safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States

International Journal of Drug Policy 53 (2018) 37–44

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International Journal of Drug Policy journal homepage: www.elsevier.com/locate/drugpo

Research Paper

Using drugs in un/safe spaces: Impact of perceived illegality on an underground supervised injecting facility in the United States Peter J. Davidsona,* , Andrea M. Lopezb , Alex H. Kralc a

University of California, San Diego, 9500 Gilman Dr MC0507, La Jolla, CA 92093-0507, USA University of Maryland, 1111 Woods Hall, 4302 Chapel Lane, College Park, MD 20742, USA c RTI International, 351 California St., Suite 500, San Francisco, CA 94104-2414, USA b

A R T I C L E I N F O

A B S T R A C T

Article history: Received 11 May 2017 Received in revised form 11 November 2017 Accepted 5 December 2017 Available online xxx

Background: Supervised injection facilities (SIFs) are spaces where people can consume pre-obtained drugs in hygienic circumstances with trained staff in attendance to provide emergency response in the event of an overdose or other medical emergency, and to provide counselling and referral to other social and health services. Over 100 facilities with formal legal sanction exist in ten countries, and extensive research has shown they reduce overdose deaths, increase drug treatment uptake, and reduce social nuisance. No facility with formal legal sanction currently exists in the United States, however one community-based organization has successfully operated an ‘underground’ facility since September 2014. Methods: Twenty three qualitative interviews were conducted with people who used the underground facility, staff, and volunteers to examine the impact of the facility on peoples’ lives, including the impact of lack of formal legal sanction on service provision. Results: Participants reported that having a safe space to inject drugs had led to less injections in public spaces, greater ability to practice hygienic injecting practices, and greater protection from fatal overdose. Constructive aspects of being ‘underground’ included the ability to shape rules and procedures around user need rather than to meet political concerns, and the rapid deployment of the project, based on immediate need. Limitations associated with being underground included restrictions in the size and diversity of the population served by the site, and reduced ability to closely link the service to drug treatment and other health and social services. Conclusion: Unsanctioned supervised injection facilities can provide a rapid and user-driven response to urgent public health needs. This work draws attention to the need to ensure such services remain focused on user-defined need rather than external political concerns in jurisdictions where supervised injection facilities acquire local legal sanction. © 2017 Elsevier B.V. All rights reserved.

Keywords: Supervised injection facilities Overdose Law Harm reduction People who inject drugs

Introduction Background Supervised injection facilities (SIFs, also called safe injection sites or drug consumption rooms) are facilities that provide a hygienic space for people to inject pre-obtained drugs under the supervision of staff trained in overdose response as well as injection-related risk reduction strategies. SIFs aim to reduce health and public order problems such as overdose, public

* Corresponding author. E-mail addresses: [email protected] (P.J. Davidson), [email protected] (A.M. Lopez), [email protected] (A.H. Kral). https://doi.org/10.1016/j.drugpo.2017.12.005 0955-3959/© 2017 Elsevier B.V. All rights reserved.

injection, and street-discarded needles by providing high-risk, socially marginalized people who regularly inject drugs in public spaces with a safe location to consume drugs out of the public eye. Ten countries currently have specific legislation or regulation authorizing the operation of SIFs (Switzerland, Germany, France, the Netherlands, Norway, Luxembourg, Spain, Denmark, Australia, and Canada), with over 100 facilities operating in 66 cities (European Monitoring Centre for Drugs & Drug Addiction, 2016; Hedrich, Kerr, & Dubois-Arber, 2010). As the terminology and precise approaches to ‘legalizing’ such sites differ from country to country and even city to city, throughout this paper we use the terms “legal” or “sanctioned” to indicate any kind of legal sanction through formalized legislation, or political sanction through agreement or approval of relevant local or state actors and authorities. “Unsanctioned’’ refers to any facility which has not

