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Safer injection sites are needed

January 1, 2008
by Hilary McQuie
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They are effective interventions for drug users and communities

The insite facility in vancouver, british columbia

The Insite facility in Vancouver, British Columbia.
Photo provided by Mark Tyndall

HIV transmission rates in the United States are double those of any other western nation, and sharing injection equipment accounts for about one-third of those cases. Drug overdose is the leading cause of death among injection drug users in the United States, and San Francisco has the highest overdose mortality rate on the West Coast. Almost half of these deaths occur in residential hotels in the Tenderloin, Sixth Street, and Mission District neighborhoods, where people one step from homelessness often use alone. Injecting alone and in public spaces strongly correlates to increased risk of overdose and HIV infection. People who inject drugs in the city at the center of the overdose epidemic desperately need a place to inject more safely—a space that can provide access to medical care, drug treatment, and support from health professionals.1

Supervised injection facilities (SIFs) are legally protected places where drug users consume preobtained drugs under medical supervision in a nonjudgmental environment, which provides them with healthcare, counseling, and referrals to other health and social services (including drug treatment). The first SIFs opened in Switzerland in the mid-1980s. Today 65 SIFs operate in 27 cities and 8 countries: Australia, Canada, Germany, Luxembourg, the Netherlands, Norway, Spain, and Switzerland. There are none yet in the United States.

SIFs tend to serve particularly vulnerable populations of injection drug users: men and women who use more than one drug, have both an addiction and a mental illness, have a history of trauma, have sought addiction treatment but have been unsuccessful and have relapsed, and/or live in residential hotels or are homeless.

Comprehensive evaluations of Insite, the SIF in Vancouver, British Columbia, have demonstrated numerous positive outcomes.2-17 Insite has been associated with reductions in public drug use and publicly discarded syringes, as well as reductions in syringe sharing among local injecting drug users. Drug users who use the facility are more likely to enter detox programs, especially if they have had contact with the on-site substance use counselor. Potentially fatal overdose situations have been managed in the facility through the administration of oxygen and naloxone as well as calls for ambulance support. Importantly, none of the overdose events at the SIF has resulted in a fatality.

The U.S.-based Harm Reduction Coalition (with an office in Oakland, California) works with the Alliance for Saving Lives (ASL), a San Francisco community consortium that came together in 2007 to explore improved strategies to lessen the harmful impacts of drug use and counterproductive drug policies on both individual and community health. ASL's members include drug treatment providers, AIDS prevention organizations, people who use drugs, researchers, homeless service providers, and other people who work intimately with active drug users. After examining the evidence and discussing our community's needs, we decided to pursue opening legal SIFs.

In October, ASL co-sponsored a symposium with the San Francisco County Department of Public Health to further explore these issues with the larger community. People in recovery and public health officials stood with advocates to welcome the public. Researchers, direct service providers, active injection drug users, and fire department first responders discussed healthcare access problems that injection drug users in San Francisco face. Mothers living in residential hotels in the area with the most open drug use on the street spoke of the need to move drug use inside and away from the gaze of their children. The president of a Tenderloin neighborhood business association spoke of his members’ support for SIFs to increase community well-being and create a better business environment. The symposium was the beginning of many conversations we need to have here in order to decide as a community what we want to do.

Just as San Franciscans responded in a timely and creative way to prevent high rates of HIV infection among drug injectors and their partners through early implementation of syringe exchange programs, a similarly urgent strategy must be employed to counteract the dramatic increases in heroin overdoses,1 while continuing to expand sterile injection equipment accessibility to prevent HIV and hepatitis C infections.

Hilary McQuie is the Western Director of the Harm Reduction Coalition. For more information, visit