Sirens echo throughout Civic Center Plaza around 11 a.m. Friday. A young man has collapsed on the pavement after stepping out of a Jeep Cherokee parked in front of the Main Public Library, his face a gruesome shade of blue. Seeing his immobile body, onlookers presume he has died of a drug overdose.
Firefighters respond to the scene and administer naloxone, an overdose reversal drug, and apply a respirator. One of the firefighters stands by and issues a warning.
“This is why you don’t do heroin,” he announces repeatedly. “This is why you don’t do heroin.”
A moment later, the young man springs up from the pavement as if revived from the dead, and a sense of relief washes over the faces of those watching in disbelief.
The incident is just one example of how the United States is in the throes of an opioid epidemic. That has prompted more cities across the nation to start discussing, in earnest, opening safe injection facilities as medical professionals are becoming more outspoken in support of the treatment strategy. There are nearly 100 such facilities around the world, but none yet in the U.S., though Seattle recently decided to open two sites.
Vermont also announced a task force last month to examine opening a safe injection site in Burlington, and the Massachusetts Medical Society is voting later this month to take an official position in support of safe injection facilities, according to WBUR’s CommonHealth. The Drug Policy Alliance has long encouraged cities across the nation to open safe injection sites and in a poll of voters in San Francisco last year showed support of more than 70 percent.
While long discussed in San Francisco, where there are an estimated 22,000 intravenous drug users, only recently is the possibility of opening a safe injection site within reach. Board of Supervisors President London Breed last week introduced legislation to have the Department of Public Health convene a task force over the next three months to study opening the facilities in locations like the Tenderloin.
Department of Public Health Director Barbara Garcia said she supports the legislation. Among other supporters in San Francisco are health professionals who work with drug addicts every day.
Dr. Vitka Eisen, chief executive officer at HealthRight 360, which operates four health clinics in San Francisco, offers a unique perspective on safe injection facilities. She was a self-described heroin addict in the 1980s before recovering after receiving treatment that began at the Haight Ashbury Free Clinics and later the Walden House.
“I think it’s just a logical extension of the work that Haight Ashbury Clinics has always done,” Eisen told the San Francisco Examiner during a recent interview. “When I was a patient, I was in and out of the detox. They had a heroin outpatient detox. I was in and out of there seven times, nine times, and every time I came back, people were not judgmental and they were incredibly welcoming. At some point, I realized that I needed to do something different. I needed to get off that path. I trusted them and said, ‘What do I do next?’ and they sent me on to Walden House.
“There but for the grace of God, it’s luck that I didn’t end up a person who died of an overdose but, in fact, lived to have an organization and people who I trusted point me in a direction where I could get healthier,” Eisen continued. “And I think that a safer injection site does the same thing. It’s a logical extension.”
Medications like methadone or buprenorphine, which San Francisco’s Homeless Outreach Team hands out to addicts on the street, can help. But Eisen stressed they only work if the patients take the medication properly, because not all do or want to. Eisen said recovery is different for everyone.
“Everybody’s path to that place is different. It fundamentally starts with not judging or shaming people. People don’t move into a place of healing because they have been judged or shamed or relegated to having to get high behind a dumpster somewhere,” Eisen said. “So we have to have many opportunities. Most important is that they feel welcomed and there are always opportunities and hope on our side for their growth and their change.”
The City’s own examination of the issue comes as a state bill is wending its way through Sacramento. The bill — AB 186 introduced by Assemblymember Susan Talamantes Eggman, D-Stockton, and co-authored by state Senator Scott Wiener — would lift barriers for local municipalities to open safe injection sites by legalizing drug use in such facilities. Drug users would be allowed to inject drugs onsite under the supervision of health care professionals to ensure they are using clean equipment, do not overdose and ultimately receive the counseling they need to get off of drugs.
“I am a big believer in harm reduction, public health strategies and trying new things,” Wiener told the Examiner in a recent editorial meeting. “The current situation is not working well. You can see that with injection drug use in our streets and syringes.”
There should not be a state law barrier to doing that,” Wiener continued. “San Francisco and other localities should have the ability to try it out. If it doesn’t work, we can scrap it. But if it does work, it could be a really positive thing.”
San Francisco has experienced a somewhat steady number of drug overdoses from opioids, cocaine and methamphetamine each year during the past decade of about 175 — though opioid overdose deaths declined between 2015 and 2016 with the increased use of naloxone.
The Drug Overdose Prevention and Education (DOPE) Project, a coalition that works to reduce overdose fatalities in San Francisco, reports an increasing number of opioid overdose reversals by lay people with naloxone each year with 886 in 2016, according to DPH. Fatal heroin overdoses in San Francisco had decreased from 120 in 2000, to about 30 in 2014.
Eggman unsuccessfully attempted to pass a similar bill last year. This year, things are faring better. The bill was approved by the Assembly Health Committee in a 9-4 vote last month after it was amended to sunset in January 2022 and limited to the counties of Alameda, Fresno, Humboldt, Los Angeles, Mendocino, San Francisco, San Joaquin and Santa Cruz. The Assembly Public Safety Committee will vote April 18 on the bill.
The bill has official support from nearly 40 groups, including several in San Francisco, such as the Drug Policy Alliance, HealthRight 360, San Francisco Homeless Coalition, the Glide Foundation, the Gubbio Project, San Francisco AIDS Foundation, St. Anthony Foundation, Saint Francis Foundation and St. James Infirmary.
The bill is opposed by several law enforcement groups, including the California Police Chiefs Association.
A study published in the Journal of Drug Issues in December took the safe injection model in Vancouver, Canada — called Insite, an operation of 13 booths for clients operating 18 hours per day — and applied it to San Francisco. The study found that “the supervised injection facility would prevent 3.3 cases of HIV and 19 cases of hepatitis C virus per year, reduce skin and soft tissue infection hospital stays by 415 days annually, save an average of 0.24 lives per year, and facilitate 110 people to enter medication-assisted treatment.”
The City would see about $6.1 million in health savings, and the facility would cost $2.6 million, a net savings of $3.5 million, according to the study.
The Department of Public Health said there remains a consistent rate of infection for people who inject drugs, with about 50 percent who have hepatitis C and about 15 percent who have HIV. But Dr. Phillip Coffin, of DPH, said HIV rates may be underestimated due to declining rates of HIV testing among those who inject drugs.
Dr. Andrew Desruisseau operates a HealthRight 360 clinic on the sixth floor of Glide in the Tenderloin that treats about 1,600 patients, an estimated 40 percent of whom are intravenous drug users.
“We have done such a great job in San Francisco from the public health perspective. We have getting to zero campaigns for HIV. We have ‘End Hep C’ campaigns. This is kind of that missing piece,” Desruisseau said of safe injection sites.
“The whole harm-reduction model works on going from a green light and maybe trying to make it yellow and slow down, and we can meet at this intersection and provide a lot of services if you are ready,” Desruisseau continued. “If you’re not, that’s cool, too. We will make sure you are not dying.”
For Eisen, there was no “light bulb moment” for recovery, nor “hitting rock bottom.” “The path to recovery is up and down. I want it, I don’t want it. I want it, I don’t want it,” she recalled.
“For most people, recovery is a really slow process of putting together more good experiences than bad experiences over a long period of time,” Eisen said. “You have to give your brain enough time to experience … to move through the misery to: I feel a little better every day.”