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formally received such recognition. In the United States, no SIF currently operates with formal acknowledged sanction, however, some state and local jurisdictions have recently begun considering authorizing such facilities (CBS Baltimore, 2017; Foderaro, 2016; Gutman, 2017; Sapatkin, 2017), largely in response to a quadrupling of overdose deaths nationally over the past 15 years (Centers for Disease Control & Prevention, 2017). Of the sanctioned facilities outside the United States, the InSite facility in Vancouver, Canada, and the MSIC facility in Sydney, Australia have been the most comprehensively described in the peer reviewed literature, with over 75 papers describing health and social order outcomes from these two facilities (Potier, Laprévote, Dubois-Arber, Cottencin, & Rolland, 2014). A smaller number of papers (most in non-English language journals) describe health and social order outcomes from European sites (Hedrich, 2004; Hedrich et al., 2010). Collectively, this literature consistently describes decreases in overdose deaths near facilities, along with other substantial positive health and social outcomes for both those using the facility and for the surrounding community (DeBeck et al., 2008; Fitzgerald et al., 2010; Kerr et al., 2006; Marshall, Milloy, Wood, Montaner, & Kerr, 2011; Salmon, Van Beek, Amin, Kaldor, & Maher, 2010; Small et al., 2008). A limited literature also exists on unsanctioned sites, describing the role of an unsanctioned site in Vancouver in meeting needs not met by InSite (McNeil, Kerr, Lampkin, & Small, 2015; McNeil, Small, Lampkin, Shannon, & Kerr, 2014), and the role of the short-lived ‘Tolerance Room’ in Sydney, Australia, in pushing the state government of New South Wales to approve a sanctioned site in the early 2000 s (Wodak, Symonds, & Richmond, 2003). We describe here the results of qualitative research conducted at a facility operating without sanction in an urban area of the United States since 2014. This work sought to broadly examine the impacts of having access to the space for people who used it, and to explore how the ‘underground’ and potentially illegal status of the site either positively or negatively impacts the utility of the space for its clients. Setting While legislatively authorized facilities operating solely or primarily as SIFs do not yet exist in the United States, people who inject drugs and the social service agencies who serve them have come up with a range of strategies to create supervised or semisupervised spaces that reduce the risk of overdose death. For example, many social service organizations in the United States which directly serve people who inject drugs are aware that people sometimes use their bathrooms1 to consume drugs as people seek safety, more hygienic conditions, and privacy from police surveillance. Due to the difficulty of preventing such use in one of the last truly private spaces in American culture, to reduce the risk of fatal overdose many agencies have adopted some level of harm reduction practice. These practices range from minimal efforts such as cutting the bottom few centimetres off bathroom doors (to allow easier detection of an unconscious person), making sure the door can be unlocked and opened from the outside andinstalling syringe disposal facilities, to having a naloxoneequipped staff member stationed outside the bathroom to allow frequent checking of individuals using the bathroom to ensure they have not overdosed (Frost, 2017; Mata et al., 2014; Wolfson-Stofko et al., 2016). In recent years, at least one state health department (New York) has mandated that needle exchanges must have minimum safety standards for bathrooms to reduce fatal overdose

1

In the United States ‘bathroom’ refers to any room which includes a toilet; we retain this usage throughout this paper.

risk (New York State Department of Health Institute, 2016). While the precise legal status of a SIF operated for public health purposes is unclear in U.S. law (Beletsky, Davis, Anderson, & Burris, 2008), concerns about potential legal consequence have meant nearly every agency practising such harm reduction measures in the United States has also chosen to operate on a ‘don’t ask, don’t tell’ model, in which drug use on the premises remains officially prohibited and users who are indiscreet may be banned from the facility or otherwise penalized. In April 2014, in response to increases in overdose deaths in public spaces, a community based organization in an urban area in the United States took a step beyond the ‘don’t ask, don’t tell’ bathroom model, and remodelled a bathroom with drug consumption in mind, before explicitly informing people who used the organization’s existing services that they could use the bathroom to consume drugs. Injection supplies were provided, and a staff member trained in emergency response and equipped with naloxone was stationed outside the bathroom door. The bathroom door was usually left open while the person consumed drugs, and 40 centimetres was removed from the bottom of the door to facilitate emergency access in the event the door was closed. In addition, the agency developed a quantitative survey to help them evaluate the impact of the facility, and approached authors Kral and Davidson for technical assistance in implementing the survey with every person who used the bathroom. Over the next six months, the bathroom was used to consume drugs 1452 times. However, it quickly became apparent that having only a single-use room available to consume drugs was logistically problematic, as the number of people wishing to use the bathroom to consume drugs greatly exceeded the capacity of the space. This rapidly led to long lines, arguments between clients and staff, people choosing to leave the facility and consume drugs in less safe public spaces nearby rather than wait, and, in effect, loss of the bathroom for its original purpose. In September 2014, the organization decided to cease use of the bathroom as a space to consume drugs and to re-furnish two adjoining rooms as a supervised injecting room and a space to relax after using drugs. The physical layout of this new space was modelled loosely on the InSite SIF in Vancouver, being equipped with five separate stainless steel injection stations and a comprehensive array of injection supplies. A staff member trained in emergency response and equipped with naloxone is stationed in the room at all times. The staff member also administers the brief quantitative survey to each person each time they use the facility. As the staff member is in the room rather than outside it, the agency expected that there would be improved opportunities to provide education around skin care and injection technique, as well as additional opportunities for referring people to other social services including drug treatment. From September 2014 to October 2017 inclusive, the facility was used for 4623 injecting events by approximately 120 people. Six overdoses occurred, with all six individuals successfully revived by staff using naloxone. In early 2016, the authors obtained funding (see acknowledgements) to support a qualitative project examining the impact of having access to the space on people who used it, and to explore whether the fact that the space was ‘underground’ and unsanctioned was having either positive or negative impacts on the utility of the space for its clients. Methods Data collection Qualitative interviews were conducted at the facility between June and August 2016 with 23 individuals, 22 of whom regularly use the facility themselves, and one staff member who does not

