Establishment and Enforcement of Operational Rules at an Unsanctioned Safe Drug Consumption Site in the United States, 2014–2020

Abstract

Objectives. To examine how operational rules are established and enforced at an unsanctioned safe consumption site (SCS) operating in the United States.

Methods. We conducted 44 qualitative interviews with people who use drugs, staff members, and volunteers at an unsanctioned SCS and analyzed them using an inductive thematic approach.

Results. Rule-making processes were largely driven by concerns raised by service users rather than driven by external pressures, and iterated rapidly in response to changing needs. The unsanctioned nature of the site produced an environment where bottom-up rule-making was critical to generating a shared sense of ownership of the site and where enforcement was necessarily fluid.

Conclusions. Removing external restrictions on operational rules for SCSs results in a flexible set of rules that are highly responsive to the social and public health needs of people who use drugs. Legislation and regulations of SCSs should aim to place as few hard limits on operating conditions as possible to maximize involvement of and responsiveness to people who use drugs. (Am J Public Health. 2022;112(S2):S166–S172. https://doi.org/10.2105/AJPH.2022.306714)

Safe consumption sites (SCSs) are spaces in which people can consume otherwise illicit drugs in hygienic circumstances with trained individuals in attendance to provide monitoring and immediate intervention in the event of an overdose or other medical emergency. More than 180 such sites operate with legal sanction in 14 countries.¹ Before December 2021, no SCSs operated in the United States with legal authorization; however, 1 SCS has operated in the United States without legal authorization since 2014 in an undisclosed urban area. The authors have been conducting qualitative and quantitative research at this unauthorized site since it opened to explore the social, public health, and public order impacts of the site.^2–5

Like any service provision space in which people who use drugs can enter, spend time, and receive services, all SCSs, whether authorized or not, have both formal and informal operational rules that shape how the space can be used, what services staff can and cannot provide, and what users of the space can and cannot do in the space. In the case of authorized SCSs, some operational rules may be determined by formal external constraints, such as those described in enabling legislation or regulation. One common example of such a regulatory constraint is a prohibition on either peers or medical practitioners assisting service users to inject their drugs.⁶

In addition to formal external constraints such as legislation, most authorized SCSs also exist in a political context in which retaining the goodwill of a range of external stakeholders is essential to being able to continue providing services. Examples of such stakeholders include neighbors, local health authorities, law enforcement,⁷ funding agencies, and local government elected officials. Keeping external stakeholders supportive of (or at least not oppositional to) an SCS may mean setting operational rules designed to meet the needs of these external stakeholders, even where they conflict with the needs of service users. For example, there may be rules preventing the sale of drugs within the site to alleviate law enforcement concerns,⁸ or rules about not congregating outside the site to alleviate local business or resident concerns. Being in the public eye may also lead SCS proponents to take public stances that focus narrowly on SCSs as a public health and public order intervention, and to avoid any broader advocacy relating to the human rights and well-being of people who use drugs.^9,10 At the most extreme, this has in some cases meant minimizing the voices and concerns of people who use drugs in public debate regarding SCSs and other approaches to reducing drug-related deaths.^11,12 Likewise, although people who use drugs have been instrumental in advocating SCSs in every location where they exist worldwide, they have often been excluded from processes of determining the operational rules of resulting SCS, with a report on SCSs in 7 countries in Europe finding that only 6.3% of SCSs had involved people who use drugs in this process (whereas 18.8% had involved police).^13(p20)

By contrast, unsanctioned SCSs have completely different sets of constraints and stakeholders. The primary external constraint at the unsanctioned SCS in the United States is the potential illegality of the service (e.g., the federal “crack house” statute stipulates up to 20-year prison terms for individuals operating premises for the purpose of consuming drugs¹⁴), and the need to minimize exposure to legal risk for both operators and users of the service. However, choices about how to do so, and what level of risk to take, have remained internal to the SCS. Likewise, the types of entities and individuals who make up the external stakeholders for most authorized SCSs are in this case largely oblivious to the existence of the SCS.

As part of a broader qualitative project exploring how the existence of the unsanctioned SCS affected the lives of those using and operating it, we found that operational rules and the ways they were made and enforced played a critical role in shaping the impact of the site on service users’ lives. In this article, we describe how operational rules at the unsanctioned SCS were generated, enforced, and changed, and in what ways the resulting rules differ from or are similar to those at authorized SCSs elsewhere in the world.

