Joe McKenna (Winner of the First Year Category)
Expanding the Research on Safe Injection Sites and Harm Reduction Services
Safe Injection Sites (SIS) were first implemented as a response to the growing opioid epidemic in Berne, Switzerland, in 1986 and continued to be implemented into more countries (Hedrich et. al. 307). SIS provide a supervised, sterile environment for people who inject drugs (PWID) and were meant to be “[complementary] to other harm reduction measures” (Potier et. al. 49). The goal of harm reduction is to “[minimize] harms related to substance use and sexual activity” (BC CDC para. 2). Studies conducted to evaluate the impact of SIS have largely found positive results in reducing harm (Potier et. al. 65), but the studies have been limited in the factors they evaluate and their overall scope (Caulkins et. al. 2110). Therefore, we ought to establish more SIS, in a variety of different settings, in order to determine if SIS are the most effective form of harm reduction.
The research done on SIS has resulted in three main groups. The first group are those who oppose SISs, and other harm reduction services (such as syringe exchanges or naloxone distribution), on the principle that they condone drug use and abuse (Potier et. al. 49). For example, in 1999, the International Narcotics Control Board (INCB) stated, “any national, state or local authority that permits the establishment and operation of drug injection rooms or any outlet to facilitate the abuse of drugs (by injection or any other route of administration) also facilitates illicit drug trafficking” (qtd. in Potier et. al. 49). The second group also opposes SIS; however, this is primarily based on the fact that none of the studies conducted have used a randomized controlled trial (RCT) (Caulkins et. al. 2110). Without the use of any RCTs, they believe it is impossible to determine that there are no negative effects from implementing SIS (2110). Lastly, the third group does believe in establishing more SCS (Safe Consumption Sites). Caulkins et. al. describes them this way: “[they note] that people are dying on the streets but not one has died from an overdose in an SCS, so immediate expansion is imperative and anything less is immoral” (2110). The conclusions from each of these groups has merit, but, on their own, they do not paint the whole picture.
When someone is first presented with the concept of SIS, it is likely for them to align with the first group initially. Facilitating the injection or consumption of illegal drugs, in anyway, seems like an acceptance of drug use in general. However, the idea that SIS and harm reduction services condone drug use is not grounded in the current research (Potier et. al. 49). Potier et. al. conducted a systematic review of 75 journal articles about SIS in 2014 (50). They found “no increase in crime, violence or drug trafficking” and “no increase in the local number of PWID,” two of the largest indicators of an increase of drug acceptance (63). Instead, the primary reason for this group’s opposition is a result of their stigma toward drug users, not the results of research. This sentiment was echoed by Saskatchewan’s Addictions Minister Everett Hindley in 2021 in an interview: “There is a stigma associated with drug use and we’re working hard to try and change the conversation” (Taylor para. 25). Kennedy-Hendricks et. al. conducted a survey in the U.S. in 2014 to see how people view individuals with prescription opioid use disorder (OUD) (463). They found a correlation between a person’s level of stigma toward an individual with OUD and their “support for punitive policies” (465). The greater a person’s stigma, the more likely they were to support punitive policies rather than “health-oriented policies” (465). The notion that SISs and other harm reduction services condone drug use or facilitate drug trafficking is founded in stigma and not supported by research. However, it is important to note that this group is asking good questions about what impact a SIS may have on their community, and they likely reject the idea of SIS because they are unaware of the research supporting SIS.
Though the first group is expressing understandable fears, their argument against SIS is lacking evidence, unlike the second group’s argument. This group is not opposed to harm reduction strategies, nor even necessarily SIS. Rather, they believe that the gaps in the research on SIS is large enough that we cannot safely say there are no harmful effects of SIS (Caulkins et. al. 2110). Without this assurance, they believe there is little to no justification for increasing the use of SIS (2110). We can see why they think this look back at Potier et. al.’s review of 75 journal articles studying SIS. 85% of those articles were done on the SIS in Vancouver and Sydney (68% and 17% respectively) (50). 85% of the research coming from just two sources is a problem, especially since those two sources are both major cities. The opioid/overdose epidemic is not just affecting cities, but it “affects a wide swath of urban, rural and suburban denizens” (Caulkins et. al. 2113). With such a narrow focus in the research, it makes it difficult to ascertain what affect SIS have on a global level. Also, while intended consequences have been studied (crime rates, PWID rates, etc.), there are some important unintended consequences yet to be researched. Caulkins et. al., in their cost-benefit review of available SIS literature, had this to say about unintended consequences: “However, none reported on possible unintended consequences, such as prolonging drug-using careers, reducing local property values or normalizing drug use in the eyes of youth” (2111). And lastly, the research comparing the effectiveness of SIS to other harm reduction services, or even what part/s of SIS work, is also lacking (2111). From Caulkins et. al. again, “many other interventions also pass that [benefit-cost] test, including medication treatment, syringe exchange and naloxone” (2111). All of these arguments are true, yet it is difficult to dismiss all of the research completely. The current research shows that something about SIS is working, and if we want to save more lives, we ought to figure out what it is that is working.
