The June 19 hearing of the City Council Committee on Homelessness, Mental Health and Recovery on a proposed Safe Injection Facility (SIF) drew almost a full house of spectators including many residents and workers in the South End, Newmarket and Melnea Cass Boulevard and Massachusetts Avenue (also known as Mass-Cass) areas, as well as addiction services advocates and active drug users.

The hearing was called by At Large councilor Annissa Essaibi-George and District 3 city councilor Frank Baker, who represents Newmarket and the corner of the South End closest to the Boston Public Health Commission (BPHC). Two panels, one comprising proponents of the SIF from the medical and public-health fields and one consisting of health-care providers opposing the SIF presented, followed by public testimony from almost two dozen individuals.

Since injection of opioids is illegal under state and federal law, major changes would be required in order for a SIF to open in Massachusetts. The hearing stems from the Massachusetts Medical Society's (MMS) proposal of a pilot SIF in Massachusetts, with Southampton Street or Mass-Cass as a possible site. Baker, Essaibi-George, South End and Newmarket neighborhood leaders and a growing number of residents and business owners oppose a SIF in Boston.

South End Forum and Rutland Square Neighborhood Association chair Steve Fox testified, commenting after the meeting, "I thought the panels were really good; they framed the issue perfectly. It was a good idea to have pro and con panels." Fox was disappointed that the panels were allowed to run overtime, curtailing the allotted time for public testimony.

Proponents touted the SIF as a "harm prevention" strategy to curtail overdoses and pointed to a SIF in Vancouver, British Columbia as a positive model, while opponents argued that the facility would be detrimental to the community and would only treat a symptom of the opioid epidemic rather than helping to decrease its spread.

The hearing began with the pro-SIF panel consisting of MMS president Dr. Henry L Dorkin, a pediatric lung specialist in Boston; executive director Monica Valdes Lupi and recovery services director Devin Larkin of BPHC; primary care physician and addiction specialist Dr. Gabriel Wishik of Boston Health Care for the Homeless (BHCH) and Aubri Esters of SIF-MA NOW, who is an active drug user.

Proponents said the SIF would provide a safe, supervised venue for drug injection but would never provide illegal drugs to users. Dorkin presented a graph illustrating the spread of opioid addiction in cities and towns across the Bay State in five-year increments from 2001 through 2015. Dorkin reported a 20 per cent drop in opioid prescriptions between 2015 and 2016, while opioid-related deaths have risen each year, reaching 2,000 in 2016.

Dorkin claimed that research on Vancouver's SIF experience showed a 35 per cent decrease in opioid mortality, a 30 per cent increase in detox and no reports of negative consequence to the surrounding community. MMS advocates a pilot SIF under the authority of a state agency. Valdes Lupi said 71 per cent of unintentional deaths below age 65 were opioid-related and outlined BPHC's efforts to help addicts, including 7 day per week street outreach offering drug education and referrals to recovery services; needle collection services and Providing Access to Addictions Treatment, Hope and Support (PAATHS), which steers users to substance-abuse treatment.

In her presentation, Esters described her method of avoiding overdose and recounted her near-fatal overdose the week before as well as the deaths of many friends, arguing that they would be alive if there were a safe place to inject. Wishik said, "Drug addiction is the leading cause of death among our population and we need to strongly support the development of SIFs as a tool to combat that epidemic."

He also mentioned BHCH's Supportive Place for Observation and Treatment (SPOT), where drug users can be medically monitored after injecting. He added that one in 10 high-risk users have been directed to treatment after visiting SPOT. Wishik cited research on Vancouver's SIF suggesting that overdose deaths near the facility had decreased, that the SIF can lead to addicts seeking treatment, and that the SIF has had a positive to neutral effect on drug related crime in its host neighborhood, while another BHCH physician spoke of a BHCH patient who died of an overdose after leaving drug detox.

In his remarks, Baker said, "My concern is more that the Southampton Street corridor being called a great site for the SIF. It is overwhelmed now. I have a hard time thinking that it will be helpful to us there and I am not even close to convinced by your testimony."

Baker cited data from Vancouver showing 263,000 visits per year to the SIF by 6,500 individuals but only 464 referrals to on-site detox. "That doesn't seem like great numbers," he said. Both Baker and Essaibi-George have expressed frustration that while drug and opioid use is epidemic across the state, other communities do not have their own treatment facilities and consequently, drug users come from all over to the Southampton Street area for methadone and other services.

Both councilors want to see other communities take the pressure off Boston by opening drug-treatment facilities for their residents. Baker also said that while there might possibly some decrease in on-street injection around the SIF, users in other neighborhoods are not going to travel across town before injecting, but will continue to inject in their own neighborhoods. City councilor at large Michael Flaherty later echoed this sentiment.

District 5 councilor Tim McCarthy said that while the human stories were compelling and some of the Vancouver data are encouraging, he agrees with Baker. "As someone who has spent his entire career trying to make Boston neighborhoods better, I really have a question." Recalling his tenure with Boston Public Works Department, McCarthy recalled the activity around the old Frontage Road methadone clinic "And it isn't pretty." McCarthy also questioned the cost to Boston taxpayers of operating the SIF. He said that while Boston is the economic engine of the state, facilities like this that are rejected by other towns are sent to Boston. "I guarantee you I can name 10 suburbs right now that would that would never be considered. This is a very tough pill to swallow for someone who lives within 500 meters [of the SIF]."

