The Controversy Surrounding Sanctioned Heroin Injection Sites
Individuals who use heroin fall into an addiction’s abyss that is dark, dirty, isolated and filled with uncertainty. Because of the overwhelming feeling of despair, family and friends sometimes abandon their loved ones when they need them most. The need to score the next high often outweighs common sense and concerns about safety. Methods for quitting heroin exist, but breaking through the walls of addiction is a daunting task.
Breaking through the walls of addiction is a daunting task.Heroin is burying more and more people in this country every year. As recent as 2013, the number of deaths stemming from drug overdoses (46,471 people) was greater than the number due to motor vehicle accidents (35,369 people) and firearms-related incidents (33,636 people). 
City and state officials are looking for new ways to address this ever-growing problem. Out-of-the-box thinking has led to the development of “safe havens” for using heroin. These will mandate that state and local governments permit facilities that allow the use of an illegal drug to operate. The word “controversy” is written all over this proposal. The reactions of residents within communities where these sites are proposed will, in all likelihood, be heated.
Alarming Heroin Statistics – A Call for Change
Heroin use has been on a steady growth rate in this country. According to the National Vital Statistics System, the mortality rates associated with heroin are on the rise: 
- Between 2007 and the 2013, the number of drug-poisoning deaths involving heroin increased from 0.7 deaths (per 100,000 people) to 2.7 deaths (per 100,000 people)
- In 2013, heroin-related overdose deaths were almost four times higher for men (6,525 deaths) than for women (1,732 deaths)
- The age group associated with the highest rate for drug-poisoning deaths involving heroin was 45 – 64 year olds (2.0 per 100,000 people, in 2000) and 18 – 44 year olds (7.0 per 100,000 people, in 2013)
- From 2000 to 2013, all regions of the country showed an increase in heroin-related drug poisoning deaths, with the most substantial increase occurring in the Midwest
Other government agencies are also analyzing the statistics surrounding the growing heroin epidemic. The U.S. Drug Enforcement Administration (DEA) reported a 244 percent increase in the number of heroin-related overdose deaths between 2007 and 2013 in the United States. It also ranks heroin and controlled prescription drugs as the most significant drug threats to this country. 
What is a Safe Injection Facility (SIF)?
According to the Ontario HIV Treatment Network (OTHN), safe injection facilities are places where drug users are able to inject pre-obtained drugs using clean equipment and in a low-risk environment, often under the supervision of medically trained personnel.  European countries have been operating SIFs since the 1970s, with many locations also providing therapy programs, meals and long-term residency. Although these sites are regulated by the government and operations involve a long list of established regulations, the controversy surrounding them still remains. 
A public health emergency was declared in one of the province’s poorest neighborhoods, Downtown Eastside.During the late 1990s, British Columbia government health officials saw a substantial increase in the number of human immunodeficiency virus (HIV) cases being reported in Vancouver. The sharing and repeated use of needles was escalating. A public health emergency was declared in one of the province’s poorest neighborhoods, Downtown Eastside. This, along with an increase in overdose deaths, steered officials away from the old, standard methods of treating people with addictions as criminals. 
In 2000, A Framework for Action: A Four-Pillar Approach to Drug Problems in Vancouver was released. The proposed, four-step approach included:
- Harm Reduction 
The harm reduction strategies included methadone treatment for individuals suffering from an addiction to heroin, needle exchange locations and the execution of a three-year pilot facility called Insite, a medically supervised SIF located in the Downtown Eastside neighborhood in Vancouver.
Insite – A success story or a failure?
The success of Insite is still ambiguous.As part of a pilot program, the safe injection site, Insite opened in 2003 in Vancouver. The facility was initially granted a 3-year exemption from the Canadian government’s Controlled Drugs and Substances Act while it was subjected to an extensive evaluation process. After numerous legal battles that went as high as the Supreme Court of Canada, Insite remained exempt from federal drug control legislation.  Whether or not it has been successful is still surrounded by uncertainty.
In an article published in the Journal of Urban Health, an evaluation of the Insite facility was done using a knowledge translation (KT) technique that is utilize by the medical, health services, and public health research communities. The KT evaluation, which is often broken down into three phases, of Insite is shown below: 
Phase 1: Review the decision maker’s problem from the decision maker’s point-of-view
Insite was not established because of extensive scientific research and data. Instead, it opened its doors because:
- The severity of the drug crisis demanded action
- Political leadership and “policy entrepreneurs” took action, in the form of lobbying and protests
- Coalition building and shifting of public opinion
Phase 2: Explore the aspects of the problem and potential solutions that matter most to the decision maker
Insite opened as a research endeavor for the British Columbia Centre for Excellence in HIV/AIDS (BCCEHA). While the research was published in scholarly journal, much of the results were based on peer-reviewed studies that were often lead by researchers at the BCCEHA. While the results of one such study indicated that the community drug use was not adversely affected, it did not indicate any of the beneficial effects. 
Phase 3: Present research results that are meaningful and actionable to the decision maker
More traditional KT strategies were used to support Insite when it came under scrutiny and closing was threatened. However, the evaluation process also included public opinion polling and endorsements by government officials, some of which were “policy entrepreneurs” behind the facility.
