THIS ISSUE BRIEF is part of a series examining a variety of controversial local and national issues, focusing on specific policy proposals that are under active consideration. The premise of these essays, as outlined here and here, is that many important public policy issues are more complicated than the most fervent adherents to either side usually acknowledge, a dynamic that often hinders our ability to engage in thoughtful debate.  (Earlier essays in the series have addressed proposals for free community college, free MBTA service, the state’s right-to-shelter law, and allowing municipalities to enact rent control.)

For each proposal in the series, I will provide some basic background, with a high-level framing of the disagreement and the polarized “bumper sticker” arguments on both sides. I’ll then present what I believe to be the most reasonable evidence-based cases, pro and con. Each issue brief will conclude with reflections on possible avenues for finding common ground or higher ground and some basic data points, with links to useful resources, to help facilitate a rational and civil dialogue, ideally leading to agreement or at least understanding, if not in the halls of power, then maybe just around the dinner table. 

The Proposal: 

Authorize the operation of “supervised injection sites” (SIS) to provide users of illicit intravenous drugs an indoor place to inject themselves under supervision of trained personnel, with access to sterile supplies, such as clean needles.

Background:

A bill is pending in the Massachusetts Legislature (S.1242) to authorize a 10-year pilot program that would direct the state Department of Public Health to license public or private health and social service organizations to establish “overdose prevention centers” that “provide a hygienic space where participants may consume pre-obtained controlled substances.” In addition to preventing or responding to overdoses, staff would also provide information about health risks associated with drug use and facilitate access to addiction services. 

People possessing drugs inside a licensed center and staff employed by the center would be exempt from prosecution under the Commonwealth’s drug laws. Although the US Department of Justice has previously taken the position that supervised injection sites are illegal under federal law (21 U.S.C. Section 856), the Biden administration has not taken action to prohibit them and is not expected to do so.

The model outlined in the Massachusetts bill is based on a program authorized by New York City and operated by OnPoint NYC, which opened in 2021.  Minnesota and Rhode Island are the only states to enact legislation authorizing safe injection sites, with a location scheduled to open in Providence this year.  Approximately 150 safe injection sites exist in 16 countries, including close to 40 sites in Canada. Sites are typically located in neighborhoods where there is already a high degree of public drug consumption.

Sticking Points and Bumper Stickers:

Advocates on this issue tend to disagree about whether reducing illicit drug use is primarily about public health or public safety.

Drug Use is a Disorder, not a Crime!: Advocates of supervised injection sites argue that drug users are suffering from a medical or biochemical condition, which is largely out of their control. As a result, SIS supporters do not believe users should be subject to arrest or prosecution, but instead should be provided health and addiction services with few conditions to save their lives and treat their disease.

Just Say No!: Opponents of supervised injection sites believe that drug users are a danger to themselves and others, while often degrading public spaces and neighborhoods where they congregate to buy, sell, and use. Instead of prioritizing law enforcement to protect the public and limit access to illicit drugs, SIS opponents argue that its supporters are enabling and normalizing drug use, encouraging more young people to experiment with drugs while laying the political groundwork for outright legalization.

Evidence-based Case in Favor:

Opioid use disorder is a global crisis that shows no sign of abating. The National Institutes of Health estimate that approximately 3 million people in the United States have experienced or currently suffer from opioid use disorder and more than 500,000 are dependent on heroin. A large percentage of these users became addicted to opioids as the result of legal prescriptions, typically to relieve pain.

There is no cure for opioid use disorder, but there are medical treatments and other addiction services that can reduce cravings and mitigate dependency. As with other addictions, such as alcoholism, however, staying sober requires ongoing effort and support, and is often fraught with false starts and setbacks.

Because opioids are so addictive and lethal, while treatments are only partially effective, the first priority has to be the reduction of harm to users, while giving them time and support to get help in bringing their addiction under control.

Supervised injection sites have existed for several decades, mostly in Europe, and multiple studies have shown they can be effective in preventing overdoses and deaths among their clients, even reducing overdoses and deaths in the neighborhoods where the centers are located. Besides their positive impact on overdoses, the sites can also help reduce the spread of disease, including HIV, by ensuring their clients are injecting in a clean environment with sterile paraphernalia. By providing a safe space, SIS also enables drug users to avoid dangerous locations where they might be abused, assaulted, or even killed.

