done, safe injection sites can be potentially paired with widespread drug education programs in schools and communities, as well as other prevention tactics. This pairing could provide solutions through both harm reduction and prevention, as safe injection sites provide aid to the current wave of opioid abusers, while education aids in their prevention. This combination of tactics would thus circumvent the ethical quandaries of safe injection sites, as they could be framed to critics as a short term aspect in a long term preventative response to the epidemic.

However, safe injection sites still cannot be considered solutions to the entire opiate epidemic, as they have a number of other shortcomings that public officials commonly cite in opposition of their establishment. For one, although overdose rates remain low in safe injection sites, rates tend to be higher within the facilities than normally reported (Potier et al. 48-68). This may be evidence of opiate users endangering themselves accidentally as they believe their risk of overdose or fatality is lower when in the care of medical professionals. This safety net of immediate medical care on site may entice especially problematic users to push the boundaries of their opiate usage, which calls into question the fundamental purpose of safe injection sites. There is also the question of whether or not they are worth the enormous financial burden that they may impose on communities. When factoring in the cost of medical staff, property, ambulances, and medical supplies such as naloxone, the local government may be spending an excessive amount of taxpayer dollars when they may be better off providing other solutions. Lastly, one of the most cited critiques against safe injection sites are the regulations on who may use them and how to deal with addicts once they have exited the facility. Outspoken critics of such lack of regulations are David Carson of the Redmond City Council and Massachusetts governor Charlie Baker. Carson in an interview after his visit to the Vancouver safe injection site, recounted a harrowing experience of encounters with “drug-addled, glassy-eyed” opiate addicts in the area surrounding the safe injection site. He also recounted seeing a man on the side of the road near the injection site and stated that he “...honestly couldn’t tell if he was alive or not…”. Baker also commented, stating that there is “virtually no evidence that (safe injection sites) lead people into treatment”. Questions on regulations such as the amount of times patients would be allowed to overdose, age limit of users, and the amount of opiate dosage allowed have also been cited by public officials (Titus).

However, there have been studies aimed at reducing the concerns surrounding such shortcomings of safe injection sites. In regards to the increased overdose rate, this may not be a characteristic of safe injection sites having severe shortcomings, but rather a shortcoming of statistical evidence. Each opiate user is statistically considered when in a safe injection site, however there may be a number of opiate overdoses in the general public that may not be accounted for as the victim may not have the means necessary to seek out medical help. This may lead to a significant underreporting of overdoses in the general public, seemingly inflating the overdose rate within safe injection sites. In regards to the economic incidence placed upon communities, economic models based upon Vancouver’s safe injection site estimated that the investment placed into the safe injection actually saved money over time. It was estimated that over a 10 year period Vancouver would have saved anywhere from $14-18 million in healthcare costs (Bayoumi and Zaric). These savings are mainly attributed to the decreased transmission of HIV between opiate users through needle sharing, which subsequently decreases HIV treatment costs. However, the economic model must be understood in the context that it may overestimate savings from assumptions it makes using overdose rates, HIV patients, and transmission rates (Bayoumi and Zaric). Yet in regards to questions on regulations, not many answers can be given, as ultimately, they are to be answered by the public officials themselves. However, this may be a fatal shortcoming of safe injection sites, as regulations regarding use could severely alter the success and/or failure of safe injection sites based on their rigidity. Standard practices throughout a country are also not feasible as each community has different capabilities and resources, possibly requiring federal support for certain communities in order to meet national regulations. However, this would also require federal governments to pass policy allowing for opiates to be legal in such an environment, which would be very difficult to pass.

One flaw that cannot be accounted for however is the lack of data coming from newly established safe injection sites. The Vancouver safe injection pilot project has been one of the few significant efforts in attempting to run a government sanctioned safe injection site that is able to collect enough data for significant conclusions to be made. Extrapolation of such results to other societies and even other cities in Canada are difficult due to factors such as population characteristics, regulations surrounding opioid prescription, societal views on harms reduction measures, and economic factors. In order to come to a reliable conclusion regarding the efficacy of safe injection sites in counteracting the opioid epidemic, more communities must adopt pilot projects for safe injection sites.

Nonetheless, safe injection sites have shown promise in their ability to reduce the incidence of the current wave of the opioid crisis through harm reduction and preventative means. However, benefits such as lower rates of overdose fatalities and HIV transmission cannot be achieved without an initial investment made by either federal or local governments into establishing pilot projects in communities ravaged by the opioid epidemic. Even with the shortcomings that may be attributed to safe injection sites, communities will continue to experience the adverse effects of inadequate public policy response to the opioid epidemic if greater resources are not devoted to its solution. Not only should safe injection sites on their own be considered, but subsequent opiate abuse education within communities should also be considered, in order to supplement the harm reduction approach of safe injection sites with prevention of future opiate abuse. At the very minimum, policymakers at all levels of government must now start to invest resources into researching and establishing pilot safe injection sites in conjunction with public health officials and communities, in order to adequately battle the opioid epidemic.

Works Cited

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Potier, Chloé et al. "Supervised Injection Services: What Has Been Demonstrated? A Systematic Literature Review". Drug And Alcohol Dependence, vol 145, 2014, pp. 48-68. Elsevier BV, doi:10.1016/j.drugalcdep.2014.10.012.

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