Supervised Injection Facilities: Combating an Epidemic

Gabe Magee (PO ‘20)

Currently an opioid epidemic is ravaging the Northeast and Midwest areas of the United States, taking almost 13,000 lives by overdose in 2015, an increase from 8,000 in 2013.[1][2] This increase in deaths is part of a rapid and troubling upward trend — a 244% increase in deaths from 2007 to 2013.[3] On top of these sobering figures, authorities are likely to underreport deaths from heroin overdose due to variations in state reporting procedures, as well as the high likelihood of authorities misattributing heroin overdoses to morphine overdoses.[4] Federal agencies like the DEA, that recognize the serious threat posed by heroin in their 2015 annual report, and the American public in general, are taking notice of troubling nature of increasing death tolls. The epidemic has been gaining prominence, even being fielded as a question during the 2016 election. While experts have produced a myriad of solutions, one of the most novel solutions holds a lot of promise — Supervised Injection Facilities, or SIFs. SIFs are sanctuaries for heroin addicts to legally and safely inject under the supervision of medical personnel. Theoretically, the environment not only provides safer needles and substance, but also has staff on site to educate addicts on safer techniques and to increase patients’ access to resources that will eventually help them break free from their addiction. While this solution may seem hopeful for compassionate drug policy advocates, currently SIFs are illegal in the United States, and will likely be the source of a large legal battle between the federal and state government, as the federal government enforces its will through the regulation of commerce clause of the constitution, and the states, in their efforts to take care of the health and welfare of their citizens. Because of this shaky legal status, currently no facilities exist in the U.S., but as many as 74 exist in Switzerland, Germany, the Netherlands, Norway, Luxembourg, Spain, Denmark, Australia and Canada.[5] Existing facilities have shown great success in reducing the likelihood of overdose dramatically in the surrounding area, as well as eventually integrating addicts into drug treatment. [6] Among some of the more impressive results, due to staff supervision, there have been zero recorded fatal overdoses at SIFs around the globe.

States where the Heroin Epidemic is strongest should consider legalizing, implementing, and operating SIFs in areas that are the most affected by the crisis, using the legal precedent of Marijuana as a way to circumvent the federal restriction of heroin in the United States.

The Success of SIFs Overseas:

Since 1986, SIFs have shown to drastically reduce overdose rates and possibly lead to reduced rates of addicted individuals in the surrounding areas. Overdoses occurring at SIFs are extremely less likely to happen for a multitude of reasons. According to a report published by the European Monitoring Centre for Drugs and Drug Addiction, this is due to the combination of “trained personnel who are able to give advice on dosage and application technique, house rules that exclude high-risk drug combinations (especially alcohol consumption) and which allow for unhurried conditions of drug consumption, as well as the availability of emergency services on-site or on call” to reduce risk.[7] These practices create an environment where addicts are less likely to feel stressed or rushed and subsequently use unsafely.

While they themselves do not explicitly try to treat addiction, SIFs expose addicts to safe environments where they can get education and introduction to social services.[8] Many eventually do get help with their addiction, likely because SIFs “act as a link to the wider system of care, facilitating access to treatment.” [9] Clients are often referred to drug treatment services such as social assistance service, detoxification, and therapy. In the SIF located in Sydney, Australia, staff provided 1,385 referrals to 577 clients over a 18-month period, with approximately one for every 41 client visits. In facilities in Germany, 54% of surveyed users reported that they had been referred, with an average of 1.5 referrals per patient. In the SIF located in Geneva, 276 referrals were reported among 736 registered service users. The study concluded that the availability of these services eventually served their purpose without creating pressure to use them, stating that “Only a small proportion of clients use the facilities for drug consumption purposes only. The majority at some point make use of other medical, counselling and treatment services.”

Critics of SIFs argue while these facilities may make heroin safer, they may work too well by removing all incentives to not use heroin. They argue that by creating a safety net around the drug, the government is coddling addicts or even reducing risk for potential users through SIFs. Empirically however, according to a study of the over 70 SIFs across the globe, the presence of SIFs has no meaningful increase on the use of heroin because the distribution is heavily regulated.[10] The study cited no correlation in heroin-consumption trends in areas with SIFs, emphasizing the lack of evidence that “consumption rooms encourage increased drug use or initiate new users. There is little evidence that by providing better conditions for drug consumption they perpetuate drug use in clients who would otherwise discontinue consuming drugs such as heroin or cocaine, nor that they undermine treatment goals.” There have been no studies concluding that SIFs perpetuate drug use in clients who would otherwise discontinue consuming drugs or that SIFs undermine treatment goals.

