The opioid crisis is a national public health emergency. The unprecedented scope of the problem is challenging everything that has been previously understood about drugs, addiction, and treatment, to the point where experts are calling for drastic – some would say dangerous – solutions. The controversial debate on supervised injection facilities represents the extent to which the opioid abuse epidemic has advanced the conversation.
The War and the Epidemic
Today offers some background as to how and why the idea of supervised injection sites has become a topic. One of the main reasons is that five decades of an unsuccessful “War on Drugs” has created a thriving black market for controlled substances, and swung the pendulum of mental health and substance abuse treatment infrastructure more toward punishment than rehabilitation (a point made by The New York Times as far back as 1993). Another is the prescription drug craze of the late 1990s and early 2000s, when pharmaceutical companies aggressively marketed their products to both doctors and patients, convincing an entire generation of Americans that pain medication was the answer to all their problems.
Combined, the two created a brand new drug epidemic, where people desperate for pain medication would commit prescription fraud for more painkillers, and recreational users stole or “borrowed” pills from friends and family members. Behind the scenes are drug rings and manufacturers, tapping into a lucrative and ever-expanding market falling under the sway of powerfully addictive substances that are ubiquitous and cheap.
The War on Drugs-era policies toward substance abuse imprinted the idea that zero-tolerance and tough-on-crime approaches were the only way to combat drug abuse, long after those ideas were largely discredited. Doctors and scientists instead called for more treatment options to be offered instead of criminalization and punishment. While most of their suggestions have been generally accepted – a number of publications and police departments have agreed that “we cannot arrest our way out of this problem” – one idea has proved particularly divisive., 
Seattle’s Radical Approach
In Seattle, the problem has reached such a point that the city records an opioid overdose death every 36 hours. This has prompted the mayor, the county executive, the county sheriff, and other public health officials to trial what Today calls “a radical approach to treating addiction.” The idea is to create two safe injection sites in the county; they would be clean, professional facilities, staffed by healthcare workers who would monitor addicts openly consuming heroin or other drugs. The facilities would not give addicts the drugs, but they will provide clean needles for the addicts to use and collect contaminated needles after injection. The healthcare workers would also provide onsite counseling, encourage addicts to seek long-term therapy programs, and intervene in case of an overdose.
San Francisco, Philadelphia, and Boston have announced their intention to investigate the feasibility of opening safe injection sites in their respective jurisdictions, but Seattle’s King County is the only location in the United States that has announced a definitive plan to do so. This comes as Washington state recorded a 10 percent increase in drug overdose deaths between 2014 and 2015, the most drastic such statistic for any of the western states.
Not Now, Not Ever
A public health officer for King County, and a member of the county’s task force to investigate countermeasures against the opioid crisis, said that the problem met the criteria for a “public health crisis.” The task force recommended the county set up two safe injection sites, one within the city of Seattle and another somewhere else in King County. The Seattle Police Department expressed confidence that such facilities would not become a public safety risk in their respective locations, but the idea has been vociferously challenged by many residents and community organizations. Five other cities in King County have passed legislation that would ban the construction of safe injection sites within their borders. A council member for one of those cities, Bellevue, said that there would “not now, not ever, not in any zone of Bellevue” be a legal place for heroin addicts to consume heroin. The mayor of Bellevue led the charge against the implementation of supervised injection sites, but insisted that he was nonetheless concerned (and “not heartless”) about the plight of his residents struggling with too many drugs and not enough treatment; however, he (and the mayors of the other cities in the county, bar Seattle) argue that giving addicts a place to get high is counterintuitive.
A Broad Strategy
The case for supervised injection facilities was made by the New England Journal of Medicine, which published a report by the medical director of the Substance Use Disorder Initiative and the Addiction Consult Team at the Massachusetts General Hospital in Boston, who said that “promising evidence” from similar locations in other countries – such as saving lives, increasing neighborhood safety, and encouraging chronic drug users to engage in treatment – demonstrate that safe injection sites are “a piece of the broader strategy to keep people safe.”
Similarly, the American Journal of Public Health wrote in 2008 that safe injection facilities have shown encouraging results in their ability to reduce the risks and social costs that come with intravenous drug abuse. Those costs are significant and have been for some decades; injection drug use is responsible for at least 36 percent of the United States’ AIDS cases. Additionally, people who use needles for their drug use expose themselves to a high risk of contracting HIV and hepatitis, as well as developing skin abscesses and endocarditis from dirty needles.
