Supervised Injection Sites Are Coming to the United States. Here’s What You Should Know.
The health risks of IV drug use are extreme — 130 people die from an overdose every day in the United States. The lifetime risk of dying from an opioid overdose is greater than that of a car collision: 1 in 96 versus 1 in 103.
The U.S. government has struggled to control the most recent waves of the opioid epidemic that have killed more than 400,000 people since 2010 (PDF, 198 KB). Other countries have decided to give people misusing intravenous drugs ownership over at least one aspect of their addiction: location.
People use opioids “wherever they can,” said Kathleen Woodruff DNP, ANP-BC, clinical assistant professor at USC Suzanne Dworak-Peck School of Social Work Department of Nursing. “The street, abandoned buildings ... they will find a place to use.”
Intravenous drug use in public spaces like restrooms, parks and pedestrian tunnels isn’t conducive to safe injection or safe communities. Advocates recommend supervised injection sites because they provide a space where those using IV drugs can inject under the supervision of a clinician who is ready to intervene in the event of an overdose.
State legislators in California recently approved a bill to start a three-year pilot program in San Francisco. Colorado and Pennsylvania are not far behind, expressing interest in opening centers in cities like Denver and Philadelphia.
This guide answers common questions about supervised injection sites, ranging from their accessibility to efficacy.
What Is a Supervised Injection Site?
Supervised injection sites are also called safe injection facilities, overdose prevention centers and drug consumption rooms (DCRs). According to Woodruff, who has worked with high-need communities in Baltimore and specializes in HIV and substance misuse, supervised injection sites serve several purposes.
Aside from providing people who inject drugs with safe and medically supervised locations to use drugs, they provide critical services such as case management and medical, social and mental health care.
Some of the services offered include:
Safe Injection Facilities
In this context, “safe” includes a few components.
Sterile supplies. Injection equipment includes syringes, sterile cookers, filters and tourniquets. Facilities that offer these provisions do not supply or inject clients with IV drugs.
Secure environment, free from criminal prosecution. Small, open booths keep clients in view of clinicians. Legally sanctioned facilities are exempt from prosecution for having illicit drugs on the premises.
Lifesaving support. Clinicians on staff are equipped with crash kits to respond immediately to an overdose.
Some injection facilities provide detox management services for clients. When users are ready to begin detox, they have access to clinician-monitored facilities through the process and are paired with counselors and coordinators to facilitate the transition.
Clients can access a range of primary care services at a supervised injection site, including immunizations, wound care, HIV and AIDS testing, pregnancy tests and sick visits.
Referral to Specialized Services
To meet the needs of the populations affected by opioid use, injection centers link to services that can help clients manage social determinants of health like housing, income and community stability. Clients are provided with information about welfare, counseling and legal services in the area.
Often, it is the most vulnerable populations that are disproportionately affected by opioid use and also lack the resources for treatment. Existing centers operate with the goal of addressing the dangers of injection, too.
“When you use a dirty needle, you can get an abscess. You can become septic; you can end up with endocarditis –– an infection of the heart’s inner lining,” Woodruff said. “All of these things are potentially life threatening.”
And although the infection rate varies depending on the type of opioid used, there is still a serious risk of HIV, AIDS and hepatitis C. In 2017, 6 percent of people with HIV cited IV drug use as the source of their disease transmission; many experts believe the number is much higher because of underreporting.
One in 23 women and one in 36 men who inject drugs will be diagnosed with HIV in their lifetime if current infection rates continue, according to a CDC report on HIV and injection drug use (PDF, 185 KB).
As of 2014, injection drug use and HCV rates are at a 10-year high among adults under 40. About 27% of 18-29 year olds admitted into drug treatment admit to injecting opioids, and the HCV rate is 2.0 per 100,000. The injection rate among those in treatment is about 22% for 30-39 year olds, and the HCV rate is 1.7 per 100,000. Go to a tabular version of data about hepatitis C and injection drug use in the United States.
Data from Uniting Medically Supervised Injecting Centre (MSIC) shows that about 70 percent of the drug users who registered at their facility had never accessed a local health center before.