Implementation of SIFs in the United States

SIFs are a measured and reasonable response to the heroin epidemic in the United States. Such “compassionate” measures that seek to lift addicts out of the grip of addiction rather than impose punitive measures upon them are gaining ground after public perception of the war on drugs has shifted negatively. The idea of SIFs could not come at a more opportune time. As previously stated, currently an epidemic of heroin overdoses exists in the U.S. heroin-related deaths have quadrupled since 2010. 12,989 people died of heroin overdose in 2015. Overdose death rates rose by 20% from 2014 to 2015.[11] Not only is the public growing ever more wary of the meteoric threat that the heroin epidemic poses, but elected officials in affected areas are listening to their constituents. Svante Myrick, the mayor of Ithaca, New York, proposed the implementation of a SIF in his city in February 2016.[12] Myrick’s initiative to help his city shows promise that politicians are beginning to open up to this promising albeit controversial plan in areas hit hard by the epidemic.

While these facilities have shown at the minimum some moderate success, it can be argued that they are located in areas that are just too culturally different than or not as sparsely populated as the United States. The taboo that exists surrounding drug use is very real in the United States compared to Europe.

Since no SIFs exist in the United States, there are no true ways to evaluate the effectiveness of them in an American society with American demographics. However, just under 25 miles from the U.S. border, a successful SIF operates in Vancouver. The fatal overdose rate within the immediate vicinity of the facility dropped by 35% and dropped by 9% in the broader Vancouver area at large. Additionally, 75% of patients changed their injection practices after using the facility. “Among these individuals, 80 percent indicated that the SIF had resulted in less rushed injecting, 71 percent indicated that the SIF had led to less outdoor injecting, and 56 percent reported less unsafe syringe disposal.”[13] While it would be erroneous to assume that Canadian and American society are identical, it cannot be discounted that they share many similarities. The only true way to determine whether SIFs would be effective in America is to implement them and compare to SIFs around the globe.

Illegality of SIFs, and a path to legality

All of this is being said, there has been little legal area for SIFs to operate.As it stands, the United States government currently outlaws the use, sale, distribution, and possession of Heroin on a federal level through the Controlled Substances Act of 1970.[14] Heroin is classified as a schedule I substance, which means that it is considered to have not only “a high potential for abuse” but also “a lack of accepted safety for use of the drug or other substance under medical supervision.”[15] Specifically, there are at minimum two sections that could be wielded to shut down SIFs authorized by any states – Section 844, which prohibits drug possession, and Section 856, which makes it illegal for anyone to “knowingly open, lease, rent, use, or maintain any place… for the purpose of manufacturing, distributing, or using any controlled substance.”[16]   The most notable case is United States v. Oakland Cannabis Buyers’ Cooperative, in which the Supreme Court ruled that the Buyers’ Cooperative could not uphold the common-law medical necessity defense to their crime of the distribution of medicinal marijuana even though medicinal marijuana had been legal in California since 1996. In the majority opinion, Justice Thomas wrote that in regards to “marijuana (and other drugs that have been classified as “schedule I” controlled substances, there is but one express exception, and it is available only for Government-approved research projects, § 823(f). Not conducting such a project, the Cooperative cannot, and indeed does not, claim this statutory exemption.”[17] Since Heroin is also a schedule I substance, this spells bad news for SIF advocates.

Even though the Controlled Substances Act makes it incredibly hard for any states hoping to implement SIFs to combat the threat of a heroin addiction epidemic, an article in The American Journal of Public Health maps out a path for states that so wish to implement SIFs.[18] The article emphasizes that SIFs could be pursued on a pilot basis, requiring not only sustained political effort by state lawmakers, activists, and researchers but also at the bare minimum untroubled operation from the federal government – functionally ignoring the Controlled Substances Act. While the article was published well before the recreational legalization of Marijuana, there is precedent for the circumvention of this statute in the legalization of both medicinal and recreational marijuana. Much like SIFs, legal sale and use of cannabis on the state level is in direct contradiction of the Controlled Substances Act. Just like heroin, marijuana is a schedule I substance, and treated with the highest amount of restriction. However, despite this, 7 U.S. states and the District of Columbia have legalized recreational marijuana, and 36 further states, as well as Guam and Puerto Rico have legalized it medicinally in some form. Currently the legal battle between the federal government and the states seems headed toward a confrontation, especially after Attorney General Sessions expressing his disdain against marijuana.[19] Lawmakers who seek to implement SIFs should look to the bills and statutes of the states that have legalized recreational marijuana, such as those of Massachusetts – coincidentally a state also heavily affected by the heroin epidemic.[20] In the “Regulation and Taxation of Marijuana Act,” Massachusetts lawmakers lay out the official stance of enforcement of federal law by the commonwealth: “A contract entered into by a licensee or its agents as permitted pursuant to a valid license issued by the commission, or by those who allow property to be used by a licensee or its agents as permitted pursuant to a valid license issued by the commission, shall not be unenforceable or void exclusively because the actions or conduct permitted pursuant to the license is prohibited by federal law.”[21] This law is extremely recent, and has yet to have any legal challenges, but future challenges could serve as a precedent for granting SIFs some protection from federal law enforcement by the states.

