Strategies and practices to reduce harm are evident in just about every area of our lives. Whether it’s seat belts, helmets, hard hats, or sunscreen, the United States has adopted rules, regulations, and recommendations that reduce the harm or potential harm of day-to-day activities.
Recently, there’s been a concerted effort to reduce the harm of the ongoing opioid crisis.
The U.S. Department of Health and Human Services estimates that more than 130 people in the United States die every day from opioid-related drug overdoses, a statistic that prompted the department to label the opioid crisis a public health emergency in 2017. With opioid-related deaths reaching critical levels, it’s apparent that existing substance abuse treatments and detoxes are not a catchall solution, which is why advocates and health officials have turned to evidence-backed harm-reduction techniques.
The National Institutes of Health defines harm reduction as a public health strategy developed for adults with substance abuse problems for whom abstinence is not feasible. The intervention philosophy includes a set of policies and programs that aim to reduce the negative health and social consequences of drug use without necessarily reducing drug consumption.
Harm reduction is not treatment, but studies have shown that drug users who engage with harm reduction services are five times as likely to enter into drug treatment than those who do not.
What’s available now
Syringe exchanges have been used as a strategy for more than 30 years. The programs started in the 1980s as a way for injection drug users to dispose of their used needles and receive clean needles. Communities have developed exchanges in response to high rates of Hepatitis C and HIV—blood-borne diseases that can be spread through shared needle use.
Studies show that syringe exchanges decrease the spread of HIV and other blood borne diseases, decrease the amount of syringe litter in areas surrounding the exchange, and can reduce the amount of injecting a drug user does per day.
While needle exchanges have been identified as a best practice by the Centers for Disease Control and Prevention since the 1990s, they are still illegal in 11 states, including Arkansas, Iowa, and Texas. When the first U.S. needle exchange opened in Washington in 1988, the federal government placed a ban on the service, stating that it sent an inconsistent message with the government’s war on drugs. Not until 2010 was legislation passed to lift the federal ban—at least partially, allowing needle exchanges to be federally funded as long as federal money isn’t being used to purchase sterile needles.
Under the federal ban, needle exchanges either operated under local laws that allowed the service or existed illegally—such as current exchanges that are in states with local bans. But, as the number of overdose deaths continue to rise, states are starting to repeal their bans, Idaho and Georgia being the most recent to do so in 2019.
People’s Harm Reduction Alliance, a syringe exchange based in Seattle, has followed a drug user-centered model since its inception in 2007 by requiring 51% of the organization be ran by active drug users.
“You wouldn’t have any other service serving a population without that population being involved in the decision making process and policy changes,” alliance director of operations Lisa Al-Hakim says. Unfortunately, Al-Hakim says, drug policy has historically been made by people who haven’t been drug users and don’t understand the experience and needs.
For example, most syringe exchanges implemented by public health departments follow a 1:1 needle exchange, meaning drug users can only receive as many needles as they return. However, carrying used syringes is illegal and can result in a felony charge. Al-Hakim said drug users pointed out that needle exchanges were asking participants to put their freedom at risk to use the services.
People’s Harm Reduction Alliance operates as a need-based needle exchange, meaning they don’t require used needles to be returned to provide clean needles. Instead, they provide people with as many needles as they request. The organization’s limit is 300 syringes per person per day, but only because they don’t have an unlimited supply of needles. That high bar allows people to stock up on clean needles if they won’t be able to access the service for a while, lowers the likelihood of the clean needles being resold on the street, and establishes the alliance as a service that trusts injection drug users to know their own needs, Al-Hakim says.
Distribution patterns depend on each person’s situation. Housed people using the needle exchange may take 300 syringes once a month and keep their home stocked, while unhoused people who are more likely to have interactions with the police or be swept from a homeless camp may take a box of 10 every other day. PHRA’s site in Seattle distributes an average of 170,772 syringes to 1,343 people per month, Al-Hakim says.
A common fear of need-based exchanges is that if drug users aren’t required to exchange their syringes, then more used syringes will be disposed of improperly. The alliance proves that wrong.
