There are some ethically challenging or particularly difficult issues that have emerged at SSPs over the years. These issues have been the subject of a good deal of debate and a variety of responses. Your organization should always place your values and the lived experience of the people you serve first regarding all policy decisions, especially those that have multiple conflicting responses that are compassionate and reasonable. Some particularly difficult issues are:
Bathrooms/ On-Site Drug Use – Bathrooms have always been an issue in SSPs because of their potential use as sites for injection drug use. On the one hand, withholding such an essential facility – especially from populations who may not otherwise have access to restrooms is clearly unethical for any agency providing public health services. At the same time, many SSPs cannot allow the drug use that may take place inside bathrooms because of laws, leases, insurance, etc. A common approach for SSPs with bathrooms is to have a policy opposing using drugs on site while simultaneously preparing for the possibility that participants may not follow it. Organizations prepare by having a lock on the bathroom that can be opened from the outside, strict time limits on (and/or monitoring of) restroom use, a sharps container, excellent lighting, available surfaces to cleanly set up a shot, and naloxone (and people prepared to administer it) on-site. Things that have proven less functional for managing this possibility including threatening participants with law enforcement and installing black lights or cameras.
Weapons at Site – Another possible issue at SSP sites is weapons. The fact of the matter is that it is not unusual for SSP participants to carry weapons occasionally. It would be unrealistic for SSPs to entirely ban weapons, but it is also true that weapons create a less trustworthy and community-oriented environment and are uncomfortable for some people to be around. To address this, many programs have adopted “don’t ask/don’t tell” policies, or policies that require weapons not to be visible.
Children at Site – Another contentious issue for SSPs is the presence of children, on site or during home delivery. This is difficult because under many state laws, parental drug use may be assumed to be parental neglect and must be reported by certain types of service providers to child welfare authorities. However, the mere USE of substances is NOT grounds for abuse or neglect – rather one needs evidence of neglect outside of mere substance use (i.e. bruises, scars, harms, etc). Reporting parents to the authorities can lead to children being taken away and to parental incarceration, outcomes that evidence shows is not beneficial for children or families. To avoid the issue of mandatory reporting, some SSPs have chosen to ban all children from their sites. However, this can have the potential consequence of further marginalizing and endangering critically vulnerable populations including very young people who use drugs and/or caregivers. Other organizations have learned that SSP workers are not mandated reporters, which means they do not have to report parents who are people who use drugs. (Some professionals, like therapists, are mandatory reporters and should advise participants, especially those they may be required to report, of their legal obligations.) When SSPs are intentional about avoiding mandatory reporting, parent and underage participants should be told that they are not in danger of being reported and asked if they need any extra services, referrals, or support.
Involving Law Enforcement – Another issue SSPs face is whether or not to involve law enforcement in escalated situations involving SSP workers. Because calling the police would seriously undermine community credibility, and because the communities served by SSPs are more likely to experience violence or murder at the hands of police, it is inadvisable for SSPs to call the police under almost any circumstances except for the most extreme. Instead, SSPs have developed a variety of ways of de-escalating situations to avoid needing to call the police. These include planning program details such as use of space, transparency, and service provision with a focus on creating community trust and goodwill. Other important strategies include training personnel in identifying agitation, de-escalation techniques, and empowering participants to help ensure sites are kept safe for everyone.