The Pollution Threat
Much of the danger associated with intravenous drug abuse comes from both the lack of sterile injection equipment (such as clean needles and places to dispose of them), and the fear that addicts have that they will be arrested and prosecuted if they are found with drug paraphernalia. In the former, this means that drug addicts will not only use contaminated needles, but often leave those needles in public places, like bus stops, parks, beaches, and the restrooms of libraries and fast food restaurants. This creates its own “pollution threat,” in the words of a Yahoo News article, reporting how the city of San Francisco – which is considering opening a safe injection site – collected over 13,000 used syringes in March 2017. In March 2016, city workers found just 2,900. The problem has become so normal for a place like Santa Cruz, that a community group tasked with cleaning up needles considers it “a rite of passage for a child to find their first needle.”
Needle exchange programs do exist, where drug addicts can simply swap out a dirty needle for a clean one, but health advocates worry that poor supervision at those sites means that addicts are not compelled to dispose of their new needle after using it off site. A safe injection site would provide adequate disposal methods.
A Complex Tangle of Laws
Needle exchanges have some local support in California, and the role they played in stemming the AIDS epidemic of the 1980s has won them some support. Orange County’s site was opened by a medical student who based the model off San Francisco’s success, “where needle exchanges are very common.” But even then, there has been resistance from the local community, mostly based in the fear that a needle exchange program will become a haven for drug use. The people who would use the facility tend to be low-income, unemployed, and without significant political support or representation. Opponents of such programs are generally better connected to their elected officials and able to mobilize campaigns and bills to keep harm reduction programs (like safe injection sites or needle exchange programs) away from their cities.
A general point of consensus between the two camps is the distribution and administration of naloxone, a nasal spray that can reverse an opioid overdose and resuscitate a user long enough for emergency services to arrive and stabilize the person. Many police officers and first responders carry naloxone kits as part of their standard gear, and private citizens in some areas can purchase the substance over the counter. However, the Addiction journal found that witnesses are often reluctant to use naloxone to buy time to call for help out of fear that they may be prosecuted for participating in illegal drug activity. As a result of this, many cities have passed “Good Samaritan overdose laws,” where witnesses and even other drug users will not be found criminally liable for reporting an overdose in progress.
However, Vice magazine reported that some police in some jurisdictions are still arresting people who call in an overdose. Due to a complex tangle of laws, individuals who try to help other drug users during a medical emergency are at risk of being arrested for crimes like aggravated battery if the victim survives the overdose. Additionally, police and prosecutors themselves are at the center of those laws; the need to demonstrate a strong law enforcement approach in the face of a thriving drug trade is often at odds with the need to prevent overdose deaths. The result is that people who witness an overdose, and may themselves be drug users, feel convinced that the police will not help them.
The Case for Supervised Injection Facilities
With all this in mind, the International Journal of Drug Policy writes that while needle exchange programs contribute to reducing the public health and law enforcement risks of intravenous drug use, the programs do not offer a “safe and hygienic setting for injection.” As a way of developing on the platform put down by needle exchange programs, 40 cities around the world (but, notwithstanding Seattle’s work-in-progress, none yet in the United States) have used supervised injection sites as a potential solution to address dangerous drug consumption environments.
What sets safe injection sites apart is that they are supervised by licensed healthcare professionals who can answer questions on how to inject heroin (or consume other drugs) with minimal risk, and administer first aid and resuscitation in the event of an overdose. Crucially, staff are also authorized to offer general medical advice, and refer clients to drug treatment and other public health programs. The Journal of Drug Issues makes the additional point that supervised injection clinics “reduce the externalities of public drug use,” by ensuring that the people who would inject in public spaces do not leave their contaminated needles in places where children, pets, or unwitting passersby may come into contact with them.