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inject drugs. Of the 22 who use the facility to consume drugs, one was also a paid member of staff and two had formal roles as volunteers at the facility. This sample of 23 was estimated by the staff of the facility to represent approximately two thirds of all users of the facility during the study period, and to have included all people who used the facility at least weekly during that period. Any individual present at the site was eligible to participate, and the only exclusion criteria was inability to provide informed consent (where inability was due to apparent intoxication the individual was informed they could participate at another time if they wished). All interviews were conducted by the first author in a separate private office. Interviewees were paid USD$20 immediately following consent procedures and before beginning the interview (to reinforce the statement made during the consent process that research participation is voluntary and they were free to end the interview at any time). Field notes were written after each interview. Two interviews were halted within the first five minutes of the interview due to intoxication and were not included in analysis (in both cases it appeared the individual had used the SIF immediately before being referred to the interviewer, and onset of intoxication did not occur until some minutes after the consent process). Interviews were based on a semi-structured interview guide developed by the authors in consultation with the staff and advisory board of the SIF, and modified iteratively as interviews progressed and new lines of inquiry emerged. The interview guide included questions about where use of the SIF fit in with other daily activities, other locations used to inject drugs and how they compare with using the SIF, changes to the SIF which would improve it, changes to drug use practices since starting using the SIF, changes to relationship with other people who use drugs who don’t have access to the SIF, and any aspects of the SIF being unsanctioned and ‘hidden’ which affected the participant. Interviews were audio recorded using a digital device with full disk encryption. Audio files were transmitted in encrypted form to a professional transcriptionist; transcripts were returned to the first author in encrypted form. Transcripts were verified against original audio recordings, then the audio recordings were securely erased. Transcripts were reviewed by the first author and all information which could potentially disclose the identity of any individual, any organization, or the urban area in which the SIF is located were deleted or replaced with pseudonyms. These ‘redacted’ transcripts were shared with authors 2 and 3 using a secure file server. As per our consent form, no individual transcripts were shared with staff or the community advisory board of the SIF. Finally, ethnographic field work was conducted over the course of the study in order to document the process of launching the facility, as well as to understand the decision-making processes and organizational structures of the various stakeholders involved in opening the site. Ethnographic field work took place at planning meetings with the executive director, community advisory board, and researchers, as well as other sites where stakeholders discussed the project or issues of injection drug use in the city more broadly. Analysis Transcripts were analysed using a thematic approach loosely based on grounded theory (Glaser & Strauss, 1967; Strauss, 1987). Analysis involved a three stage process, in which transcripts were read through completely once (all transcripts were read through completely by at least two of the authors) before being read through a second time and annotated using descriptive ‘open’ codes. Transcript data was then sorted around these initial codes. As material was found which did not neatly fit initial codes, new

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codes were developed to better organize and describe the material. Memos were written on each of the thematic codes which emerged from this process, along with additional memos on relationships between codes (e.g. the interplay between the perceived illegality of the service and the ability to access resources needed to improve the service) which form the basis of our results below. Sample characteristics Three of 23 interviewees were female. Sixteen interviewees were white, 2 Hispanic, 4 African American, and 1 Pacific Islander. These demographics closely match the demographic profile of all users of the SIF in quantitative data collected by the agency over the previous two years and described elsewhere (Kral & Davidson, 2017). A higher proportion of service users are white and male compared to people who inject drugs in the immediate surrounding neighbourhood, but service users are demographically similar to opioid overdose decedents in the urban area as a whole.2 Two of the interview respondents had only begun using the facility within the past week, one of who had only begun using the facility on the day of the interview. All remaining interviewed users of the facility had been doing so for a minimum of several months, and many said they had been using the facility since it first opened in 2014. Ethics approval The project was given ethics approval by the Institutional Review Board of the University of California, San Diego (Protocol #160354). Results Our analysis revealed four key domains: issues relating to public health and public injecting; issues around stigma and community; the constructive consequences of operating without formal sanction; and the limitations and problems stemming from operating without formal sanction. Public health and public injecting We found that overall, many of the public health benefits described in the literature on sanctioned SIFs from around the world were also described as being present at this unsanctioned facility. People described the impact of simply being able to take their time injecting in a clean, well-lit environment: Q: Has anything changed about the detail of how you shoot drugs since you started using this side? IJ12: Other than not rushing and worrying about somebody walking up on me that could potentially get me in trouble, yeah, I don’t miss very much of anything anymore. Because I don’t have to rush through, and push it in, you know? So I’ve been saving the conditions of my arms definitely. And it’s a lot cleaner, a lot cleaner. Others explicitly noted the impact of this on soft tissue infections: IJ22: Oh yeah, I haven’t had any abscesses in a while since using this place. I used to have abscesses a lot. So that’s nice.

