Establishing Sanctioned Safe Consumption Sites in the United States: Five Jurisdictions Moving the Policy Agenda Forward

The United States is facing a sustained addiction and overdose epidemic that is historic in magnitude and pervasiveness. Drug overdose deaths in 2017 surpassed 70,000 (1). Reversals in life expectancy gains have been attributed in part to rising drug overdose mortality rates (2). Fentanyl, a synthetic opioid that is significantly stronger than heroin, has become increasingly prevalent, escalating the lethal risk of drug consumption (3, 4). In addition, growing incidence of hepatitis C virus (5) and recent regional HIV outbreaks have been traced to injection drug use (6). The federal government and a number of states have declared public health emergencies (7, 8).

Despite efforts to curtail the epidemic, the rates of addiction and overdose deaths continue to escalate. In this context, jurisdictions are searching for new approaches. One proposal involves safe consumption sites, also known as supervised injection facilities and overdose prevention sites, among other related terms. These are places where people can use preobtained drugs in a hygienic setting, with supervision by trained staff, and connect to other health and social services (9). Creating safe consumption sites is one of many harm reduction strategies, including syringe services programs, overdose education, and naloxone distribution. By facilitating access to respectful and relevant services, harm reduction programs enable people who use drugs to make positive changes. Proponents view safe consumption sites as one element of a multifaceted strategy to shift the drug policy paradigm away from criminalization and toward interventions emphasizing the health and well-being of people who use drugs. Over 100 sanctioned safe consumption sites exist in cities in Canada, Australia, Mexico, and Europe (9).

Insite, which opened in 2003 in Vancouver, Canada, was the first safe consumption site in North America. Evaluations of the facility suggest that safe consumption sites can produce important benefits for people who use drugs, including reducing fatal overdoses (10, 11), facilitating safer injection and less sharing of syringes (12, 13), and increasing connection to addiction treatment (14, 15). Research also indicates that the surrounding neighborhood experienced a decline in public drug use and syringe debris (16), with no increase in drug-related crime (17). Systematic reviews of research conducted in a wider range of geographic settings found that safe consumption sites were associated with positive outcomes (18, 19). Cost-benefit analyses focused on San Francisco and Baltimore point to the potential cost savings of this intervention through reduced spending on medical complications of unsafe drug consumption (20, 21).

To date, no sanctioned safe consumption site exists in the United States. An underground site has been operating in the United States since 2014 (9, 22), and some syringe services providers have pushed legal boundaries by operating quasi-safe consumption sites in their facility bathrooms (23). By the end of 2018, legislation to establish safe consumption sites had been introduced in at least six states (California, Colorado, Massachusetts, Maryland, New York, and Vermont). California’s state legislature was the first to pass a safe consumption site bill, although it was vetoed by the governor (24). On the local level, Philadelphia announced plans to facilitate the establishment of safe consumption sites and the Seattle city council allocated funding for safe consumption sites (25), but so far neither city has opened a site.

Few studies have explored the processes currently underway to facilitate adoption of policies that would permit the use of safe consumption sites (26–28). Furthermore, we are unaware of research that has examined the growing movement to establish these sites in the United States. Through interviews with key informants in five locations across the country, we describe the local context related to drug use that these sites aim to address, characterize the organizing strategies employed by advocates, and consider barriers to and facilitators of adoption of sanctioned safe consumption sites.

Methods

Data Collection Efforts

Of the eight states with active, ongoing efforts at the state or local level to change safe consumption site policy, we purposively recruited interviewees from five states in which advocates have secured support from key elected officials (e.g., public mayoral support) or have built significant momentum in advancing policy to establish sanctioned sites (e.g., advancing legislation out of committee). We identified an initial set of study participants through the networks of two study authors (A.H.K. and S.G.S.) with ties to the harm reduction community and used snowball sampling to recruit additional participants. To maintain confidentiality, we have not identified the location of the participants included in our sample.

