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By: Michelle Cardona Vinasco, Volume 103 Staff Member

While using drugs may initially start off as a choice, it often ceases to be one; addiction takes this choice away. Helping people obtain treatment should be one of the goals in the pursuit of improving the public welfare and combating the ongoing drug crisis, but it should not be the only goal. There are many intermediate steps between addiction and full recovery that can make an immense difference in the lives of people who use drugs and in society as a whole. One of these intermediate steps is creating and running safe injection sites. These sites provide a clean, safe space where people can use drugs as well as sterile injection equipment and trained staff who can assist in cases of drug overdose.[1] In addition, the sites often provide information and assistance with finding treatment and rehabilitation centers.[2] These facilities are important to providing a comprehensive treatment plan for those suffering addiction because it allows them a safe place to use while they still use drugs, and offer them assistance on how to get on the path toward rehabilitation once they are ready to do so. As such, permitting the establishment of these safe injection sites is vital, particularly considering that in the U.S. more people die of drug overdose than from a car accident.[3] The U.S. is facing a continued epidemic that is not slowing down. Based on the CDC’s data there were over 70,000 deaths reported in 2017 due to drug overdose but the real number is likely closer to 72,000.[4] This number does not appear to have decreased in 2018.[5]

I. Use in other countries and results

Safe injection sites already exist in many countries in Europe as well as in Canada and Australia and the results have demonstrated the value of this practice.[6] Insite in Vancuver, Canada began as a pilot site and has been in operation since 2003. [7] The facility provides holistic addiction treatment services and when the safe injection program began, Canada required scientific evaluations to track the impact of this supervised injection site, such data is available and has been overwhelmingly positive.[8] For example, Insite has supervised more than 3.6 million injections, assisted people in more than 6,000 overdose situations, and has never had anyone die at the facility.[9] Safe injection sites are associated with lower overdose mortality (88 fewer overdose deaths per 100,000 people per year), 67% fewer ambulance calls, and a decrease in HIV infections.[10] This is because injecting in public carries immense risk resulting from the minimal sterile supplies readily available and used, a lack of hygiene practices during use, and a higher risk of overdose because the circumstances under which people are injecting and the criminalization of the act may lead people to rush in order to avoid detection.[11] Safe injection sites can thus help reduce transmission of HIV or hepatitis C by providing sterile supplies and clean needles, while reducing the number of overdose deaths by having medically trained staff on site[12] with breathing masks, overdose antidotes, and information on safe injection practices and about drug treatment programs.[13]

II. Legal challenges with establishing safe injection sites in the U.S.

Because the use of safe injection sites has had a profound impact in the communities where they are permitted,[14] there has been rising interest in establishing safe injection sites in the United States. The legal challenge in the U.S. lies in the Controlled Substance Act. This act makes it unlawful to “manage or control any place . . . and knowingly and intentionally . . . make available for use, with or without compensation, the place for the purpose of unlawfully manufacturing, storing, distributing, or using a controlled substance.”[15] The Department of Justice has warned that establishing safe injection sites would violate federal law[16] and the government has indicated that it will enforce this.[17] Because, by definition, safe injection sites would be made available for the use of controlled substances, they appear to fall within the text of the statute.

III. Attempts in the U.S.

Despite these threats, U.S. cities are trying to join Australia and Canada by establishing safe injection sites. With the highest rate of opioid deaths in the U.S. in 2017, Philadelphia has been one such city.[18] Safehouse, a nonprofit in Philadelphia that currently provides overdose prevention services, began taking steps toward operating a safe injection facility.[19] While Philadelphia Mayor Jim Kenney supports Safehouse and Philadelphia District Attorney Larry Krasner has stated he wouldn’t prosecute the safe injection facility, Pennsylvania Governor Tim Wolf and Attorney General Jim Shapiro object to the injection facility. U.S. Attorney William McSwain for the Eastern District of Pennsylvania filed a complaint on February 5, 2019 alleging that Safehouse’s safe injection practices would violate federal law.[20] This complaint is asking the federal court to declare that supervised consumption sites are illegal.[21]A decision has not been reached and Safehouse is still moving forward with its plan to obtain funding.[22]

California was also poised to pass a bill creating a pilot injection site in San Francisco,[23] but in September 2018 CA governor Jerry Brown declined to sign the bill. He stated that he does not believe “enabling illegal drug use in government-sponsored injection centers—with no corresponding requirement that the user undergo treatment—will reduce drug addiction.”[24] Specifically, contrary to all of the existing evidence on injection sites, he stated that “enabling illegal and destructive drug use will never work,” and that this method of combatting the opioid epidemic is all carrot and no stick—that instead there should be mandatory treatment programs.[25]

What these actions show is that regardless of the numerous studies indicating the benefits of instituting safe injection sites and the dearth of negative findings—such as that it would increase use[26]—the U.S. remains critical of the practice. This skepticism and opposition is likely as a result of the stigma relating to drug use in general.

