On July 14, 2021, MedPage Today reported on how Rhode Island became the first state to authorize a safe injection facility -- a site which allows people to inject or consume their own illegal substances under supervision. As part of our review of top stories in 2021, we follow up on what has happened since this authorization, with the launching of a pilot program for the same type of overdose prevention centers in New York City.
On November 30, 2021, New York City opened the first official overdose prevention centers in the country. Users bring their own drugs into the sites, where they are monitored by staff who provide clean needles and give overdose reversal drug naloxone when needed.
One underground, unsanctioned site has been active in the U.S. since 2014, but New York is the first city to open such a facility publicly with the support of local officials. Over 100 safe injection sites are currently operating in at least 10 other countries.
"With more than 100,000 people across the country dying unnecessarily" from drug overdoses, it was the right time to act, said Melissa Moore, director of civil systems reform for the Drug Policy Alliance, a non-profit that supports harm reduction and drug decriminalization.
In just those 3 weeks up until December 21, the New York City sites have been used more than 2,000 times and their staff helped to avert 59 overdoses, Moore told MedPage Today.
"We are meeting people who use drugs where they are in their life journey to support them in building their self-worth," said Sam Rivera, executive director of OnPoint NYC, in a press release from the New York City Department of Health celebrating the latest data.
James Baker, MD, MPH, past chair of the Massachusetts Medical Society's Committee on Mental Health and Substance Use, whose son died of a heroin overdose at the age of 23, said he was pleased to see the city putting the health of its people "ahead of outdated laws." And, he added: "That's very hopeful for places like Boston."
Advocates in Boston, Seattle, San Francisco, Philadelphia, and several other cities are battling to open their own sites, and often face serious opposition from community leaders, local officials, and sometimes the federal government. The sites are still, in fact, illegal.
Some critics argue that sites like New York's will simply enable users who will go on to die in other settings.
David Murray, PhD, co-director for the Center for Substance Abuse Policy Research at the Hudson Institute in Washington, D.C., said claims that the sites work are "really pretty dubious" given what he views as weak and biased studies.
The fact that there are overdose reversals on site at a facility "may be very misleading," he said. People who use drugs often do so multiple times in a day and may continue to inject in settings where they aren't protected, Murray said.
"We see evidence that people continue to die, to overdose -- but just not on the facility itself," he noted.
Others say the centers will have minimal impact.
Keith Humphreys, PhD, a professor of psychiatry and behavioral sciences at California's Stanford University, said the sites are "just not that consequential," nor are they "scaleable."
"The first of these sites was 30 years ago, there's not even 150 of them on the entire planet," he said.
Humphreys said that while he wouldn't stop anyone from opening a site, there's a key question he wants answered: "What else could your public health department have done with that same amount of money?"
Humphreys, a former Obama administration senior drug control policy advisor, stressed that the question isn't only whether a public health tool "works" but how well it works relative to other investments, such as methadone and other forms of medication assisted treatment with stronger evidence behind them. He also compares the sites to more scalable tools like needle exchange programs and naloxone -- "things that could take care of a whole population rather than a very, very small number of people who happen to live in a very small area around a supervised injection room."
Alex Kral, an epidemiologist from the nonprofit health research institute RTI International, argued that there's never as much debate around how to save a person who's had a heart attack from dying, for example. "If the goal is to make sure that we improve these people's lives as much as possible, the first thing we have to do is save them; because if we don't save them, we're not going to improve their lives."
Baker agreed. "Right now ... there are so few options available to help people who are out on the street and using every day. Any option that helps bring them back to their families and to society and health is a good option."
New York City's Program
The site in Washington Heights follows a peer model, meaning staff supervising users have their own lived experience with addiction, explained Kral, who visited both sites a week before they opened.
In contrast, the East Harlem site, which is modeled off of Insite, a well-known safe injection site in Vancouver, has medical staff and a health clinic on site. Both sites have booths for injecting or consuming drugs and ventilated smoking vestibules, Kral explained.
For users, it's about more than having a safe place to inject, Moore said. "It's actually about the relationships that staff within the harm-reduction agencies are able to build with people, and then be able to connect them with other care, other forms of public health support," she said.
Sites also provide users with fentanyl test strips, which given the increased danger of fentanyl contamination and poisoning is "really crucial," Moore said.