2 The relative representativeness of service users is based on comparison with cross-sectional samples of drug users from other research conducted in the neighbourhood, and with medical examiner/coroner data on demographic characteristics of individuals who had died from opioid-related overdose. We have not cited these comparative data to avoid identifying the urban area in which the SIF is located.

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Users of the space described learning new skills and habits, such as more consistently using clean needles and how to recognize and respond to overdose: Q: Has anything changed about your use since you started using this space? Anything you’ve learned about using or anything like that? IJ23: Just to use clean stuff all the time. The more that's it’s available, the more I'm able to use cleaner rigs every time instead of having to re-use things. I got educated on a few things, like how to use a Narcan [naloxone] and what to do in certain situations. So that's good because it’s educational too for people that are using. Because there's certain things that a user should know if you find yourself in a sticky situation obviously. Likewise, people described changes in how and where they disposed of used needles: Q: Is there anything that’s changed about the way you use drugs since you started using this place, you think? IJ13: I’m a lot more responsible with my disposing of needles. It’s really brought an awareness to me of how I should be disposing of my needles, and not using the same ones over. Q: Where did you used to dispose of them before you were using this place? IJ13: Just in the trash. I’d never even seen a sharps container until I came here. While users of the SIF recognized its utility in protecting them from fatal overdose, there was also a clear sense that the space created safety in far broader ways by creating a non-predatory, socially supportive environment: IJ19: . a number of things can happen to you while you’re on the streets, sober or not, especially if you’re in a different state of consciousness. People can take full advantage of you in a number of ways, be it a guy or a girl. Plus, just say you’re by yourself and, God forbid, but events go down and everything and make a turn for the worse and you’re just stuck by yourself. At least here, there’s people around looking out for each other, on top of the staff. This was contrasted, often explicitly, with where people would be injecting drugs if they were not using the SIF. While some respondents described sometimes having a living arrangement that provided them with the privacy needed to use drugs, all described routinely using drugs either on the street or in public bathrooms, talking about the discomfort and stress they experienced from being in the public eye: Q: When you said [the SIF is] too good to be true, what’s really good about it? IJ13: So it’s the difference between sitting on a curb next to faeces and you got people walking by you, and cops driving by constantly. And any time kids come by, the majority of us we keep an eye out for them. We’ll put it [the syringe] away and not expose the kids to that, but then you’re rushing your shot in, you don’t even really get to enjoy your high that much because there’s always . . . people out there bumming off you and stuff. It’s really crazy and dirty out there. Stigma and community Many users of the site explicitly described their discomfort with how their use of public bathrooms or the street to inject impacted other members of the community (although in this case the respondent also notes that use of a public bathroom comes with the benefit of not sharing a space with other people who use drugs):

