How Safe Injection Sites Work

With Safe Injection Sites, ‘Somebody Has to Go First.’ It Could Be Philadelphia

How Safe Injection Sites Work

This story was updated to clarify that Safehouse hasn’t settled on a location for its first supervised injection facility and does not plan to deploy mobile units.

Read more Stateline coverage of the opioid epidemic.

PHILADELPHIA — In a massive, soot-stained 19th century former Methodist church that fills an entire block here, dozens of addiction counselors and peer support specialists work to help injection drug users stay as healthy as possible until they decide they’re ready for treatment. And then they help them find it.

Called Prevention Point Philadelphia, the 28-year-old syringe exchange center also provides packages of the opioid overdose antidote naloxone to anyone who wants it, to rescue fellow drug users who overdose.

On a chilly afternoon this month, a crowd of regulars at the storied center in east Philadelphia’s drug-blighted Kensington neighborhood were signing up to receive a fresh supply of the life-saving drug at a card table outside. Visitors hugged staffers and one another before departing what most in this once-thriving industrial section of the city call a valuable community resource.

Without Prevention Point and naloxone, Philadelphia health commissioner Thomas Farley estimates, the city’s already staggering overdose death toll — more than 1,100 last year in a city of 1.6 million — would be much higher.

But he and others here say much more needs to be done. Even if it means charting new territory.

A preliminary decision by a federal judge last month could put Philadelphia on a path to becoming the first U.S. city to host a so-called safe injection facility, where users can come in off the street and consume their illicit drugs under the watchful eyes of medical professionals who will rescue them if they overdose.

Politicians and harm-reduction advocates in Boston, Denver, New York, San Francisco and Seattle have tried to open similar facilities but have been stalled by red tape and state and local opposition, as well as federal lawsuit threats.

And lawmakers in Maryland, California, Colorado, Maine, Massachusetts, New York and Vermont, who have proposed bills that would authorize and fund supervised injection sites, have met similar opposition.

“People come running in screaming, ‘We have an overdose on the corner.’”

A 2018 report by Vermont Republican Gov. Phil Scott’s opioid commission found that safe injection sites were not a viable option because they were illegal under federal law and “highly controversial.” And then-California Gov. Jerry Brown, a Democrat, vetoed a safe injection site bill in 2018 for similar reasons.

When Prevention Point opened its doors in 1991, possession of a syringe was a state crime. Then-Mayor Ed Rendell, a Democrat who later served as governor, supported the program anyway and issued an executive order allowing syringe exchanges in the city, because he said too many Philadelphians were dying of HIV/AIDS, which was spreading through injection drug use.

Shortly after it opened, the state police threatened to arrest Prevention Point’s operators and participants, but Rendell said he told them to come to his office and arrest him instead. That didn’t happen.

Today, the center serves 15,000 people each year and is one of the largest in the United States.

As the opioid overdose death toll shifts from rural America to major urban centers, Philadelphia has become the epicenter.

The rate of overdose deaths here — 65 per 100,000 residents — was the highest of any major city in the nation and over three times the national average in 2017, according to data from the Centers for Disease Control and Prevention.

And its heroin and illicit fentanyl supply is the cheapest, most plentiful and deadliest in the United States, according to the U.S. Drug Enforcement Administration.

‘Far From Over’

In October, U.S. District Judge Gerald McHugh denied a petition, filed by the U.S. attorney for the Eastern District of Pennsylvania, arguing that safe injection or overdose prevention sites violate a 2003 provision in the federal Controlled Substances Act known as the “crack house” statute, which bans the operation of a facility for the purpose of using illegal drugs.

In his first-in-the-nation ruling, McHugh found that Safehouse, a Philadelphia-based nonprofit, would not violate federal law by opening a supervised injection site in the city. He found that the purpose of the proposed site was not to facilitate drug use, but to save lives and reduce drug consumption by helping more people get into treatment.

U.S. Attorney William McSwain, who filed the lawsuit against Safehouse in February, swiftly vowed to appeal the final decision and use all available enforcement measures — including asset seizures and prison sentences of up to 25 years — to stop the facility from opening.