METHODS

The unsanctioned SCS was created by an existing community-based organization that provided other legally sanctioned services to people who use drugs. The organization believed that legal authorization of SCSs was many years away and, in response to unacceptably high overdose death rates among their service users, chose to begin SCS services without authorization to prevent further deaths. Details about the site have been published elsewhere.^2–5 Use of the space is by invitation only, with those who have been invited being referred to as “members.” As members cease drug use or move away, new individuals are invited to “join” from the surrounding community. At any given time there are approximately 50 active members. The site is open 4 to 6 hours per day, 5 days per week, and is staffed by a small number of paid staff and a larger number of volunteers. Many volunteers and staff also use the space for drug consumption themselves, although not while working.

Procedures

We conducted qualitative interviews with 44 individuals in 2 distinct rounds associated with 2 separate periods of grant funding, with 21 interviews being conducted between June and August 2016 and 23 interviews conducted between July 2019 and December 2020. Four of the participants were staff or volunteers, 30 were members, and 10 were members who also held staff or volunteer positions. The gender and ethnicity of respondents closely matched those of service users as a whole but are not reported, as this may indicate the urban area in which the site is located.

All participants were recruited at the SCS. All interviews were conducted by authors Davidson and Wenger. Most interviews were conducted in a private room at the SCS or at the research team’s community-based field site. Interviews following the onset of COVID-19 were conducted with social distancing or by telephone. Interviews took between 20 and 60 minutes. All participants were remunerated $20 in cash for their time. Interviews were audio-recorded on devices with full disk encryption and sent encrypted to a professional transcription service.

Interviewers used a brief “probe sheet” listing topics of interest to guide the interviews, informed by a theoretical perspective shaped by both the feminist science and technology studies perspective that “users matter”¹⁵ as well as the literature on peer-driven advocacy and service delivery by and for people who use drugs.¹⁶ We iteratively modified the probe sheet throughout the data collection process to allow interviewers to follow up on topics emerging from earlier interviews—for example, the emergence of the importance of the rule-making processes described here. Topics discussed included what SCS membership means to respondents, experiences working at the program (for current and former staff or volunteers), descriptions of rules and how they were made, and changes the respondent would like to make in programming or rules. After each interview, interviewers wrote brief field notes.

Analytic Approach

We analyzed data using an inductive analysis approach as described by Thomas.¹⁷ We began with a close reading of all transcripts by authors Wenger and Davidson to identify and define categories and themes. We then developed an initial code list from the probe sheet and added to the list as we reread the data and additional categories emerged. We applied the code list to the entire data set and selected appropriate quotes to illustrate the meaning of each category.

Finally, we summarized operational rules described in the 2017 “Drug Consumption Rooms (DCRs): Current Practice and Future Capacity” report,¹⁸ a survey of 49 authorized SCSs representing approximately 54% of the known authorized SCSs at that time, which included data on eligibility criteria and operational rules for services.

RESULTS

Following a brief comparison of rules common at authorized SCSs, we have organized results into 2 major thematic areas emerging from our analysis. In the first, we describe site rules and the processes for rule-making and how these changed over time. In the second, we describe the ways in which enforcement of those rules are discussed and enacted.

The Unsanctioned Site vs Authorized Sites

The 2017 Census of Drug Consumption Rooms, referenced in Methods, lists both eligibility criteria for being able to use SCS services and operational rules of those services. Table 1 shows eligibility criteria and operational rules instituted at more than half of surveyed authorized SCSs and whether these criteria and rules were ever in place at the unauthorized SCS. Only 1 of 5 common eligibility criteria (entry interview) and 1 of 5 common operational rules (no on-site drug sales) were consistently implemented at the unauthorized SCS.

TABLE 1—

Most Common Eligibility Criteria and Operational Rules in an International Survey of Authorized Safe Consumption Sites (SCSs) Compared With the Eligibility Criteria and Operational Rules of the Unauthorized SCS: United States

	Authorized SCSs Globally With This Criterion or Rule, %	Did the Unauthorized SCS in US Have This Criterion or Rule?
Eligibility criteria
Must be a certain age	87	No
Drug dependent/established drug user	67	No
Must undergo an entry interview	62	Yes
Complete a “registration” survey	56	Requested but not required
Sign a “terms of use” document	56	No
Operational rules
Do not sell drugs on-site	96	Yes
Do not use alcohol on-site	76	No
Do not inject other people	64	No
Do not share drugs on-site	60	No
Limit users’ time in the service per visit	58	Time at injecting station limited if others waiting to use one

Note. Authorized SCSs were surveyed by Belackova et al between September and December 2016; unauthorized SCS rules were consistent throughout the time frame covered by this article (i.e., 2014–2020).

