Overdose Prevention in the United States: A Call for Supervised Injection Sites

Cities across the United States are contending with escalating fatal overdose epidemics associated with prescription opioid misuse. Between 1999 and 2014, deaths involving prescription opioids quadrupled in the United States, increasing from an age-adjusted death rate of 1.4 to 5.9 per 100 000.¹ As pressure mounts to address this urgent public health crisis, some policymakers are considering establishing supervised injection sites (SISs), where individuals can inject preobtained drugs under the supervision of trained staff.² Along with measures such as medication-assisted treatment and naloxone distribution, SISs are among the few interventions that have been shown to be effective in reducing fatal overdoses.

However, to date, not a single SIS has been established in the United States. Given the ongoing fatal overdose epidemic and international evidence demonstrating the numerous health and social benefits of these facilities, there is now a pressing need to reconsider the potential role of SISs in this country.

In 2003, North America’s first government-sanctioned SIS, Insite, opened in Vancouver, Canada, in response to dual epidemics of HIV infection and overdose. The facility acquired exemption from federal drug laws under the condition that it be subject to an arm’s-length scientific evaluation. To date, this evaluation has resulted in more than 40 peer-reviewed studies demonstrating Insite’s various benefits, including a 35% decrease in overdose deaths in the surrounding neighborhood, reductions in syringe sharing, and increased uptake of addiction treatment.² Studies have also documented benefits to the broader community, including declines in public injection and publicly discarded syringes.² In contrast to fears expressed before the facility opened, Insite’s establishment did not contribute to increases in community drug use, drug-related crime, or initiation of injection drug use.² Furthermore, three separate studies have shown the facility to be cost-effective.²

Despite the large body of evidence demonstrating Insite’s health and community benefits, the facility faced considerable opposition from the former Conservative government of Canada during its tenure in office from 2006 to 2015. The federal government’s refusal to extend Insite’s exemption to operate culminated in a legal showdown in the Supreme Court of Canada. Many of the country’s leading health organizations, including the Canadian Medical Association and the Canadian Nurses Association, intervened in the case to support Insite. In a landmark decision in 2011, the Supreme Court unanimously ruled to uphold the facility’s exemption to operate, stating “Insite has been proven to save lives with no discernable negative impact on the public safety and health objectives of Canada.”³

In contrast with its Conservative predecessors, the new Liberal government of Canada has provided clear signals of support for SISs. Indeed, within three months of election, the federal government approved a second SIS in Vancouver in January 2016.⁴ One week later, the Federal Minister of Health toured Insite and commended the facility for saving “countless lives.”⁴ The government has also invited applications to establish additional SISs, and a number of municipalities across Canada, including Toronto, Ottawa, and Montreal, are currently undertaking the planning and feasibility work necessary to do so. These plans are not surprising given the success of similar efforts in Europe, where SISs have increasingly been implemented in recent decades and account for the majority of the more than 90 such facilities now operating worldwide.²

Unfortunately, progress in translating evidence supporting SISs into the realms of policy and practice has been extremely slow in the United States, where federal approval of these facilities seems unlikely in the foreseeable future. Nonetheless, momentum for the establishment of SISs appears to be building at both the municipal and state levels. Health care advocates and elected officials in several cities, including Seattle, Washington; San Francisco, California; New York City; and Ithaca, New York, are advocating for these facilities as part of local strategies to address overdose and other drug-related harms. Meanwhile, state officials in Maryland, California, and New York have proposed legislation that would permit legal operation of SISs under these states’ respective laws.

Although this progress is encouraging, such efforts to establish SISs will likely face significant legal and political barriers. Gaining approval of legislation to exempt these facilities from state drug laws will be challenging, as these proposals have already attracted opposition from law enforcement and state officials. For example, Republican state senators recently denounced proposed legislation to authorize SISs in New York State, and similar legislation was withdrawn in Maryland after receiving an unfavorable report by the state’s Health and Government Operations Committee. Political resistance to SISs may be even stronger in the country’s rural areas, where access to drug-related services remains particularly limited despite rapidly increasing overdose mortality rates.⁵ Of further concern is that if state or municipal laws authorizing SISs are eventually approved, operators, staff, and users of these facilities could still risk criminal prosecution under federal drug laws.

Notwithstanding these obstacles, there is hope for the successful establishment of SISs in the United States. If municipal or state governments were to authorize SISs in the absence of federal approval, there is reason to believe that federal law enforcement agencies might not intervene. This has thus far been the case with the federal approach to cannabis regulation. Although cannabis use remains illegal under federal law, numerous states have passed legislation to legalize medicinal and recreational cannabis use with minimal federal interference to date.

Growing federal support for public health responses to the opioid crisis provides further reason to believe that federal authorities may not interfere with the implementation or operation of SISs. Specifically, the federal government has begun to acknowledge the limitations of punitive approaches to drug use and recently announced a federal drug strategy that includes funding dedicated to prescriber education, prescription drug monitoring, and addiction treatment and harm reduction initiatives, including expanded access to needle exchange programs, medication-assisted treatment, and naloxone.⁶

Providing impetus for these shifts in the federal drug strategy is growing concern about drug enforcement among the general public. Such concern has partially been rooted in heightened public awareness of police brutality and mass incarceration of Black Americans for low-level drug offenses. Moreover, with rising opioid-related fatality rates among White Americans, there have been more pronounced public calls for treatment and prevention efforts in place of the enforcement approaches that have historically dominated responses to drug epidemics concentrated among racial/ethnic minorities.⁷

In light of these recent shifts in public opinion and the federal approach to drug use, there may be no better time than the present to advocate for SISs as part of a comprehensive response to the nationwide overdose epidemic. Although federal support of SISs would be ideal, local and state efforts to implement this form of health intervention may ultimately serve to catalyze change in broader political and legal contexts, as was the case with Insite in Canada. Thus, such efforts should be an urgent priority of municipal and state officials.

Given the outstanding harms associated with opioid misuse, in particular the escalating fatal overdose epidemics occurring throughout the United States, we can no longer afford to ignore evidence and uphold barriers to lifesaving health services. Instead, policymakers and elected officials should heed the scientific evidence, learn from decades of international experience, and do all they can to facilitate the establishment of SISs as part of an evidence-based response to drug-related harms in the United States.