“The Department of Justice remains committed to preventing illegal drug injection sites from opening,” McSwain said in a statement. “Today’s opinion is merely the first step in a much longer legal process that will play out. This case is obviously far from over.”

Rendell — the former Philadelphia mayor and Pennsylvania governor who is on the board of Safehouse — has repeatedly said he’s willing to be arrested for opening the country’s first safe injection site. “They can come and arrest me first,” he said last year in an NPR interview.

Moving Forward

For now, Safehouse has permission to pursue the project.

“Advocates across the country are watching Philadelphia,” said Daniel Raymond, policy director for the New York-based Harm Reduction Coalition. “Somebody had to go first.

“The federal court ruling isn’t final, and it isn’t binding in other states, but it gives encouragement to cities and health departments to say, ‘You know what? This isn’t so crazy after all,’” Raymond said. “Now it’s a question of when, not whether.”

Stateline Story January 12, 2018 Quick View

By the end of the year, McHugh is expected to issue a final order in the case.

“We feel confident we’ll get a final decision in our favor, given that the judge’s opinion was the idea that our purpose was to provide medical care and actually to discourage drug use, not to facilitate it,” said Ilana Eisenstein, an attorney with Philadelphia-based international business law firm DLA Piper who is arguing the case for Safehouse.

Until then, city officials, including Democratic Mayor Jim Kenney and District Attorney Larry Krasner, are working with Safehouse President Jose Benitez and the city’s police department on a plan for keeping the peace, discouraging drug dealing and ensuring users won’t be arrested for consuming illicit drugs around the proposed facility.

According to Benitez, the group plans to open several facilities in the city.

“This is a citywide problem,” he said.“We’re hoping to have multiple sites opening up in ZIP codes with the most overdose deaths.»

Even one facility, if opened in Kensington, could save 50 lives every year the number of overdose deaths already occurring in that area, said Farley, the city’s health commissioner. “It would be a valuable adjunct to the other things we’re doing to prevent overdoses in the city.”

Fentanyl Has Changed Everything

For more than three decades, staff at safe injection sites in Australia, Canada and Europe have invited tens of thousands of illicit drug users to consume heroin and other drugs in supervised facilities instead of in back alleys and parks.

Research indicates the facilities have reduced overdose deaths and lowered overall drug consumption in their surrounding neighborhoods.

In Vancouver, Canada, for example, where the safe injection center Insite has operated since 2001, drug overdose deaths declined 35% in the neighborhood and 9% in the rest of the city between 2001 and 2005. And 30% more drug users got into treatment, according to surveys conducted at the University of British Columbia.

Stateline Story February 13, 2018 Quick View

Safehouse hasn’t settled on a location for its first supervised injection facility, but there have been discussions about putting it in Kensington, where, on a recent day, people could be seen shooting heroin on nearly every block as police and emergency medical teams stood by.

Drug use has been a part of daily life for many Kensington residents for decades, but the death toll has never been as high as in the past five years.

According to Benitez, who runs Prevention Point, “Fentanyl has changed everything. Instead of using four times a day, people are shooting up eight to 12 times a day. And when they overdose, we have much less time to rescue them.

“We’re now experiencing two to three overdoses on most days. People are using outside of the [Prevention Point] building and then walking in and overdosing. Or they use in our bathrooms and overdose. Or people come running in screaming, ‘We have an overdose on the corner.’

“That’s what we’re up against.”

At the more than 300 syringe exchanges around the country, drug users can get clean needles and syringes, testing for hepatitis C and HIV/AIDS and wound care and other medical services. They also can get help finding addiction treatment.

“But then we tell them to go outside and use their drugs between parked cars or under stoops using puddle water,” Benitez said. “Why not provide a clean, well-lighted place for them to consume drugs so we know where they are and can rescue them if they overdose?”

Nationwide, many drug users are aware that syringe exchange centers have naloxone on hand. If they’re concerned about whether their stash might have fentanyl in it, they drop in and use their drugs in the bathroom so someone will rescue them if they overdose. Most syringe exchanges also offer test strips to detect fentanyl.

