Source Insights

How Safe Injection Facilities Could Save San Francisco Millions of Dollars in Healthcare Expenses

By: Katie Beyer, Student Fellow

There are 22,500 estimated injecting drug users (“IDUs”) living in the city of San Francisco. In 2015, males accounted for 71.4% of IDUs[1] and in 2017, the city recorded 100 deaths due to injected drug overdose.[2] For those who live in San Francisco, this number may not be so alarming. The majority of San Francisco’s injecting drug users are homeless – meaning drug consumption often occurs in public spaces. The short walk from City Hall to the Civic Center Bart station is overwhelmed by people injecting drugs in broad daylight. Orange plastic syringe caps and used needles are scattered over the sidewalks throughout the Tenderloin neighborhood. In fact, the city’s Public Health Department retrieved 164,264 needles from public streets in the month of August 2018 alone.[3] In addressing this problem, the city spends $70 million per year on street cleaning.[4]

People who inject drugs are at risk of contracting severe infectious diseases, such as HIV, Hepatitis B (HBV) and Hepatitis C (HCV). Deaths caused by HCV or HCV complications have been increasing for decades—a trend that is especially pronounced for HCV associated liver cancer.[5] Since 2013, the number of HCV-related deaths in the United States has exceeded the number of deaths associated with HIV and 59 other infectious diseases combined.[6] HCV is predominantly contracted from contaminated equipment used to inject drugs.[7] Most injection-drug users infected with HCV contracted the disease as a young adult. These individuals are at risk for chronic HCV and could face years of burdensome health care expenses, and if left untreated, they could transmit HCV to others.[8] The cost of caring for people with HCV places further strain on an already fragile healthcare system. Furthermore, because young adults are entering their most productive years, HCV infection affects the economic productivity of the country for years to come by reducing the amount of capable workers. One study reported that each person who injects drugs while infected with HCV is likely to infect about 20 others, and that this rapid transmission of the disease occurs within the first three years of initial infection.[9] Since 2007, more than 16,000 people have contracted HCV in San Francisco.[10] The organization, End Hep C SF, estimates that 70% of active HCV infections are among IDUs.[11] HCV is the most burdensome and costly infectious disease in the United States.[12]

Safe Injection Facilities (“SIFs”) provide life-saving services to injecting drug user populations.   SIFs are a type of harm reduction intervention used to target at risk injecting drug users.[13] They provide a hygienic space for high-risk drug users who are not ready or able to quit drug use. Staff members do not directly assist in consumption, but are present to provide sterile injection supplies, answer questions on safe injection practices, administer first aid as needed, and monitor for overdose. With medical professionals on staff, SIFs can help communities reduce overdose deaths, HCV and HIV infections, and other medical related complications.[14] Additionally, these sites allow client access to primary health and social services and lead to a reduction in public drug use.

In 2017, San Francisco initiated a task force to research the effects a Safe Injection Facility would have on the city. In their report, the task force found that one SIF would[15]:

  • Prevent 3.3 HIV cases per year, with a lifetime treatment cost of over $402,000, which translates to an annual savings of $1.3 million;
  • prevent 19 HCV cases per year, with a lifetime cost of $68,000, which translates to an annual savings of $1.3 million;
  • reduce hospital stays by 415 days per year, which translates to savings of roughly $1.7 million;
  • save an average of 0.24 lives per year, which translates to $284,000 in financial benefit; and
  • assist 110 injecting drug users to enter treatment, resulting in an annual financial benefit of $1.5 million.

In summary, the researchers found that each dollar spent on an SIF would generate $2.33 in savings, totaling a net annual savings for the city of $3.5 million.

SIFs almost became a reality under California’s AB 186 in the 2018 legislative session. However, Governor Brown surprisingly vetoed the bill in October, meaning this harm reduction strategy lacks explicit legal footing. Two major statutory considerations under Title 21 of the United States Code Controlled Substance Act (CSA) create legal hurdles for local SIFs. Section 844 (c) of the CSA promulgates that it is unlawful “for any person knowingly or intentionally to possess a controlled substance unless such substance was obtained directly, or pursuant to a valid prescription or order, from a practitioner, while acting in the course of his professional practice.” Furthermore, this section broadly criminalizes “the possession, distribution, manufacture, cultivation, sale, transfer, or the attempt or conspiracy to possess, distribute, manufacture, cultivate, sell or transfer” any controlled substance.

