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A Safe Place to Shoot Up

San Francisco is considering opening the United States’ first legal space for people to inject drugs. Can the city pass the compassion test again?

Sammy Mullally, a nurse at Vancouver’s Insite center, assists a client as he injects drugs he bought on the street.


This story is part of our special report on the private tragedies and public toll of our injection drug epidemic. Read more of One City, Under the Syringe here.



“Nobody wants to be stuck in a park dropping their drawers and injecting in their groin. That’s not an ambition when people begin to use drugs,” says Paul Harkin, HIV services manager for Glide. But as condos encroach on SoMa alleys and SROs are cleared out in favor of hotels, shooting up in public has become a necessary evil for many people who inject drugs.

That might soon change, as San Francisco is poised to become the first U.S. city to open supervised injection facilities. Grounded in harm reduction philosophies, such facilities provide safe, nonjudgmental spaces in which people can inject pre-obtained drugs using sterile equipment under medical supervision. Advocates say such sites are often the first step on a person’s road from addiction to recovery. 

Safe injection facilities have existed in Europe for more than 30 years, and Bay Area advocates have been clamoring for them for at least a decade. But for most civic leaders, the idea of officially sanctioning injection drug use was anathema. “When this idea was first brought to my attention several years ago, my reaction was, ‘Why would we pay for a place for people to shoot up?’” says Board of Supervisors president London Breed. “I was very closed to the idea.” But the increasing number of discarded syringes and public injectors, coupled with memories of her sister, who died of an overdose, slowly convinced her of the need to study the model. Around the same time, a coalition of Tenderloin businesses, nonprofits, and residents formed to explore solutions to increased public injection. And Mayor Ed Lee, who like Breed had been adamantly opposed to safe injection sites, also expressed openness to them.

With the time finally ripe, Breed convened a task force in April that included current and former drug users, business owners, medical professionals, policy experts, syringe access workers, and a representative from the San Francisco Police Department to study the risks and benefits of opening one or several sites. “I’m still trying to get my mind around it, but I feel strongly that doing what we’re doing now—which is basically nothing, with no potential ideas to change it—is not working,” Breed says. “If there’s a real possibility that it’s working in other places, then let’s understand why it’s working there and let’s understand what the data says and let’s make an informed decision.” 

One of the first things that those who study the issue learn is that injecting drugs in public has serious negative physical and psychological consequences. Rushing an injection can lead to complications, such as bruising and abscesses. Unsanitary conditions are a hotbed for disease transmission and soft-tissue infection, which can lead to loss of limbs or death. And public injection can be a source of deep and abiding shame for the person behind the needle. Many people who inject in public are particularly worried about being seen by children. “On some blocks they have spotters who yell, ‘Children on the block! Children on the block!’ and people change up on what they’re doing,” says Terry Morris, director of the San Francisco AIDS Foundation’s 6th Street Harm Reduction Center. 

The bottom line is that, as Harkin says, “A lot of people are injecting in very kind of shambolic circumstances.” A supervised injection site, he says, would remove some of that chaos and stigma, making eventually getting clean a little easier.


The first legal safe injection site opened in Berne, Switzerland, in 1986, but there were none in North America until 17 years later, when one opened in Vancouver. Currently, just shy of 100 supervised consumption sites exist in 10 countries worldwide. At their most basic, these facilities consist of a table and chair, sterile injection equipment, a mirror for people who inject in hard-to-see places, and some sort of trained supervision. On the more elaborate end, sites provide a broad range of services, including rooms where people can smoke or vaporize drugs, space for people to relax in after using, residential detox and treatment, medication-assisted therapy, counseling, and linkages to medical care. Some supervised consumption spaces are mobile or pop-up, others are just a booth or two within an existing agency, and others still, like the Vancouver facility, Insite, are stand-alone buildings.

Whether large or small, mobile or brick-and-mortar, these facilities all serve the same goal: to make life safer and healthier for people who consume drugs and better for the communities affected by drug use. Studies of Vancouver’s Insite facility have found that it has not increased drug-related crime, that it has reduced public injection and syringe litter in the surrounding area, and that it has reduced the transmission of diseases including HIV and hepatitis C. Insite has hosted upward of 3.6 million injections since it opened in 2003, and clients have suffered some 6,400 overdoses in that time. But there has not been a single fatality.

