The novel coronavirus in 2020, as a once-in-a-century pandemic, has upended many things—and the push for a safe consumption site (SCS) for drug users in the U.S. is one of them, advocates say. The problem is, the overlapping crisis of COVID-19 is making these efforts more difficult, while the need for these facilities, with staff to prevent overdose deaths and HIV transmission, is even more urgent.
Safe consumption sites, also known as supervised injection sites, offer a protected space and clean supplies for people to inject drugs under the watch of trained staff. They are legal in Canada, Australia, the Netherlands, and Germany, and they are a proven method for preventing overdoses. That’s important in the U.S., which saw 72,000 drug-related deaths last year alone. They are also helpful in connecting people with health care and addiction counseling. But in the U.S., hampered partly by federal policy, local efforts to get these sites up and running have run a gauntlet of opposition.
In 2019, the U.S. Justice Department filed a complaint to stop Philadelphia-based nonprofit Safehouse from opening an SCS, saying that such a site violated the federal Controlled Substances Act, which bans the operation of a facility for the purpose of using illegal drugs.
In February 2020, Safehouse was given the legal go-ahead when U.S. District Judge Austin McHugh issued a final ruling declaring the facility would not violate federal drug laws. It underscored an October decision marking the first time a federal court weighed in on the legality of an SCS.
Soon after McHugh’s February ruling, the U.S. attorney filed a motion for a stay as well as an appeal with the 3rd Circuit Court of Appeals. In June, McHugh ruled that the stay must continue because, “The ongoing challenges posed by COVID-19 and the deep social currents and introspection following the tragic killing of Mr. Floyd make this the wrong moment for another change in the status quo.”
A hearing on the appeal is pending, and oral arguments may happen this fall. Ronda Goldfein, executive director of AIDS Law Project of Pennsylvania and a co-founder of Safehouse, told TheBody that if they prevail with the appeal, safe consumption sites will be legal in all of the third U.S. circuit, which includes all of Pennsylvania, New Jersey, Delaware, and the U.S. Virgin Islands.
“In ruling on the stay, [McHugh] expanded his February ruling and concluded that the safe consumption site is in the public interest, which is the same conclusion we reached. He said basically that the facility was a good idea, but the timing is wrong for opening it.”
Goldfein said that there was also broad public support for opening the site, with a smaller but “much louder” opposition.
There has not been overwhelming community opposition, so far, to a California bill that would allow San Francisco to launch a six-year pilot program for a safe consumption site. Nevertheless, the bill, AB 362, failed to move forward in the Senate this year after being passed in the Assembly, and it was put on hold until the next legislative session in order to gain more support. Gov. Gavin Newsom has expressed support for it, which is a step forward; in 2018, a similar bill passed both houses before it was killed by then-Gov. Jerry Brown. Brown opposed the bill because, he said, safe consumption sites were illegal under federal law and “highly controversial.”
A More Dangerous Time
Still, there are hurdles to establishing an SCS in the U.S., and two overlapping health crises, COVID-19 and overdose deaths, create a paradox: A key strategy to prevent COVID infections—social isolation—is harmful for preventing overdoses.
“If you overdose and it’s witnessed, you can survive, but the chance of death increases when you’re alone,” said Kristen Marshall, DOPE Project manager at the San Francisco office of Harm Reduction Coalition.
The San Francisco Department of Health did not respond to TheBody’s request for preliminary data on overdose deaths in 2020, but Marshall said that overdose reversal numbers, reported by community organizations that receive Narcan through the DOPE Project, are “through the roof.”
“In 2019 there were 2,610 reversals, meaning people saved from overdose deaths. For 2020 from January to June, we’ve tallied 1,500.”
Marshall said the rise in overdoses and related deaths has been because “every root cause of overdosing has been amplified.”