“Being need-based, we actually get more used syringes returned to us than we give out,” Al-Hakim says. The CDC considers a 90% syringe return rate a success and the alliance has maintained a 98% return rate at their Kitsap County location, and has seen return rates over 100%.
Al-Hakim believes that the organization sees so many returns because of the trust and respect that has been fostered through the community.
“The most important thing you do in harm reduction is not the things you hand out, it’s the relationship[s] you build,” says Al-Hakim, highlighting the support and unconditional love that the alliance fosters.
On a cold February evening, Ronald St. Clair visited PHRA’s Seattle location to gather some supplies. The exchange is a small table set up underneath an awning outside of a storage room in the basement of a church. The table has self-serve boxes for supplies that don’t have restricted quantities, including ties, paper clips, cookers, and cotton swabs. Everything else is supplied by the people staffing the exchange.
St. Clair is a semi-regular at the exchange—he was greeted with excited hugs when he walked up to the table—and says he chooses to use the service because of the quality of the equipment and community.
“The [syringes] they sell in the store are cheap and crack easily,” St. Clair explained, adding that PHRA’s equipment is the best he can get. “Plus, you get to meet cool people.”
Because of the judgment drug users often receive when trying to access medical care, the alliance has expanded into a multiservice health care center, offering a same-day clinic, mental health services, case management services, fentanyl test strips, and Narcan, an overdose reversing drug. The organization also provides pipes for smoking meth, crack, and heroin. Providing effective pipes for drug users is a harm-reduction technique because it can keep people from switching to injecting.
“We’ve branched out to a lot of stuff because a lot of syringe exchanges and harm-reduction programs have become people’s primary health care because they’ve been treated badly when they go into a hospital setting or a clinic setting because they are drug users,” Al-Hakim says.
When it comes to changing perception and influencing local policy, Al-Hakim advises harm-reduction advocates align themselves with health professionals such as hospital staff and public health leaders who both understand the evidence backing harm reduction and who the public look to as professionals.
“A health board can make or break you,” she says.
What’s to come
While syringe exchanges continue to morph into comprehensive harm-reduction health centers, some cities are preparing for the next level: safe injection sites.
A safe injection site is a designated space for injection drug users to self-inject drugs under the supervision of medically trained staff. If a patient overdoses, the staff will be able to revive them, saving their life. The site also has other harm reduction services, such as drug testing for fentanyl and connections with other community resources.
Although the idea of a safe injection site has triggered fears of radical enabling, more than 70 studies have found that the presence of supervised injection sites increased access to health care for the most marginalized intravenous drug users and reduced overdose frequency. The same studies stated safe injection sites were not found to increase drug injecting, drug trafficking or crime in the surrounding area.
Most of those studies focus on Insite, a safe injection site in Vancouver, British Columbia. Insite was the first site to open in North America in 2003. While its success has prompted more sites to open, all North American safe injection sites are still located in Canada.
Insite is operated and funded by Vancouver Coastal Health, a health authority that provides senior administrative and health care workers at the site. The site is a cliniclike setting with partitioned metal tables where people can self-inject drugs and a secondary “chill-out” room where they are observed for potential overdose after injecting. In November 2019, Insite’s supervised injection room had 8,939 visits—a 2010 report by Insite estimated each client visited the site 11 times a month, meaning an estimated 813 people visited the site in November. Of those visits, 92 overdoses were reversed. According to Vancouver Coastal Health, there have been more than 3.6 million visits to Insite, 6,440 overdose interventions, and no deaths since it opened in 2003.
Insite also takes a multiservice approach, offering detox and drug treatment programs on the upper floors of their three-story building and providing wound care and drug testing for fentanyl or other substances on their lower level.
While Insite is a necessary service, says Dr. Mark Lysyshyn, a medical health officer at Vancouver Coastal Health who helps develop public health responses to the opioid crisis, it’s not adaptable to the current needs of the opioid crisis.
