Needling for Change

AP Images/Jae C. Hong

For the first few years Liz Evans worked at the Portland Hotel Society, a network of homeless shelters in central Vancouver, she would arrive at her job already exhausted. On her morning walk through Downtown Eastside—a neighborhood infamous as the poorest zip code in Canada—she stepped over drug addicts passed out in doorways and sidled around alleys where people would cook dope and shoot up in broad daylight. It was 1993, and Vancouver was in the throes of an HIV epidemic. Tens of thousands of impoverished injection drug users were crammed into a fifteen-block radius. The Portland Hotel Society was one of the few housing projects in the city that welcomed drug addicts, and working there felt like triage. Evans, a nurse, trained her staff to intervene when the residents overdosed.  “It was such a painful time,” Evans says. “These weren’t people who were partying or using drugs to have fun. They were poor and sick and dying.”

Desperate for a solution, city officials decided to try a controversial public health strategy. Pioneered in Switzerland and the Netherlands in the 1980s, Supervised Injection Facilities or SIFs are places where drug users can shoot up—without fear of arrest—under medical supervision. After obtaining an exemption from the federal government, Insite, the first (and only) SIF in North America, opened in 2003. Predictably, Insite inspired protracted political handwringing—especially after Canada’s Conservative Party took over in 2006 and tried to remove its exemption—but over the intervening decade, the results have been remarkable.

Today, the number of fatal drug overdoses in Downtown Eastside has dropped by 35 percent. There are fewer needles in the street, HIV infection and syringe-sharing rates are down, and open-air drug use is far scarcer. Insite users are also much likelier than other Downtown Eastside drug addicts to enter treatment.

Insite, which operates as a partnership between the provincial government of British Columbia and the Portland Hotel Society, is a plain storefront in Downtown Eastside. Inside, nurses watch as people in twelve booths inject heroin or other drugs; they provide clean needles and syringes, teach best-practices for injecting to avoid infection, and care for drug users’ wounds. When users overdose—which happens regularly—the staff intervenes to keep them alive. In 2012 alone, nearly 500 people overdosed at Insite. None died.

The clamor for supervised injection facilities is intensifying in the U.S., spurred by rising rates of heroin use. Philip Seymour Hoffman’s death by heroin overdose two weeks ago put a famous face on a public health crisis that primarily affects people on the margins of society. In 2012, the U.S. Substance Abuse and Mental Health Services Administration reported that the number of people with heroin abuse and dependence had doubled over the past decade; the number of yearly overdose deaths is also quickly multiplying. Sudden unexpected death is especially common among heroin addicts who inject on the street. These users are often homeless or transient, with little access to health care or stable housing. These are the communities SIFs were designed to help.

Despite the clear need for some kind of intervention to check drug overdose rates, SIF advocates in the U.S. are fighting an uphill battle. For years, drug addiction has inhabited an uneasy middle ground between criminal justice and health policy. The criminalization of hard drugs like heroin makes it difficult for public health advocates to reach users, despite the growing consensus that drug addiction is an illness, rather than a failure of will or morality. “There’s a stereotype that people who inject drugs are selfish and uncaring, just waiting for their next hit,” says Laura Thomas, a deputy state director with the Drug Policy Alliance, an organization that supports SIFs. “It makes it easier to dismiss those people as criminals.”

After decades of scare-‘em-straight drug education programs like DARE, it’s hard for most Americans—much less politicians—to wrap their heads around a program that creates a safe, publicly-funded space for people to inject heroin into their veins. Wouldn’t that just send the message that heroin is safe to use? Thomas Kerr, a professor at the University of British Columbia who has conducted numerous studies on Insite, says the opposite is true. “The facility is connecting people to treatment,” Kerr says. “There’s no evidence that it’s encouraging people to start using drugs.”

In Insite’s case, rehab is just a staircase away; Onsite, a detox facility, is on the floor above Insite. This model uses Insite as a health care entry point, a way for drug users to build trust with the staff and transition to treatment at their own pace. “To succeed at recovery, people need to feel like they have control over their addiction,” Evans says. “We see lots of people ending drug use, but it’s not a six week program. In many cases, it’s six years.”


Implementing a supervised injection site in New York or San Francisco—two of the cities where activists are pushing for a pilot program—would be difficult, given the realities of U.S. drug policy. Colloquially known as “crack house statutes,” federal and state laws delineate harsh civil and criminal penalties for landlords who knowingly rent their property to drug users. The crack house statutes could easily be applied to supervised injection facilities, which are explicitly designed as havens for illegal drug users.

Back in 2007, the San Francisco public health department sponsored a symposium to discuss whether a facility like Insite would succeed in the Bay Area. Since then, support for supervised injection facilities has climbed—the San Francisco city and district attorneys both support SIFs—but progress remains slow. If they want to avoid federal retribution, SIF advocates will need to get the California legislature behind them—no easy task, even among Democrats.

Health interventions that target hard drugs remain a tougher sell than marijuana reform. Syringe exchanges—programs designed to quell the spread of diseases like HIV and hepatitis by drug users who shared needles—emerged in the early 1980s and were initially condemned for normalizing addiction. Clean syringes counted as “drug paraphernalia,” and in many states, couldn’t be purchased without a prescription. For years, the exchanges operated underground. Now, 33 states and a handful of cities have issued exemptions from the drug paraphernalia laws for people who distribute sterile syringes, but the programs are chronically underfunded. In 2009, Congress lifted a federal funding ban on syringe exchanges, only to reinstate it in 2011 because of GOP saber rattling over budget cuts.

On the other hand, states are increasingly willing to rethink drug war policies that seem to do more harm than good. “People are more open to drug policy experimentation right now, so the timing would be appropriate,” says Leo Beletsky, an assistant professor of law and health sciences at Northeastearn University. Over the past decade, fifteen states and a handful of cities have decriminalized the possession of small amounts of marijuana. Pot is legal for medical use in over twenty states; in 2012, Washington and Colorado legalized marijuana for recreational use. The federal government is also reconsidering the harsh mandatory minimum sentences on crack cocaine offenders that were the hallmark of the War on Drugs.

The political culture that allowed Insite to open could be difficult to reproduce, even in Canada. After his election in 2006, Conservative Prime Minister Stephen Harper fought Insite to the Canadian Supreme Court, arguing that prevention and treatment should be the main goals. The Court ruled unanimously in Insite’s favor, saying that shutting it down would threaten the lives of Vancouver’s drug users. What’s less clear is whether Harper’s administration will allow exemptions from federal drug laws for SIFs that might try to open in other cities.

Reproducing a facility like Insite would be complicated for other reasons. Vancouver has an unusually high concentration of marginalized drug users in Downtown Eastside; in other urban centers, these populations are more spread out. There’s also the question of the epidemic of heroin use in places like rural New Mexico. A centralized SIF in Albuquerque or Santa Fe would do little for these users. Right now, needle exchange vans criss-cross the state, offering clean syringes at appointed times each week. This model, according to Thomas Kerr, could only go so far. “High-risk drug users have trouble keeping track of the vans’ schedules,” he says. “That’s not a reason not to do it, because it might work for some people, but I wouldn’t expect it to be as successful as an urban site.”

Thomas, who is helping lead the charge for a supervised injection facility in San Francisco, says these are details that can be worked out along the way. What’s important, to her, is breaking down the stigma around helping drug users in the first place. Right now, Insite’s biggest problem is capacity—by the time it opens in the morning, there’s already a line. “It’s so rare that these people are treated with compassion and respect,” she says. “Sometimes that’s all they need to start thinking about treatment.”

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