Paul Harkin on what you need to know

This month, Barbara Garcia, director of San Francisco’s Department of Public Health, announced that the city was looking to pilot two Safe Injection Sites (SIS) for intravenous drug users as early as July 1. This announcement comes amid a spiraling opioid crisis that has encouraged many city leaders across the U.S. to consider adopting some of the evidence-based approaches already working in other countries. Locally, Director Garcia’s announcement comes less than a year after the Board of Supervisors created a task force to investigate the feasibility of operating such sites in San Francisco. The task force’s findings strongly supported the idea.

With Director Garcia’s announcement, San Francisco is now poised to be the first city in the country to open a SIS. This development has great significance for the people and communities GLIDE has long served. In their outreach work throughout the Tenderloin, GLIDE’s Harm Reduction team is literally on the front lines of the opioid epidemic. Given the recent developments, we are reposting excerpts from an earlier interview with Paul Harkin, manager of GLIDE’s Harm Reduction Services, who speaks to the scope of the problem and to the arguments in favor of Safe Injection Sites (also known as Supervised Consumption Services) as a viable, compassionate and rational approach.

Visitors made signs about why they support SIS and spoke with harm reduction professionals from GLIDE and St. Anthony’s at January’s Four Corner Friday in the Tenderloin.

Paul Harkin advocating for Supervised Injection Services with St. Anthony’s at the January 2018 Four Corner Friday.

How has GLIDE been involved in the move toward opening Safe Consumption Services locally?
We’ve been involved in meetings in the Tenderloin that have been about creating a healthier Tenderloin, which includes drug users as well as members of the public who don’t want to see syringes discarded or see anybody shooting up on the streets. We know that there are 22,000 people who inject drugs in San Francisco. Thirty-one percent (31%) are in the Tenderloin. And the Tenderloin has the highest number of injectors who get HIV and Hepatitis C. So having one in the Tenderloin makes perfect sense. But we all believe that they should be in other neighborhoods as well. That’s not because [as some people worry] the Tenderloin will become a magnet and everyone will come here to inject their drugs. That won’t happen. Studies show that people don’t travel more than 20 minutes to get high, which makes sense if you think about someone’s dope cycle and their disorder. They’re just going to go up a lane or find a bathroom before they would get on a bus or a train and come all the way over here.

Why is this an important issue for GLIDE?
When you talk about unconditional love; when you talk about radical inclusivity—it’s saying I accept you unconditionally. If you’re an injection drug user, then I’m accepting that you inject drugs. My job, as a compassionate person, is to improve the health of drug users. It’s not about condoning it. The people that are injecting drugs are in chaotic patterns of drug use. They need support to reduce the harms of their drug use. Telling them to stop hasn’t worked. There’s no evidence it’s ever worked. Saying I won’t give you clean needles to inject yourself just meant that everybody got HIV and Hep C. It didn’t stop people injecting. When somebody’s compelled to inject because they have a disorder they’re going to find other ways. Our duty is to recognize that. Do you not give a diabetic insulin? It’s important for a place like GLIDE, a champion of marginalized populations, to stand up and be counted at such a moment in history.

When you talk about unconditional love; when you talk about radical inclusivity—it’s saying I accept you unconditionally. If you’re an injection drug user, then I’m accepting that you inject drugs. My job, as a compassionate person, is to improve the health of drug users.

Is this the best way to address the problem?
One of the key things that people need to remember: People are injecting already. The point is they’re injecting in unsterile, dangerous conditions. There’s public discarding of syringes; there are children around, families coming by, and they see it. We want to remove that and bring it in where it’s safe, so it’s good for the individuals who use drugs and it’s good for the individuals who don’t use drugs.

Is this a proven approach?
There are over a hundred of these in the world. There’s never really been a down side. What you will see is people getting connection to services. It’s medically supervised, so there will be nurses. Usually they have a fast track to substance use services, whether that’s out-patient or in-patient. If they want to keep using, we’ll still be reducing HIV—there’s never been an HIV transmission in a facility because the equipment handed out is sterile and you’re not allowed to share. There’s never been a Hep C transmission for the same reasons. And there’s never been a fatal overdose because there are always people present. Recently, overdoses [in general] have increased dramatically. We’re seeing a surge of overdoses in this opioid crisis. There’s tainting of drugs with fentanyl. There are more reasons than ever to have a place that’s safe.

How else has the opioid crisis been manifesting itself in San Francisco?
We track overdoses in San Francisco. One of the things we’ve noticed in the data is that many, many more overdoses—about 67% now—occur outdoors, whereas as recently as three years ago, I believe, it was around 30%. It was mostly happening in SRO hotels. So we’re seeing this increase in public overdoses. When you talk about people being traumatized by seeing injectors—obviously, injectors are also traumatized by having to inject in public—you now have to also talk about seeing people overdose and possibly dying, or EMTs coming in and reviving people. It’s not a pretty sight. This would be avoided if we had a facility. There are some very compelling, humane reasons to have such a facility. And again, we’re talking about services. It’s not just HIV and Hep C; there’s wound care, abscesses—all of these things cost millions of dollars to the city’s tax payers through people having emergency room visits. Just for HIV and Hep C alone, we saw that we can save the city something like $3.5 million a year by averted infections.