IV. Action required

The U.S. should allow pilot safe injection sites to be opened and require mandated studies on them as Canada did. Only through this will data be obtained in the U.S. to support what has already been found to be true in numerous other countries: supervised and safe injection sites help communities, help reduce negative factors relating to drug use, and do not result in increased drug use. In addition to creating these pilot programs, the U.S. should also establish laws and protections so that people entering the sites aren’t penalized for using them.[27] It would be of little benefit to the community to have a safe injection facility if authorities were always right outside waiting to arrest those coming out of it. This practice would entirely counter the purpose of the safe injection sites relating to increasing safety by deterring people from seeking out these locations and incentivizing users to continue injecting in public, which as described above, increases risks associated with drug use. Legal protections for those visiting safe injection sites must be put into place in tandem with the pilot safe injection facilities.

While the legal challenge of establishing safe injection sites in the U.S. remains as a result of the federal law, it is likely the societal stigma that is truly playing the influential role in keeping them from opening. Despite the obvious benefits of clean needle exchanges, it took 20 years and a large HIV outbreak among opioid users for these programs to be supported in the U.S. and by the individual states.[28] It was the societal stigma that stalled needle exchanges and it is societal stigma stalling injection sites today.[29] In the U.S. “we have a tradition of being very slow to adopt socially progressive policies despite lots of evidence and thousands of preventable deaths occurring in the time between [the] proposal of these policies and their final adoption.”[30] The U.S. should fight this tradition by introducing pilot programs and running studies to find for itself the benefits of safe injection sites and begin working to improve its approach to countering the drug and opioid crisis.

  1. German Lopez, One Way Cities Can Reduce Overdose Deaths: Open Safe Spaced for Injecting Heroin, Vox (Jan. 24, 2018, 10:50 AM), 
  2. Liz Highleyman, Supervised Injection Sites Reduce Drug-Related Harm Facilities Prevent Overdose Deaths and Connect Drug Users With Addiction Treatment, Medpage Today (Oct. 23, 2018),
  3. In 2016 an estimated 40,000 people died from motor vehicle related deaths and 39,000 from gun related deaths whereas approximately 64,000 died from an overdose. Center on Addiction, The Buzz, 
  4. Provisional Drug Overdose Death Counts, Center for Disease Control and Prevention,
  5. Id. 
  6. Elana Gordon, What’s The Evidence That Supervised Drug Injection Sites Save Lives?, NPR

    (Sep. 7, 2018, 2:40 PM),

  7. Id. 
  8. Id. 
  9. Id. 
  10. Jennifer Ng et al., Does Evidence Support Supervised Injection Sites? National Library of Medicine National Institutes of Health, Nov 2017,
  11. Highleyman, supra note 2. 
  12. Lopez, supra note 1. 
  13. Gordon, supra note 5. 
  14. Highleyman, supra note 2 (discussing how over 40 peer reviewed studies have concluded that supervised injection sites “reduce the risk for infectious disease transmission, reduce overdose morbidity and mortality, and increase access to healthcare” particularly regarding infection and addition treatments). 
  15. Complaint for Declaratory Judgement in the Eastern District of PA, U.S. v. Safehouse, 
  16. Lopez, supra note 1. 
  17. Amanda Robert, Federal Prosecutor Moves to Block Nonprofit From Opening Nation’s First Safe Injection Facility, ABA J. (Feb. 8, 2019), 
  18. Id
  19. Id. 
  20. Id.see generally Complaint for Declaratory Judgement in the Eastern District of PA, U.S. v. Safehouse, 
  21. United States v. Safehouse, Safehouse, 
  22. Id. 
  23. This bill included text giving these sites immunity from violating state drug use and distribution laws to allow them to be established. Letter from California Governor to the Members of the CA State Assembly (Sept 30, 2018),
  24. Id. 
  25. Id. 
  26. Gordon, supra note 5. 
  27. Roe v. City of N.Y., 151 F. Supp. 2d 495 (S.D.N.Y. 2001) (describing plaintiffs’ motion seeking injunctive relief and alleging that the defendants, the City of New York and its police department, were unlawfully harassing, arresting, and prosecuting injection drug users who were registered participants in the state authorized needle exchange programs. The court agreed with the plaintiffs in their motion seeking declaratory and injunctive relief protecting the right of a class of registered participants in licensed needle exchange programs legally to possess injection equipment obtained from or to be returned to those programs.). 
  28. Highleyman, supra note 2. 
  29. Id. (describing how Jeffrey Duchin, MD, of the University of Washington and the Seattle and King County Public Health Department compared the resistance to implementing safe injection facilities today to the resistance in implementing syringe exchange programs that occurred in 1980-90). 
  30. Id. (quoting Jeffrey Duchin, MD).