Between April and July 2018, we conducted 25 telephone interviews with a purposive sample of four to six key informants from each location until we reached data saturation. We determined saturation had been achieved when new themes were no longer emerging during interviews conducted within the same jurisdiction. Participants included organizers and advocates, local government officials, and personnel with social service and health organizations, including organizations considering operating a safe consumption site. Interviews ranged from 45 minutes to 1 hour. The study team drew on the literature and team member expertise on this topic to develop a semistructured interview guide. One study team member took detailed notes during each interview. According to the Johns Hopkins Bloomberg School of Public Health Institutional Review Board, the study was not designated as human subjects research.

Analysis

Analysis of interview notes employed a hybrid inductive-deductive coding process. All study team members reviewed the interview notes, identifying important themes. Using this initial set of themes to develop codes, one author (A.K.-H.) systematically analyzed the data by using NVivo 12 Pro qualitative analysis software (29). Segments of the text were initially coded for the a priori themes identified during the group review of interview notes, and the text was then coded iteratively to capture new themes emerging during the coding process. Related coded text segments were then categorized into overarching themes.

Results

Defining the Problem

Interview participants reported that safe consumption sites were eliciting interest because of the following problems: overdose deaths, development-induced displacement and homelessness, and publicly visible drug use and syringe debris. Many participants identified all three problems as driving interest in sanctioned safe consumption sites. However, the salience of these issues varied by geographic region. Participants suggested that rising overdose death rates were playing a greater role in driving policy discussions in areas where overdose mortality rates are rising rapidly. However, even in areas of the country where death rates have increased more slowly, there was a sense that the broader national narrative about the overdose epidemic had contributed to a greater willingness to consider a policy in support of safe consumption sites.

In several locations, participants noted that interest in safe consumption sites appeared to be driven more by concern about public drug use and syringe debris than about the well-being of people who use drugs. Participants viewed the issues of development and displacement, homelessness, visible drug use, and syringe debris as interrelated. In cities experiencing rapid gentrification, people who previously used drugs in more hidden settings (e.g., abandoned buildings) were now using drugs in the street or in public bathrooms. In some cities, people congregated in tents or other visible encampments. Most participants characterized safe consumption sites as a critical but incomplete policy response to the issues affecting people who use drugs and the neighborhoods in which they live.

Becoming Part of the Policy Agenda

Four of five locations had established government-sponsored committees that formally recommended adoption of safe consumption sites. Three jurisdictions organized these committees around a broader topic (e.g., the opioid crisis) and included sanctioned safe consumption sites as one of several recommendations. The reports generated by these committees attracted media attention, raised the profile of safe consumption sites among the general public, catalyzed organizing efforts, and provided political cover for supportive elected officials.

Participants in two locations described efforts as exclusively focused on changing policy at the local level (see online supplement). They reported that state politics drove this decision but also felt that state-level policy action was not necessary to establish a safe consumption site. Among the three jurisdictions that had introduced state legislation to establish safe consumption sites, all were pursuing other mechanisms for achieving legal sanction as well, including authorization of a research pilot, city ordinance, or health department action.

Organizing and Coalition Building

Efforts to organize around safe consumption sites were heterogeneous in terms of the groups leading the movement, the extent to which the advocates constituted an organized coalition, the level of involvement from people who use drugs, and the tactics employed by advocates to engage relevant groups and garner political support (Box 1). Participants in all jurisdictions emphasized the importance of engaging those with diverse perspectives on safe consumption sites and diverse motivations for supporting them. Engaging diverse voices enabled organizers to build a broader coalition and more successfully lobby policy makers. Participants emphasized the importance of supporting potential allies on other issues, or “showing up,” as they built a coalition, illuminating both the transactional nature of organizing and the extent to which allies often share a wider set of political goals. Although participants in all jurisdictions emphasized the importance of including and elevating people who use drugs in advocacy efforts, there was variation in the extent to which this goal had been achieved. People who use drugs were more involved in places that had established drug user unions, whereas in other jurisdictions, organizing around safe consumption sites drove efforts to mobilize this population. Political strategy involved initially targeting policy makers who were anticipated to be receptive to the issue, educating policy makers and connecting them to information, pressuring key policy makers who resisted publicly supporting safe consumption sites, engaging in acts of civil disobedience, and positioning safe consumption sites as a campaign issue on which candidates were forced to comment.