Based on the legitimacy behind some of the research, the success of Insite is still ambiguous. A former columnist for the Vancouver Province and Vancouver Courier, believes that the media is at the center of the success surrounding Insite. He states:
“When the BC Centre stages a press conference, it’s always the same formula. A handful of Kerr-authored studies and an obligatory recovering addict who owes his life to Insite. The reporters in attendance nod along and write or broadcast the same story with the same quotes and BC Centre statistics.” 
However, due to a rise in overdoses from fentanyl, Canadian health officials are not deterred by the controversy regarding SIFs. They are considering opening additional supervised injection sites in community health clinics. 
Take-Away Messages Supporting SIFs
While the controversy lingers, the SIF facility in Vancouver remains open. Its purpose was to decrease public disorder, improve public safety, reduce deaths from overdose, diminish the number of blood-borne infections and expand access to health and social services.
According to the Drug and Crime Prevention Committee, a Joint Investigatory Committee of the Parliament of Victoria, the advantages to SIFs can be subdivided into the following areas:
- Trained personnel that provide services, advice and equipment
- Free availability of sterile injecting equipment
- Education on safe drug use, drug treatment and life skills
Reduction in costs stemming from –
- Ambulance and hospital emergency visits
- Healthcare costs from serious blood-borne viruses
- Preventable general healthcare needs
- Needle/syringe clean-ups 
Coming to a City near You
The thought of having a place in a neighborhood where it is safe and legal to take heroin is a terrifying idea to many people. On the other hand, it might be a comforting thought to know that your children will not stumble upon an individual who is addicted to heroin shooting up across from their school because there is designated location for them. However, many states have the authority to administer harm reduction techniques, including the opening of an SIF facility.
According to a study done by Temple University, 19 states have implemented syringe exchange programs, pharmacy syringe sales or both.  Currently, no laws are explicitly written that either authorize or forbid the opening of an SIF in this country. The legality of this type of facility would depend on the interpretation of laws related to drug possession and maintaining a premise for illegal drug use.
A place where it is safe and legal to take heroin is a terrifying idea to many.At a 2007 symposium discussing the idea of opening an SIF facility in this country, Dr. Bertha K. Madras, a former Deputy Director for Demand Reduction in the White House Office of National Drug Control Policy (ONDCP), states “The underlying philosophy is, ‘We accept drug addiction’ and that ‘This is a form of giving up.’”  While many people are of the same mindset, some of the U. S. cities that have considered opening either an SIF or a safe consumption site (SCS) inside of another facility include:
- Boston, MA
- Ithaca, NY
- New York City, NY
- San Francisco, CA
- Seattle, WA 
The main difference between an SIF and an SCS is that the injection of an illegal substance that occurs at an SIF is not permitted at an SCS. If an individual is already experiencing the effects of a drug, an SCS provides a secure environment and personnel that will monitor and offer treatment, if necessary.
An Innovative Plan or Delusional Concept
A strategy as outrageous as providing sexual education to teenagers.Why are city leaders seeing these facilities as viable options? Recently, Ithaca, New York was ranked one of the ten smartest city in the United States.  Not long ago, its mayor, Svante Myrick proposed opening an SIF as a way to combat the escalating drug problem. According to Myrick, whose father was a heroin addict, “This is a strategy that sounds as outrageous as the strategy that we came up with to provide sexual education to teenagers, something that was unthinkable in the ‘70s.”  His proposal was based on input from various focus groups and published in The Ithaca Plan: A Public Health and Safety Approach to Drugs and Drug Policy.  The findings in the area of harm reduction included
- More comprehensive training is needed on how to provide services to people at different points on the substance use continuum.
- Harm reduction is not widely understood, and few Ithacans know of the existing and effective local harm reduction programs already in operation.
- Harm reduction services need to be expanded.
These findings will not dissuade all of the concerns and legalities associated with opening an SIF in a U. S. city.
Providing support to individuals who would otherwise be on the street.Along “Methadone Mile” in Boston, Massachusetts, people are often seen walking the streets in various stages of a drug-induced high.  Instead of proposing an SIF, Boston Health Care for the Homeless Program (BHCHP) recent initiated a service known as Supportive Place for Observation and Treatment (SPOT). This program will not allow the injection of any substances onsite. However, it will provide support staff that will monitor and provide care and treatment to individuals who would otherwise be on the street. SPOT will also have a public health advocate and people who are recovering from addiction onsite to provide assistance. 
No Easy Choices
Are SIFs a solution to the rising drug problem in this country? Or, are they just a way that cities are waving the white flag on the epidemic that their communities are facing? Parties for both sides can give the pros and cons that surround this type of harm reduction technique. While there is no simple answer to the problem, the united conclusion is that something must be done.
 Fafard, P. (2012). Public Health Understandings of Policy and Power: Lessons from INSITE. Journal of Urban Health: Bulletin of the New York Academy of Medicine, 89(6), 905-914. doi:10.1007/s11524-012-9698-2
 Kerr, T., Stoltz, J., Tyndall, M., Li, K., Zhang, R., Montaner, J., & Wood, E. (2006). Impact of a medically supervised safer injection facility on community drug use patterns: A before and after study. BMJ, 332(7535), 220-222
This article was written by addiction care experts at Behavioral Health of the Palm Beaches. We are committed to offering the most comprehensive addiction treatment services in the nation and being thought leaders in the addiction recovery community.