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Author Topic: The Law (and Politics) of Safe Injection Facilities in the United States  (Read 6009 times)

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The Law (and Politics) of Safe Injection Facilities in the United States

2008 February ... Some excerpts follow:


Safe injection facilities (SIFs) have shown promise in reducing harms and social costs associated with injection drug use. Favorable evaluations elsewhere have raised the issue of their implementation in the United States.

Recognizing that laws shape health interventions targeting drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Although states and some municipalities have the power to authorize SIFs under state law, federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally-authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or decided not to interfere.

Given legal uncertainty, and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation.


The mechanisms through which a SIF prevents infections and overdoses among clients are straightforward. Studies of existing facilities have generally reported beneficial results for clients and positive or neutral results for the site neighborhood. Whether, or at what level of use, a SIF can have a measurable impact on overall population health is a matter for continuing research. We base our analysis on the proposition that the SIF is a potentially useful public health intervention that should be available for evaluation and adaptation in the United States.

SIFs have been operating in Europe since the 1980s. Reviews report that SIFs have consistently led to fewer risky injection behaviors and fewer overdose deaths among clients, increased client enrollment in drug treatment services, reduced nuisances associated with public injection, and saved public resources. Demonstrating a community-level impact has been difficult, however, because many programs have been “pilots” with limited coverage, operating under sometimes counterproductive regulations.

In 2001, after several years of public deliberation and the closure of a short-lived illegal facility, a pilot SIF opened in Sydney, Australia, under a license issued by the New South Wales (state) government. In 2003, the Canadian federal government waived its drug laws to allow a pilot SIF in Vancouver. Here, too, there had been considerable debate about harm reduction strategies, and health activists had for a time operated an unauthorized SIF.

Both facilities have been extensively evaluated. In multivariate analyses of an IDU cohort in Vancouver, SIF use was negatively associated with needle sharing (adjusted odds ratio [AOR]=0.30) and positively associated with less-frequent reuse of syringes (AOR=2.04), less outdoor injecting (AOR=2.7), using clean water for injection (AOR=2.99), cooking or filtering drugs prior to injecting (AOR=2.76) and injecting in a clean location (AOR= 2.85).

In Sydney, both SIF clients and nonclient injectors in the same neighborhood reported high rates of sterile syringe use and low rates of sharing even before the SIF opened, but 41% of SIF clients reported adopting at least 1 safer injection technique since using the facility. A series of 3 annual neighborhood surveys found that SIF users were more likely to use new syringes than were nonusers and less likely to share injection equipment other than syringes, although these differences were not statistically significant.

Both the Sydney and Vancouver facilities were effective gateways for addiction treatment, counseling, and other services. By the third annual survey, SIF clients in Sydney were significantly more likely to report starting drug treatment in the previous year than were non-clients (38% vs 21%). In Vancouver, SIF attendance and contact with its addiction counselor were each associated with a more rapid uptake of detoxification services. Overdoses do occur in SIFs—in Vancouver, the rate was 1.3 per 1000 injections—but the more relaxed environment and the presence of medical assistance likely account for the lack of any reported overdose deaths in a SIF.

Both the Vancouver and Sydney evaluations found some positive and no negative effects on the surrounding community. In both cities, there was a significant reduction in observed instances of public injection in the neighborhood. The numbers of discarded syringes and the amount of injection-related litter in the vicinity also declined substantially. In neither instance was there an increase in crime or drug dealing in the vicinity (although in Sydney there was a slight increase in the negligible level of loitering around the SIF.)

A series of surveys in Sydney found that area residents and business owners had experienced a sustained decline in exposure to public injection and discarded syringes following the opening of the SIF. Evaluators sought, but did not find, any evidence that the SIFs had encouraged new drug use or discouraged its cessation.

In theory, SIFs can save public funds by preventing death, disease, and crime, but analysis of costs and benefits has been limited. Fiscal benefits in the form of lower ambulance and hospital utilization have yet to be conclusively documented but may be significant given the evidence that SIFs prevent wound infections and successfully treat large numbers of overdoses on-site.31,51 In spite of their positive results, both the Sydney and Vancouver SIFs are currently threatened with closure because of changes in government leadership.


We have mapped a rocky legal path for SIFs. There is enough evidence of effectiveness to justify state and local health officials implementing SIFs on a pilot basis. A period of careful evaluation and adjustment of protocols would be required to determine how to operate a SIF to optimal effect and, ultimately, whether SIFs represent a good investment of public health resources in any particular community.

If SIFs are to be tested in the United States, state authorization is desirable if not absolutely necessary, and would itself be a political challenge. Once approved by a state or local government, there would still be the question of winning federal support or at least tacit acceptance. Implementation of SIFs in this country will therefore require careful planning and a sustained political effort. The US experience with syringe exchange programs—as well as the SIF experience in Australia and Canada—suggests that progress will be slow and will depend on:

activists willing to push the agenda, public officials willing to exercise leadership, researchers able to present authoritative findings, and proponents who effectively mobilized resources and worked to build community coalitions, using persistent but nonadversarial advocacy.

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