In New York’s Washington Heights neighborhood in the northern tip of Manhattan, for example, it’s an open secret that the syringe exchange center Corner Project keeps track of how long people have been in the bathroom, so they can open the door and rescue them with naloxone if they’ve overdosed.

Softening Opposition

In other cities and states, proponents of safe injection sites sought financial support from their legislatures and the backing of public health and law enforcement officials, local politicians and residents, and businesses before launching a facility. But those broad-based initiatives so far have not worked.

Safehouse, a privately funded nonprofit, decided to take a different route.

“We decided, ‘Nah, it’s not going to work that way in Philadelphia,’” said Ronda Goldfein, executive director of the AIDS Law Project of Pennsylvania, which is a partner in the project. “Instead, we decided to work with private funders and not get bogged down with all the politics.”

Immediately following McHugh’s ruling in favor of Safehouse, two Democratic state senators who represent Philadelphia, Anthony Williams and Christine Tartaglione, announced plans to introduce a bill that would ban supervised injection sites from operating anywhere in the state, arguing they violated federal law and could attract drug users.

But later in the month, the two lawmakers revised their proposal, allowing municipalities the option of authorizing supervised injection sites as long as they held public hearings, had a medical professional on site and included a policing plan. The bill was filed in late October. It has six new sponsors, including five Republicans.

On Nov. 7, Williams announced plans to repeal the statewide ban on syringe possession by amending the state’s controlled substances statute. “As Pennsylvanians continue to deal with the impact of the opioid crisis,” he said, “syringe exchange programs should be allowed to operate freely across the commonwealth.”

Stateline Story April 15, 2019 Quick View

Average Americans, including many Philadelphians, consider safe injection sites a bridge too far.

A national survey published by Johns Hopkins Bloomberg School of Public Health last year found only 29% of respondents supported legalizing safe injection sites in their communities. Support for syringe services was 39%.

But a poll of Philadelphians — funded by The Pew Charitable Trusts, which also supports Stateline — found residents roughly split in their approval of the proposed safe injection site.

Public opinion toward syringe exchanges is softening, said Raymond with the Harm Reduction Coalition. Republicans are starting to favor them because they ultimately save the government tons of money, he said.

But hurdles to opening a safe injection site remain steep in most places. In Philadelphia, even drug users who stand to benefit from the centers have said they’re concerned about getting arrested, said Farley, the health commissioner.

And beleaguered Kensington residents who regularly encounter people overdosing on the sidewalks have reportedly said in local council meetings that they worry that a safe injection site would attract drug users and that drug dealers would follow them.

But a study by the Rand Corporation found that hasn’t happened in countries where safe injection sites have operated for decades.


Supervised Consumption Services

How Safe Injection Sites Work
Insite, North America’s first legal supervised injection site, in Vancouver.

(Photo courtesy of Vancouver Coastal Health)

Supervised consumption services (SCS) are provided in legally sanctioned facilities that allow people to consume pre-obtained drugs under the supervision of trained staff and are designed to reduce the health and public order issues often associated with public drug consumption. They are also called overdose prevention centers, safe or supervised injection facilities (SIFs), and drug consumption rooms (DCRs).

Facility staff members do not directly assist in consumption or handle any drugs brought in by clients, but are present to provide sterile injection supplies, answer questions on safe injection practices, administer first aid if needed, and monitor for overdose.

This is particularly pertinent to fentanyl because the onset of overdose is rapid and waiting for an ambulance may mean death or permanent brain damage due to lack of oxygen.

SCS staff also offer general medical advice and referrals to drug treatment, medical treatment, and other social support programs. 

There are approximately 120 SCS currently operating in ten countries around the world (Australia, Canada, Denmark, France, Germany, Luxembourg, the Netherlands, Norway, Spain and Switzerland).

 In July 2021, Rhode Island became the first state in the nation to authorize a two-year pilot program to establish «harm reduction centers» where people can consume pre-obtained substances under the supervision of trained staff. We hope other states will follow Rhode Island’s example.