One of the BHCH physicians suggested focusing first on feasibility of a SIF and debate the location later. Dorkin said that research suggests cost savings from projected reductions in emergency treatment of drug users, HIV infection treatment and other health-care expenses. Asked by District 8 councilor Josh Zakim whether the SIF could be authorized under existing law, Valdes Lupi said No, butBPHC is focused on existing services such as needle exchange, street outreach and treatment.

At large councilor Michael Flaherty claimed, as the longest-serving councilor on the committee and a member of a "recovery family, "No one has done as much around treatment and recovery as me." Flaherty called treatment on demand and court-mandated treatment better options than the SIF. Citing many deaths among friends, neighbors and loved ones, he called the SIF idea "asinine" and said the end game should be sobriety, not normalizing drug use.

District 7 councilor and mayoral candidate Tito Jackson lamented the harsh sentences imposed on crack addicts in his native Roxbury in the 1980s and 1990 as opposed to the compassion for users evident in the hearing. He spoke angrily of the abrupt closing of Long Island facilities and the city-run methadone clinic and the drug deaths that followed.

"The state of Massachusetts has failed the city of Boston in permitting methadone clinic after methadone clinic in the same area," Jackson said. Jackson wants residents and businesspeople from the community on the task force. "There is a disproportionate burden felt by a small part of the city of Boston," Jackson said.

Opening for the panel of SIF opponents, primary care physician Dr. Robert Baratz said that "safety" surrounding injected drug use should encompass not only the safety of the user but also the neighborhood and the medical staff. Baratz presented statistics showing increased deaths from illicit drugs in British Columbia through the 2010s.

Baratz detailed the increasing potency of street drugs as heroin is supplanted by synthetics such as fentanyl and carfentanyl and the ease of manufacturing them, adding that 85 per cent of deaths in Massachusetts last year resulted from mixtures of heroin, fentanyl and cocaine or other drugs. Regarding feasibility of a SIF, Baratz said that since the law prohibits hosting the use of illegal drugs, the presiding physician in such a facility could be lose malpractice insurance.

He described the exponentially increasing potency of the next generation of new drugs and feels that SIFs cannot overcome that danger. Longtime nurse-practitioner Brianne Fitzgerald, who worked on AIDS prevention among IV drug users in the 1980s and 1990s, called the SIF "hospice care for end stage addiction," equating it with giving up on recovery.

"It is enabling a behavior with no good outcome," she said. She proposed a mobile van traveling around the state to addiction hot spots to prevent drug deaths, offer HIV and hepatitis testing and refer users to treatment. Allison Burns, Pharm. D., CEO of the non-profit End Mass Overdose, Inc. in the Southampton Street area, presented a wealth of statistics on SIFs in Sydney, Australia and across Europe, challenging the validity of data presented by proponents on the Vancouver SIF. She refuted the 35 per cent decrease in mortality and explained that 10 overdoses averted does not equal 10 individuals saved, as those 10 overdoses might reflect multiple overdoses by the same few persons.

She also said the data show that some drug users in Vancouver and Sydney continue the risky sharing of needles, even when clean needles are offered at the SIF. Referring to the aforementioned 263,000 visits to the Vancouver SIF in 2015 by 6,500 individuals, only 262 completed treatment, or 2 per cent. Burns advocated providing addiction treatment over the legally precarious SIF proposal.

Steve Fox led the public testimony, praising Baker's and Essaibi-George's "tremendous and unflagging support" for the South End Forum's year-long Task Force on Homelessness and Recovery. Pointing to conflicting data, Fox said more research is needed before his group can embrace the idea of a SIF anywhere in Massachusetts.

Fox said the South End is a welcoming community which supported BHCH's SPOT program and the South End Community Health Center's suboxone program while already hosting the greatest number of homelessness, addiction and recovery services in the city because those programs are offered as part of primary care.

"We believe that any additional service is inappropriate for us. We are at the breaking point," Fox said. Fox proposed a public-private partnership to create an addiction-recovery campus in the Lemuel Shattuck Hospital area, away from the drug nexus of the Southampton Street area.

President Michael Rothschild and executive director Susan Sullivan of the Newmarket Business Association and Newmarket-area businesses repersentatives described drug users walking into the traffic; rampant break-ins, drug dealing, aggressive panhandling and injecting in plain view, predicting that these behaviors would increase with a SIF in the area.

Another witness cited Vancouver police reports that many drug users inject outside rather than waiting in long lines for the SIF. One witness called for de-privatizing methadone clinics to discourage the profit motive from perpetuating methadone dependency. In her moving remarks, Sullivan asked for an end to "enabling" approaches like the SIF and challenged the medical community and city and state government to devise strategies to change the behavior of drug abuse. Sullivan urged MMS to support "comprehensive, state of the art" recovery campuses across the state.

"There are thousands of people dying out here every day, they just aren't dead. They certainly aren't living," Sullivan said. About a dozen opponents were followed by a similar number of SIF proponents, including drug users and addiction service providers. While the two sides were miles apart in their views, shared a passion for their respective positons. The hearing can be viewed on-line at
https://www.cityofboston.gov/citycouncil/cc_video_..asp?id=11240.