Research Paper
Using drugs in un/safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States

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Abstract

Background

Supervised injection facilities (SIFs) are spaces where people can consume pre-obtained drugs in hygienic circumstances with trained staff in attendance to provide emergency response in the event of an overdose or other medical emergency, and to provide counselling and referral to other social and health services. Over 100 facilities with formal legal sanction exist in ten countries, and extensive research has shown they reduce overdose deaths, increase drug treatment uptake, and reduce social nuisance. No facility with formal legal sanction currently exists in the United States, however one community-based organization has successfully operated an ‘underground’ facility since September 2014.

Methods

Twenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples’ lives, including the impact of lack of formal legal sanction on service provision.

Results

Participants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being ‘underground’ included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services.

Conclusion

Unsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction.

Introduction

Supervised injection facilities (SIFs, also called safe injection sites or drug consumption rooms) are facilities that provide a hygienic space for people to inject pre-obtained drugs under the supervision of staff trained in overdose response as well as injection-related risk reduction strategies. SIFs aim to reduce health and public order problems such as overdose, public injection, and street-discarded needles by providing high-risk, socially marginalized people who regularly inject drugs in public spaces with a safe location to consume drugs out of the public eye. Ten countries currently have specific legislation or regulation authorizing the operation of SIFs (Switzerland, Germany, France, the Netherlands, Norway, Luxembourg, Spain, Denmark, Australia, and Canada), with over 100 facilities operating in 66 cities (European Monitoring Centre for Drugs & Drug Addiction, 2016; Hedrich, Kerr, & Dubois-Arber, 2010). As the terminology and precise approaches to ‘legalizing’ such sites differ from country to country and even city to city, throughout this paper we use the terms “legal” or “sanctioned” to indicate any kind of legal sanction through formalized legislation, or political sanction through agreement or approval of relevant local or state actors and authorities. “Unsanctioned’’ refers to any facility which has not formally received such recognition. In the United States, no SIF currently operates with formal acknowledged sanction, however, some state and local jurisdictions have recently begun considering authorizing such facilities (CBS Baltimore, 2017, Foderaro, 2016, Gutman, 2017, Sapatkin, 2017), largely in response to a quadrupling of overdose deaths nationally over the past 15 years (Centers for Disease Control & Prevention, 2017).

Of the sanctioned facilities outside the United States, the InSite facility in Vancouver, Canada, and the MSIC facility in Sydney, Australia have been the most comprehensively described in the peer reviewed literature, with over 75 papers describing health and social order outcomes from these two facilities (Potier, Laprévote, Dubois-Arber, Cottencin, & Rolland, 2014). A smaller number of papers (most in non-English language journals) describe health and social order outcomes from European sites (Hedrich, 2004, Hedrich et al., 2010). Collectively, this literature consistently describes decreases in overdose deaths near facilities, along with other substantial positive health and social outcomes for both those using the facility and for the surrounding community (DeBeck et al., 2008, Fitzgerald et al., 2010; Kerr et al., 2006; Marshall, Milloy, Wood, Montaner, & Kerr, 2011; Salmon, Van Beek, Amin, Kaldor, & Maher, 2010; Small et al., 2008). A limited literature also exists on unsanctioned sites, describing the role of an unsanctioned site in Vancouver in meeting needs not met by InSite (McNeil, Kerr, Lampkin, & Small, 2015; McNeil, Small, Lampkin, Shannon, & Kerr, 2014), and the role of the short-lived ‘Tolerance Room’ in Sydney, Australia, in pushing the state government of New South Wales to approve a sanctioned site in the early 2000 s (Wodak, Symonds, & Richmond, 2003).

We describe here the results of qualitative research conducted at a facility operating without sanction in an urban area of the United States since 2014. This work sought to broadly examine the impacts of having access to the space for people who used it, and to explore how the ‘underground’ and potentially illegal status of the site either positively or negatively impacts the utility of the space for its clients.

Section snippets

Setting

While legislatively authorized facilities operating solely or primarily as SIFs do not yet exist in the United States, people who inject drugs and the social service agencies who serve them have come up with a range of strategies to create supervised or semi-supervised spaces that reduce the risk of overdose death. For example, many social service organizations in the United States which directly serve people who inject drugs are aware that people sometimes use their bathrooms1

Data collection

Qualitative interviews were conducted at the facility between June and August 2016 with 23 individuals, 22 of whom regularly use the facility themselves, and one staff member who does not inject drugs. Of the 22 who use the facility to consume drugs, one was also a paid member of staff and two had formal roles as volunteers at the facility. This sample of 23 was estimated by the staff of the facility to represent approximately two thirds of all users of the facility during the study period, and

Results

Our analysis revealed four key domains: issues relating to public health and public injecting; issues around stigma and community; the constructive consequences of operating without formal sanction; and the limitations and problems stemming from operating without formal sanction.

Discussion

In this paper, we have examined the experiences of people who inject drugs using an unsanctioned SIF in an urban context in the United States. As with other qualitative examinations of the impacts of InSite in Vancouver, we found users of this facility reported that access to the SIF reduced their “contextual risks” such as the need to rush injections (Kerr, Small, Moore, & Wood, 2007), and reduced the “everyday risks” associated with injecting in public such as negative interactions with

Conflict of interest statement

The authors declare that they have no financial or personal relationship with people or organizations that could inappropriately influence this work.

Acknowledgements

Funding: This work was supported by a gift from Laura and John Arnold. The authors would also like to thank the users and staff of the facility for their wholehearted cooperation and thoughtful reflexivity. We find ourselves in the unusual position of being unable to acknowledge by name the individuals and organizations who were central to our ability to conduct this work, and even to include as named authors individuals whose review of drafts of this paper contributed meaningfully to its final

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