Close the bathroom door at Supportive Place for Observation and Treatment (SPOT), and you have two minutes and 50 seconds. Then the alarm sounds, warning staff to check on the person inside. People sometimes inject drugs in SPOT’s bathroom, just as they do in the bathrooms of Starbucks or McDonald’s. The longer you wait to reverse an overdose, the harder it gets. SPOT, run by Boston Health Care for the Homeless, has had to shorten that window, from five minutes, to four, to three, and now, to two minutes and 50 seconds — even a 10-second margin means life or death.
Many people use drugs far from the clinicians who could save their lives if they overdose. And the drugs they use have become more lethal — fentanyl, a synthetic opioid many times more potent than heroin, is now common throughout Massachusetts. People die within minutes after injection. SPOT cares for people who’ve already used. But, it would be better to have clinicians present during the life-threatening moments of and right after drug use.
Supervised injection facilities (SIFs) would provide people more support and clinical care in those most vulnerable moments. SIFs are facilities where people can use drugs under clinical supervision. None currently exist in the United States (with the exception of one underground SIF), but they’ve operated for years in Canada, Europe and Australia. Advocates and lawmakers in the U.S. want to establish SIFs here, too. They meet a need that facilities like SPOT can't.
SIFs reconnect people with the health care system, and bridge them to other care and programs
I learned about SIFs three years ago and didn’t know what to think. I wondered, how can this be legal? Does condoning drug use really help people? Isn’t there a less extreme, expensive, legally complex and risky fix for this problem? I researched SIFs, as part of my master of bioethics degree, and contributed to a report published by the Massachusetts Medical Society on the ethics, legality and feasibility of establishing a SIF in Massachusetts.
We found that SIFs save lives. Treating overdoses is only one thing they do. SIFs reconnect people with the health care system and bridge them to other care and programs — drug treatment, yes, but also primary care, and housing and food programs targeted at addressing the social determinants of health.
SIFs reduce the spread of communicable diseases — HIV, hepatitis C — by promoting safe injection practices, just as needle exchanges do. They also reduce violence and crime, helping the neighborhoods they’re in. Police can focus on crime, rather than prosecuting substance use disorder, an illness. And SIFs save money, both directly, by avoiding needless ambulance rides and emergency room visits, and in the longer term, precluding the need to treat the HIV and hepatitis C that people might otherwise have contracted.
Public opinion is shifting in favor of SIFs. Data from a new WBUR poll shows that 50% of respondents support SIFs. And many of SIFs’ once-vocal critics, including Boston Mayor Marty Walsh, have become supporters.
But there's a notable exception: U.S. Attorney for Massachusetts Andrew Lelling, who published an op-ed decrying SIFs in The Boston Globe in January. Lelling is a Trump appointee whose nomination didn’t cause immediate outrage — he had, if not bipartisan support, at least bipartisan respect — but that changed recently, when he was accused of being “overzealous, grandstanding, and politically motivated,” after he indicted a sitting Massachusetts judge for not being sufficiently harsh to an undocumented immigrant.
Those critiques — overzealous and grandstanding — apply to his position on SIFs, too. People learning about SIFs for the first time look for arguments for and against them. Lelling's platform gives him credibility in that conversation, and he misuses it to malign SIFs.
Lelling joins other vocal opponents in criticizing SIFs on three grounds: He claims they’re ineffective, illegal and morally wrong. I’ve already addressed the first of those arguments.
To the legality point: Yes, SIFs are currently illegal. But laws change for good reasons. Legalizing SIFs wouldn’t mean throwing out existing drug laws, and those laws exist to criminalize drug trafficking, not to jail people for drug use.
SIF use “reduced overdose mortality by 35%” and “significantly increased access to drug treatment."
At the core of the anti-SIF argument is a moral injunction: “Injection sites normalize intravenous drug abuse, encourage a horrible addiction and let down the people who suffer from it,” Lelling wrote. That mindset follows from a common misconception: that abstinence is the only way to treat a substance use disorder. But harm reduction approaches, such as needle exchanges and SIFs, are ethically justifiable, evidence-based types of care that meet people where they are. Harm reduction works; purely abstinence-based approaches don’t. In Vancouver, Canada — the location of the world's best-studied SIF, Insite -- SIF use “reduced overdose mortality by 35%” and “significantly increased access to drug treatment."
Lelling’s views also reflect and perpetuate the stigma that harm reduction fights against. Harm reduction requires seeing people who use drugs as people, not “addicts,” as Lelling writes. “Us,” not “them.” (This is precisely why I use the terms “substance use disorder” and "person who uses drugs," instead of “substance abuse," or "addict,” which perpetuate stigma.)
We know from implicit bias research that we all have innate prejudices, and that’s true of substance use disorder stigma. It’s not a sin to approach SIFs with skepticism at first — that’s a normal reaction. But it is reprehensible — especially if you have Lelling’s platform, and you use it — not to educate yourself about these biases, but to deepen them.
Imagine pouring water into a cracked bowl. The water will leak out — a single crack compromises the entire system. Without SIFs, we have a crack in the continuum of care, at the time of injection. People fall through it.
Repair the crack, and we can keep people alive. They’ll gain access to the full spectrum of services — needle exchanges, medication-assisted treatment, counseling, interventions addressing the social determinants of health and more. SIFs aren’t a freestanding solution. They’re a component of a linked system of care.
SIFs can hold the system together, by keeping people alive to use it.