Boston’s only needle exchange program has a clear bathroom policy. Sarah Mackin, the program’s director, designed a system where each person that uses the restroom gets three minutes. Once the outside timer goes off after three minutes, a volunteer or employee of the program pounds the door three times and asks, “Are you alright?” If there’s silence, the team explodes into the bathroom. Silence means there’s a possible overdose.
Many clients, most of which are homeless, inevitably use the restroom because it’s illegal for them to inject drugs within the facility. That’s not the case in Canada, Australia and several European countries, which allow drug users to inject while supervised by licensed healthcare providers. Those countries have opened safe injection facilities to combat drug overdosing, drug trafficking and promote safety. A number of scientific studies have demonstrated the efficacy of such programs. The United States does not have a single safe injection site. However, in response to the opioid crisis, some cities in the U.S. are working to introduce the country’s first safe injection facilities.
Safe injection facilities were first introduced in Europe in the mid 80s and 90s. Cities in Germany, Switzerland and the Netherlands had developed safe injection facilities not only to reduce the number of overdose deaths, but also to reduce HIV and hepatitis C transmission and encourage contact with healthcare staff who could help drug users seek treatment programs. The first safe injection facility in North America opened in Vancouver, Canada in 2003 with the same goals. It worked: a 2014 meta-analysis of studies of safe injection facilities found that they reduced the rate of overdoses in areas with such facilities. Vancouver’s safe injection site reports an overdose rate of 1.3 per 1000 injections in the city, but the presence of a medical staff likely explains the fact that there still hasn’t been a single overdose death on site. According to a review in the American Journal of Public Health, safe injection sites in Vancouver and Sydney, Australia have shown a significant reduction in observed instances of public injection and discarded syringes in their neighborhood. Nor did the presence of safe injection sites increase crime or drug dealing in the areas.
The closest thing to a safe injection facility in Boston has long been a bathroom in South Boston next to Boston Medical Center. Addicts Health Opportunity Prevention Education, or AHOPE, runs the needle exchange program to provide drug users with clean needles to reduce the spread of HIV and Hepatitis C infection. They also work to prevent fatal and nonfatal overdosing by handing out Narcan, a medication that’s used to reverse narcotic overdoses.
AHOPE’s three-minute policy has usually provided an ideal length of time to allow anyone some respectable privacy without a great concern for an overdose going unnoticed. Since the recent emergence of fentanyl, a highly potent opioid, people have been overdosing in shorter times. In the past year in Massachusetts, 70 to 80 percent of the total 1,600 opioid related deaths had fentanyl present.
Mackin remembers an instant, for her, that clearly demonstrated the effects of fentanyl and a possible reason for the country to start developing safe injection facilities. A few months ago, Mackin had let a client use AHOPE’s restroom. After 30 seconds passed, the client’s friend came by and knocked on the door.
“Bro, he just went in. Just give the kid a couple of minutes” Mackin said. “We’ll take care of it.”
The friend knocked on the door again and gave a “heeey.” Mackin suspected something was wrong. She asked the friend if he had been getting answers from the client in the bathroom. Once Mackin heard “no,” she blasted into the bathroom and found him completely blue.
“In 30 seconds, complete respiratory arrest,” she said. “I could not count on all the fingers and toes, and then some, the amount of fucking overdoses I have reversed. I’ve never seen anything like it.”
Mackin gave him rescue breaths while her colleague grabbed Narcan to reverse the overdose as someone else dialed 911. He survived the overdose.
In response to the high frequency of clients overdosing in AHOPE’s bathroom, the Boston Health Care for the Homeless program opened a not-for-profit safe room for drug users to ride out highs while supervised by health professionals, although they’re not permitted to inject on the spot. The safe room, Supportive Place for Observation and Treatment, or SPOT, is located adjacent to AHOPE and contains eight reclining chairs, medical devices that monitor vital signs and a supply of oxygen, IV fluids and Narcan. In just the first 4 months, the center had over 983 encounters with 218 unique individuals.
Safe injection sites, a somewhat counter-intuitive concept, has certainly had its share of criticism. Dr. Christopher Shanahan, Assistant Professor at Boston University School of Medicine, specializes in substance abuse and believes the core issue is stigma.
“They don’t want those people in our neighborhood because they are dirty, nasty, unworthy low-life people. The truth,” Shanahan said, “is that they’re no different than anybody else. They have a drug use disorder that drives their brain to do bad things.”
That stigma can be as outwardly apparent as Missouri State Senator Rob Schaaf’s comment that when people die of overdoses, that “just removes them from the gene pool.”
Others, like Ron Hill, a community organizer in Boston and a recovering drug user of 30 years, believe that safe injection facilities prolong the addiction. He advocates for treatment through abstinence because nothing, including substitution treatments such as methadone and buprenorphine, had worked for him except for a 12-step recovery program with Alcoholics Anonymous.
Some health care practitioners within health care are also against safe injection facilities. Brianne Fitzgerald, a registered nurse practitioner, published an Op-Ed in the Boston Herald in February of this year expressing her concerns about the enabling power of safe injection sites. Even though studies from other countries have demonstrated that safe injection facilities reduce rates of overdoses, Fitzgerald subscribes to an abstinence philosophy with a combination of substitution treatments. She believes injection sites encourage drug use instead of stopping it.
Dr. Jeffery Samet, the chief of general internal medicine at Boston Medical Center and a primary care physician, has a more pragmatic view than Fitzgerald. He sees the value of substitution treatments, such as methadone and buprenorphine, as a path for drug users to eliminate their dependency on illegal opiates. His views about needle exchanges and safe injection sites are that they are important strategies that address concerning outcomes of drug addiction—the spread of communicable diseases and death.
“I’ll take whatever works,” he said. “I want the problem to either go away or mitigate its consequences.”
The ultimate goal for facilities like AHOPE and SPOT is to save lives and reduce the spread of infections like HIV and Hepatitis C. Mackin says these facilities do not condone drug use, but they do abide by a harm reduction philosophy. She describes the philosophy as a notion that drug users who are not ready or willing to receive addiction treatment services should have access to resources for safe drug use. Clean needles, a safe place to ride out a high, or a safe injection facility helps reduce harm to individuals with a drug addiction. Mackin considers these tools to be necessary for an urban patient population to avoid drug use in dangerous environments where there is a higher risk for infections or death.
There is a wall at the AHOPE facility that is covered, like wallpaper, with photos and obituaries of people who have recently died of drug overdoses. Mackin knows that it’s dangerous to wish and hope each person who comes in will get treatment and improve their quality of life. Occasionally, someone comes in and tells her that they can’t live this way anymore and that they need help.
“There’s a guy who has been coming in every single week, almost every day, and has a really really long rap sheet, a lot of trauma in his life,” Mackin said. “I’ve been trying to get him a job. And he just called me to tell me that he got a job. If you don’t believe me, I’ll fuckin’ let you listen to the voicemail. I just got it. And he’s so happy.”
Mackin plays the voicemail for me.
“Hey what’s goin’ on Sarah, this is Chris calling. Hey Sarah I got some good news. I got a job. It was that restaurant that we googled earlier.”
She stops the recording.
“This is a huge leap forward despite all the set backs and despite the fact that he has no idea how to navigate the system,” Mackin said. “He’s just been pounding pavement and he’s strong and he hasn’t given up and he’s done really really well. He’s overdosed many times. Many times we thought he was dead. I think I probably Narcaned him myself, but he’s still going.”