“It’s difficult for places like Insite to innovate because they are subjected to such firm regulation by people who really don’t understand the services there,” Lysyshyn says. “The emerging models are different, they are much more community-based, lower barrier, and they don’t necessarily have health care workers working them.”
According to Lysyshyn, the real innovation has come from Vancouver’s overdose prevention sites—sites that were started under an emergency order issued to combat a surge in overdose deaths in 2016. The overdose prevention sites are technically illegal, but Lysyshyn says the health authorities such as Vancouver Coastal Health have an agreement with local law enforcement that federal drug laws won’t be enforced at the sites.
Because the overdose prevention sites were sanctioned to handle an emergency, the sites are less bound by regulations, allowing Lysyshyn and his colleagues to respond more fluidly to the needs of Vancouver’s drug users. Whereas it took five years of community consultations and planning to develop Insite, Vancouver Coastal Health was able to open a women’s only site, several hot spot sites, and peer-to-peer sites as soon as the materials and staff were coordinated.
Lysyshyn says the emergency sites have had no community pushback because they have been strategically placed “where previously there were dead bodies.”
“You need both of these models,” he says. “The overdose prevention sites are really an emergency response model and Insite is more of a permanent solution.”
Safe injection sites in the U.S.
Cities such as Philadelphia, San Francisco, New York, and Seattle have made preliminary moves to open safe injection sites, but local efforts have been threatened by Justice Department representatives citing a statute referred to as the “Crack House statute.” The ruling, created in 1986, prohibits proprietors from knowingly leasing or providing spaces for manufacturing, selling, or using illegal substances.
In October 2019, however, a Philadelphia district judge ruled that a proposed site in Philadelphia is not in conflict with the statute because the safe injection site’s exclusive purpose is to provide medical care, not facilitate illegal drug use. While that ruling provides protection for the facility itself, the people who work in the facility could still be prosecuted.
“I think it’s the philosophical opposition to the idea that you’re allowing people to facilitate drug use,” Lysyshyn says about the strong opposition to safe injection sites in the U.S. “Essentially you are doing that, but you’re allowing people to stay alive. No one can recover from drug use if they are dead.”
In San Francisco, a coalition of social services aimed to change that opposition by building a mock safe injection site in 2018.
“People who were fearful of the injection sites admitted that in their mind when they thought of an area where people could inject drugs, they had those pop culture ideas of opioid dens and shooting galleries,” says Kenneth Kim, the program director for Glide, one of the community organizations that led the mock site project, called Safer Inside.
A couple months before the mock site opened, a video of several drug users injecting in a BART station hallway made the rounds in local news. When community members heard of an overdose prevention site where drug users were allowed to inject, that was the image they thought of.
Instead, tour participants saw stainless steel tables, well-lit spaces, and medical equipment similar to what one would see in a doctor’s office. Kim remembers several tour participants being surprised at how medical and sterile the mock site was. The results were promising, with several community members indicating they were interested in seeing the site open as soon as possible.
While Kim says some legislative movement right occurred after the opening, that momentum has decreased, leaving Glide and the other local organizations in the planning and public education stage. Kim says Glide is planning as extensively as possible, so when they get the green light from local lawmakers the site can be up as soon as possible. A major part of the planning, Kim says, is jumping in where leaders like Insite are now, not where they started from, and taking advice from drug users.
“It’s not enough just to build it, you also have to consider service design and what that experience is for those folks to encourage its use and effectiveness,” Kim says. So far, that has meant advocating for several different types of sites like the emergency sites Lysyshyn mentioned, and modifying the design of the brick-and-mortar site to fit the requests of drug users, such as adding more flat surfaces for unhoused users to reorganize and pack their bags before they leave.
In the meantime, the organizations will continue to dispel myths about safe injection sites—including that a site would increase or glorify drug use—with education campaigns.
From Canada, Lysyshyn points out that people are dying from preventable overdose death every day, and he encourages Americans to advocate for their emergency sanctions and develop these services without the support of the law.
“Once you start operating these sites and collecting data and showing people that you’re saving lives every day, it actually becomes very difficult to close them because those would be dead bodies on the streets,” he says.