We monitor overdoses very closely. On our outreach it’s very common for us to revive someone [with naloxone, or Narcan]. It happens once every other week that we save a life when we’re out on outreach.

Why is there a rise in public overdoses?
In San Francisco, as we know, real estate scarcity is an issue. There used to be more spaces, derelict buildings and such places where people could be in the shadows injecting. There’s less and less of that as San Francisco tries to utilize every square inch. I also feel that public injection begets more public injection, because people start to see it becoming a common thing. That’s not a good thing for anyone. These facilities won’t solve homelessness, let’s be real about that, but they will help reduce the volume of public injection. And some of those people who have substance use disorders might become connected to housing through their contacts [with a SCS], because there will be social workers and peer navigators that work in these institutions.

How often does the Harm Reduction team see this firsthand?
We monitor overdoses very closely. On our outreach it’s very common for us to revive someone [with naloxone, or Narcan]. It happens once every other week that we save a life when we’re out on outreach. We also train peers to look after people in our DOPE program, which is Drug Overdose Prevention Education… We had 855 occasions [last year] where they [came in for a refill of Narcan and] said it was because of an overdose. I think the numbers are going to be higher this year.

If you think about the chaos of the street and using, and then you think about having a comfortable, sterile, safe environment, it’s just a whole different world. . . And people get a chance to gather their thoughts and talk to people who know about substance use disorders, who maybe have been there and are now doing something else.

What is the data on how many people are helped to find treatment, stabilize and maybe improve their lives?
In one study, people were up to eight times more likely to get treatment. In another study it was up to four times. The point being, substantially. It was statistically significant. In the cost analysis I mentioned, which said $3.5 million would be saved: for every dollar spent on syringe exchange you save $2.33 in health costs down the line. Hospital stays, people with HIV, Hep C, injection drug use entering treatment. One risk-benefit analysis estimated that we would have 110 people accessing treatment from one facility.

If you think about the chaos of the street and using, and then you think about having a comfortable, sterile, safe environment, it’s just a whole different world. Much fewer things can go wrong. And people get a chance to gather their thoughts and talk to people who know about substance use disorders, who maybe have been there and are now doing something else. There’s always going to be a peer component. It’s different from this idea that we’re going to arrest our way out [of this crisis] and tuck people away in jail. Jail is not the place for treatment. This is an evidence-based model. They do work. We’re seeing a movement nationally, in cities like Seattle, New York, Philadelphia, Boston—there’s a lot of legislation now going through to try and have these facilities.

Why do you think it’s happening now?
I think it’s a lot of intersectional stuff. Mass incarceration, the failure of the drug war, the rising overdose deaths. I just read an article telling us that the fatal overdose numbers nationally are higher than the number of people who were dying of AIDS when that epidemic was at its peak. Once you get from seven degrees of separation to one degree, you have mothers and fathers coming in to see their legislators and asking what the hell is going on, this is crazy, this is a public emergency.

What do you say to people who accept the reasonable, evidence-based argument for SCSs but still have strong emotional feelings called up around the idea of having such a facility in their community?
That’s a real thing. What we say in our public meetings is that drug users are already here. They’re already injecting in GLIDE’s bathrooms, in Hospitality House’s bathrooms, in St. Anthony’s bathrooms, they’re already injecting in the little café you go to, and between your parked cars. Injection drug use is with us. This [opening SCSs] is a way of managing it. Because what we’ve been doing doesn’t work, and it’s actually having catastrophic impacts on many levels. We’re going to reduce some of them. It’s not going to be the magic silver bullet, but it’s going to definitely diminish all the things that we discussed. You’re supporting public health and a transformative policy change. I think public health policy can’t be based on knee-jerk reactions. It has to be based on the evidence. And the evidence says these will be very successful.

For more information on Safe Injection Sites and harm reduction-based care, Paul recommends the following recent articles and video clips:
www.yestoscscalifornia.org/facts/
www.harmreductionactioncenter.org/
www.sfchronicle.com/news/article/SF-safe-injection-sites-expected-to-be-first-in-12553616.php
www.latimes.com/opinion/editorials/la-ed-safe-injection-sf-20180208-story.html
www.kron4.com/2018/02/07/interview-san-francisco-to-open-safe-injection-sites-as-soon-as-july/
www.americanhealth.jhu.edu/fentanyl.html
www.vice.com/en_us/article/8xd9pv/women-are-leading-the-fight-against-the-war-on-drugs