By Therese Fitzgerald, PhD, MSW
MMS Director of Health Care
Research, Analytics, and Insights
InSite, North America’s first legalized supervised injection site, in Vancouver. Photo courtesy of InSite
Supervised injection facilities for people who use drugs may shortly be coming to the US, potentially establishing a new frontier in the fight against opioid overdose deaths.
In April 2017, when the MMS passed policy to advocate for a “pilot supervised injection facility (SIF) program in Massachusetts,” it became the first medical society in the US to endorse such sites. The American Medical Association (AMA) followed suit, voting in June 2017 to support the development of pilot SIF programs.
Organized medicine’s endorsement of SIFs has changed the debate on Beacon Hill. In the months since the MMS SIF policy passed, Massachusetts legislators have debated a
bill that would allow for SIF programs — also known as “safer drug consumption programs” — to operate in Massachusetts and proposed a budget amendment to study the feasibility of SIFs. Secretary Marylou Sudders, the Baker administration’s chief of health and human services (HHS), said on WGBH in January 2018 that she is “open to understanding more” about supervised injection sites, while anticipating that “federal law would pose a challenge to launching any in Massachusetts.”
Other States Pushing Ahead
Other states have introduced legislation that would affirmatively authorize SIF programs. Advocates and attorneys working toward legalizing SIFs believe they have a strong case, given the authority of states and localities to remove criminal penalties if an action is in the interest of the public’s health.
California is demonstrating how quickly this issue can gain political momentum, according to the Drug Policy Alliance, an advocacy coalition based in New York. “In 2016, we couldn’t get the California SIF bill out of a single committee at the state legislature or get the votes needed to move it forward. Last year we got the bill to move quickly out of committee on both the House and Senate side with robust, bipartisan support,” says Lindsay Lasalle, a senior staff attorney with the Alliance, who has been working with states to draft bills authorizing SIFs. “We’re now only two votes shy of getting this bill to the governor’s desk. Going into 2018, the bill picks up where it left off and will likely move forward.” Other state legislatures actively considering SIFs include New York, Maryland, Vermont, Maine, and Washington.
Cities and Towns Lead the Way
But it’s the local cities and towns that will likely catalyze the legality of SIFs in the US. In Philadelphia, Baltimore, New York City, Ithaca, Seattle, and San Francisco, efforts to legalize SIFs have intensified. “Several cities look set to make this happen in the near future,” says Alex Kral, PhD, principal scientist at RTI International, a nonprofit research and development institute.
In February, the San Francisco Department of Public Health unanimously endorsed a task force's recommendation to open a SIF. The project has strong mayoral support and six potential sites, including a religious organization, says Dr. Kral. In January, Philadelphia city officials appealed to private and nonprofit entities to help develop and fund such sites. New York City could see SIFs opening at three potential sites, given the support of the city’s mayor and city council, as well as growing support from the state’s governor. In Seattle, funding has been set aside for SIFs, with strong support from the mayor.
Meanwhile, an underground SIF is currently operating at an undisclosed location in the US. Dr. Kral secured a three-year grant to study its outcomes. During its first two years of operation, the facility provided a safe space for 2,500 injections, according to the
American Journal of Preventive Medicine (2017). The two on-site overdoses in that (pre-fentanyl) period were successfully treated, and the program averted over 2,300 instances of public injection and 1,725 instances of unsafe syringe disposal.
Efforts to legalize SIFs are not without opposition. In Boston, several city councilors strongly oppose opening a SIF. Washington state saw an unsuccessful attempt to introduce a ballot initiative to outlaw SIFs. In February, a legislative committee in Colorado rejected a bipartisan bill to open a facility in Denver.
Federal Hurdles Remain
As Massachusetts HHS Secretary Sudders noted, federal law may become a deal breaker. For example, the federal government could choose to enforce the federal “crack house law,” which makes it illegal for anyone to “knowingly open or maintain [or] manage or control any place for the purpose of unlawfully using a controlled substance.” Since SIFs share the same intent as the crack house law — improving public safety — they arguably do not violate it. That said, the Department of Justice has thus far emphasized the strict enforcement of drug laws over state discretion; US Attorney General Jeff Sessions and US attorneys recently vowed to crack down on states’ legalization of marijuana. In this context, SIF supporters need to prepare for federal pushback.