Source. Belackova et al.¹⁸

Rule Creation and Modification

After the initial decision was made to start offering SCS services, a primary consideration was to minimize the potential risk of legal consequence should its existence become public knowledge. As a staff member explained:

Well, the first rule of course was that it was a myth, that if anyone asked about it, it didn’t exist.

Other initial rules were developed on the basis of the staff’s previous involvement with providing services within the community as well as members’ experiences with street drug use. For example, to ensure smooth participant flow and allow all the members who want to use the space to do so, a 30-minute time limit was set for use of injection spaces. Other early rules included drug use in designated areas only, no violence, no stealing, no dealing or exchanging drugs, and no smoking drugs (until an air extraction system was installed).

Other operational rules emerged somewhat organically in response to problems as they occurred. Members were involved in the process of rule-making and rule modification by design, through a process of weekly meetings held in the space as people were using it. One staff member described the process of rulemaking:

A discussion would start [at a regular meeting] with someone bringing up an issue that had drawn their attention, then it gets talked through, the ED [executive director] would usually “provide guidance” and suggest a rule which seemed to articulate the concern, then it’d get thrashed out some more.

The executive director of the organization noted that the unauthorized nature of the service in many ways both facilitated and required this inclusive process:

For me it was to make sure that as many people are involved in the decision-making as possible, not only because that’s what we said we’ll do, or what many organizations like ours say we’re going to do, but also because we’re doing this thing that’s [potentially] illegal. The way that I basically created a sense of security was to include people in how the place was run, how it looked, how it was designed, so that they had this really strong buy-in because it was now part of their structure, their life, their ideas in this space, and they had a means to protect it, they had a reason because otherwise, we didn’t really have any security; we were just crossing our fingers.

The executive director added that participating in the process of creating and modifying operational rules for a shared space was seen as directly contributing to destigmatization processes for members:

Thanks to the nature of our work and having this room where people could come in and use safely, it was also this room where people could discuss these ideas. So, people would all be sitting around in a circle and be able to do what they needed to do to feel better, and having these conversations also normalized their use, and made them more human also.

In most organizations, once a rule is defined and approved, the next step is propagation of the new rule and enactment. At the unsanctioned SCS, the process of enactment often formed part of the rule-making process itself. As a staff member put it:

People tend to have strong feelings about specific rules when they were being discussed, but once the rule was actually agreed on there’s sometimes a decline in interest, meaning it was inconsistent what happened next. Some rules people followed and put social pressure on each other to comply with, others not so much. . . . “Major” rules like not stealing stuff tend to be more strongly and consistently enacted. . . . Some rules went through a kind of “test run”—were people actually going to practice the rule and help encourage others to do so?—if it didn’t actually stick then it tended to become abandoned.

Respondents also described how rules changed over time in response to either changing conditions or the development of more nuanced understanding of the underlying issue that a rule was attempting to respond to. For example, the “30 minute rule” was modified several times as it became clear that the limiting factor was not how long it took to inject—as the vast majority of members could easily inject within 30 minutes—but rather that members used the injecting tables for other purposes, such as unpacking and reorganizing the contents of their bags. As a staff member explains, the rule was altered to reflect this reality:

As time went on, we did not care about time limits. It was only if people came in and we had to free up a station, we’d be like, “who’s done?” But another thing that happened is that people would move on to their table because it was the only time that they ever had a surface that was clean to unload their bag . . . and if someone has already done their shot, yet they had spread out their entire life on one of our tables, you had to get them to clean it up. They sometimes would be too high; we’d have to help them, but there’s biohazard shit involved with helping them. So not unpacking at the table then also became a, instead of a “time” rule, it was . . . more about “don’t unpack your shit at the table.”

Rule Enforcement

Rule enforcement—specifically, implementing consequences for breaking rules—was also a common topic of discussion for respondents. Many respondents complained that rules were not enforced consistently—for example, when asked about stealing at the site, a member who also worked as staff articulated a common complaint:

People have been caught red-handed stealing and they still are allowed here . . . I would make it so that if you are caught stealing, you are immediately kicked out.