The previous group’s argument is heavily based on the statistics and data, but this final group’s argument is grounded more in a moral imperative than anything else (Caulkins et. al. 2110). A lot of people are suffering and dying from drug overdoses; in 2019, the number of drug overdose deaths had “quadrupled since 1999” in the U.S. (U.S. CDC para. 1). This death and suffering requires us, morally, to do something to help. Since people are not dying from overdoses in SIS (Potier et. al. 62), this group would say that we should be using them everywhere as soon as possible (Caulkins et. al. 2110). While morally this makes sense, the biggest issue with rapid expansion of SIS is that running an SIS is expensive (Caulkins et. al. 2111). The Insite SCS in Vancouver supervised around 150,000-200,000 drug use episodes a year with an “operational cost of [CAD] $3 million in 2008” (2111). According to Caulkins et. al., if we wanted to expand SCS service to the whole of the U.S., it “would require on the order of 7000 Insite-like facilities and probably cost more than $10 billion [USD] per year to operate” (2111). This estimate does not even account for the increasing use of fentanyl or expanding services to other drugs (2111). Now, if we could say for certain that SIS are the most effective harm reduction service and that they have no harmful effects, then the cost of implementing them becomes negligible when compared to the loss of life if not implemented. But we cannot say this with any kind of certainty. However, this fact does not discount the moral imperative that we do have in trying to prevent the loss of life and wellbeing of all humans. We have to do something, and SIS are preventing overdose deaths with no currently observed harmful consequences.
So, in order to satisfy both the data and our moral imperative, we ought to expand SIS, along with other harm reduction services, to further the research in pursuit of determining the most effective harm reduction service. All of the groups share valid concerns in how to best address the opioid epidemic. An epidemic that has already caused an immense amount of suffering, and will continue to do so, if we do not do something. By discovering the best harm reduction practices, we have the potential of making a real impact in reducing the amount of suffering caused by this epidemic. The potential to save lives that would otherwise not have a chance.
BC CDC. “Harm Reduction Services.” BC Centre for Disease Control. Provincial Health Services Authority. Last modified 2022, http://www.bccdc.ca/our-services/programs/harm-reduction#About.
Caulkins, Jonathan P., et al. “Supervised Consumption Sites: A Nuanced Assessment of the Causal Evidence.” Addiction, vol. 114, no. 12 (2019), pp. 2109–2115., https://doi.org/10.1111/add.14747.
Hedrich, Dagmar, et al. Harm Reduction: Evidence, Impacts and Challenges. Office for Official Publications of the European Communities, Luxembourg (2010), pp. 305–331.
Kennedy-Hendricks, Alene, et al. “Social Stigma toward Persons with Prescription Opioid Use Disorder: Associations with Public Support for Punitive and Public Health–Oriented Policies.” Psychiatric Services, vol. 68, no. 5 (2017), pp. 462–469., https://doi.org/10.1176/appi.ps.201600056.
Potier, Chloé, et al. “Supervised Injection Services: What Has Been Demonstrated? A Systematic Literature Review.” Drug and Alcohol Dependence, vol. 145 (2014), pp. 48–68., https://doi.org/10.1016/j.drugalcdep.2014.10.012.
Taylor, Stephanie. “Province Rejected Funding despite Advice Drug Consumption Sites Save Lives.” CBC News. Last modified April 6, 2021, https://www.cbc.ca/news/canada/saskatchewan/advance-consumption-sites-funding-1.5976434. Accessed April 17, 2022.
U.S. CDC. “Understanding the Epidemic.” Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. Last modified March 17, 2021, https://www.cdc.gov/drugoverdose/epidemic/index.html. Accessed April 16, 2022.