Safer consumption spaces are a vital piece of the solution, say advocates in New York and beyond
Sharon, a 49-year-old former nurse from Long Island, first injected heroin around 2000: an escape from painkiller withdrawal after a cancer surgery. “It was amazing,” she recalls. “It was like the best feeling I ever had.”
The mother of three has passed through 37 detox centers, five inpatient facilities and at least 10 stints in jail. Over more than 15 years of heroin use, she has injected at weddings and funerals, in the bathroom of a sheriff’s office during an arrest and inside a supermarket while pushing a shopping cart. “I proceeded to leave the needle on the shelf … you get so nervous, you do stupid s–t,” Sharon, who now stays at a Sheepshead Bay shelter and hasn’t used in at least a month, tells Moneyish. “It’s not even that I didn’t care; I just want to get it off of me because I don’t want to get arrested.”
She is one face of a dire, growing national crisis: Opioid overdose deaths in the U.S. have quadrupled since 1999, and 91 people die every day from overdosing on opioids. Heroin use among women spiked from 0.8% to 1.6% between 2002-2004 and 2011-2013 — a 100% increase — and increased 50% for men, from 2.4% to 3.6%. New York City numbers paint their own grim picture: Unintentional overdose deaths rose 46% from 937 to 1,374 between 2015 and 2016, with black New Yorkers seeing the greatest increase, 80%. In 2016, 82% of city overdose deaths involved an opioid.
For the uninitiated, the opioid umbrella covers heroin; the 50-times-more-potent synthetic fentanyl, often used to lace heroin supply; and prescription painkillers like hydrocodone, oxycodone, morphine and codeine. About 3.6% of people who misuse prescription painkillers graduate to the cheaper and more easily obtainable heroin, while nearly 80% of heroin users started on painkillers. Treatment involves methadone- or buprenorphine-based medically assisted treatment (MAT), along with counseling — though “significant gaps between treatment need and capacity exist at the state and national levels,” one 2015 study warned.
Now, a coalition of New York organizations, health care professionals and public health advocates is pushing a radical idea to prevent overdose, get dirty syringes off the streets, reduce disease risk, and, most vitally, save lives: giving drug users a safe, hygienic place to legally inject under medical supervision.
Safer consumption spaces — also known as safe-injection sites, or supervised injection facilities (SIFs) — allow their typically marginalized, unstably housed participants to use pre-obtained drugs with clean equipment and under the guidance of a trained, nonjudgmental staff. Almost 100 facilities already operate in 66 cities in nine countries. While no SIFs operate legally in the U.S. — though a recent report revealed an unsanctioned, location-undisclosed facility in operation since 2014 — the first in North America was Canada’s Insite, launched in 2003 in the notorious Vancouver drug haven of Eastside.
Operated and funded by Vancouver Coastal Health, the 13-booth facility opens at 9 a.m. and closes at 3 a.m.; a morning line out the door can sometimes stretch a block, Insite spokeswoman Anna Marie D’Angelo tells Moneyish. Clients receive clean supplies, head to an assigned booth and use their drugs as a nurse waits nearby, armed with overdose-reversing naloxone and oxygen. Afterward, clients dispose of supplies and head to a “chill room” with staff to monitor and free coffee and juice. (Onsite, a 12-room detox, lives right upstairs.) Insite staff have supervised more than 3.6 million clients’ injections and intervened in 6,440 overdoses — with zero deaths.
Critics have long denounced SIFs as little more than government-endorsed enabling of drug abuse. But “the public health outcomes are worth more than our fears,” Kassandra Frederique, New York State director at the Drug Policy Alliance, tells Moneyish: Research suggests SIFs curb overdose deaths, reduce HIV risk behaviors and decrease public injection and improper needle disposal. A 2007 study found Insite was associated with a 30% increase in the rate of detox service use, and 2006 research found Downtown Eastside area arrest rates for drug trafficking, robbery and assault had not significantly increased.
They’ve also proven cost-effective: Insite, which costs taxpayers about $3 million Canadian a year, yields around $17.6 million in savings associated with HIV-related medical costs, according to a 2010 study. A recent study found establishing a 13-booth SIF in Baltimore modeled after Insite would cost about $1.8 million a year and save the city nearly $7.8 million by preventing HIV and hepatitis C cases; reducing hospital stays; saving lives; preventing ambulance calls, ER visits and hospitalizations; and leading people into treatment.
Could giving heroin users a safe, clean place to inject help stamp out the opioid epidemic? https://t.co/vJHFZazzEk
— Moneyish (@Moneyish) October 10, 2017
New York, Maryland, Vermont and Massachusetts officials are considering legislation, while initiatives in New York City, Ithaca, San Francisco and Washington’s King County are underway. If implemented in New York, SIFs would join a suite of existing harm-reduction services like syringe exchanges and naloxone kits.
State Assemblymember Linda Rosenthal (D-Manhattan), who introduced a bill in June to enact the Safer Consumption Services Act, envisions New York SIFs operating out of existing syringe exchanges or facilities that offer health or social services. A SIF, she tells Moneyish, would ideally connect opioid users with “the whole panoply of services” they need, including mental and physical health care, counseling and housing resources.
“What we’re doing now is not working,” she says. “Based on that alone, I think people should take a leap of faith.” Cost is “still something we’re researching,” Rosenthal adds, citing variables like where a SIF would be sited, how it would be administered and whether or not a nonprofit would run it. She believes people will slowly warm to the idea, as they did with once-controversial needle exchanges: “You don’t really hear people yelling about that anymore.”
