Supervised consumption services (SCS), also known as safe injection facilities (SIFs), or overdose prevention programs, are one proven solution to improve the health of people who use illicit drugs, prevent overdose deaths, reduce public drug use, improve neighborhood health and safety, reduce infectious disease, save costs, and improve linkage to drug treatment and other medical and social services.
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Although there are more than 165 supervised consumption services operating worldwide, they are often viewed as prohibited by U.S. federal law and remain controversial among many people outside the harm reduction community. But the tide is turning for SCS in the Bay Area, with public leaders and community members calling for innovative and evidence-based solutions to solve some of the problems caused by increasing rates of homelessness, drug use and overdose.
If you still have questions about what SCS might mean for our cities and communities, read on for what we know from the experience of other cities and countries.
What are supervised consumption services?
Let’s start with the basics. Because there are more than 165 SCS operating worldwide, there is some variation in what supervised consumption services can look like and what resources they provide. But they all provide a clean, welcoming environment for people to use pre-obtained substances (drugs), with trained support staff who are available in case of an overdose or other emergency, and harm reduction supplies including sterile syringes.
Oftentimes, SCS have table spaces separated by partitions where people can set up their sterile equipment and inject. Some SCS have separate smoking rooms for people who smoke their drugs. Many SCS provide counselors, substance use treatment services, and other social services. Take a look at pictures of SCS around the world.
Safer Inside Demonstration produced by Safer Inside community and the Tenderloin Health Improvement Partnership (TLHIP), photo taken by San Francisco AIDS Foundation
Do SCS increase or encourage drug use in a community?
Some people may worry that providing sanctioned spaces for people to use drugs will increase the amount of drug use in a community. But, we know from the experience of SCS currently operating around the world that these spaces do not increase substance use–but rather help connect people to substance use treatment services, counseling, and other social services.
Evidence from Insite, an SCS operating in Vancouver, actually shows that people who regularly visit the site and who have contact with counselors working at the site are more likely to enter into substance use treatment. With a random sample of 902 participants visiting Insite between 2003 and 2006, 281 participants were enrolled in some type of substance use treatment service already, and an additional 261 individuals entered into substance use treatment during the course of the study. After 24 months in the study, nearly a quarter (23%) of participants reported stopping injection (defined as at least six months without any episodes of drug injection).
Do SCS increase crime or cause other neighborhood problems?
Studies of neighborhoods before and after SCS have been established answer questions about the impact that SCS have on neighborhood “public order” issues, including crime, drug sales, improperly discarded syringes, and public drug use. Overall, SCS have a positive impact on injection litter and public injection, and don’t seem to change drug sales or neighborhood crime.
Again, evidence comes from evaluations of Insite in Vancouver. One study counted the number of improperly discarded syringes in the 10 blocks around the site during the six weeks before and the 12 weeks after the site opened, and found that the number of improperly discarded syringes per day were reduced from an average of 11.5 to 5.4. Instances of public injection were reduced from a daily average of 4.3 to 2.4, and the daily counts of injection-related litter around the facility were cut in half from 601 to 310.
These numbers make sense: Giving people a desirable, safe indoor space to consume substances reduces the amount of public drug use and the amount of substance-use related litter that makes its way onto streets, sidewalks and other public spaces.
A different study in Copenhagen found that people who used supervised consumption services changed their syringe disposal practices after they started using the facility. The percent of people surveyed who reported returning needles to the needle exchange or SCS increased from 34% to 88%, and a large percentage of people surveyed (62%) reported that their syringe disposal practices changed from “not always disposing safely” to “always disposing safely.”
Although SCS don’t seem to decrease drug sales or neighborhood crime, they also don’t seem to cause any increases. One study compared crime statistics from the Vancouver Police Department in the year prior to Insite opening, to monthly averages during the year after Insite began operations in the Downtown Eastside neighborhood.
There were no obvious differences in the amount of drug trafficking (which includes drug sales, administration, giving, transporting, or delivering), with monthly averages being 124 in the year prior to 116 in the year after; and no difference in assault and robbery, with monthly averages being 174 in the year prior to 180 in the year after. There was a significant decline in vehicle theft after the site opened, although the study’s authors caution against concluding that the SCS caused this reduction.
A similar study of crime data from Kings Cross in Sydney found that rates of robbery, theft and drug dealing did not increase in the nine years after a supervised consumption site opened. In fact, rates of robbery and theft fell dramatically in the neighborhood (similar to trends across Sydney).
Are SCS cost effective?
The good news for cities is that supervised consumption services are extremely cost-effective–reducing burdens on emergency room visits for overdoses and skin and soft tissue infections, and preventing HIV and hepatitis C infections. Vancouver’s SCS, Insite, saves the city more than $6 million per year by preventing an estimated 35 HIV infections and three deaths per year.
One cost-benefit analysis of a hypothetical 13-booth SCS in San Francisco concluded that each dollar spent on the site would result in more than $2 in savings, for an annual savings of $3.5 million for a single site. The bottom line is that establishing even one SCS in San Francisco could save our city millions of dollars.
Do SCS save lives?
In San Francisco, it’s estimated that more than 22,000 residents use injection drugs, and fatal overdoses have gone up in recent years. With COVID-19 Shelter in Place rules–people staying home and isolating from others–the risk of fatal overdose has only increased.
Without a doubt, supervised consumption services save lives by preventing fatal overdose. One study examined overdose mortality rates in the two and a half years before Insite opened, to the two and a half years after its opening, and found that fatal overdose rates decreased by 35% (within 500 meters of the site) after Insite opened. During that same time period, the fatal overdose rate for Vancouver overall decreased by only 9%.
Who supports SCS?
SCS are supported by major national medical, public health, and HIV organizations, including the American Medical Association, AIDS United, amfAR, Harm Reduction Coalition, and the American Public Health Association. In California, the California Medical Association, California Society of Addiction Medicine, and California Association of Alcohol and Drug Program Executives, among dozens of other medical, health care, substance use treatment, HIV, and harm reduction organizations, support SCS.
In San Francisco, there is broad consensus among elected and civic leaders. The Board of Supervisors, in partnership with Mayor London Breed, unanimously passed an ordinance in June 2020 to authorize the services. Organizations from the San Francisco Chamber of Commerce and SF Travel to the Democratic Socialist Alliance (DSA) have endorsed them, and polling by Dignity Health showed that 77% of San Franciscans polled supported them. Most recently, California Attorney General Xavier Becerra signed an amicus brief supporting SCS efforts in Philadelphia as well as supporting California legislation to allow San Francisco to open sites.
San Francisco AIDS Foundation has been involved in local efforts since 2007. We are one of the co-sponsors of state legislation and have been a part of local task forces, community forums, demonstration projects, and neighborhood dialogues. Our strategic plan calls for us to take bold action to maintain and expand our substance use services, syringe access and overdose prevention efforts including establishing safer injection sites.
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