 SCSs can play a vital role as part of a larger public health approach to drug policy. They are intended to complement – not replace – existing prevention, harm reduction, and treatment interventions.

Benefits of SCS

Over 100 evidence-based, peer-reviewed studies have consistently proven the positive impacts of supervised consumption services, including: 

  • Increasing entry into substance use disorder treatment
  • Reducing the amount and frequency that clients use drugs
  • Reducing public disorder and public injecting while increasing public safety
  • Reducing HIV and Hepatitis C risk behavior (i.e. syringe sharing, unsafe sex)
  • Successfully managing frequent on-site overdoses and reducing drug-related overdose death rates (there has not been a single overdose fatality at any SCS worldwide)
  • Saving costs due to a reduction in disease, overdose deaths, and need for emergency medical services
  • Increasing the delivery of medical and social services

Barriers to SCS in the U.S

No SCS currently exist in the United States due to a host of legal and ideological barriers. SCS arguably violate various state and federal drug laws, including laws that make it illegal to use, open, or maintain property where any controlled substance is consumed. 

July 2021 Update: Rhode Island became the first state in the nation to authorize a two-year pilot program to establish «harm reduction centers» where people can consume pre-obtained substances under the supervision of trained staff.

Beyond legal obstacles (which can be overcome), there can be a lack of community support fears that SCS will cause an increase in drug use and crime. These fears are unfounded, however. In areas surrounding existing SCS, there has been no evidence of increased community drug use, initiation of injection drug use, or drug-related crime.

“Studies from other countries have shown that supervised injection facilities reduce the number of overdose deaths, reduce transmission rates of infectious disease, and increase the number of individuals initiating treatment for substance use disorders without increasing drug trafficking or crime in the areas where the facilities are located.” – American Medical Association

See our fentanyl report to learn about more health-centered solutions to the overdose crisis.

Our Work

The Drug Policy Alliance has been advocating for SCS pilot programs in California, Washington, Colorado, Vermont, New York, and Maryland, among other states. San Francisco and New York City are moving forward with plans to open SCSs over the next year.

While gaining acceptance for a U.S. facility will be an uphill battle, we are committed to challenging the stigma surrounding drug use and introducing political leaders and the public to the health and societal benefits that SCSs bring to local communities.

Learn more about our efforts to establish SCS in California.


Supervised Injection Facilities Face Obstacles, But That Shouldn’t Stop Them

How Safe Injection Sites Work

Supervised injection facilities (SIFs) are clean indoor environments where people can consume pre-obtained drugs with trained health professionals present to ensure safe injection methods, respond in the event of an overdose, and provide counseling and referrals to vital social services and treatment options. More than 100 facilities with formal legal sanction operate in ten countries, although no such facility legally exists in the United States. Extensive research has shown supervised injection sites reduce overdose deaths, increase addiction treatment uptake, and reduce social nuisance. Although supervised injection sites are not the sole answer to the opioid crisis, they are being considered by American cities and states as a way to fill an immense gap in the current system of care and engage a highly vulnerable and difficult to reach population – ultimately reducing the public health burden and saving lives.

Current Efforts To Open SIFs In The US

Supervised injection facilities have been operating in Europe, Canada, and Australia for decades, and evidence shows their effectiveness. These facilities allow patients access to sterile injection equipment to safely use illegal drugs they previously obtained.

The idea is to give vulnerable people a safe place to do what they would be doing anyway, but in a safe environment under supervision of professionals ready with Naloxone, the opioid overdose antidote, if necessary.

The sites also link people, who may be difficult to engage otherwise, to addiction treatment and services.

In the United States, safe injection sites have long faced public opposition. However, as the opioid epidemic continues to stump policymakers, there is a renewed interest in these facilities as a potentially life-saving intervention.

Several American cities are leading the way in advocating for supervised injection sites as a response to the opioid epidemic.

In New York City, Philadelphia, Seattle, and San Francisco, officials hope to open legally sanctioned sites as early as 2019 — but they will need to overcome significant legal obstacles and shift public opinion if these plans are to become a reality.

