There is a debate happening right now in Philadelphia about opening a safe injection site (SIS). The conversation has been in both official health commissions and in the media. The discussion is important. Evidence suggests that a facility would save lives, reduce transmission of disease and infection, decrease harms of public injection on communities including, possibly, crime, and conserve public health resources. But such a facility would also represent a big step, and there is value in subjecting even well-supported ideas to scrutiny.
In the spirit of rigorous debate, we would like to share findings from our recent study exploring how a group of people who inject drugs in Philadelphia perceive such a facility.
We interviewed them as part of a project aimed at understanding how they experience skin and soft-tissue infections, including the decision to seek medical care. Given the value that the injection sites have demonstrated in other countries in reducing the causes of these infections and the local interest in such sites, we also asked our participants if they would support an SIS in Philadelphia and how it would influence their injecting practices.
Our participants relayed three points, which we think are especially relevant to ongoing discussions.
First, they overwhelmingly supported opening such a facility in Philadelphia. They told us that an SIS would allow for safer injecting practices by providing a clean and secure setting. It would also, they believed, decrease community harms. And by harms, our participants meant much more than just discarded needles and injection litter. Although it was not a topic we planned to explore, the discussion of a potential SIS repeatedly turned toward their guilt about exposing the community to public injection and intoxication.
This leads to our second takeaway: Our participants want to be a part of the solution for reducing the burden of public injecting on the community. They were more concerned about exposing children in the community to injection or intoxication than they were with being stopped by police. The decision to seek out secluded spaces, like the Conrail tracks, was described as a way to respect the community. Of course, secluded spaces are dangerous, especially when fentanyl is circulating so widely. For participants without stable housing, an SIS is the only way to resolve opposing motivations to avoid attention – so as not to harm the community – and to maintain attention – in case an overdose strikes.
The third point: Although all of our participants expressed the belief that a facility would improve individual and community health, only those participants who lacked stable housing suggested that they would use a facility. This is consistent with previous research on facilities in other countries, and reflects an important feature of injection sites: They represent a targeted intervention for the most vulnerable people who inject drugs.
These three points reflect the likely value and the probable limitations of an SIS. A facility would not prevent all, or even most, overdoses in Philadelphia. Many people who inject drugs will continue to inject at home whether an SIS exists or not. We should continue expanding access to naloxone and to high-quality drug treatment, while reckoning with the determinants of opioid addiction. But people who inject drugs who lack a clean and secure place to inject will use a facility for their own benefit and for the benefit of the community.
How much will an SIS improve the health of people who inject drugs in Philadelphia? How will it affect the community? These important questions must be studied. Preventing as much avoidable harm as possible here and in other cities requires rigorous and transparent evaluations. A recent study of crime and public disorder around an overdose monitoring facility in Boston provides a good model. But given that the individual and community harms of public injecting are fundamentally constituted by the fact that some people who inject drugs lack a clean and secure place to inject, do we really need more evidence before providing such a place?