There are no easy answers or quick fixes to drug addiction or the opioid crisis.  As difficult as it is, helping drug users gain access to services is the only way forward, but studies repeatedly fail to show that successful treatment can be compelled. “Low threshold” supervised injection sites are an essential component of a broader strategy to inform drug users about the availability and efficacy of services, while developing trusting, non-judgmental relationships that can encourage voluntary steps towards recovery.

Evidence-based Case Opposed:

Supervised injection sites are undoubtedly safe places that prevent overdoses and deaths on their premises, but for many, if not most, drug users who avail themselves of SIS, these centers are just one place among several where they inject illegal substances. As a result, SIS do not fully protect their clients from unhealthy or unsafe situations. 

More important, there is little evidence to date that SIS have any meaningful positive impact, either directly or indirectly, on the larger opioid crisis. In Canada, which has the most supervised injection sites in the world, opioid usage remains at crisis levels, with trends that mirror those in the United States. In Vancouver, which is home to a dozen SIS, the first of which opened in 2003, drug deaths have increased by a factor of seven since 2013.

Studies suggest that drug users who patronize supervised injection sites are somewhat more likely to seek out addiction treatments and other health or social services, but it’s unclear how long clients persist or whether they become drug-free over time. 

Given the limitations in the scope and quality of these studies, it’s also not clear whether people who have enough concern for their health or safety to access the centers in the first place are inherently more predisposed to eventually seek help on their own. And there is little, if any, research on whether SIS have a larger impact on the health of illicit drug users compared to other intervention strategies, such as needle exchange programs or the more widespread distribution of Narcan (naloxone), the anti-overdose treatment.

Since SIS clients have to bring their own drugs to the sites, they are by definition continuing to violate state and federal laws prohibiting drug sales and possession. As a result, the presence of supervised injection sites requires local officials and police to turn the other way with regard to the sites themselves and their immediate environs, which can lead to a more lax approach to drug laws, generally. For example, last year British Columbia, where the Vancouver sites are located, decriminalized possession of small amounts of opioids, cocaine, methamphetamine, and ecstasy. 

No matter how well intentioned, supervised injection sites are an unproven strategy to address drug addiction and the ongoing opioid crisis, with potential unintended consequences that could outweigh any benefits.

Potential for Common Ground or Higher Ground:

The one thing that is clear about the global opioid crisis is that no one has yet devised a viable and scalable strategy for significantly reducing drug usage, addiction, overdoses, and deaths, whether through law enforcement or public health. In the face of such widespread suffering, it’s not surprising that policy makers are looking for creative approaches, even if they are untested or incremental. 

Given this discouraging situation, a reasonable approach in the near term might be to carefully design and pilot potential solutions, including SIS, that can be rigorously evaluated to determine if they are worth expanding and replicating. 

Running multiple controlled experiments with consistent oversight and research methods requires coordination, as opposed to an ad hoc or decentralized approach that relies on private organizations or state and local governments. So, this might be a job for a collaborative initiative involving federal health and law enforcement agencies. (The National Institutes of Health recently awarded a contract to study the two existing sites in New York, as well as the new site that is planned for Providence.) 

In the meantime, efforts to increase affordable access to drug rehabilitation programs and “medication assisted treatments” could be pursued, consistent with new federal regulations, in tandem with expanded mental health services and other basic needs supports, such as health care, housing, and job placement.

Jim Peyser served most recently as Massachusetts secretary of education under Gov. Charlie Baker.

Data:

U.S. Drug Overdose Deaths: 109,360 (2022), up 55% percent over 2017

MA Drug Overdose Deaths: 2,331 (2022), up 16% over 2017 and up 144% over 2013

Percent of U.S. Drug Overdose Deaths Related to Opioids: ~75% (2021)

U.S. Arrests for Drug Abuse Violations (manufacture, sale, and possession): 766,595 (2022), down 78% from 2017

Percent of U.S. Arrests for Drug Manufacture or Sale: 12% (2022)

MA Arrests for Drug Abuse Violations (manufacture, sale, and possession): 4,432 (2022), down 55% from 2017

Percent of MA Arrests for Drug Manufacture or Sale: 37% (2022)

Sources & Resources:

The Centers for Disease Control and Prevention, The Drug Overdose Epidemic: Behind the Numbers (https://www.cdc.gov/opioids/data/index.html)

Massachusetts Dashboard on Opioid Statistics and Overdose (https://www.mass.gov/lists/current-overdose-data)

FBI Crime Data Explorer (https://cde.ucr.cjis.gov/LATEST/webapp/#/pages/explorer/crime/arrest)