“The full intention of injection sites is to provide an avenue to reduce harm and to connect clients with appropriate services,” Woodruff said.
Even though Woodruff doesn’t see her patients in an injection site, she describes similar conversations to try and direct them toward the safest route possible.
“I make sure that they know about the needle exchange van,” she said. “I ask, ‘Do you have naloxone? Do you know how to use it? Do you know where to get it? Please, make sure you’ve got that.’”
Are Safe Consumption Sites Legal in the United States?
There are about 100 safe injection sites throughout Canada, Australia and Europe. The Netherlands have the most — almost 40 injection sites throughout the country (PDF, 594 KB). But there are currently no sanctioned supervised injection sites in the United States. A December 2017 evaluation of drug consumption facilities discusses an unsanctioned site in the country that operates under the direction of an unnamed agency.
The Expansion of Supervised Injection Facilities Around the World
The first legally sanctioned “drug consumption room” opens in Bern, Switzerland.
More DCRs open in Switzerland, Germany and the Netherlands.
Uniting Medically Supervised Injection Centre (MSIC) opens in Sydney, Australia. It remains the only facility of its kind in the country.
Insite Vancouver opens in Canada and is the first legal supervised drug injection site in North America.
The Supreme Court of Canada rules that safe injection sites are exempt from federal prosecution in Canada v. PHS Community Services Society.
A King County, Washington, opioid taskforce recommends the creation of two safe injection sites in the state.
San Francisco, Philadelphia and Denver are among some of the cities seriously considering safe injection sites. None have been opened yet in the country.
The legality of safe consumption facilities in the United States remains unclear. Much like the legalization of marijuana, states have the power to permit activity at their discretion. However, this can bring states in direct conflict with federal law.
The Controlled Substances Act prohibits the possession of illicit substances and the management of places for the purpose of using a controlled substance. However, the courts can’t rule on whether the law will apply to safe injection sites until one is actually built. And although city and state leaders are sponsoring proposals in more than a dozen locations, warnings from the federal government have made it difficult to proceed further.
For now, the United States has needle or syringe exchange programs, which offer sterile supplies and facilitate the proper disposal of used ones. In 2018, the Foundation for AIDS Research counted 320 such programs in 39 states, plus the District of Columbia and Puerto Rico. Unlike injection sites, these programs do not provide a space for clinicians to monitor users.
What Are Supervised Injection Sites Like?
Carrie Stefanson, public affairs leader at Vancouver Coastal Health, described what the typical experience is like for a client at Insite, the first legal supervised injection site in North America:
- Clients sign in at the front desk using a consistent identifier. This doesn’t have to be a state-provided ID or driver’s license, just something that the client will use for every visit to provide some sort of history — a name will suffice. Admission prerequisites vary from injection site to site, worldwide (PDF, 594 KB). At Australia’s Uniting MSIC, for example, clients must be 18 or older, cannot be pregnant, and must agree to not sell drugs on the premises.
- In the reception area, clients wait their turn to be called back to the injection space. Stefanson said that although Insite supervises an average of 415 injections a day, there usually isn’t a long wait.
- Staff buzz clients into the back, a secure space where they receive supplies and are directed to one of 13 booths. Each is in open sight of the space and has a large mirror so clinicians can see everything (pictured below).
- After clients inject themselves, they enter the “chill room,” a lounge where they can wait a few minutes before leaving.
A row of open injection booths line the walls at Insite Vancouver, a safe consumption site in Canada. There are 13 booths in this facility. Photo courtesy of Vancouver Coastal Health
Every injection booth at Insite Vancouver is identical. Small partitions on the side of a countertop provide privacy and a large mirror lets clinicians see everything. Photo courtesy of Vancouver Coastal Health
Do Supervised Injection Sites Work?
Supervised Injection Sites Around the World
Worldwide, there are about 100 legal supervised injection sites, which are locations where people who use illicit intravenous drugs can do so under medical supervision. As of September 2018, zero deaths have been reported at any site. But what else do we know about them?