In California, a bill was just vetoed by the governor that would have allowed supervised injection sites in San Francisco and similar bills in Massachusetts and Colorado are being considered, but will ly face the familiar barrier of unfavorable public opinion.

Seattle appears to be furthest along — officials have given the green light on what will be the nation’s first safe injection facility (SIF), although funding and facilities still need to be obtained and the timeline for opening is undetermined. With no existing legal SIFs in the United States, and the issue remaining highly controversial among the public and political officials, it is time to reconsider the philosophy behind this intervention — and why Americans are so opposed.

Why SIFs Are Controversial

Health experts have long recommended harm reduction approaches, such as needle exchange programs, as successful interventions to combat the opioid epidemic and contain the spread of certain viral infections, such as HIV, hepatitis B, and hepatitis C.

While needle exchange programs have gained federal approval and traction across the United States (now operating in 33 states), supervised injection sites remain highly controversial and stigmatized.

The public and political concerns are clear: supervised injection sites promote drug use, they will bring drug users to the neighborhoods they are located in, it is morally and legally wrong to encourage and allow drug use, and so on. This battle illuminates the societal impact of the war on drugs and a country that criminalizes addiction.

From the perspective of America’s no tolerance drug policies, allowing people to use drugs in a safe and supervised space feels counterintuitive. But safe injection sites challenge the status quo. This approach, advocates argue, is not about enabling drug use, it’s about saving the lives of those who are already vulnerable and addicted to drugs.

And if the goal is to save lives, a more compassionate approach that includes harm reduction will be necessary. How this issue is framed impacts intervention and policy options, and advocates continue to support treating drug abuse and addiction as a health issue, rather than a criminal issue.

Although asking officials, along with the general public, to tacitly accept illegal drug use is a seemingly impossible challenge, there has never been a stronger impetus to work outside of the criminal justice system to mitigate drug use.

As the death toll continues to rise from the opioid epidemic, many argue that it is time for a new perspective that encompasses all evidence-based approaches to reducing opioid fatalities — even if it challenges our instincts to treat drug use criminally.

Since it is evident the supervised injection sites will continue to face an uphill battle in shifting public opinion, it is important to let the research speak for itself.

Meeting People Where They Are Works

The framework behind SIFs is rooted in the philosophy of meeting people where they are.

Individuals can come into a clean, non-judgmental space where they are provided with a sterile needle to inject pre-obtained drugs under the supervision of health workers, who are ready to intervene if the patient overdoses and counsel patients in their treatment options.

These facilities have been consistently proven to reduce risky injection behaviors, transmission of blood-borne infections, overdose deaths, and nuisances associated with public injection (such as outdoor injecting and disposing needles in the surrounding neighborhood).

The facilities also boast increased client enrollment in substance use treatment services, demonstrating that the facilities can operate as effective connectors to addiction treatment, counseling, and other services.

Not only can SIFs save lives, decrease public nuisance, stop the spread of blood-borne infections, and get people into treatment, but they also save money and reduce the public health burden of addiction. One analysis conducted in San Francisco estimates that for each dollar spent on supervised injection sites, $2.

33 would be saved in emergency medical, law enforcement and other costs, yielding a yearly savings of $3.5 million.  Another report from Johns Hopkins Bloomberg School of Public Health found that opening just one supervised injection facility in Baltimore would save the city $6 million annually. These fiscal benefits stem from lower ambulance and hospital utilization, the prevention of infections, and the ability to treat large numbers of overdoses on-site. Additionally, this report estimates that a SIF could enroll over 100 new people in treatment every year — significantly reducing drug use, rather than encouraging it as public opinion suggests.

The international success of supervised injection facilities is abundantly clear, and these studies that estimate the impact that SIFs would have on American cities demonstrate similar findings.

The research suggests that these spaces do not, in fact, encourage or increase illicit behavior, but rather they reduce needle sharing, unsafe injection practices, and bring individuals that are left vulnerable to violence and possible death when injecting on the streets into safe, clean, supervised spaces.

By meeting people where they are, supervised injection facilities connect people to lifesaving resources, curb illicit and unsafe behaviors, and ultimately reduce the public costs associated with addiction and overdoses.

