San Francisco may flout state and federal law to address the opioid epidemic on its downtown streets. The city is looking at providing supervised injection sites — a radical harm-reduction strategies to treat addiction — even though heroin is illegal, as is providing a space for using it.
More than 22,000 people inject drugs in San Francisco. Helder Peralta is one of them.
“In general before all the drugs and all the bad stuff kicked in, I was a pretty positive outgoing person. I really enjoyed my life,” he tells me.
But then 10 years ago, Peralta started using drugs. He began injecting heroin two years ago when he became homeless.
“I’ve been the person in the tent,” he says, “starving, not eaten in three days.”
The city wants to get people like Peralta off the street and into rehab programs. A key part of this effort is “safe injection sites.” They’re clean, medically-supervised places for drug users to shoot up.
At first glance, it’s counterintuitive: To make the city healthier, the plan is to provide a space for drug users to inject themselves with potentially lethal drugs.
But the promise is, these facilities would take drug use off the streets and get users somewhere safe and clean.
This sounds like a great plan to Peralta. We met at HealthRight360, his clinic on Mission street.
“I know plenty of people who would [go to safe-injection sites],” he says.” I’ve literally mentioned it to people and their eyes got wide open, like, ‘Yeah!’”
Supervised injection sites are a step beyond the harm reduction services San Francisco already has, like clean needle exchanges and the wide availability of the overdose reversing drug, Narcan. The goal is to save lives and reduce disease.
But Peralta sees a bonus: restoring his dignity.
“Like not being humiliated in the street, not having to hide, not having to put a sweater over your head with a flashlight in your mouth,” he says. “[Y]eah, it would help.”
Walking back towards the shelter where he’s staying in the Mission, he dreams of his own apartment and a job. Before his car was repossessed, Peralta drove for Uber.
Peralta’s the kind of guy supervised injection sites are supposed to help — addicts who are ready to get clean. But it’s a brand-new concept to Americans.
They haven’t been done before because they’re currently illegal. San Francisco might be the first city in the United States to operate one, so most people don’t know what they are.
Activists are trying to introduce the concept to the community. At a recent Sunday Streets festival in the Sunset, the Harm Reduction Coalition was out tabling to raise awareness.
Charles Hawthorne demonstrates what one of the safe injection booths would look like. “It’s a nice metal sterile booth where we’re able to wipe it down and keep it clean,” he says.
The booth looks like a station at a hair salon. Except instead of scissors and shampoo there’s needles and Narcan, making it a kind of outlier at a street fair where families are cruising by on bikes.
He picks up some of the equipment inside: “Needles, ties, cookers, whatever they need to prepare their drug,” he says. “It’s ... a personal space so you can spread out your stuff, relax, don’t have to be rushing on the ground trying to hide it.”
He makes it sound comfortable. Which isn’t something you usually associate with hard drugs. But making it comfortable is key to getting people to come to these places instead of shooting up in alleys.
Trained staff would watch out for overdoses, teach safe injection techniques — and connect users to treatment programs.
“Mostly it’s a way to just bring people into the healthcare system in general,” Hawthorne says. “They might feel isolated. Left out of the system in a lot of different ways.”
Harm reduction is healthcare to mitigate the damage of addiction. Advocates say that it functions like a seatbelt for addicts. It doesn’t prevent a car accident, but it can save your life when you crash.
San Francisco has a long history of harm reduction policies and non-judgemental medical treatment, such as the Haight-Ashbury Free Clinic, and needle-exchange programs in the city. These programs cut through the stigma of drug use to deliver health care services that save lives.
But even here, a supervised injection site can be a hard sell. Hawthorne says people have strong reactions to drug use.
Arguably, the past 40 years of national drug policy has taught us to look down on drug users because they didn’t “just say no.” Safe injection sites accept the reality that many people have said yes — and need support.
“The concern people voice the most about them is that they feel like its enabling,” Hawthorne explains. “Like, if we really cared about people who use drugs we’d be trying to get them to stop, we’d be getting them to not use. What I say to that is the only thing I enable people to do is stay alive. Because dead drug users don’t recover.”
The Department of Public Health says about 100 people per year die from opioid overdoses in San Francisco.
Changing policy, changing needs
New public health research shows supervised injection sites can keep addicts out of the hospital without increasing drug use.
In Vancouver, where the sites are legal, the number of injection drug users hasn’t grown in the past 10 years that safe injection sites have been operating.
“I think the most compelling results are just that it reduces the likelihood of dying from overdose,” says Alex Kral, a public health researcher who conducted the study. “It reduces HIV infections, hepatitis C infections, saves city money.”
In fact, one safe injection site could save San Francisco more than $3 million dollars per year. That’s according to a study Kral, who works for the nonprofit Research Triangle Institute, published in the Drug Policy Journal.
He says a designated place to inject would help solve another vexing problems — the proliferation of needles on the street.