The American Journal of Public Health writes that the laws surrounding drug use and possession, and the enforcement of those laws, typically complicate the issue over whether (and how) safe injection sites can be set up and how they can function. This has the effect of limiting the amount of harm reduction they can do. With heroin being a Schedule I drug, for example, a supervised drug use facility would be vulnerable to police raids, and clients could be understandably worried that possessing heroin would increase their chances of being arrested. Staff members might also be in danger of being implicated by association, and a criminal record could lead to disciplinary measures by professional licensing authorities. The journal theorized that if safe injection sites remain on the wrong side of the law, it might force health activists to open “underground” locations, to still try and meet the needs of intravenous drug users. Without funding or public and political support, however, these underground solutions are at greater risk for being stopped by the police, and they will not have enough resources to help people who have not responded to other forms of treatment, who thus need the most help.
The Vancouver Model
The point was also made by the Journal of the American Medical Association, which offered support to an idea put forward by the mayor of Ithaca, New York, to develop that city’s own supervised injection facilities. While acknowledging that taking the step seems “radical and [a] desperate way to reduce the harms of drug use,” JAMA says that the safe injection site in Vancouver, British Columbia – the only such facility in North America – was instrumental in reducing needle reuse and sharing. Additionally, Vancouver’s site was tied to fewer public injections and discarded needles, an increased rate of entry into local detoxification programs, zero overdose deaths, and no evidence of there being any drug-related crime in the neighborhood.
Researchers writing in the British Medical Journal found that safe consumption zones “do not appear to promote injection drug use.” Using data from one year before the Vancouver site’s opening and one year after it opened, the researchers “found no substantial differences in rates of starting or stopping injecting drug use.” A different study by the same research team reported that in a random sample of 1,065 drug users who used Vancouver’s supervised site, only one person shot up on heroin for the first time there.
Health and Community Benefits
Responding to criticism that drug users would be compelled to engage in riskier consumption behavior because of the safety net provided by the personnel at safe injection sites, the American Journal of Drug and Alcohol Abuse looked at 1,090 people who used the Vancouver facility, and used the findings to “refute the suggestion” that the presence of a safe injection site will increase the likelihood of an overdose. Other research found that overdose mortality decreased in the neighborhoods surrounding the Vancouver site compared to more remote areas, where intravenous drug users may be unable to safely consume heroin.
A review of the Vancouver site by the Canadian Medical Association Journal found “a large number of health and community benefits,” adding that there was no evidence that the facility caused communal or health harms. The International Journal on Drug Policy found that the site provides economic benefits worth as much as five times more than it costs to run, and prevents at least 35 HIV-AIDS cases per year, adding to the cost value. Another study by the Canadian Medical Association Journal calculated that the Vancouver program “saved up to $20 million […] principally through reduced HIV infection” over a decade of operation.
A review of the Vancouver site by the Canadian Medical Association Journal found ‘a large number of health and community benefits.’ Another study by the Canadian Medical Association Journal calculated that the Vancouver program ‘saved up to $20 million […]’
Sydney’s Safe Injection Site
Reviews of Australia’s supervised injection facility in Sydney (the first such facility to open outside Europe) estimated that the safe injection program was responsible for the prevention of four deaths per year as well as an increase in substance use treatment, fewer instances of public heroin consumption, and fewer contaminated needles left in public areas. JAMA notes that a majority of the members of the Sydney community where the site is located support its operation.
Reviews of the safe injection facilities in Europe have found that such sites “consistently lead to fewer risky injection behaviors and fewer overdose deaths.” Furthermore, their presence results in clients having a much higher engagement rate with drug treatment services, fewer complaints by the locales about public drug use and contaminated needles, and cost savings in public resources.
‘Giving Up’ on Helping Addicts
But for all the scientific support for supervised injection facilities, the idea of creating a safe space for heroin users to shoot up – a safe space funded by taxpayer dollars – causes some very strong feelings in people who will have to live in the same communities and neighborhoods as the facilities.
For example, the mother of a Seattle resident who fatally overdosed on heroin wrote in the Seattle Times that “safe injection sites make no sense” for drug users, non-drug users, taxpayers, or law enforcement. If King County and Seattle provide a place for heroin users to use heroin, it sends the message that city and county government sponsor drug use, which is not the message that should be sent out at a time of national crisis.
The British Columbia site is being used as a model by Seattle’s government, but Canada’s own experiment with safe injection sites has been met with skepticism. Writing in The Hill, the medical director of New Jersey’s first outpatient detox program said that it was the equivalent of “giving up on addicts,” and that allowing addicts to shoot up would encourage more people to continue their drug use, “rather than take the much harder path to recovery.” It might also entice regular heroin users to persist with their habit, in the belief that since they will be resuscitated if they overdose, the consequences of addiction are reduced.