Of course, the whole idea could place both clients and facility staff in law-enforcement crosshairs: The federal Controlled Substances Act prohibits drug possession and includes the so-called “Crack House Statute,” which bars maintaining a place for the purpose of unlawfully using a controlled substance. But state and local governments could authorize SIFs through either executive order or legislation, Northeastern University law professor Leo Beletsky tells Moneyish. Attorney General Jeff Sessions is “a total wildcard,” he adds. “I don’t see him being very enthusiastic about a safe consumption space given his stance on marijuana legislation … (and his approach to) the opioid crisis through basically doubling down on punitive approaches.”
The community nonprofit VOCAL New York, which operates a needle exchange, has outfitted its bathrooms with stainless steel countertops, a syringe disposal and an intercom system lest members use and overdose. But the group doesn’t condone using its facilities for drug consumption — and establishing a SIF, co-executive director Jeremy Saunders argues, would increase the volume of people the nonprofit could serve, their level of engagement and the ability to connect them with public health resources.
Other corners of state and local government appear receptive: A $100,000 New York City Council-funded study is investigating the possibility, and Gov. Cuomo, while he has yet to take a public stance, expressed support for his AIDS task force’s recommendations that included establishing SIFs.
Meanwhile, President Trump, who campaigned on a vow to stamp out the opioid epidemic, has yet to formally act on his task force’s recommendation that he declare a national emergency — a move that could avail FEMA money to states and waive certain federal program requirements — save for verbally describing it on Aug. 10 as a “national emergency.”
As expected, SIFs have fierce detractors.
City Council candidate Bob Capano, for example, visited Tucker Carlson’s show in December to bash the idea. To him, they may as well be “legal shoot-up galleries.” “I’m all for giving addicts counseling and rehab, but to sentence them to a lifetime of addiction by basically encouraging (drug) use, I think, is wrong,” he tells Moneyish. Assemblymember Nicole Malliotakis, the presumptive Republican nominee for mayor, calls SIFs in New York “dead on arrival.” “I think it really shows that we are losing this battle if we are actually putting resources to provide a community center for people to come and inject illegal drugs,” she tells Moneyish. “The resources really should be put towards those who want to get off of heroin and have been unable to access a bed” in rehab facilities.
Few object to harm reduction in the case of an alcoholic reducing his intake or a cigarette smoker using a nicotine patch, D’Angelo says. “But once you get into illicit drugs, all bets are off.” The problem with fixating on treatment, SIF advocates say, is that not all injection drug users are ready or willing to get clean. In the meantime, they could overdose and die.
Sharon’s youngest of three sons, now 24, once discovered her using in the bathroom. “When you have your eight-year-old son come up to you and say, ‘I hate you because you do drugs; you don’t love me, and you still won’t get clean,’ would you think that would be a choice?” says Sharon, who volunteers at VOCAL. “That broke my heart … Because I couldn’t stop.”
Thirty-five-year-old Jennifer, a VOCAL member and mom of two from Elmira, N.Y., has attended five rehab programs, completing her most recent one in September at Cornerstone in Queens. “You have to want it,” she said days before entering the latest program. “And if you don’t want it, nobody can make you want it.” She has been clean since Sept. 1.
“A lot of people who use drugs don’t trust, because all they hear is people wanting them to go into treatment, go into treatment, go into treatment,” says Robert Suarez, a VOCAL organizational leader whose mother died in his arms after contracting HIV from intravenous drug use. Harm reduction, says Suarez, gives people the chance to “make a healthy choice at their own pace or in their own time.” “What we want, if you’re not ready to stop using, is for you to stay alive for one more day,” he says. “Don’t die on us.”
Yet drug overdose is the leading cause of death in Americans under 50, the New York Times reported recently. Around 150 activists on International Overdose Awareness Day on Aug. 31 marched to the New York City Mortuary at Bellevue Hospital; protesters, wearing black clothing and waving signs bearing the stories of lives lost to overdose, jolted Manhattan with the chant “NOT ONE MORE!” and a New Orleans-style jazz procession. “It’s been too quiet,” Frederique says, blowing on a vuvuzela.
It wasn’t lost on some marchers that opioid addiction permeated headlines and lawmakers’ agendas after it struck white suburbia in recent years. (White people saw the greatest increase in heroin use between 2001-2002 and 2012-2013, a recent study says.)
“I am glad that some of my Republican colleagues and some of my more conservative colleagues have finally come onto the bandwagon and realized that we have to dedicate resources to be able to save people’s lives,” State Sen. Gustavo Rivera (D-Bronx) tells Moneyish. But the crisis gained national prominence only after “a certain hue of folks started dying,” he says, despite overdose deaths having plagued poor, working-class people of color in communities like the Bronx for decades.
Proponents of SIFS acknowledge they’re a piece of the puzzle, not a silver bullet. But safer consumption spaces, Saunders maintains, would allow for more honest conversations around relapse and recovery. “It’s important for us to disrupt stigma,” says Frederique. “And I think we can’t deal with a situation that’s not out in the open.”
A late-August interview session on the back porch of VOCAL’s Brooklyn office evolves into a support group of sorts. “The day I stop using heroin, I will never touch another drug in my life — never,” says Jennifer.
“You can’t say never,” Sharon interjects. “Just say you’ll try your best.”
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