“I think people are just fed up! They’re like fix it, just fix it,” Mayor-elect London Breed explained in her campaign office near Civic Center. “If it’s gonna work, if it’s gonna get the needles off the street, if it’s gonna possibly be an opening to help someone who struggles with addiction — then let’s try it.”
She served on a task force to explore the possibility of safe injection sites in San Francisco, visited sites in Vancouver — and decided she supports the controversial idea.
But safe injection sites didn’t make sense to her at first.
“The first thing I thought,” she says, “was: ‘That’s crazy, why would we do something like that? Why would we make it more convenient for someone to shoot up?'”
People are shooting up where it isn’t convenient — downtown and in public. So, City Hall’s policymakers see the misery of drug use right there in the streets around Civic Center. It’s a daily reminder of where their efforts fall short.
Many San Francisco politicians are ready to take a risk on safe-injection sites — which break almost every conceivable drug law, short of selling the stuff. They violate the federal “crack house statute,” which bans providing a place to use drugs.
Mayor-elect Breed wants the city to move ahead anyway.
“I mean it’s San Francisco! we operate differently than other places in the world,” she says.
The city already does have a track record of breaking the law first and changing the law later on issues such as same sex marriage, sanctuary cities, and marijuana.
“Ultimately,” Breed says, “We just need to do it and let the chips fall where they may.”
A different direction
The city and people running the safe injection site could be liable if the federal or state government decide to enforce the law.
Healthcare providers working at such a facility could lose their medical licenses. Whole buildings could be seized.
But San Francisco District Attorney George Gascon says not only will he not prosecute safe injection sites, he supports this experiment.
“Sometimes when the law hasn't caught up with the need of the community, we have to be bold and we have to act in a different direction,” he says.
The federal government is more likely to enforce drug laws than local or state law enforcement. On the state level, there’s even a bill before the Legislature that would allow safe injection sites in certain counties.
Mayor-elect Breed says San Francisco may move ahead before that bill passes, and Gascon thinks that’s a good thing.
Gascon says criminalizing drug use hasn’t reduced the addiction problem.
“To the contrary,” he says, “we’ve seen a tremendous increase in the last three decades. Drugs are cheaper, more people use them, more people are dying. So what have we done that has worked?”
Helder Peralta struggles with that question as part of a three-month detox rehab program. Supervised injection sites could connect drug users with programs like the one he’s in now.
“I’m worried that it might not work. That I’ll fail again just like I’ve fail when I was doing it by myself,” he says.
Peralta tried to get clean by himself, but it never worked. Injection drugs are a notoriously hard habit to kick. Studies say about half of all users who do kick, relapse.
Peralta says that this time feels different. “[N]ow someone’s taking responsibility,” he says, “and going: ‘Alright, we’re going to help you.’ And I’m afraid of letting them down.”
He’s a month into his program and says he’s committed to sticking with it.
Public health at the public library
Some institutions in San Francisco are already shifting to a public-health perspective in dealing with opioid addiction. One example is the library.
Nick Loya, a guard at the San Francisco Public Library, kicks users out of the library every day. He and his fellow guards are not just policing drug use, they’re also saving lives. He opens up the first aid kit and a box of nasal Narcan to demonstrate.
It looks like allergy medicine.
The library decided to stock Narcan, an opioid blocker, after a fatal overdose on its premises. The antidote is kept next to the band aids — and the metaphor is hard to ignore.
Like a bandaid, Narcan is a short term fix. It saves a life, but it doesn’t cure addiction. It’s not a substitute for treatment.
“So this goes in the nostril, all one shot, just hold it like you would a nasal spray,” Loya demonstrates. “It comes out in a fine mist. There’s no real set time for how long it takes to work, buta they say between two and four minutes, depends how long they’ve been down for.”
Loya has only been working at the library for six months, but he says he’s had to administer Narcan three times already. Over 100 library staff volunteered to learn to use nasal Narcan.
Librarians are effectively serving on the front lines of this public health crisis. And drug users keep coming to the library because it’s safer than the street.
Helder Peralta says it’s because it’s safe: “You’re not gonna get beat up in there … There’s security in there, that’s why we would get kicked out when I was in there. And we would get kicked out on a regular basis.”
But I was curious: if Peralta had a safe, dedicate place to go, would he be less committed to quitting drugs?
“I know what your asking—and some people could say — and will say — safe injection sites will cause people to automatically want to use more drugs,” he says. “People don’t wake up in the morning saying I’m going to be a drug addict. People wake up in the morning saying I’m wonder how long I’m gonna live today. And if there’s people out there to make it safe for you to live? Hey. Let it be.”
Local governments can start new programs to fight existing health threats without approval from the state. So London Breed could make a city run safe injection site happen.
It’s a bold move with no umbrella of protection from state law, which is important protection.
Even so, a sanction from the Mayor could allow these sites — and maybe more people like Peralta — to move forward.