Additionally, in the same case where the Supreme Court ruled that the necessity defense for medicinal use of marijuana does not supercede the federal statute of the Controlled Substances Act, the court also noted that “as a policy matter, (whether) an exemption should be created is a question for legislative judgment, not judicial inference,” noting that legalization matters would have better luck if they were taken to Capitol Hill instead.[22]

Even though the Controlled Substances Act gives authority to the federal government to prosecute marijuana users, recreational marijuana is still alive and well in states which have legalized it. The reason why authorities haven’t focused their efforts on these state-legal users can be attributed to a memorandum sent out by Deputy Attorney General David Ogden to select United States Attorneys in 2009, in which the Attorney General’s office set the Department of Justice’s priority away from “individuals whose actions are in clear and unambiguous compliance with existing state laws providing for the medical use of marijuana.”[23] However, the memo also makes it clear that it “does not “legalize” marijuana or provide a legal defense to a violation of federal law.” This memo may prove as the best precedent for how the federal government treats the legalization of scheduled substances by the states. The success of legal cannabis, and by extension SIFs, may well end up at the discretion of the Attorney General and the Department of Justice as medicinal and recreational marijuana is for the time being.

Review:

Heroin-ravaged states should try to implement SIFs on a pilot basis as a compassionate tool in the fight against heroin addiction in the United States. Through their implementation around the globe, they have shown to produce meaningful results in in health, in the reduction of overdose death rates in the surrounding area. Additionally, by introducing addicts to a social services net, SIFs lift those afflicted out of the cycle of addiction and back into productive society. While there may be cultural and demographic differences between the United States and European countries, nearby Vancouver, Canada implement the SIFs with similar amounts of success. Although SIFs would be deemed illegal through the Controlled Substances Act if implemented now, state lawmakers implementing SIFs may take a similar path as lawmakers who implemented marijuana.

While lawmakers should not consider one strategy to be a catch-all, end-all solution to the ever-more-dangerous threat that is the heroin epidemic, supervised injection facilities are certainly one of the most promising path that state governments can take to fight against it. While currently federal law does explicitly prohibit the use of these facilities, the precedent set by state marijuana legalization allows a way for states to implement them. The empirical evidence gained from the dozens of locations around the world show that supervised injection facilities produce meaningful change – something desperately needed to reverse the tragic trend in American communities. However, the ultimate fate of SIFs would lie in the hands of an administration currently hostile to looser drug laws, or courts whose opinions have not yet been heard on broader state-level legalization.

 

 

 

 

Works Cited

Beletsky, Leo, Corey S. Davis, Evan Anderson, and Scott Burris. “The Law (and Politics) of Safe Injection Facilities in the United States.” American Journal of Public Health 98.2 (2008): 231-37. Web.

“The Case for SIFs.” SIF NYC. SIF NYC,   Web. 28 Feb. 2017.

Derespina, Cody. “Mayor Wants to Open Supervised Injection Facility for Heroin in NY City.” Fox News. FOX News Network, 22 Feb. 2017. Web. 28 Feb. 2017.

Dooling, K., and M. Rachlis. “Vancouver’s Supervised Injection Facility Challenges Canada’s Drug Laws.” Canadian Medical Association Journal 182.13 (2010): 1440-444. Web.

Hotakainen, Rob. “Sessions Says Marijuana Should Not Be Sold ‘at Every Corner Grocery Store’.” Miami Herald. Miami Herald, 28 Feb. 2017. Web. 06 Mar. 2017.

United States v. OAKLAND CANNABIS BUYERS’ COOPERATIVE, 532 U.S. 483, 121 S. Ct. 1711, 149 L. Ed. 2d 722 (2001).

David W. Ogden, Deputy Attorney General, “MEMORANDUM FOR SELECTED UNITED STATES ATTORNEYS”, October 19, 2009

Hedrich D. European report on drug consumption rooms. Lisbon: European Monitoring Centre for Drugs and Drug Addiction, 2004.

