Denver is one of the first cities in the country working to find a feasible approach to combat the rising number of overdose deaths for intravenous drug users, in the form of a facility for said users that offers more than just a safe place to use.
The city has quite the task before it, as Denver recorded 174 overdose deaths as well as 6,126 users admitted to treatment for heroin use in 2016 alone. The most effective approach currently to tackling this issue is by utilizing harm reduction centers.
Denver’s Harm Reduction Action Center (HRAC) is working to bring a site to the city, and Executive Director Lisa Raville is at the forefront of this work.
“We are in the midst of an overdose epidemic and we have to try all evidence-based interventions.” Raville said.
“HRAC lost 6 participants to overdose in January over a two-week period. Staff and participants were greatly affected by the loss of some of our core participants. We vowed that would never happen again.”
Harm reduction centers include not only health education classes and syringe exchange programming, but a variety of additional services including HIV/HCV/STI testing, registering homeless and former felons to vote, and referrals to additional services such as mental health and long-term housing services.
To figure out how such services might be given a boost, it’s important to figure out what this site is, who supports it, who doesn’t, and why.
A staffed injection facility (SIF) is a site where medically trained professionals monitor intravenous drug users, making sure they do not overdose, as well as a site where users can exchange needles and receive Naloxone (often known as Narcan) if a user does overdose.
Narcan is administered to someone who has overdosed, by either a nasal spray or an intramuscular needle, and reverses the effects of overdose for a short period of time, usually ranging between 30-90 minutes.
Users will need to have their own drugs, as these sites do not provide any form of narcotics, outside of administering Narcan.
Denver’s barriers to a SIF faced by other major cities
Raville has reached out to businesses in the areas around HRAC’s current location across from the Colorado Capitol building on East Colfax, and is the go-to contact person when reaching out to numerous public health officials familiar with this ongoing initiative.
HRAC’s director has made every effort to create partnerships that are mutually beneficial. Part of the reason why Raville is trying to cover every base is that other cities currently attempting the same feat of creating a site are running into formidable barriers.
In Seattle, where the most progress has been made for a SIF in the form of a task force being created to find possible solutions for this issue, that progress has been frozen by active residents who are against the proposal of such a site being opened. Steve Gustaveson, Project Manager for King County’s Department of Community and Human Services described the situation in Seattle.
“A citizen’s initiative is now on the ballot for February 2018 that would prohibit the opening of any such facility,” Gustaveson said.
“Until that ballot measure has been resolved one way or the other, it is unlikely that King County will move ahead with siting a facility anywhere in the jurisdiction.”
The citizen’s initiative resulted because of the King’s County Task Force recommending at least two of these sites be opened in the county, including the one being contested now in Seattle. Those citizens who are against the possible sites are concerned about where it will be placed and its impact on whichever neighborhood it’s placed next to.
Raville and other supporters of this kind of facility in Denver are hoping to avoid this.
A handful of officials in Denver when asked for an interview on this subject advised that they could not speak officially on behalf of their office, due to the uncertainty surrounding this kind of site. Every official approached for a statement indicated support for the facility. But it’s clear that due to this uncertainty, making an official statement of support from one’s office is too much of a risk at this point in time.
Another barrier standing in the way of this site is determining how to work around Federal law on such facilities.
Federal roadblocks to a SIF encourage local solutions
The Controlled Substances Act has a couple of sections that would be directly violated by a SIF, namely section 856. Section 856 is known as the “Crack House Statute”, and states “it shall be unlawful to knowingly open, lease, rent, use, or maintain any place, whether permanently or temporarily, for the purpose of manufacturing, distributing, or using any controlled substance.”
In essence, the users using in the facility would make the SIF illegal; however, nothing at the state or local level legally states that such a facility is unlawful.
This could lead proponents of a SIF to follow in the footsteps of medical marijuana dispensaries across the state of Colorado. Dispensaries have established through their existence there is precedence for a local facility to curtail federal legalities that are not being actively enforced.
That’s a fine line to walk, but one that might be the only option until statewide legislation is passed in the future. However, legislation on this issue could be introduced sooner rather than later, as six bills have been drafted and could be introduced in the upcoming January legislative session to address this crisis.
One bill in particular would create a pilot program that would permit a test site somewhere in Denver; this could lead to figuring out if a SIF would address overdose deaths in the city.
Trauma plays a large role in overdose deaths, too
A different plan of attack when it comes to helping intravenous drug users could be finding solutions to the trauma encountered in their lives thus far.
What’s intriguing to learn from public health officials working in these facilities is how much trauma plays a role in both drug use and homelessness, and how it requires some form of a coping mechanism for said trauma to not completely overwhelm the individual. While overwhelming situations do happen, there are services that can assist in these instances.
Laura Rossbert of the Delores Project in Denver (a transitional shelter program that provides shelter and helps women and transgender individuals plan paths to stability) pointed this out when discussing what her center has experienced with individuals utilizing services provided by their program.
“We do find, that once people have more stability in their lives they do move to being able to make healthier choices about coping mechanisms,” Rossbert said.
Rossbert isn’t the only one in this line of work who has observed the link between gaining stable housing and decreased use by intravenous drug users. Executive Director of the St. Francis Center Tom Luehrs has noticed a similar situation in his center’s work as well.
“We estimate that perhaps as high as 30% of our population is using some kind of drug,” Luehrs said. “I think for sure we have seen people lessen or suspend their substance use indefinitely upon living in housing.”
These noted observations from people working with homeless populations is encouraging for those who work in harm reduction. It appears to be further proof as to why establishing a supervised injection facility in Denver could enhance additional services that are already offered in harm reduction centers and syringe access programs today.
In addition to what’s been said by staff who work with both homeless and intravenous drug user populations, users themselves have been surveyed as stating that they think this kind of site would be mostly beneficial.
University of Nebraska Medical Center’s College of Public Health physician J.K. Costello crafted a first of its kind 61-page report on the potential benefits and data behind a SIF possibly coming to Denver. In that report, users of Raville’s HRAC were surveyed on what they thought about a SIF.
However, a few reservations are held by those surveyed, and it has to do with stigma.
When participants were asked their thoughts on the positive effects a SIF might have, they responded with the following: “Answers included: “humanize[s] users in a safe, comfortable setting,” and “bridge[s] the gap on public acceptability.” It seemed that some respondents felt like a supervised injection facility could become a liminal space between their stigmatized, illegal activities and societal tolerance and acceptance.”
Part of what’s stigmatizing to those who would visit a SIF is the risk of public shame often assigned to intravenous drug users, which leads to another vital expectation of a SIF: confidentiality.
“Over 20% of respondents stated that a breach of confidentiality would dissuade them from utilizing a SIF.”
Intravenous drug users do not have many options when it comes to services that help them to safely exchange and use syringes, gain training on a variety of health-related services, and receive referrals to long-term housing solutions, all in one location. Services are often spread out among multiple facilities, and figuring out how to navigate the process of finding help for issues previously mentioned can be daunting if not downright discouraging.
HRAC and other facilities in Denver continue to work on decreasing the number of overdoses and those infected with HIV and Hepatitis C. If the bill introduced that would grant a test site to be opened passes, help might be on the way for these facilities that continue to work with those most impacted by the opioid crisis.