Community Engagement

A key element of organizing was community engagement (Box 2). Some jurisdictions viewed community engagement as part of a long-term process of building relationships and engaging the community around drug policy more broadly. Most participants viewed early engagement of the community as critical to building public understanding of the concept of safe consumption sites and quelling potential opposition. In one jurisdiction, community engagement mostly occurred after the local government announced support for safe consumption sites and community opposition had emerged as a roadblock. The majority of jurisdictions engaged with the community through public meetings, often involving local government representatives and members of the task force. Many participants felt that smaller meetings enabled more productive discussions about how to address community concerns and led to less fraught public meetings.

One key theme was the importance of taking community concerns seriously. In describing their approach to engaging the community, participants evoked the harm reduction philosophy of meeting people where they are and not reflexively attributing concerns raised about safe consumption sites to intractable stigma or NIMBY-like attitudes. Advocates also emphasized the importance of finding trusted members of the community to champion the cause and to ensure transparency in the process of building support for safe consumption sites.

Challenges

One of the challenges mentioned most commonly involved finding the right location (Box 3). This theme encompassed neighborhood resistance and identifying the right physical space. The issue of physical space overlapped with uncertainty about the enforcement of 21 USC Section 856, the so-called Crack House Statute, which prohibits operation of spaces for the use of illegal substances (30, 31). Participants anticipated reluctance by property owners to rent space for use as a safe consumption site, limiting options. Also related to the Crack House Statute were concerns that the federal government might seize assets from established providers or withhold funding from local jurisdictions if they opened a safe consumption site.

Several participants identified challenges in building trust among communities of color that have been disproportionately affected by the “War on Drugs” and its punitive drug policies. These participants felt strongly that efforts to advocate for safe consumption sites should either be preceded by or clearly framed as part of a broader effort to confront the racially unjust impact of punitive drug policy. Without this framing, safe consumption sites appeared to some community members as privileged treatment of white communities, which have experienced high rates of opioid addiction and overdose (32). Other challenges included financing; bureaucratic delays; reluctance by incumbents to endorse safe consumption sites in an election year; and other legal issues, such as protecting the professional licensure of providers who might work at these facilities.

Facilitators

At least three locations had considered safe consumption sites before the acceleration of the drug epidemic, and participants felt that these conversations were a helpful foundation for current efforts. Participants identified a variety of existing policies, programs, or partnerships as having laid the groundwork for adoption of safe consumption sites (Box 4). These included decades-long efforts to implement syringe services programs (33), the provider type most frequently identified by participants as a potential operator of safe consumption sites; overdose education and naloxone distribution programs (34); other interventions targeting people who use drugs and people experiencing homelessness (e.g., Housing First initiatives) (35); activism around HIV/AIDS; organizing to end punitive drug policy; and broad diffusion of a harm reduction orientation throughout a jurisdiction or service system.

Other key facilitators included having political champions who actively engage in advocacy around safe consumption sites, public support, and favorable media coverage. Another facilitator, exposure to Insite, either through visits to Vancouver or meetings with key Vancouver officials, often was effective in persuading key public officials and community groups. However, several participants also noted that some visitors were confused about the causal relationship between neighborhood conditions and Insite, not realizing that conditions in the surrounding high-poverty neighborhood predated Insite. Several participants mentioned that the anticipated opening of a sanctioned site in the United States would catalyze their own efforts. Finally, research was identified as a facilitator, including research on the unsanctioned U.S. site (9) and the cost-effectiveness of these sites in U.S. cities (20, 21). Participants also cautioned that research was not sufficient to move policy adoption, and some also noted that community distrust of research diluted its power as a persuasive tool.

