Allowing people to inject illicit drugs under the supervision of medical professionals is a simple but inevitably controversial healthcare strategy for making drug use safer. After numerous successes in Europe and Canada, it's finally gaining a foothold in the United States as politicians grapple with an unprecedented spike in opioid use disorders and overdose deaths.
Last week, officials in Seattle finalized plans to open two safe injection facilities in the city and surrounding area. Boston, New York and Ithaca have also expressed interest in establishing safer spaces for drug users. Dan Morhaim, a Maryland state lawmaker and medical doctor, introduced legislation this week that would legalize "safe consumption programs" and decriminalize possession of small amounts of marijuana, heroin, cocaine and other drugs in his state.
"Maryland has the opportunity to serve as a model for the country in treating drug use for what it is -- a public health issue," Morhaim said in a statement.
Safe injection sites primarily serve people with chronic opioid dependency, and provide first aid and clean equipment in a hygienic space. Doctors and nurses stand by with the opiate antidote naloxone, which can reverse a potentially fatal overdose. The facilities also serve as an entry point for addiction counseling and treatment services, should users want to pursue those options.
There are nearly 100 safer drug use facilities in nine countries, mostly in Europe, according to the Drug Policy Alliance. North America's first supervised injection site opened in Vancouver, Canada in 2003, and safer drug use programs have become popular among Canadian policy makers despite conservative opposition.
Numerous studies show that safe injection sites, along with other harm reduction strategies such as syringe exchange, prevent overdose deaths, cut HIV and hepatitis C infection rates and help people with a chronic illness lead more healthy and stable lives. In general, people with opioid disorders do not inject drugs to get high; they use regularly in order to stave off painful withdrawals that make doing anything else with their day, such as showing up for work or doctor's appointments, all but impossible.
Such outcomes should look attractive to policy makers in states like Maryland, where opioid overdoses increased by 20 percent from 2014 and 2015, according to the Centers for Disease Control. Nationally, rates of accidental death from opioid use have quadrupled since the late 1990s.
A Missing Piece to the Overdose-Reduction Puzzle
Susan Sherman, a researcher at John Hopkins University who is working with a grassroots coalition to bring safe consumption programs to Baltimore, told Truthout that safe injection sites are the next logical step for a city that has embraced innovative harm reduction strategies in response to spikes in fatal overdoses.
"It's really a missing piece of the puzzle in these East Coast cities that are dealing with the overdose epidemic that is largely driven by prescription drug use and fentanyl," Sherman said.
Fentanyl is a powerful painkiller that is often cut into heroin and other drugs to increase their potency. Users who are used to weaker drugs are at risk of overdosing when encountering drugs cut with fentanyl. At safe injection sites, batches of heroin and other street drugs can be tested for fentanyl, allowing advocates to track the drug and warn users. The presence of fentanyl in the North American heroin supply has grown substantially in recent years, and last year 86 percent of the drugs tested at Vancouver's safe injection site contained fentanyl.
Sherman said safe injection sites also save the health system money because they cost much less than rushing overdose victims to the emergency room in an ambulance or treating infections and heart problems caused by unsafe injection practices. However, harm reduction efforts like safe consumption programs are not just about improving public health outcomes -- they're about human rights.
"The first word that comes to mind … is dignity," Sherman said.
People who inject drugs to deal with opioid disorders face stigma and criminalization due to their disease, and they often use in secret and in circumstances that are too rushed to do it safely, according to Sherman. At safe injection sites, drug users can do what they would be doing anyway in a space where they are treated as human beings with rights and health needs, rather than as "criminals."
"It's [a] perfect public health scheme because it's based in dignity and respect for where someone is at in their life," Sherman said.
In a September op-ed for The Influence, Norwegian journalist Sturla Haugsgjerd acknowledged that he is "actively addicted to heroin," but emphasized that shaming him and others like him into the shadows does nothing to help.
"Is it really absurd to imagine a world where people who are addicted, or who use drugs for any reason, can stand up straight and contribute to society, without having to sneak into toilets or parking lots to take their drugs?" Haugsgjerd writes.
Politics vs. Common Sense
Safe injection sites make sense on paper, but they still face a steep uphill battle in the political world. A Republican state lawmaker in Washington has already introduced legislation that would ban safe injection facilities like the ones being drawn up in Seattle. In Canada, attacks by conservatives and arguments over where sites should be located have bogged down the expansion of safer drug use facilities for years.
In Maryland, Morhaim has introduced similar bills in the past but they've never made it out of committee. Lindsay LaSalle, a senior staff attorney with the Drug Policy Alliance who helped draft the legislation, said other lawmakers still need some help "wrapping their heads around" the idea of providing safe spaces for drug use.
"I do think we understand that it will most likely be a multi-year effort," LaSalle said.
Technically, safe injection sites are considered illegal in the US under federal law. However, so are medical marijuana programs, which are now being implemented in the majority of states. How safe injection programs would fare under the Trump administration is anyone's guess, but President Trump's "law and order" rhetoric and extreme right-wing cabinet picks are not leaving advocates feeling hopeful.
Scientists, human rights groups and medical professionals tend to support harm reduction initiatives such as safe injection sites, but it's the Justice Department that generally sets federal policy on drug enforcement. Sen. Jeff Sessions, an archconservative from Alabama and President Trump's pick to head the department, is a "nightmare" nominee who would be a "disaster for drug policy" and criminal legal reforms, according to a statement from the Drug Policy Alliance.
With support from the outgoing Obama administration, Congress recently approved $1 billion in grant funding for states to address prescription opioid misuse and expand addiction treatment. With the Trump administration now in charge of distributing the funds through the Department of Health and Human Services (HHS), advocates worry that much of this money could be diverted to law enforcement.
Policing tends to discourage drug users from seeking resources and treatment because police have spent so many years harassing and locking them up in jail. Establishing safe injection sites in Seattle and beyond could set an important precedent for supporting solutions to drug problems that involve trained medical professionals and community advocates instead of the police.
Trump's pick to head the HHS, Rep. Tom Price, is currently embroiled in an insider trading scandal and has a spotty record when it comes to evidence-based solutions to drug problems. Like other House Republicans, Price has voted to maintain a ban on federal funding for syringe exchange programs in the past. In 2015, an HIV outbreak among injection drug users in rural, red state Indiana forced GOP lawmakers to change their tune and lift the ban.
Meanwhile, Price's wife, Georgia state Rep. Betty Price, introduced legislation that would have expanded syringe exchange programs in Georgia. Her husband's district, which includes a large chunk of Atlanta, has an opioid problem and has experienced high rates of HIV infection and fatal overdoses.
The CDC considers syringe exchanges to be highly effective in preventing the spread of HIV and other diseases, but Betty Price's proposal was too controversial for the Georgia's conservative legislature and failed to pass. Atlanta and the rest of the state continue to have some of the highest rates of HIV infection in the nation.
The CDC also says that opioid-related deaths have reached epidemic levels despite the efforts of law enforcement, and that's one reason why treating opioids as a public health issue rather than a criminal problem is becoming a mainstream idea. As Seattle prepares to make history and calls for safe injection sites in cities like Baltimore become too loud to ignore, perhaps political stigma will finally be overcome by common sense.