Supervised injection facilities (SIFs) are increasingly being discussed in the United States as a way to reduce overdose deaths in the opioid epidemic. Here’s the second article in our week-long debate on SIFs as a harm reduction strategy. Read parts one, three, and four here.
As the opioid epidemic continues to unfurl and claim lives, the Massachusetts Medical Society, composed of around 30,000 physicians and medical students, voted overwhelmingly in late April 2017 to approve the creation of supervised injection facilities (SIFs) in MA. The strong evidence attesting to their efficacy notwithstanding, policymakers and legislators continue to offer ideological arguments against the creation of SIFs. Therefore, this is a timely juncture to unpack some common myths about these facilities which continue to provide fodder for such ideological resistance.
Myth 1: SIFs have not been rigorously studied.
This depends on one’s definition of “rigorous.” The gold-standard in public health research is the vaunted randomized control trial (RCT). The ethical and legal quandaries that would accompany conducting such a study, however, puts it out of the question. The prospect of randomizing injection drug users (IDUs) into groups that are either allowed to access SIFs are not, should give one serious pause – that is of course if one can circumvent the inherent complexity that comes with obtaining informed consent from such beleaguered populations. After all, IDUs are stuck in a vicious cycle where their social circumstances not only enable, but reinforce their drug use. Maher and Salmon aptly express their concern about studying SIFs with an RCT:
The scientific, practical, and ethical issues involved in applying [RCT] methodology to evaluating complex public health interventions such as SIFs mean that the likelihood of obtaining this level of evidence is negligible (emphasis mine).
But that doesn’t mean that there isn’t any evidence. There are numerous observational studies attesting to the efficacy of SIFs. One of the most cited studies in furthering the cause of SIFs was conducted by Wood et al. on Canada’s first, and still only, SIF InSite. By 2004, their cohort was almost 900 strong. Wood et al.’s landmark study found that the site had reached capacity within two months of opening its doors in Vancouver, with an average 500 injection episodes occurring every day. According to their own figures, as of 2015, 12 years after they first opened their doors, and after nearly three-and-a-half million visits and close to 5,000 overdose episodes, there have still been no fatalities at InSite.
Myth 2: SIFs don’t help all individuals living with opioid addiction.
This one is actually true. That said, it still doesn’t take anything away from SIFs.
In reviewing pertinent research and scholarship, nowhere does one find an argument about SIFs being the panacea that will help all heroin users, and consequently prevent all overdose deaths. Arguments of this sort completely betray decades worth of research that belies the categorization of IDUs in rigid binaries. Addiction exists on a broad spectrum, and addict behavior is protean in nature. The aspirations of SIFs are modest: to help IDUs who can’t or are simply unable to cease heroin use, yet still possess the wherewithal to prioritize their safety.
So where does this leave us? Yes, SIFs will not help all individuals living with addiction, nor will they save every life claimed by an opioid overdose. But just because they can’t save all lives, does that mean they should save no lives? Surely the lives that SIFs do save, are worth saving.
Myth 3: SIFs are vehicles for increased drug use.
The evidence points to the contrary. The fact is that SIFs no more promote drug use than they reduce it. In their research published in 2007, Kerr et al. studied over 1000 participants over the course of two years and found that only a single individual had begun injection drug use on InSite premises. Fourteen other individuals started using since the SIF opened, but none of them on premises. Extrapolate this trend upon the entire 5000 strong clientele at InSite, and you only have five individuals who may have begun injection drug use on the premises, and another 70 off of it. If these numbers seem too high for comfort, they pale in comparison to the rate of drug injection initiation among a comparable number of Vancouver street youth: 100 new users per year. Moreover, there is no reason to believe that the 14 aforementioned individuals wouldn’t have begun using had InSite not been in their community. After all, most of their clientele are longtime users who had been injecting for a median of almost 16 years.
Opponents will still argue that even if SIFs don’t promote drug use, they should play a role in reducing it. This, however, is not what they are meant to do. It is quixotic to think that every act of injection drug use can be eliminated. SIFs shed idealism for pragmatism: If drug abuse cannot be eliminated, the next best thing is to make it safer, so that at-risk lives can be saved.
Myth 4: SIFs are nothing more than glorified shooting galleries.
There would be merit to this claim, had SIFs not taken steps to ensure that their clientele are put in touch with a continuum of services. At InSite, for instance, IDUs who express a desire to seek treatment are put in touch with health care professionals at the facility. According to a survey conducted by Poschadel et al. of all German SIFs, more than half the clientele reported being referred to at least one other social service by a staff member.
Myth 5: SIFs delay an IDU’s entry into a treatment program.
The jury is still out on this one. The protean nature of IDU behavior makes this a difficult metric to gauge. After all, IDUs might delay entering a treatment program due to a whole of host of reasons that may have nothing to do with the existence of a SIF in their communities.
DeBeck et al. did, however, conduct a study to investigate the factors associated with cessation of injection drug use at InSite. Over the course of two years, 23% of participants from a cohort of a little over 900, experienced an incidence of cessation. Within the same period, almost 60% of individuals entered addiction treatment. Even though the results are encouraging, there are caveats: One must bear in mind that addiction is a “chronically lapsing condition,” and that cessation is being considered in a very short frame of time. Therefore, it is difficult to posit whether or not the results are representative of IDU behavior in a longer frame of time.
There is no question that the argument for the creation of SIFs is gaining momentum, particularly in the Commonwealth of Massachusetts. Moving forward, one can expect both advocates and opponents to make strong arguments for their positions – a part and parcel of the democratic process. For its role, public health must ensure that these arguments are grounded in evidence and not ideological myths. The stakes are simply too high.