Additionally, Section 856 of the CSA, which is popularly known as the “Crack-House Statute,” presents the largest legal impediment to San Francisco’s Safe Injection Facilities. The statute makes it unlawful to “(1) knowingly open, lease, rent, use, or maintain any place, whether permanently or temporarily, for the purpose of manufacturing, distributing, or using any controlled substance; (2) manage or control any place, whether permanently or temporarily, either as an owner, lessee, agent, employee, occupant, or mortgagee, and knowingly and intentionally rent, lease, profit from, or make available for use, with or without compensation, the place for the purpose of unlawfully manufacturing, storing, distributing, or using a controlled substance.”[16] The Crack House statute explicitly criminalizes the use of property for drug use, manufacture, or distribution and imposes liability on property owners who would not otherwise be convicted under Section 844 of the CSA. If the city were to open such a facility, the government would be intentionally making it available as a place for the use of controlled substances and could be criminally prosecuted under the Crack House statute.

The two laws under the CSA do present a risk of federal prosecution for San Francisco authorities and individuals who would work for or use SIFs. With that being said, there are always risks in implementing new harm reduction strategies; for example, California legalized medical marijuana without authorization from the federal government, yet the Drug Enforcement Agency has yet to exercise its power and arrest individuals for engaging in marijuana use or distribution. More importantly, however, the state must look at benefits that could outweigh the risks. San Francisco’s past efforts have improved issues associated with injection drug use, but they are not enough. SIFs offer the most effective solution in assisting marginalized communities, reducing risk of infection and overdose frequency, and increasing access to primary health care. SIFs offer greater opportunities for patients to connect with health workers and thus receive appropriate courses of treatment. This connection allows health care providers to direct patients to primary care, drug treatment programs, and other rehabilitation services, ultimately saving millions of dollars in preventable treatment. SIFs also remove drug use from the public line of sight. Offering users an alternative space would reduce the hazardous litter and eliminate other unsafe conditions from city parks, public playgrounds, and street corners. San Francisco should consider the impact these facilities have not only to the individuals who need these resources, but also in terms of the city’s healthcare expenditures.



[1] Id. at 5.

[2] San Francisco Department of Public Health, San Francisco Safe Injection Services Task Force 4 (2017) available at:

[3] Thomas Fuller, Life on the Dirtiest Block in San Francisco, N.Y. Times (Oct. 8, 2018),

[4] Id.

[5] Interview with Doctor Megan Morris, UCSF, October 5, 2018 @12:00 pm.

[6] T. Jake Liang and John Ward, Hepatitis C in Injection-Drug Users — A Hidden Danger of the Opioid Epidemic, New England Journal of Medicine, March 2018.

[7] CDC, Hepatitis C: General Information 2 (2015).

[8] T. Jake Liang and John Ward, Hepatitis C in Injection-Drug Users — A Hidden Danger of the Opioid Epidemic, New England Journal of Medicine, March 2018.

[9] J. Grebely et al., Sofosbuvir and velpatasvir for hepatitis C virus infection in people with recent injection drug use (SIMPLIFY): an open-label, single-arm, phase 4, multicentre trial, NCBI, March 2018.

[10] San Francisco Department of Public Health, San Francisco Safe Injection Services Task Force 6 (2017) available at:

[11] Facente et al., Estimated hepatitis C prevalence and key population sizes in San Francisco: A foundation for elimination 5 (2018)

[12] Interview with Doctor Megan Morris, UCSF, October 5, 2018 @12:00 pm.

[13] Vendula Belackova et al., Online census of Drug Consumption Rooms (DCRs) as a setting to address HCV: current practice and future capacity 8 (2018).

[14] Id.

[15] San Francisco Department of Public Health, San Francisco Safe Injection Services Task Force 6 (2017) available at:

[16] 21 USCA §856 (2006).


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