“There is trauma, there is a strong and inconsistent drug supply, isolation, despair, and poverty.” It’s not just SCS that are impacted. While most such sites are largely, though not exclusively, meant to protect users from opioid overdoses, a long-promised meth sobering center San Francisco due to open last February has been shelved for now, a victim of the COVID-19 crisis. “With COVID, it’s a bad idea to have a lot of people in the same place,” Marshall said.
Laura Thomas, director of harm reduction policy at San Francisco AIDS Foundation (SFAF), told TheBody in an email that the city had seen an overdose crisis before COVID-19 hit. “During shelter in place, more people in San Francisco have died of overdose than COVID-19,” she wrote, adding SFAF is a key part of the work to bring harm-reduction services and supplies into the shelter-in-place hotels. “But we’re not doing enough, and it’s part of the frustration that AB 362 isn’t moving forward—we need these overdose prevention services now more than ever.”
Thompson added that there is “very strong community buy-in and support” in San Francisco for a safe consumption site and that SFAF is planning to provide these services as soon as they are legally able to do so.
The COVID-19 pandemic has disrupted global supply chains for both legal and illegal drugs, which has led to stronger or more dangerous drugs and caused users to “co-use” when supplies are scarce—a toxic combination that can lead to a higher rate of overdoses and needle-spread diseases like hepatitis C and HIV.
A comprehensive report on the role of overdose prevention sites in the U.S. notes that authorities around the country have been reporting “a surge in overdose deaths as part of the pandemic fallout, with fatality rates rising by 100% in some counties.” The report, authored by Sterling Johnson, board member of Angels in Motion and the Black and Brown Workers Cooperative, and Leo Beletsky, professor of law at Northeastern University School of Law, emphasizes that disruption of treatment and harm reduction services is “undermining any progress being made in overdose prevention.
“At the same time,” Johnson and Beletsky write, “people who use opioids and other drugs are especially vulnerable to coronavirus infections and severe disease because of health and structural stressors.” The authors urge a response to these overlapping health crises based on “science-driven prevention measures,” measures their own polling found to have 60% support from U.S. voters, and 53% support among Republicans.
Although Judge McHugh’s rulings said that such sites do not violate federal drug laws, even if, technically, the individual use and carrying of such drugs do violate the law, there is still concern about being raided whenever the first SCS is opened, Marshall said.
“We could open [an SCS] now, but I am not going to prison for it,” Marshall said. “San Francisco has a big target on it.”
Evidence, American Style
Several other U.S. cities have been considering opening SCS, or safe-injection sites, in the wake of a well-publicized opioid crisis. And there is a growing body of evidence that these sites do save lives and increase access to health services.
But policymakers want studies that have been done in the U.S., not Europe, before they will consider opening them, and that creates a catch-22, according to Barrot Lambdin, Ph.D., M.P.H., a senior implementation scientist at the nonprofit research institute RTI.
“We’re trying to build the evidence [for safe-injection sites] where we can, but we keep hearing, ‘Well, this evidence isn’t from here,’” Lambdin told TheBody.
Lambdin did start a U.S. body of evidence, though from an underground SCS, and co-authored his findings in a recent letter to the editor in the New England Journal of Medicine. Using five years of data and insights from an unsanctioned SCS somewhere in the U.S.—due to the legal issues around federal drug prohibition, Lambdin wouldn’t even disclose off the record where it was—the authors tallied 10,514 injections and 33 opioid-involved overdoses over five years, all of which were reversed by naloxone administered by trained staff. “No person who overdosed was transferred to an outside medical institution, and there were no deaths,” Lambdin and his co-authors write. They conclude that “sanctioning sites could allow persons to link to other medical and social services, including treatment for substance use, and facilitate rigorous evaluation of their implementation and effect on reducing problems such as public injection of drugs and improperly discarded syringes.”
Whether this evidence will be enough to sway policymakers across the nation, or especially at the federal level, remains to be seen. For now, the COVID-19 crisis has put efforts to establish a safe consumption site anywhere in the U.S. in a holding pattern.