Drug Enforcement Administration. “National drug threat assessment summary.” (2015).

Derespina, Cody. “Mayor Wants to Open Supervised Injection Facility for Heroin in NY City.”Fox News U.S. Fox News, 22 Feb. 2017. Web. 6 Mar. 2017.

Feyerick, Deb, and Chris Boyette. “‘The Meat and Potatoes’ of Fighting Drugs.” CNN. Cable News Network, 02 Sept. 2014. Web. 6 Mar. 2017.

21, §§ 13-812-856 (1970). Print.

Lee, Kurtis. “What Is the Future of Recreational Marijuana in Trump’s America?” Los Angeles Times. Los Angeles Times, 7 Mar. 2017. Web. 7 Mar. 2017.

Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 26 Jan. 2017. Web.07 Mar. 2017.

“Today’s Heroin Epidemic.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 07 July 2015. Web.07 Mar. 2017.

“Supervised Injection Facilities.” Drug Policy Alliance. Drug Policy Alliance, Feb. 2016. Web. 7 Mar. 2017. <http://www.drugpolicy.org/sites/default/files/DPA%20Fact%20Sheet_Supervised%20Injection%20Facilities%20(Feb.%202016).pdf>.

[1] Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 26 Jan. 2017. Web.07 Mar. 2017.

[2] Drug Enforcement Administration. “National drug threat assessment summary.” p25-39. (2015).

[3] Drug Enforcement Administration. “National drug threat assessment summary.” p25-39. (2015).

[4] Drug Enforcement Administration. “National drug threat assessment summary.” p25-39. (2015).

[5] Dooling, K., and M. Rachlis. “Vancouver’s Supervised Injection Facility Challenges Canada’s Drug Laws.” Canadian Medical Association Journal 182.13 (2010): 1440-444. Web.

[6] Hedrich D. European report on drug consumption rooms. Lisbon: European Monitoring Centre for Drugs and Drug Addiction, p 79, 2004.

[7] Hedrich D. European report on drug consumption rooms. Lisbon: European Monitoring Centre for Drugs and Drug Addiction,p50, 2004.

[8] “The Case for SIFs.” SIF NYC. SIF NYC, Web. 28 Feb. 2017.

[9] Hedrich D. European report on drug consumption rooms. Lisbon: European Monitoring Centre for Drugs and Drug Addiction, p59, 2004.

[10]Hedrich D. European report on drug consumption rooms. Lisbon: European Monitoring Centre for Drugs and Drug Addiction, 2004.

[11] “Today’s Heroin Epidemic.” Centers for Disease Control and Prevention. Centers for Disease Control and Prevention, 07 July 2015. Web.07 Mar. 2017.

[12] Derespina, Cody. “Mayor Wants to Open Supervised Injection Facility for Heroin in NY City.” Fox News U.S. Fox News, 22 Feb. 2017. Web. 6 Mar. 2017.

[13]“Supervised Injection Facilities.” Drug Policy Alliance. Drug Policy Alliance, Feb. 2016. Web. 7 Mar. 2017.

[14] 21, §§ 13 (1970). Print.

[15] 21, §§ 13-812 (1970). Print.

[16] 21, §§ 13-844-856 (1970). Print.

[17] United States v. OAKLAND CANNABIS BUYERS’ COOPERATIVE, 532 U.S. 490, 121 S. Ct. 1711, 149 L. Ed. 2d 722 (2001).

[18] Beletsky, Leo, Corey S. Davis, Evan Anderson, and Scott Burris. “The Law (and Politics) of Safe Injection Facilities in the United States.” American Journal of Public Health 98.2 (2008): 231-37. Web.

[19]Lee, Kurtis. “What Is the Future of Recreational Marijuana in Trump’s America?” Los Angeles Times. Los Angeles Times, 7 Mar. 2017. Web. 7 Mar. 2017.

[20] Feyerick, Deb, and Chris Boyette. “‘The Meat and Potatoes’ of Fighting Drugs.” CNN. Cable News Network, 02 Sept. 2014. Web. 6 Mar. 2017.

[21] “Regulation and Taxation of Marijuana Act,” Section 10, Contracts pertaining to marijuana enforceable

[22] United States v. OAKLAND CANNABIS BUYERS’ COOPERATIVE, 532 U.S. 490, 121 S. Ct. 1711, 149 L. Ed. 2d 722 (2001).

[23] David W. Ogden, Deputy Attorney General, “MEMORANDUM FOR SELECTED UNITED STATES ATTORNEYS”, October 19, 2009

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