My brother died for a few seconds– just long enough for his heart to stop beating, and just long enough for him to be literally beaten back to life. He was one of many drug users in America– a future blurred by one too many heroin overdoses and relapses.

He became the black sheep in the family. You were not allowed to mention “he who had thrown his life away,” the cautionary tale of too many bad decisions. Yet, the lack of spoken words did not account for the many thoughts that passed through everyone’s mind. Though he sought help, it was never enough. The relapse rate for substance abusers is between 40% and 60%. He had specifically requested to be treated at home where he took prescription medicine in order to lessen the withdrawal symptoms. More than once, he would shake uncontrollably, vomit, yell, restlessly stay up all night and sleep through the whole day.

Then he would do it all over again until he left. I have not seen him since 2016.

The CDC reported over 70,000 drug overdose deaths in 2019. Yet, in my opinion, society is not doing enough. Threatening to jail drug users will not reduce drug-related deaths, decrease drug usage, or help struggling families. Sentencing users to prison is supposed to act as a deterrent, but it proves ineffective because of a lack of direct correlation between usage and completing sentences. Prison does not prevent nor disincentivize relapsing once a drug user does their time.

One day I heard about Safe Injection Sites (or Supervised Consumption Sites), legally sanctioned facilities that allow people to consume pre-obtained drugs under the supervision of medically trained staff in order to reduce the health and public order issues often associated with public drug consumption. If an addict were to overdose, medically trained staff would be able to revive them with an overdose antidote like Naloxone, also known as Narcan.

Though I heard of the concept long after my brother was gone, it did not make sense to me. Users needed treatment, not incentive. A drug user needed help rehabilitating, not help remaining an addict. I held this belief for over a year. Attending the University of San Francisco has allowed me to observe the scope of this issue in one of America’s most iconic cities: San Francisco.

The Tenderloin

One of my very first weeks in San Francisco, I took a bus to a store near the Tenderloin in search of materials I needed. The Tenderloin is the city’s densest neighborhood and is home to a large homeless population. The city of San Francisco has around 8,000 homeless in the city. Tenderloin streets are covered with countless tents, needles in people’s arms, syringes on the ground, and an unsustainable amount of trash. Those living on the streets often do not have access to sanitary restrooms or spaces.

Many of the needles on the ground came from the Department of Public Health. These were distributed free of charge in order to decrease the spread of HIV and Hepatitis C through shared needle usage. As a result, 4.45 million syringes are handed out each year, and only around 3 million of those are returned.

I returned to the Tenderloin a few weeks ago, in an effort to see if anything had changed. I was greeted with a feeling of desolation. People, mainly males, were either in a state of idleness or engaging in obscure conversation. Some were propped up against the walls– seemingly staring at their feet. Others were talking with each other and yelling at someone they recognized across the street. Walking through those streets as a young woman did not produce the fear I had expected.

I was cautious. I was walking with a camera around my neck, and I knew that any one of them could have easily approached me, to yell at me or rob me. I also knew why the area was not one of San Francisco’s brightest. The streets were far from clean– trash lined up the sidewalks and homeless people seamlessly wandered around. Despite its state, it was the place many called home.

Endorsement and Support

Since 2018, the San Francisco Department of Public Health has endorsed safe injection sites with the aim of curbing the opioid epidemic. All of this is in an effort to take on a “harm reduction” approach, where widespread drug users should be accepted by mitigating the adverse effects to the public and the users themselves, under exemption from prosecution under federal drug laws. Assembly bills under consideration are purposefully written to make injection sites exempt from state drug laws, only legalizing certain types of drugs, which would allow them to operate without any federal sanctions.

California State Senator Scott Wiener (D-San Francisco) now wants to bring safe injection sites to San Francisco, and has reintroduced a bill that would allow the city to open pilot supervised injection sites. San Francisco Mayor London Breed and the Board of Supervisors have supported this legislation since it was first introduced in 2018 but vetoed by outgoing Governor Jerry Brown. Breed had stated in a news conference that you can’t control people’s addiction but you can be there for them. Senator Weiner had also emphasized the need to treat drug users as a public health issue and not a criminal one.

The war against drugs is a war against people who are seen as less than people.

Mike Discepola, VP of Substance and Behavioral Abuse of the nonprofit San Francisco AIDS Foundation, told Globus in a phone interview, “The idea is for us to have easy access all the way up to more intensive levels of care which can lead up to levels of treatment. We’ll be with the person in the way they want to be.”