Contact Netz in Berne, Switzerland
- Opened in 1986
- About 200 injections a day
- First legal supervised injection site in the world
Uniting MSIC in Sydney, Australia
- Opened in 2001
- About 180 injections a day
- 12,000 referrals for other forms of care accepted by clients
- 15,400 clients since opening
Insite Vancouver in Vancouver, Canada
- Opened in 2003
- About 415 injections a day
- 3.6 million supervised injections since opening
- 3,708 primary care interventions in 2017
- 6 overdose interventions a day
Oslo Injection Room in Oslo, Norway
- Opened in 2005
- About 90 injections a day
- 295 overdose interventions in 2016
- 0.9% overdose risk with every injection
“What the Uniting MSIC does,” Uniting. Accessed March 6, 2019.
“Insite User Statistics,” Vancouver Coastal Health, 2017. Accessed March 4, 2019
“Get to Know Our Story,” Uniting MSIC, 2018. Page 5. Accessed March 5, 2019.
Schatz, Eberhard and Nougier, Marie. “Drug consumption rooms evidence and practice,” (PDF 594 KB) International Drug Policy Consortium, June 2012. Accessed March 12, 2019.
“Alternative to Public Injecting,” (PDF 4.9 MB) Harm Reduction Coalition, 2016. Pages 8-9. Accessed March 13, 2019.
A major component of the debate regarding supervised injection sites is whether or not they are effective in reducing disease and death. What effects do they have on drug users and the communities that host them?
Research into the efficacy of supervised injection sites is ongoing. So far, there is little empirical evidence that suggests these sites do more harm than good. A 2017 review of evidence on injection sites (PDF, 1.5 MB) found encouraging results but recommended evaluating potential success with caution. A 2018 meta-analysis questioning the benefits of safe injection sites was retracted for flawed methodology.
Every community is different; sites should be proposed and monitored thoughtfully for the greatest benefit.
For IV Drug Users
Data shows that overdose preventions are incredibly effective — as of September 2018, news outlets reported zero deaths at a safe injection site. That success extends beyond the walls of the facilities.
A study on overdose mortality in Vancouver found the fatal overdose rate in the area around the Insite injection facility decreased by one-third after it opened. The rest of the city saw a 9 percent drop.
Woodruff said increased contact with users comes with opportunities for clinicians to direct patients toward care.
“You’ve built up a rapport of making them safer; they feel able to talk to you,” she said. “You are available when they’re ready for treatment to get them into the appropriate type of care.”
Many supervised injection facilities promote the use of rehabilitation and methadone treatment among users; the facilities introduce patients to more than just drug-related care. A 2014 literature review found that interaction with a supervised injection facility also increased interaction with primary care services.
For the Community
Stefanson said that when Insite opened “there were concerns that it would increase crime, but that has not been borne out.”
Another common concern that hasn’t been proven in research is that safe injection sites will encourage people to use and do so more frequently. Indeed, the successes of facilities means they operate with continued community support — Uniting MSIC claims a 70 percent approval rating from local businesses (PDF, 918 KB) and 78 percent from residents.
Woodruff points out that reductions in overdoses relieve a burden on community resources. Emergency room visits, ambulances and emergency overdose treatments all cost time and money. The same data from Uniting MSIC shows that ambulance calls in the area dropped 80 percent after it opened. In the three months following Insite’s opening, the number of publicly discarded syringes and injection-related litter found dropped by about half, according to a 2004 study of Insite Vancouver.
Despite the success of Insite, Stefanson notes that supervised injection centers are doing the best they can with a harsh reality.
“People are going to be using drugs. We know that. And they may use them in public spaces,” Stefanson said. “The idea is that this is a safe space to use.”
The following section contains tabular data from the graphic in this post.
Hepatitus C and Injection Drug Use in the United StatesReturn to infographic
HCV Rate (cases per 100,000)
|Year||Among 18 to 29 year olds||Among 30 to 39 year olds|
Percent of Admissions into Drug Treatment from Opioid Injection
|Year||Among 18 to 29 year olds||Among 30 to 39 year olds|
Citation for this content: Nursing@USC, the online FNP program from the University of Southern California