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Harmful Harm Reduction?: The Controversial Nature of US Safe Injection Sites

Source: Elana Gordon/WHYY via NPR

Drug overdoses in the United States have grown enormously over the past five years. As a consequence, public health officials across the country have lobbied for harm reduction policies. In December 2021, New York City became the first city in the United States to open a supervised injection site, hoping that a safe haven for drug users would lower overdose rates and the transmission of diseases through used needles. Site critics, on the other hand, evoke the illegality of the drugs themselves and, by proxy, safe injection sites. Nevertheless, neither side actually addresses the root causes of drug overdoses: specifically, the continued gaps in access to healthcare.

Since 2015, rates of overdose deaths in the United States have doubled. Initially, the spike in drug use coincided with the widespread use of fentanyl in drug production. As a more potent and yet cheaper drug, fentanyl gained traction in drug markets, especially for heroin. In turn, the United States saw an unprecedented increase in drug overdoses last year, totalling 100,000 deaths in the first 12 months of the Covid-19 pandemic alone. The compounding rise of mental health problems, loss of social connections, and diminished access to treatment resulted in record-high overdoses. In response, local health departments across the United States have lobbied for safe-injection sites. 

New York City’s safe injection sites set an important precedent for drug policy. These sites were created with the intention of reducing the number of drug-related deaths from overdoses and disease transmission. Equipped with clean needles, staff with emergency medical training, and the opioid antagonist naloxone (which rapidly reverses a drug overdose), officials hope these centers will tackle the immediate risks of using drugs. In addition, proponents of these sites hope that they will disseminate information about rehabilitation centers and treatment alternatives. New York, however, is not the only American city to campaign for this public health intervention. Four other cities across the country have attempted and failed to establish their own safe-injection sites. But in March 2022, Rhode Island’s legislature passed a law that would allow private parties to submit applications to establish “harm reduction centers” monitored by the Rhode Island Department of Health. This pilot program will provide a clearer picture into Rhode Island’s opioid epidemic—which claimed 322 lives in 2021—and save lives. This is the country’s first statewide law authorizing safe injection sites. 

In San Francisco, proponents received criticism over concerns that these sites would foster crime in surrounding neighborhoods. Seattle & King Country Public Health “green-lighted” injection sites before facing backlash from the Acting Attorney General Jeffrey A. Rosen for their supposed illegality. In Boston and Philadelphia, Massachusetts Governor Charlie Baker and the US Court of Appeals for the Third Circuit, respectively, insisted on taking a legal approach to drug overdoses. In opposition to establishing safe injection sites, they cited the 1986 Anti-Drug Abuse Act, which makes it illegal to operate a drug facility. While efforts in these places have been unsuccessful, New York City and Rhode Island’s establishment of safe-injection sites exemplify important changes in the long-term management of the opioid epidemic. State legislatures and safe injection site supporters are now looking to the Biden administration for a new direction. 

Supporters of these sites hope that President Biden will follow former President Barack Obama’s easing of drug policy, whose Justice Department did not challenge states’s legalization of marijuana. In a press release in November 2021, the Biden Administration announced steps toward combating the “overdose epidemic.” While the announcement did not explicitly name safe injection sites as a primary prevention method against overdoses, it did outline the intention of establishing “harm reduction, evidence-based treatment, and recovery support services for all Americans.” Despite the Biden Administration’s intention to manage the overdose crisis through more lenient policy, it has still failed to address the most important barrier to sustainable change for people who use drugs: comprehensive healthcare reform.  

Spiking overdose and drug abuse rates are not unique to the United States. Supporters point toward successful drug injection sites in Canada and Australia, hoping that their own cities can mirror the decline in drug overdose experienced in these countries. In Canada, Vancouver’s pilot site has shown significant reduction in fatal drug overdoses. Since 2003, the site’s medical staff has intervened in over 6,000 overdoses. A study in Canadian Family Physician found that the establishment of the safe-injection sites has reduced HIV infections; another study in the Lancet found that safe injection site users were more likely to seek treatment and less likely to engage in behavior that risks HIV infection. 

While studies in Canada have evidenced that safe injection sites can successfully reduce drug overdoses, a key difference exists between the United States and other developed nations with similar drug programs. One of the cornerstone arguments for safe injection sites is that these centers will act as more than just a drug safe haven, but as a potential gateway to treatment centers. Site proponents in the United States, however, have failed to consider that the greatest barrier to treatment is not users’ willpower, but rather access to health resources. 

The primary difference between the United States and comparable nations with safe-injection sites lies in access to treatment. In the United States a lacking comprehensive healthcare system means that in the US it is “easy to get high and hard to get help.”  The costs of getting drug rehabilitation in the United States are steep and not always covered by insurance. The full cost of treatment ranges from $15,000 to $27,000, depending on the length, location, and amenities of the program. Those battling a substance abuse disorder may not be able to afford such fees. According to the National Comorbidity Survey-Replication, 15 percent of people with mental and substance abuse disorders who refuse treatment cite lack of insurance or high costs as the greatest barriers to addiction care.

The establishment of safe injection sites in the United States represents an important step toward ensuring proper long-term management of the overdose epidemic. The effectiveness of safe injection sites beyond clean needles, however, will depend on a larger effort to implement accessible treatment to drug-users. Without a healthcare system and treatment plan to back up safe injection sites, though, they will not come close to solving the opioid epidemic.