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San Francisco Will Be First U.S. City With Legal Injection Site to Prevent Opioid Overdoses; Others Scramble to Follow

February 12, 2018

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Secret U.S. Site

Patricia Sully

Patricia Sully in Seattle (Credit: Selfie by Patricia Sully)

Somewhere in an American city, an SIS has been operating underground since 2014. Late last year, researchers Alex Kral and Peter Davidson published a paper about the site in the American Journal of Preventive Medicine after being invited by the site operators to evaluate it. "They wanted to see if what they were doing was successful and also to bring it to a larger audience so that eventually there would be legally sanctioned sites," says Kral.

According to Kral, all eight overdoses that have happened thus far at the site have been reversed. The site has also referred people to drug treatment. "There are two main rooms," he says, "one with six stainless steel counters, mirrors to help inject, and biohazard buckets to put used needles in. Opposite them is a person monitoring. If someone is taking less than five breaths per minute, they're overdosing, and they need Narcan."

Users bring their own drugs, but the site provides test strips to see whether the supply has fentanyl in it. "Because you're not outside afraid of getting caught," says Kral, "you don't need to rush your shot, so you can do a little and see how it is."

There are also comfy couches. All to make illegal drug users comfortable? "On the face of it, it sounds crazy, I know," says Kral. "But over half a million Americans have died since 2000 of overdoses. People are using drugs whether you have these sites or not. And people also want needles and injectors off the streets. I've found that this is an idea that people hate until they learn about it, then they swing completely."

That's definitely been the case in Seattle, where the city council just OK'd $1.3 million for the city's first SIS, which might be in the Capitol Hill area, where drug users concentrate and community support for a site is solid. (A feasibility study comes next.)

Patricia Sully, a staff attorney with the city's Public Defender Association who is also on an SIS task force, says she hopes a site will be up and running this year. "We're seeing a record number of deaths -- I think 332 fatal ODs last year," she says. "Like many West Coast cities, we have a big homeless population, and there is some overlap between the two issues. If you're using alone in your tent and you OD, nobody is going to be there to help you."

Safe sites, she says, can also help cut down on the spread of hepatitis C and other bloodborne illnesses. "When people don't have a sanitary place to put down their supplies and wash their hands, we see a lot of infections."

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Seattle is quite liberal by the standard of American cities, but Sully says that SIS advocates still had to effect a mind-shift among officials and residents. "When we first explained this, we met strong resistance," she says. "We've been raised in a society that has embraced the war-on-drugs mindset, putting people in jail and making them hit rock bottom. But it's not working. And data [from other countries] showing that safe injection sites work has already existed for 30 years."

To get community buy-in, Sully and other advocates displayed "mock" pop-up SIS (with everything but the drug users) to get residents used to the idea. Exit surveys, she says, showed that 95% of people who'd previously never heard of the idea came out of the mock sites supporting it.


Racial Dynamics

Underlying the current movement for SIS in the U.S. is the bitter reality that a more humane way of treating drug users has only emerged with a drug epidemic that devastates white communities. It was a different story in past decades when both the heroin and crack epidemics were decimating primarily black communities -- and when countless users were demonized and forced to serve long prison sentences, cut off from family and community support, rather than being offered harm reduction or addiction treatment options. (According to the Drug Policy Alliance, almost 80% of people in federal prison and 60% of those in state prison on drug charges are black or Latino.)

"It's a lesson in what racism takes from you," says Frederique of the Drug Policy Alliance (DPA) about the disparity. "Seeing the kinder rhetoric around the current opioid crisis has hurt me deeply." The DPA, she says, has started a campaign to envision modes of reparative justice for the damage that the war on drugs has done to generations of black families. "We need some sort of truth process where institutions and governments have to sit there and listen and be held accountable for what they've done."

One example, she says, is the Chicago Torture Justice Memorials, which sparked a public education campaign in the city on the damage that the criminal justice system has done to black families. "These solutions should be based on what people who have been impacted want."

Because of this painful history, it can be harder to get an SIS off the ground in a heavily black city like Baltimore -- with its fraught history of police abuse of black citizens -- than in a mostly white one, such as Vancouver, Seattle, or San Francisco.

"My job is to make sure that communities here are ready for this," says Baltimore's Gudlavalleti, "not just throw this into impoverished black neighborhoods. And we have to walk a line with the police, too, because we would want them to leave sites alone but not for police leadership to say, 'I support this,' because then people here won't trust it if it's coming from the police."

So, for the time being, she and other advocates are taking small steps toward reframing the city's handling of the opioid crisis around what she calls "a racial justice perspective." They've nurtured Baltimore's version of the LEAD Program, started in Seattle, in which cops divert low-level drug or prostitution offenders toward case management services rather than arresting them.

There's also the LEAP program, in which retired cops, citing their own experiences, advocate for harm reduction and safe consumption options for drug users.

"We'd love to have an SIS in a year," Gudlavalleti says, adding that the fact that nearby, heavily black Philly is moving toward opening a site provides a big boost to the effort in Baltimore. "If you tell people here they're doing this in Seattle or San Francisco," she says, "you may as well say 'Holland.' But if you say 'Philly,' people say, 'Oh, I have family there.' They get it."

Tim Murphy has been living with HIV since 2000 and writing about HIV activism, science and treatment since 1994. He writes for and has been a staffer at POZ, and writes for the New York Times, New York Magazine, Out Magazine, The Advocate, Details and many other publications. He is also the author of the NYC AIDS-era novel Christodora.

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