Q: Can you tell me more about the other places, like the other spaces that you use to inject drugs? Is there anything that you prefer about other places to inject rather than here? IJ06: [Regional fast food chain] bathroom. I’m by myself in there. I can come in and go out right away. There’s no politics. As much as I say there’s no judging [here at the SIF], you always have to keep your bag by your side and things like that. Just the [regional fast food chain] or [national fast food chain] bathroom is nice. But then I have fear of employees seeing me through the crack. Somebody actually needing to use the bathroom and I’m a kind person so if there’s a lady out there who is crying because she’s about to have diarrhoea, I’m going to stop shooting even if I have blood in my rig and be like, “God damn it, bitch,” and stomp out there, but still give her the commode. Having access to a SIF appeared to assist with reducing both the stress and sense of stigma associated with injecting in public view, not only by providing a space out of the public eye, but also by providing a space where the nuances of drug use and the needs of people who use drugs were understood: Q: What did you think when they first said they were going to open this place? IJ22: Well, I was very excited. I thought it was cool because I’d never seen anything like it. Instead of a place kicking me out, it’s a place asking me to come in. It’s new for a heavy drug user like me. Participants described a sense of camaraderie and co-construction of social space which overrode some of the competitive and exploitative relationships they experienced with each other in street settings: IJ06: The one thing we may all come with [is] our own dysfunction. Some of us may steal from each other. Some of us may talk shit about each other behind their back, but the one thing we do is we try to not judge each other’s addictions. I had to drop my trousers this morning and hit myself in the groin and I did that right in front of two other participants. Would I normally do that on the street? Oh my God, I would never do that. But because it’s the [SIF] and we’re all in here and they understand. . they know that I have to get well and they’re not going to make me feel bad or say anything about, “Oh, I can see your butt,” or “nice panties,” or something like that while I’m trying to get myself because they know, “just leave her alone, she’s trying to get right.” In many respects the unsanctioned nature of this SIF seemed to contribute to the sense of camaraderie and ownership of the space: Q: Do you think the fact that this place is secret, illegal, helps to create a sense of community? IJ10: Yes. Because I feel like it brings together equal because lot of people have physiological problems and having a place where you feel safe when you’re at home diffuses the animosity and the tension in one’s self. Damn it’s like a little family, like a little community, we’re all watching over each other. I could leave my phone out there on the charger and not have to worry about somebody swooping my shit up or anything of that nature. Yes. I think it’s great. Others explicitly bundled physical and social notions of safety: Q: I guess what we’re really trying to get at is how the fact that this place exists, how does that affect you? IJ10: It affects me in a positive way because I have less of chance of catching something, I have less of chance of not knowing what I’m doing and hurting myself. I have less of a chance of OD’ing. And it’s like I said, it builds a community and it builds trust and it builds a foundation within all of us to take the tension and the animosity, to be able to be amongst one another

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and be comfortable and peaceful. I feel when I come in here now, I feel peace, I feel comfortable. I feel peaceful, like the people around me are not all out to get me or they don’t just want to be in my face or something Finally, participants often expressed a reflexive understanding of the possible broader political meanings of the space in the US context: IJ19: . it’s history in the making. It’s the first of its kind. Constructive consequences of being unsanctioned The lack of legal sanction has a wide range of complex interrelated impacts on the service. In the simplest sense, the SIF would not yet exist if the organization had decided instead to seek formal permission to open: despite energetic educational and advocacy efforts in a number of cities in the United States dating back (in some cases) over a decade (Associated Press, 2007; Foderaro, 2016; Guard, 2007; Gutman, 2017; Leff, 2007; Sapatkin, 2017), and the considerable progress made toward the goal of opening a locally sanctioned SIF in one of these locations, at the time of writing none of these efforts have yet been successful. The Executive Director of the agency running the SIF described in a meeting with the researchers both the initial decision to overtly allow drug consumption in the bathroom and the later decision to operate a SIF as deriving from a sense of urgency: “too many of our people were dying, every week, and if we waited until someone gave us permission we’d still be waiting and everyone we cared about would be dead.” The absence of need for approval from external government agencies meant that after a year of planning and six months of operating the bathroom, when the Executive Director and Community Advisory Board voted to operate a SIF, implementation was able to take place quickly: IJ21: And then [the agency Executive Director] was like, “Fucking A, we’re going to do it,” and [the Executive Director]’s like, “Two weeks,” and our minds were kind of blown ‘cause that seemed insane. Further, the “underground” and secret nature of the SIF means the service has completely sidestepped any of the kinds of ‘Not in my backyard’ community opposition frequently face by services for people who inject drugs (including the sanctioned SIFs in other parts of the world) that might have led to difficulty and delays in finding an acceptable location for the facility (Davidson & Howe, 2014; Hyshka et al., 2013; Mennie, 2011; Williams, 2016). In our ethnographic data, it also became clear that on a day-today basis, the lack of formal sanction meant the structures and rules governing how the space was operated had emerged organically from those working, volunteering at, and using the site, rather than being externally imposed. In addition, the users of the space also played major roles in larger decisions, such as whether to open a SIF in the first place (potentially putting other services offered by the organization at risk) and whether to invite the authors to conduct research at the facility Possibly as a consequence, when asked how they would feel about the space being operated by the local Department of Public Health, many respondents expressed discomfort with a perceived loss of control of the space: Q: What would you think if the Department of Public Health was running a place like this? IJ18: It would be horrible. Q: How come? IJ18: Because the government is inefficient and can’t run anything properly. It should be underground. There's good people underground. It should just be more money put into it thought by other people. Proprietors. Because most of those –

