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"A transformative way of dealing with drug use": Paul Harkin on Safe Consumption Sites

Due to concern about HIV, Hep C and overdose deaths, there has recently been a surge in discussion both locally and nationally about creating Safe Consumption Services (or Safe Injection Facilities) where people who use drugs can take them under medically supervised conditions. These facilities would mitigate the risk of harm to folks who are already using drugs in very unsafe surroundings, such as in the streets or in bathrooms of businesses.

After months of meetings, research and rallies, the city now awaits a decision from a designated Safe Injection Services Task Force on whether Safe Injection Services will be made legal in San Francisco. GLIDE spoke with Paul Harkin, HIV/Hep C & Harm Reduction Programs Manager, to learn more about the need for legalized Safe Injection Services and how these facilities exemplify compassionate harm reduction-based policy.

Who is behind the San Francisco Safe Injection Services Task Force?
London Breed, President of the Board of Supervisors, [introduced] resolution #123-17. It basically says it’s time to look at [Safe Consumption Sites] as a feasible way [forward], it’s exploring it. There’s an expert panel of local folks that are working with people who use drugs from across the range of substance use: service providers, doctors who are experts on so-called addiction, and representation from people who use drugs as well.

I’ve heard different terms for it; is there a preferred term for these facilities?
Some people say Safe Consumption Spaces or Safe Consumption Services. That’s for people who can come in there and snort their drugs or smoke their drugs and still have medical supervision. Because things can go wrong with different modalities of use. With other people, because it’s normally focused on injection, they want to call them Safe Injection Sites. The drug users were polled, so to speak, along with organizers, and they came up with Safe Consumption Services as the preferred term. So “Yes on SCS” means “yes on safe consumption services”. But the San Francisco Task Force kept the “safe injection” in it, so they call it the San Francisco Safe Injection Services Task Force.
How and why is GLIDE involved?
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.

One of the key things that people need to remember: People are injecting already. The point is they’re injecting in unsterile, dangerous conditions.

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 inhibition. 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. It’s really about reducing the local problem.

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 facilities in the world. There’s never really been a down side. What you will see is people getting connected 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 who are trained to prevent an overdose.

How important is it to have these services available now rather than later?
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.

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. 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—but then also seeing people overdose and possibly dying or EMTs coming in and reviving people is 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.

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. 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.

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.

What do you say to people who understand and even accept the rational evidence-based argument, but have a strong emotional response to having 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 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.

How does GLIDE’s mission and its values dictate its approach to this subject?
When you talk about unconditional love; when you talk about radical inclusivity—to me 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. If I allow them to inject in safer conditions I’m mitigating much of the harms and that’s a really good service. … It’s not about condoning it. Many of 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. In countries where you get beheaded for using drugs, guess what? People still use drugs. It’s a compulsion. It’s a disorder. They’re not going to stop using it just by telling them to. Our duty is to recognize that and to treat them. Do you not give a diabetic insulin?

And 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. There’s legislation on its way in several states and we’re going to see this. In the Tenderloin, with its historic connection to drugs, what better place than GLIDE? Harm reduction includes recovery. It includes abstinence. But when you mandate abstinence you’ve moved away from harm reduction. We feel we have the radically inclusive approach, the humane approach and the compassionate approach. We also have the science and the evidence on our side: these facilities work. Their success is uncontestable.

GLIDE’s Harm Reduction team see this on a daily basis: the power of simply saying to someone, I see you, I care about you.
It’s huge. I’ve had people come up to me years later and just say, “That day when you saw me… I was on the edge and it kept me from going over”. It’s powerful. We get a lot of that.

No people who inject drugs want to use in public; they just don’t have other spaces. They have a disorder and they need to get well, and so they have to shoot up.

Think about the horrible situation with bathrooms in the Tenderloin. There were no public bathrooms, it is very difficult to find a bathroom that you are able to use if you are homeless, so people were constantly relieving themselves in public. Not only was this unsightly, it is also unhygienic and a health hazard. Then they brought in the portable bathrooms and they put them up in these areas where there’s high volume traffic for homeless people. It’s very clean, super sterile, it’s great. And they have disposal boxes. They just have a monitor to make sure everything is safe.. When they got the Pit Stop portable bathrooms—one went up across from GLIDE. They rotate around the Tenderloin and SoMa—it reduced people going to the toilet on the street  dramatically. Everybody benefitted. The person entering the bathroom; the public walking by; the overall hygiene of the city. A very simple solution.

This is very similar. We’re saying we’re going to remove the public part of this that’s causing a lot of stress and tension for the user and for the public, and we’re going to take it inside a medically supervised place…. We’ll treat it with humanity and compassion. And a lot of those folks that come in, they’re going to get better, they’re going to get well, they’re going to be connected to primary care, or they’re going to be connected to substance use treatment. There’s going to be less wound care required, fewer hospital visits, everything like that is going to go down and a lot of their wellness measurements are going to go up. That’s the bottom line. This is a transformative way of dealing with drug use.

Interview by Robert Avila, Director of Communications, August 2017.