Discussion

In this study, we considered the strategies being employed to advance the policy agenda on safe consumption sites in the United States. Political scientist John W. Kingdon (36) theorized that policy entrepreneurs can take advantage of windows of opportunity to enact meaningful policy change. These windows occur when a problem appears on the political agenda, a policy exists to address this problem, and the political climate is favorable. Drug use and addiction are present on the political agenda in the five locations we studied, and in many cases, sanctioning safe consumption sites is increasingly viewed as a valuable component of a multifaceted policy response. The local political climate in the locations considering safe consumption sites may be conducive to change, given that policy makers—including mayors, city council members, health agencies, and state legislators—have endorsed the establishment of these sites.

Nevertheless, jurisdictions face both logistical (e.g., locating a site) and political (e.g., opposition from key political officials) obstacles to establishing these sites. Some jurisdictions lack the support necessary from key policy makers to move forward, but community advocates are hopeful that the results of upcoming elections will alter the political climate. In the meantime, participants reported working to establish policies and procedures for safe consumption sites, identifying partners for service provision, and exploring potential funding opportunities so that when official sanction of safe consumption sites occurs, they can act quickly. Some participants also have engaged in civil disobedience by establishing quasi-safe consumption sites to force the hands of political officials while also addressing the current needs of people who use drugs. Advocates in other countries, such as Australia, Denmark, and Canada, also practiced civil disobedience prior to safe consumption policy change (27, 37).

A major uncertainty looming over efforts in all jurisdictions is the potential federal response to implementation. Following the completion of these interviews, the Deputy Attorney General of the United States published an opinion piece strongly opposing safe consumption sites (38). It is unclear how this public statement may affect efforts moving forward. Participants reported being well aware of the legal obstacles to implementation and had undertaken legal analyses to prepare and mitigate liabilities (30). Although not all localities had champions at the state level, state intervention appeared to be of lesser concern than the potential federal response.

An important theme emerging from these interviews was the essential role of people who use drugs in organizing around safe consumption sites. Schneider and Ingram’s (39) work suggests that the social construction of target populations is an important determinant of the policy agenda and design. According to this theoretical framework, strategies must be put in place to counteract the lack of political power among people who use drugs. Otherwise, policy makers enact punitive policies targeting this group as a default position. Organizing this community is one approach advocates have pursued to strengthen the political influence of people who use drugs on the policies that affect them.

This study had several limitations. Our sample lacked representation from people who currently use drugs, although three participants described themselves as in recovery. Attitudes toward safe consumption sites among people who use drugs have been explored in prior research (40). To our knowledge, there has been little research on the role of this group in driving policy change in the United States (41–43); this topic should be explored further. Another limitation of the study was its generalizability. Although we focused on five localities that have made measurable progress in advancing policy, there may be other places that have made similar progress. Another limitation was that most study participants represented urban, politically progressive settings. Their experiences may be less generalizable to rural settings, where the availability of services on which to build safe consumption sites—such as addiction treatment and syringe services programs—is more limited (33, 44) and where the political environment differs.

Conclusions

Although the people and organizations driving progress on safe consumption site policy vary across the country, interviews illuminated many common themes. The success of organizers in positioning the sanctioning of safe consumption sites as a politically viable policy option has involved responding to questions and concerns with openness; engaging a diverse set of allies; organizing people who use drugs and involving them in advocacy efforts; urging politicians to support safe consumption sites with behind-the-scenes and public pressure; and addressing mistrust in the community, particularly concerns about racial injustice in drug policy. As localities independently engage in efforts to move safe consumption site policy forward, they are closely watching one another’s progress, which has important implications for their own likelihood of success. As one participant noted, the “X factor . . . will be if another city actually implements [a site].”