The "Supervised Injection" Laundromat

In a response to the recent spike in U.S. deaths from heroin usage (from 3000-4000/year to over 10,000 in 2014), there has been increasing interest in "supervised injection facilities," or SIFs. Users can bring their drugs to the supervised site and inject it under the watchful gaze of trained medical staff ready to intervene if there's a problem.

Such facilities are currently illegal throughout the U.S. (although the Mayor of Ithaca, NY has proposed one) but have been implemented successfully in Australia, Canada, Portugal, Germany, and a number of other countries.

Besides supplying medical assistance, SIFs address several of the social problems associated with drug use.

Sharing of needles too often leads to the transmission of HIV and hepatitis, and we know from New York's experience that needle exchanges can dramatically reduce the incidence of new HIV infections. The SIF model provides new needles, but goes beyond exchange, allowing the user to inject on the spot. If widely used, SIFs should cut down on the "needle park" areas that so incense local residents. Used needles are collected on-site for safe disposal.

The SIF model is a very positive development, but the user still has to find the drugs to inject (and may well be committing crimes in order to finance the purchase). In this respect, the injection facility is like a Laundromat--you bring your goods to use on site. Isn't this a little weird? Overdose at a supervised site and professionals will do their best to resuscitate you, but nothing prevents the user from buying a lethal dose in the first place. That is a consequence of the illegality of the heroin market.

While we use the term "heroin overdose," the problem is rarely an overdose of pure heroin. It is more like the situation during Alcohol Prohibition (1920-1933) when thousands of Americans died from consuming adulterated alcohol. Between 1920 and 1925, the death toll from alcohol poisoning rose from 1,064 to 4,154.

What is sold as heroin on the street is often cut with Fentanyl or other adulterants, or may be something else entirely. In an illegal market, suppliers have every incentive to cut quality to increase profits. There is no fear of violating label or purity requirements of the FDA or a state Alcoholic Beverage Control Board, and there's no risk of consumer protection lawsuits. The injection process may be safer, but the substance injected is not.

Let's take a page from the Swiss experience and expand on the SIF model. Since 1994, any person addicted to heroin in Switzerland can go to a government clinic and inject pharmaceutical grade heroin. Overdoses are extremely rare, and HIV, hepatitis, and crime rates are all down. Initial usage by younger people is also down; there are fewer "shooting galleries" to serve as social recruitment sites, and there is nothing romantic about a substance that is served up at a government clinic. Heroin maintenance--harm reduction--is now becoming the norm in Western Europe.

The U.S. has not yet considered heroin maintenance as a strategy. We have no problem with maintaining people on drugs to control diabetes, high blood pressure or cholesterol, but perhaps view those who are addicted as less worthy. However, while other conditions may arise from poor diet or lack of exercise, we don't blame the individual and refuse treatment.

Heroin usage is a serious problem, but maintenance may well be the best interim solution. It allows us to address some of the problems of a criminal market (sales to kids, corruption, gangs and cartels) as well as help those who are addicted get their lives together instead of insisting that they scrounge for supply and bear the continual risk of overdose.

And of course, if we stop spending resources on police, prosecution, and prison for a failed War on Drugs, we could put resources into effective treatment for those who want it, and address some of the social problems (poor schools, joblessness, child abuse) that lead people to try heroin in the first place.