What Will California Do?
If Seattle’s government is successful in setting up even one of its two intended safe injection sites, it would be the first such establishment in the United States. But all eyes are on California; the Golden State is also the bellwether state for America, influencing the rest of the country on topics like climate change, taxes, prison reform, same-sex marriage, and drug legislation.
Writing about the extent of the opioid crisis, the Los Angeles Times suggested that with overdoses being the leading cause of accidental death for Americans younger than 50 years old, the time has come to consider harm reduction programs that go beyond the exchange of clean needles. There are some drug users whose mental health problems, including substance use disorders, are so severe that they cannot respond to standard treatment programs. Safe injection sites are the logical continuation of the same initiatives behind needle exchange programs, and equipping first responders and even members of the public with naloxone.
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California and the AIDS Epidemic
The Times argues that while supervised injection sites are a drastic answer to a complicated issue, they are “consistent with California’s efforts to treat addiction as a disease, and not a crime.” There is some precedent for this. The city’s “courageous” and “prescient” needle exchange program in the early days of the AIDS epidemic saved countless lives, writes the Times, suggesting that the then-controversial public health program was worth the controversy and condemnation.
The language employed by critics of LA’s program is strikingly similar to that used by opponents of the proposed supervised injection facilities: Why give people who break the law the tools to do it? Why make a bad problem worse? But as the AIDS epidemic ravaged LGBT communities and beyond, city leaders put their foot down and championed the cause of needle exchange programs. Now, “decades of research have vindicated decisions” that not only saved a generation of LGBT people, but have relevant and topical implications for intravenous drug users. 
The connection to the past is not lightly made. New York Magazine wrote that “the opioid epidemic is this generation’s AIDS crisis,” and Vox notes that drug overdoses caused the death of more people in a single year (2015) than HIV-AIDS did in 1995, considered to be the peak of that epidemic.,  The New England Journal of Medicine even compared the similarities of the two crises, suggesting that the success in turning back the AIDS problem offers lessons in “how to combat an epidemic.”
The Tool in the Toolbox
California has also led the way on prison and drug reform. The state’s Proposition 47 ended decades of the unpopular, expensive, and unconstitutional mandatory minimum sentencing laws, that saw tens of thousands of people given prison sentences lasting 25 years to life for even trivial convictions. The infamous “Three Strikes” law crippled the penal system to such a degree that after a Supreme Court ruling, California downgraded low-level drug possession from a felony to a misdemeanor. Proposition 47 won praise for being a smarter and more modern approach to the issue of crime and drugs, but it was more cautiously received by law enforcement and some public health advocates.
California’s proposed implementation of safe injection sites is also supported by a number of AIDS prevention groups. However, the idea has detractors; law enforcement groups and politicians worry that safe injection facilities will become “government-sanctioned drug dens,” and there are questions surrounding liability if (or when) a client dies at a site before they can be revived. Per the Los Angeles Times, these concerns can be satisfactorily addressed, and much of the opposition to safe injection sites is based on urban legends and fearmongering. No one has died at Vancouver’s facility, writes the Times, and the 1,781 people who were revived at the site in 2016 would almost certainly have died elsewhere. Of the 6,532 people who used the facility in 2015, 464 went to a detoxification program, and more than 50 percent completed treatment.
Will California Be Proved Right?
In the same way that the opioid crisis of today mirrors some aspects of the AIDS epidemic of the 1980s and 1990s, some see the “tough-on-crime” policies of the Donald Trump administration as an echo of the much-maligned War on Drugs. Rewire wonders if the “zero tolerance” approach put forward by Attorney General Jeff Sessions might encourage more Californians to support the idea of supervised injection sites, since the state knows all-too-well the consequences of mandatory minimum sentencing.
The Drug Policy Alliance, one of the key supporters of AB 186, suggested that “the direction of the federal government” is compelling legislators in California to listen to their community members and the evidence surrounding the implementation of supervised injection sites. Drug reform is one of the many ways that California is “fighting back against President Trump’s administration,” says TIME, and there is some precedent behind the sentiment. Assemblywoman Eggman’s communications director noted to Rewire that California has more experience leading the way on controversial and pioneering issues than any other state in the country, “and we’ve been proved right many times over.”
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