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10% of the money would go for as this and 90% would go towards paying their salaries. And it wouldn’t even be the same. Never be the same. Although one respondent noted cynically that a local government department was already ‘operating’ a de-facto injecting facility, whether they were aware of it or not: Q: Are there any other places you regularly use to inject heroin? IJ05: The [government department] bathroom, that’s a big shooting gallery. Staff explicitly made analogies to the early days of needle exchange in the United States, when exchanges started as underground acts of civil disobedience before gradually gaining local government sanction and support, but then experienced restrictions in operational rules to meet political rather than user need. IJ21: The way things are right now, this place is not like we have this SIF. It functions based on the fact that we only invite certain people and if we had better funding and we were legitimate, we could actually invite everyone in and that would be a beautiful thing. These people would be sad because they’d lose their clubhouse, but when I worked that front desk and then people [who could not get in due to space constraints] go right outside and shoot up, it sucks, you know? And while I want these folks to have a place where they can hang out, if we had multiple sites throughout the city, there would be that feeling anyway. . . . Yeah, [have a department of public health] take it over. Yeah, do it, make it happen, give more people access. Sometimes there’s only like two people in three hours, so I don’t know. I think it’s worth it, and that a lot of the rules [likely to be imposed at a sanctioned site] are going to affect people negatively that like need help hitting or stuff. But all the other 5000 people out there that still have that problem, that aren’t in here, that’ll be a lot less people without access. So yeah, I don’t know. It’s just going to be interesting seeing what kind of rules they come up with and stuff. It’d be fun to be part of that conversation. Limitations and problems stemming from perceived illegality While in many respects lack of official sanction may have facilitated the development of user-centric operational procedures for the space, the lack of sanction, and concern about possible legal consequence, also appeared to have led to at least some operational decisions which had more to do with maintaining secrecy rather than meeting the needs of users: Q: Is there anything else about how you set the place up that you’d do differently if this was totally legal? IJ06: We have to maintain an extreme level of calm in the front and an extreme level of discretion. . Anybody who’s fighting or being loud is going to be ousted right away and that’s not necessarily always fair becomes sometimes somebody might be loud for a legitimate reason, but you always have to think about the safety of the [SIF], always, always, always. You have to really tiptoe around. In addition, the unsanctioned nature of the site was a source of constant low level stress for staff and volunteers, and speculation about ‘who knows’ about its existence. Both staff and users made reference to the assumption that police, or at least undercover agents and street patrol officers “must know” about the site. Staff reported at least one user of the space describing an incident where a police officer, catching him injecting between two cars on the street, had actively referred him to the agency as a place to go where he could inject out of the public eye. Likewise, in meetings

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with the researchers, senior agency staff and advisory board members described interactions with local public health officials and other non-government social service agencies who were clearly aware of the existence of the space and were supportive enough to not interfere, but who had made it clear they would not be willing to support the agency if the SIF should be discovered. Cumulatively: IJ06: Yeah. We have to be like a kid on the playground who has to keep their head down because they’re afraid their daddy is going to see their bruises. More subtly, but more perniciously, the secret nature of the SIF had meant the initial process of opening access to the SIF had been by invitation only to individuals with a well-established relation to the agency who were felt to be “reliable” enough to not disclose the existence of the facility, and then slowly by word of mouth through these participants’ social network. This had inadvertently led to a user group which was perceived to be younger, more male, and more white than the broader street-based drug using community in the immediate area: IJ21: This exclusive thing, it sucks. And also because it’s word of mouth or we have our participants refer new people. And so since most of our first participants were white, most of them have white friends and most of them have men friends, and so it’s hard to reach out to new communities and it keeps it kind of exclusive and all, so yeah. Or, as one participant (who had earlier in the interview made racist remarks about older black men in the neighbourhood) put it when asked about how to improve the service, IJ15: Another thing I would change is – it’s weird that I never really felt like I thought this way, or I’d be this person – but I’d like to see more diversity here. And I don’t think it’s, again, been a specific thing; I think this is just where the chips have fallen. (Note that since these interviews were completed, addressing this lack of diversity has been a major priority for the agency). In addition, staff discussed how individuals with serious mental illness had been explicitly excluded out of concerns about increased risk of disclosure – arguably a more than usually vulnerable group who would benefit substantially from a safe environment like a SIF. More broadly, the need for secrecy placed practical limits the number of individuals who could know about and use the space at any one time, limiting the overall impact of the site on public health and public safety outcomes in the community. The underground nature of the SIF has other direct consequences on the nature of services offered. One question asked consistently of most respondents was ‘how could the space be made better.’ Interestingly, almost all respondents were deeply reluctant to say anything that might be interpreted as criticism, prefacing any suggestions for improvement with statements that made it clear that they thought it was remarkable that any such facility was available to them at all. The most common request for improvement was simply longer opening hours: Q: Is there anything they could do to this place to make it better? IJ23: More hours, make it open more, more availability because drug addicts are 24/7. Many other suggestions spoke to the need for other forms of resources access to vein care products, or additional infrastructure such as vein-finding technologies, a particular need of longtime injectors: IJ21: At [service in another city], they have one of those vein finders, that would be cool, and more knowledgeable staff on or someone that could be here that knows more about veins and vein care.

