By Carly Roberts
Supervised injection sites, also known as safe injection sites, are among the most effective, evidence-based harm reduction tools available to counter the opioid overdose crisis.
Supervised injection sites are legally sanctioned locations that provide a hygienic space for people to inject pre-obtained drugs under the supervision of trained staff. Safe injection sites often provide additional services including needle exchanges, drug testing (especially important for detecting lethal fentanyl-laced drugs and preventing “mass overdose” events), and referral to treatment and social services.
The opioid overdose crisis in the U.S., which had a death toll of over 45,000 in 2018, and which is predicted to worsen amid the COVID-19 pandemic, warrants a bold, brave, and thorough response. Harm reduction programs, including supervised injection sites, should be integrated into opioid epidemic response strategies in order to save lives and improve individual and community outcomes.
In countries including Canada, Australia, France, Germany, Spain, and Switzerland, safe injection sites have been shown to improve individual health by reducing overdose mortality rates, increasing access to health and social services, and decreasing transmission of viral infections like HIV and viral hepatitis. Supervised injection sites have also been shown to improve community health and safety, and reduce community costs associated with drug use. A study of an unsanctioned supervised injection site in the U.S. showed similar outcomes.
Despite the proven success of supervised injection sites, a milieu of federal opposition and morally divided public opinion has blocked implementation in the United States.
During the Trump administration, Department of Justice (DOJ) officials took the position that supervised injection sites were tantamount to government-sanctioned drug use and promised to “meet the opening of any injection site with swift and aggressive action.”
This was indeed the case when Safehouse, a Philadelphia nonprofit, attempted to open the first supervised injection site in the United States. William McSwain, U.S. Attorney for the Eastern District of Pennsylvania, filed a civil lawsuit against Safehouse, asking a federal court to declare supervised injection sites illegal.
On January 12, 2021, the Third Circuit ruled that safe injection sites are unlawful under the Comprehensive Drug Abuse Prevention and Control Act of 1970 (CDAPCA) — a law passed to shut down crack houses. Safehouse has expressed intention to appeal this decision, but until their appeal is successful, or there is an indication of changed policy from the Biden administration, the Third Circuit’s decision could have a chilling effect on similar efforts in states like Washington, New York, and Colorado.
Removal of legal barriers is necessary to pave the way for supervised injection sites. Additionally, advocates must wage education campaigns to win acceptance and support from local communities.
While the Biden administration has not expressed a clear position on injection sites, President Biden’s campaign platform included support for evidence-based harm mitigation programs including syringe service programs. With sustained advocacy from local governments and community organizations, the Biden DOJ could be swayed to halt enforcement actions against safe injection sites and drop pending lawsuits — resembling the DOJ response to state-level marijuana legalization under the Obama and Trump administrations.
Congress could circumvent the need for federal judicial or executive action by amending the CDAPCA to clarify that it does not apply to supervised injection sites, or by passing other legislation authorizing them. While such a bill might seem a tall order considering the current hyper-partisan climate, there may be stirrings of support. Jerrold Nadler (D-NY), Chair of the House Judiciary Committee, recently spoke in favor of harm reduction policies, including supervised injection sites, at a Committee hearing on March 11, 2021.
In the absence of changes on the federal level, state and municipal actors may attempt to force the DOJ’s hand on an enforcement decision by forging ahead with planned supervised injection sites. However, some states may have additional legal hurdles to clear before opening supervised injection states — for example, many states have laws that consider syringes illegal drug paraphernalia, without any exemption for syringe service programs.
In the interim, harm reduction community groups have arisen to meet the need for support and safety in their communities, including the Church of Safe Injection in Maine, and the Portland Peoples Outreach Project in Oregon. These groups rely on volunteers and, depending on the jurisdiction, often operate in grey areas of legality, which limits their reach and subjects them to the risk of being shut down by law enforcement.
Whatever the path to legality, supervised injection sites need to be part of a comprehensive response to the opioid epidemic.
Even with current shifts in the substance use policy landscape to focus on a public health approach, the need for relief still far outpaces available resources. There is not enough capacity to treat everyone who wants to be treated, and some people experiencing addiction may not willingly seek treatment for any number of reasons. A more comprehensive approach is needed to care for people who fall into these gaps and to fully address the opioid epidemic. Harm reduction practices implemented alongside decriminalization and expanding treatment availability can help fill these gaps.
If we do not act to implement supervised injection sites, we will tacitly endorse the current state of affairs that condemns people experiencing addiction to unnecessarily hazardous conditions, and essentially requires service industry employees to function as supervisors of injection sites in public restrooms and streets. We can and we must do better. We should follow the data and implement strategies that have been proven to reduce harm as part of a comprehensive and robust response to the opioid epidemic.
Carly Roberts is a 2L at Gonzaga University School of Law where she is a Thomas More Scholar and Editor in Chief of the Gonzaga Law Review.