While public opinion remains a hurdle for the development of safe injection sites, the legality of such facilities is largely up for interpretation.

There are no laws that explicitly authorize or forbid SIFs, but the challenge remains in how local, state, and federal officials interpret state and federal laws on drug possession and the maintenance of facilities for illegal drug use.

Experts suggest that political climate will determine if the authorization of a SIF would be challenged locally or federally.

In examining the political climate, there is no question that the Trump administration is a vocal opponent of supervised injection sites, going so far as to have threatened legal action against cities and states that allow them.

Deputy Attorney General Rod Rosenstein has also criticized the sites and warned officials that the sites are illegal under federal law.

Two sections of the federal Controlled Substances Act could be interpreted to bar a SIF: Section 844, which prohibits drug possession, and Section 856, (colloquially known as the “Crack House Statute”) which prohibits knowingly maintaining a place for the purpose of unlawfully using a controlled substance.

It should be noted, however, that federal law enforcement rarely targets simple possession by individuals, which would be the case for all individuals utilizing a SIF, and public health interventions were not the intended focus of the “Crack House Statute.

”  The ambiguous nature of how these statutes would be enforced are thought to make the most important legal consideration into a political one: would federal lawmakers and law enforcement ignore, if acceptance is off the table, a state or city authorized SIF? The current political climate suggests that the Trump administration does not plan on looking the other way.

So, what should officials do that want to test SIFs as an intervention in response to the opioid crisis, but fear retaliation from the U.S. Justice Department? There are a few options to move forward.

  • State authorization to pursue SIF development. State legislatures have the authority to sanction the operation of SIFs, and they have a duty to protect and preserve the welfare of their citizens. Explicit state authorization is the ideal course as it eliminates uncertainty surrounding SIF legality state-wide and protects SIF clients and staff from police pressure or interference. State authorization also is the strongest option to withstand a challenge from the federal government.
  • Authorize SIFs through state executive branch action. Health agencies and governors in all states have authority to make rules to protect public health – in fact, that’s how some states such as Indiana implemented needle exchanges in the first place. State health commissioners and governors could pass regulations or executive orders to authorize SIFs, although these could be vulnerable to legal challenges if they are interpreted to be outside of the executive branch’s authority.
  • Authorize SIFs at a local level. Local governments have the discretion to implement programs that have reasonable evidence of effectiveness in combating existing health challenges. Just as syringe exchange programs authorized by local governments have been operating in cities across the country without state authorization, SIF authorization could come from a mayor, local health commissioner, or city council. This approach, however, would have the weakest support up against a federal or state challenge. Additionally, implicit agreement among stakeholders would be crucial if a local approach was taken to ensure that staff and clients of the SIF would not be arrested or shut down.

Regardless of which route officials take, under the current administration any SIF authorization will ly end up in front of a federal judge. This makes it even more important to move forward with SIF legislation, as an official ruling would clarify much of the legal ambiguity and potentially open up a clear path forward for widespread SIF implementation.

What’s Next for SIFs

The hurdles facing supervised injection facilities are daunting. However, with vast evidence of the life-saving and cost-saving benefits of SIFs, advocates for drug policy reform must push forward with their efforts.

Nationally, professional organizations should help turn the tides by publicly endorsing the intervention and continuing to conduct research on its’ impact.

Additionally, state legislatures should propose bills to authorize supervised injection facilities, and in states where that’s not possible, cities should take it upon themselves to locally authorize such sites.  Advocates, researchers, and lawmakers should pay close attention to cities Seattle that are paving the way.

With the Trump administration actively rejecting the concept of SIFs, it is important to remember that cities and states don’t need federal approval to establish these facilities.

The opioid epidemic will not be solved by the Trump administration’s “tough on crime” approach and refusal to acknowledge the effectiveness of harm-reduction solutions.

Although public opinion and legal challenges remain significant obstacles, it is time for policymakers to reconsider supervised injection facilities as a crucial evidence-based intervention in mitigating the opioid epidemic.


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