Others suggested improvements to the physical layout of the space. IJ06: I would like to have dividers between the stalls. I’d like to have a little bit more visual privacy. If [agency executive director] had more of a budget I would like to have more dividers, just for contact precaution, things like MRSA [methicillin-resistant staphylococcus aureus, an antibioticresistant bacteria]. (Note that in response to this feedback the agency has since installed floor-to-ceiling dividers between the injecting stations, has increased operating hours, and has sought training opportunities for staff around vein care). The two other major categories of request were for better integration with other social and medical services, and for more focus on education. While, as described above, many respondents mentioned skills and practices they had learned through their use of the SIF, a small number suggested that the organization could do more along these lines, describing what they saw as poor injecting practices they’d seen among others using in the SIF. They argued that the organization could do more to intervene constructively in these instances including the insightful suggestion that one difference between a SIF and other places where people go to inject drugs was not so much who runs it but the presence or absence of such focused interventions: IJ15: And so yeah, I’m not clear, is this place here to prevent overdose? Is it here to provide a safe environment to inject drugs, and whilst teaching and educating and putting that . . . Because I don’t think you can just say here’s the place to do it, and leave out the education part. Otherwise, it’s no different from my friend’s hotel room. You know what I mean? If we get to just decide and make it up as we go, and there’s no repercussion for, you know? A second set of disadvantages described by both staff and users had to do with the inability to closely integrate the SIF with other social service agencies due to perceived need to keep the agency at ‘arms length’ from other agencies to reduce risk of inadvertent disclosure about the service being provided. There was a clear sense among staff that if the SIF was an ‘above ground’ service, the users of the site would justifiably be regarded as a high priority population and close integration with opioid substitution therapy services and other social and medical services, such as at the SIF in Vancouver, would be a likely and highly desirable outcome. IJ21: Also, more organized referrals . . . Yeah, I’d like to be able to refer people to services and know what more of them are and kind of have more training based around that, you know? I’d like to have more community interaction but we are–as the way that we operate and function, it’s just necessary that we’re a little bit more of an unknown. Ultimately, almost all of these suggested improvements are deeply interrelated with the issue of the SIF being unsanctioned, both in terms of being able to accurately describe needs to funders in order to build staff capacity and better equip the site, through better integrating the site into other available health and social services. Discussion In this paper, we have examined the experiences of people who inject drugs using an unsanctioned SIF in an urban context in the United States. As with other qualitative examinations of the impacts of InSite in Vancouver, we found users of this facility reported that access to the SIF reduced their “contextual risks” such as the need to rush injections (Kerr, Small, Moore, & Wood, 2007), and reduced the “everyday risks” associated with injecting in public such as negative interactions with police and the broader

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public (Small, Moore, Shoveller, Wood, & Kerr, 2012) As with Rance et al’s description of the impact of the Sydney SIF on stigma and sense of self among users (Rance & Fraser, 2011), this group of participants reflected on how the SIF functioned as a valuable social space in which the stigmas and dangers ordinarily experienced by street-based people who inject drugs were reduced. In contrast to the impacts of regulatory limitations described in the literature on acceptability and use of the sanctioned SIF in Vancouver (Small et al., 2011), and as with the ethnographic work describing an unsanctioned SIF in Canada (McNeil et al., 2015, 2014), participants in this study spoke to the constructive consequences of the site’s lack of sanction, such as the ability to initiate services quickly in response to rampant overdose deaths in the neighbourhood, an avoidance of community opposition (e.g., not in my backyard sentiments), and the fact that rules of operation were community generated rather than imposed in a top-down structure dictated by municipal or state institutions. However, participants also spoke to the limitations and problems that arise out of lack of formal sanction and uncertainty about legal status. These included the need to prioritize secrecy above all else for fear of getting the site shut down, the ways in which secrecy has acted to reproduce de-facto racialized divisions in the neighbourhood, and finally, the lack of ability to discuss the project openly with other agencies which in turn may have reduced the ability to make beneficial referrals to evidence-based drug treatment and/or broader health and social services. This study has a number of limitations. Like all qualitative research, the data presented do not lend themselves well to generalizability, even in cases such as this where almost all of the population under study (current regular users of the facility) were interviewed. The small scale of the facility and the unique social context in which it operates may limit the generalizability of these findings to other unsanctioned facilities, although our findings are in line with those of ethnographic work conducted at an unsanctioned site in Canada (McNeil et al., 2015, 2014). In addition, social desirability may have shaped interviewee responses, particularly given that all interviewees were extremely aware of and reflexive about the political and legal risks being taken by the facility operators. A number of community-based and governmental groups are currently advocating for the legal and social changes needed for SIFs to operate in a clear, legal, sanctioned manner in the United States. While legality would indeed allow many improvements to be made to the services offered at the SIF described, these findings also point to a tension between addressing the limitations and problems of illegality and maintaining the benefits of it, such as user-led regulation and structure, and a strong sense of community. Legality might be a precondition for some types of improvements, such as more staff, better integration with other services, and addressing exclusionary processes. But legality does not guarantee these improvements because in many cases they also require more resources, something legality, especially in already resource-limited contexts, will not inherently produce. Legality also has the potential to lessen the current sense of solidarity and community that comes from being a small and underground facility, although (ideally) it does so with the substantial benefit of greatly increasing the number of individuals who can access the site and further contributing to public health and public order in the neighbourhood in which it is located. While SIF advocacy is under way in multiple contexts in the US, it is important to reflect on how legality impacted and eventually shaped similar public health interventions such as needle exchange, and what were the specific consequences and trade-offs of legality in terms of community-generated structures and senses of community. As needle exchanges first began to enjoy legal sanction in parts of the