Neither site has had to call for an ambulance, which is another benefit -- reducing the strain on an overburdened hospital system, particularly during COVID, according to Moore.
More sites are expected to open in 2022. One in the Bronx, one in Manhattan, and a third in an undetermined location, she added.
Will the Feds Intervene?
In opening these overdose prevention centers, New York ignored federal law. A section of the Controlled Substances Act, dubbed the "crack house statute," makes it illegal to operate, own, or rent a site with the intention of using, selling, storing, or manufacturing drugs.
In Kral's view, Mayor Bill de Blasio (D) simply ignored that law. Incoming Mayor Eric Adams has said he supports the sites, as do four out of five district attorneys, who penned an op-ed asking President Biden to endorse them, Moore said.
So, there's little concern for interference from local government but still a chance the federal government could shutter the sites, Kral said.
Moore, however, is hopeful. She quoted HHS Secretary Xavier Becerra who, in a recent interview with NPR on drug policy in October, spoke of being "willing to go places where our opinions and our tendencies have not allowed us to go [before]."
While that statement wasn't an explicit endorsement, Moore characterized it as "a fair amount of dancing around it, but some signaling there."
Kral pointed out that, in spite of Becerra's known support for overdose prevention centers as Attorney General of California, the HHS Overdose Prevention Strategy released last month made no mention of the sites.
As for the other important federal player, Kral noted, "we've heard absolutely nothing ... from the Department of Justice."
Over the last 50 years of drug policy, Kral said a pattern has emerged, which starts with an act of civil disobedience, (the opening of an unsanctioned overdose prevention center) and continues with a city or two adopting a controversial measure, and after some time, a state or two.
Both needle exchange and naloxone programs followed this pattern, he noted.
The federal government did nothing to stop those programs, nor did they help them, he said, for as long as 20 years.
Given that context, "I wouldn't expect to hear from the federal government on this issue for ... maybe another decade or so," Kral said.
How to Open a Safe Injection Site
There are two routes to opening safe injection sites or overdose prevention centers: one is the legal route, and the other is the political route, Kral said.
New York took the political route, as de Blasio essentially thumbed his nose at federal officials and said, "We're just gonna do it." Philadelphia and several other cities and states appear to be taking the legal route.
Ronda Goldfein, Esq., vice president of Safehouse, the Philadelphia nonprofit working to establish an overdose prevention center there, despite praising New York's "wonderful, brave move," said her group has "consistently said that it wouldn't open without legal authority to do so."
The nonprofit is also not in the position to ignore a court order, said Goldfein, who is also executive director of the AIDS Law Project of Pennsylvania.
Under the Trump administration, the Department of Justice sued Safehouse in 2019 and is still in active litigation. Ignoring the order would only create a "distraction" for the movement, over whether the group would be in contempt or not. Instead, Goldfein said, Safehouse wants to "keep our eye on the prize, which is to save lives and do it in the safest way, for all concerned."
Rhode Island Gov. Daniel McKee (D) signed a law in July authorizing safe injecting sites there. In California, a bill known as SB-57 that would allow California to open safe injection programs in San Francisco, Oakland, and Los Angeles, passed the state Senate in April 2021. Kral noted it is expected to head to the state assembly early next year.
However, Philadelphia, oddly, is in the best position to negotiate its case.
In October, the Supreme Court chose not to review the case against Safehouse, Goldfein said during a panel discussion in November. But by petitioning the Supreme Court, Safehouse forced the Biden Administration to weigh in on its plans.
"In many ways, we don't regret being sued," Goldfein said, because the lawsuit has allowed the group to have conversations with the Biden administration on the issue that, to her knowledge, no other advocates are having.
The nonprofit initially expected a response from the DOJ -- the "first tell" from the Biden administration regarding where they stand on these sites -- in November, but this was postponed to early January.
And now, Goldfein told MedPage Today, the DOJ and Safehouse agreed to another extension to the government's response, this time to March 7, 2022.
With that extension, Goldfein wrote in an email, "Safehouse is optimistic that, with continued conversations, a mutually satisfactory resolution will be reached."
As for New York's influence, Goldfein said, "I think that every day that a site stays open, that lives are saved and that ... there's no residual fallout ... I think that all strengthens our position."
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