Discepola emphasized the point of interpersonal relationships. He recognized that many people believe drug users do not want to do well. Discepola disagreed. Addicts face a stigma. “The war against drugs is a war against people who are seen as less than people,” he said.

Discepola participated in a Safe Injection Sites Services Task Force in 2017. Their final report supported an integrated model. This model would include on-site services and linkages to other services.

When talking to people, Discepola said he likes to ask them, “Would you want your mother to be on the street injecting in a puddle? Would you want her to lose her life with a needle in her arm on the sidewalk?”

When conducting Discepola’s interview, his words brought up emotions I had not felt in a long time. He reminded me of the uncertainty I felt every time my brother came home. He reminded me of a period in my life where I struggled to understand what he was going through. I was mad. For a long time, I was selfish. I didn’t understand why he was the way he was. I was mad that he had turned my whole world upside down. I was mad that he could not be the brother I used to know.

“It’s okay to love people who are struggling,” Disceopla lamented.

I changed my mind on Safe Injection Sites when my brother was long gone. On more than one occasion he would narrate a story about life on the streets– finding someone who sold what he needed, hiding from the cops, and putting his life in constant danger. Once I started to look at the evidence, I realized he didn’t have to be on the streets. At times I like to play with the idea that maybe if he had built those interpersonal relations, he would have sought help. He could have been better.

Our Neighbor Next Door

Following a growing trend of these sites worldwide, Canada currently operates around 40 facilities, the largest one being in Vancouver, British Columbia. Vancouver is home to North America’s oldest safe injection site, Insite, located in the Downtown Eastside. The region’s main health agency, the Vancouver Coastal Health and a non-profit, the Portland Hotel Society, oversee this Safe Injection Site which opened in 2003.

Upon attempting to contact someone from this location, I was told staff are instructed not to speak to the media. Numerous publications have indicated these sites have been effective. In 2019, there were over 170,000 visits, 1,314 overdose interventions, and 3,158 clinical treatment interventions at Insite. Within Vancouver alone, overdose deaths have decreased from around 250 to 160, with a 9% hospital admittance compared to 35%. It is reaffirmed that these sites’ primary objective is not treatment but decreased disease transmission and reduced overdose deaths.

Everyone has a story. No one is born an addict.

Individuals sit on the sidewalk of a street in the Tenderloin, San Francisco. Pedestrians walk by.

Street in the Tenderloin. PHOTO D.C.

Safe Injection Sites decrease drug overdoses and help stop the transmission of diseases; however, they can only be a first step. Critics argue that Safe Injection Sites encourage drug use and bring crime, and the perception of endorsing illegal activity to the surrounding community.

“We’re not endorsing people to use drugs,” said Professor Kimberleigh Cox in a Globus interview. Cox is a senior nurse practitioner who had started a 21-day residential treatment detox in San Francisco. “We’re talking about a harm reduction model that already exists. Our history of criminalizing drug use has not been effective,” she said.

Cox took care of patients with mental illness and substance abuse disorder. It was a holistic treatment practice, working with patients where they were at. Now she is a professor in the School of Nursing and Health Professions at the University of San Francisco.

Cox explained that there’s a lot of societal stigma, where people do not want to talk about Safe Injection Sites. She thinks it is important to start with pilot projects, then study them. Cox believes a lot of the rhetoric surrounding these sites is politicized, especially when it comes to the granular details including location and staffing.

Cox volunteered at a needle exchange program in the early 2000s in South of Market, San Francisco. She said, “Surprisingly, there were a wide variety of age groups and professions. I remember people coming in right after their financial services job. It wasn’t all people living on the street. These were people that you wouldn’t necessarily know they had a bad habit.”

Workers from different sectors, as well as those living on streets, would come in and get their clean needles, dispose of their used ones, and receive printed educational materials. At the time, Cox noted, these sites were not widely publicized. Law enforcement would look the other way.

“It got around by word of mouth,” she said. “We need to shift our thinking. There are opportunities for Safe Injection Sites beyond the prevention of overdoses.” The benefits are plentiful– ranging from overdose prevention, to the lesser use of costly services such as ambulances and hospital treatment.

Both Discepola and Cox agree that there is no one answer for everybody, but Safe Injection Sites are a first step.

My story is one of many. I am only a sister of a brother. But many people are parents, children, spouses, loved ones, or friends of someone who continues to struggle. If the evidence exists, we need to take a step back and realize that there is hope. The war on drugs has failed us, but it is time we realize that our new war… is a war against stigma.