Like Breed, fellow task force member Lydia Bransten, who manages the dining room at St. Anthony’s, came to support the idea after much study. St. Anthony’s runs an abstinence-based recovery program, and it used to be part of Bransten’s job to kick out people who were using drugs in the bathroom. This often led to conflict and distress, as she recently discovered when a client who injects drugs admitted that she’d always been a little scared of Bransten. “‘I’ve only ever been eighty-sixed’—which means removed from services—‘once,’” Bransten recalls the woman saying. “‘And that was you coming over the stall of the bathroom catching me ready to inject.’” This memory is enough to make Bransten’s eyes well up and her voice waver. “Eight years later she remembers that, and for me—I didn’t remember her at all…. It’s traumatizing for everybody not to be able to say to someone who desperately needs help, ‘We can help you.’”

Supervised injection facilities can help users in many ways. Crucially, not only do they reduce disease transmission and overdoses, but they also have been shown to increase the number of people who seek treatment. The first year after Insite opened, there was a 33 percent uptick in the number of people in detox programs. Addiction care professionals credit supervised injection facilities with enabling them to build trust with clients and to offer help without coercion or pressure. “You don’t manipulate clients, you don’t shame them, you work with them,” Harkin says. A 2010 study of more than 600 people who inject drugs in San Francisco found that 85 percent would use a supervised injection site if it were conveniently located. 


In early August, at its final public meeting, the task force released a draft recommendation supporting the idea of multiple sites across the city located within organizations that already serve people who inject drugs. The final recommendation will be released in September and will go to the Board of Supervisors and Mayor Lee for consideration.

The task force’s draft recommendation proposes facilities in neighborhoods with high rates of public drug use, including the Tenderloin, Civic Center, SoMa, the Mission, the Bayview, and Haight-Ashbury. It also calls for a model that links clients to other services, employs trained peers who use drugs, and considers expanding to serve people who use drugs without injecting them. Factoring in reduced disease transmission, soft-tissue infection, and overdoses, as well as an increased number of people in treatment, one 13-booth supervised injection site could save San Francisco as much as $3.5 million annually. So far, public commentators at task force meetings have been overwhelmingly supportive, with only a handful of critics questioning whether safe injection sites would attract drug dealing and other criminal activity, become a lure for outside drug users, or waste taxpayer dollars on additional security measures.

Still, formidable hurdles to opening even one safe injection facility remain. The city’s ever-present NIMBY factions could block it, as happened in Seattle, which approved a supervised injection facility this year but hasn’t yet built it because of community backlash. And there are legal barriers, including the so-called crack house statute, a section of the federal Controlled Substances Act that criminalizes landlords who knowingly allow drug use on their property. A recently introduced bill, AB 186, would have exempted property owners, staff, volunteers, and clients of injection facilities from such charges. But it fell short by two votes in mid-September. Even if it’s revived and passes at the state level, city-sanctioned facilities could face federal opposition from Attorney General Jeff Sessions, given the Department of Justice’s revived war on drugs.

Despite these obstacles, injection site supporters are optimistic. “It’s going to happen because I believe that this city is a loving city, a caring city, that has always stepped forward,” says Bransten. “Whether it was the AIDS crisis or needle exchange, throughout the years we have shown ourselves to be leaders in the field of compassion.”

For Paula Lum, a member of the task force and a doctor at Zuckerberg San Francisco General Hospital, the significance of a supervised injection site goes far beyond cost savings. Lum was around in 1993 when the city got its first syringe exchange, in 2000 when it adopted harm reduction as official policy, and in 2003 when it became the first American city to make naloxone, which reverses opioid overdoses, widely available to the public. The unconditional acceptance at the root of safe injection sites is “the original spirit of San Francisco,” Lum says, “which I think we’ve seen less of over the years.” In the idea of a supervised injection facility—a place where drug users could come with their trauma and their illness and be welcomed, respected, and helped—she sees the potential for the city to return to its radical, compassionate roots, and heal.



Originally published in the October issue of San Francisco 

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