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United States in the late 1980s, in many cases new operational rules were imposed externally which reflected political acceptability rather than being grounded in empirical research (Moore & Wenger, 1995). Such rules were often counterproductive, creating barriers to full access and to public health benefits. For instance, many early legal needle exchanges in the US had strict one-for-one exchange policies, and others required some form of formal ‘registration’ as a condition of use of the exchange, a considerable barrier for users with some types of mental health issues or with fears about police and the possible legal consequences of being a ‘documented’ drug user (Kral, Anderson, Flynn, & Bluthenthal, 2004). Further, these early policies in some cases remained in place even years or decades after research demonstrated their negative public health and public safety impacts (Bluthenthal et al., 2007; Sherman et al., 2015; Strathdee & Beyrer, 2015). One possible argument against SIFs in the United States is that the U.S. is so exceptional in its drug use environments that the research findings showing benefits from SIFs in other countries might not apply. Our work provides preliminary evidence that this is not the case by describing a facility which, despite being unsanctioned, has for several years been successful at providing a group of individuals with a clean, well-lit, supervised alternative to drug use in public spaces. As such, our work serves to support calls to trial a sanctioned SIF in the United States, while also pointing to the need to avoid some of the pitfalls experienced by other services such as needle exchange as they transitioned from being unsanctioned to sanctioned. Conflict of interest statement The authors declare that they have no financial or personal relationship with people or organizations that could inappropriately influence this work. Acknowledgements Funding: This work was supported by a gift from Laura and John Arnold. The authors would also like to thank the users and staff of the facility for their wholehearted cooperation and thoughtful reflexivity. We find ourselves in the unusual position of being unable to acknowledge by name the individuals and organizations who were central to our ability to conduct this work, and even to include as named authors individuals whose review of drafts of this paper contributed meaningfully to its final form. We hope in years to come we will be able to provide an electronic update to this paper with these individuals included by name. References Associated Press (2007). S.F. considers ‘shooting gallery’ for drug addicts. (2007, October 18), Retrieved March 31, 2017, from http://www.nbcnews.com/id/ 21367579/ns/health-addictions/t/sf-considers-shooting-gallery-drug-addicts/ ]. Beletsky, L., Davis, C. S., Anderson, E., & Burris, S. (2008). The Law (and Politics) of Safe Injection Facilities in the United States. American Journal of Public Health, 98 (2), 231–237. http://dx.doi.org/10.2105/AJPH.2006.103747. Bluthenthal, R. N., Ridgeway, G., Schell, T., Anderson, R., Flynn, N. M., & Kral, A. H. (2007). Examination of the association between syringe exchange program (SEP) dispensation policy and SEP client-level syringe coverage among injection drug users. Addiction, 102(4), 638–646. http://dx.doi.org/10.1111/j. 13600443.2006.01741.x. Baltimore (2017). Illicit-Drug use OK In ‘Safe’ site under maryland bill. (2017, February 17), Retrieved March 30, 2017, from http://baltimore.cbslocal.com/2017/02/17/ illicit-drug-use-ok-in-safe-site-under-maryland-bill/. Centers for Disease Control and Prevention (2017). Opioid overdose: Understanding the epidemic. Retrieved March 3, 2017, from https://www.cdc.gov/ drugoverdose/epidemic/index.html. Davidson, P. J., & Howe, M. (2014). Beyond NIMBYism: Understanding community antipathy toward needle distribution services. International Journal of Drug Policy, 25(3), 624–632. http://dx.doi.org/10.1016/j.drugpo.2013.10.012.

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