However, a number of factors shaped actual enforcement policy. One point of tension around enforcement relates to the unauthorized nature of the service: if someone is permanently banned from the service (or if a staff member or volunteer is fired) they have less incentive to preserve secrecy and may even feel aggrieved enough to deliberately disclose the existence of the service. However, as a member who also held a staff position explained, a stronger driving motivation for relatively limited and sometimes inconsistent enforcement was the shared understanding that people who use drugs often do not get second chances:

So we’ve never taken membership away from somebody. If their behavior is just—like let’s just assume it’s just a little bit off, we just take a little bit more time and try and befriend them. . . . I kind of feel like people put these barriers up in their minds because they’re afraid of things and we try and show them those barriers end up having these behaviors that come with them. And so we show them it’s not like they think it is; it’s all cool. There’s not going to be no judgment and if they make a mistake, we’re cool with it, we’ll talk about it, and we’ll find the solution to it, but we’re not going to throw you out in the winter. And then they’ll let some of those walls down and with them, some of those behaviors go away.

DISCUSSION

A limited literature exists on unsanctioned SCSs, although a growing body of literature examines Canadian overdose prevention sites (OPSs), a recent development in which legal protection is provided by province-level blanket authorizations but whose implementation is largely left to local control. McNeil et al., writing about a pre-OPS unsanctioned SCS in Vancouver, Canada, found that that site had emerged despite the existence of an authorized SCS in the same city. Specifically, a regulatory prohibition (since rescinded) against assisted injection made the authorized site useless to the 40% of people who use drugs who needed assistance from others to inject.¹⁹ One ongoing discussion at the SCS documented in our field notes regarded what would happen if the jurisdiction in which the unauthorized US SCS is located were to formally authorize SCSs. Mirroring McNeil et al., a major thread of this “what if” conversation was the belief that the unauthorized SCS would and should continue to operate underground, on the assumption that any authorized site would be operating under top-down rules that would limit the utility of the site to many users. Our respondents expressed the hope that they might get to contribute as subject matter experts in discussions of how an authorized site might be operated, but the shared assumption was that such expertise—coming as it did from people actively using drugs—would be ignored.

Besides their immediate practical impacts, rules and rule-making at authorized SCSs play a broader political role in that they are in dialogue with broader societal notions of what drug use is and how it must be responded to.^11,20 Fraser and Moore have noted that “drug use activities,” “the drug using way of life,” and people who use drugs are all often portrayed in policy debate as “inherently chaotic” and hence requiring externally imposed “solutions,” which almost by definition cannot meaningfully include input from the “chaotic” individuals involved.²¹ Rules at authorized SCSs are by necessity in dialogue with such notions, either acceding to them—for example, by being designed to maximize the appearance that the SCS is restoring “order” to otherwise chaotic situations and people—or (more rarely) explicitly opposing them. Although rules and rule-making processes at the unsanctioned SCS are not overtly engaged with such dialogues, they do serve to illustrate the fallacy of these assumptions.

Our data suggest that both rules and rule-making processes at the unsanctioned SCS evolved organically to meet the needs of the individuals involved in the service. This had a number of substantial benefits, ranging from operational flexibility to the ability to create what Duncan et al., writing about an authorized SCS in Germany, termed an “atmosphere of engagement” in which destigmatization and respect for the human dignity and rights of people using the service are foregrounded.²² However, this ad hoc approach also has the potential for arbitrariness, in that the nature of any individual’s relationships to staff and to other people using the service can influence how or even whether a given rule is applied to them, in a way that may be the case less often at an authorized site with more procedural rule enforcement.

More recent work following the development of the OPS approach in Canada has suggested a middle ground, in which legal protection is provided, but most operational rules are left to local design. Wallace et al. compared multiple models emerging from OPS authorization; in line with our data, they found that OPS organizational structures designed and implemented by people who use drugs are more responsive to the needs of service users and to changing circumstances than those with limited input from people who use drugs.²³ In early work on OPSs, Boyd et al. found that they provided some protection from gender-based violence prevalent in street drug use settings, but that they remained “masculine spaces” that may create barriers to access for women and transgender people who use drugs,²⁴ findings which are reflected in some of our earlier work on the unsanctioned US SCS.⁴ In more recent work, however, Boyd et al. have described how the flexible OPS framework has allowed women who use drugs to lead the establishment of an OPS restricted to women, transgender women, and nonbinary persons to address such concerns.²⁵

In short, in line with literature from both other unsanctioned SCSs outside the United States and the rapidly emerging OPS literature from Canada, our data suggest that operational rule-making processes for SCSs (and other services for people who use drugs) that are minimally constrained by externalities and the concerns of people who do not use drugs tend to be highly responsive to the actual needs of people using the services. Our data suggest that such rule-making processes are also associated with a deep and constructive sense of ownership and belonging among the people using the services. This in turn reduces many of the kinds of problems that require rules in the first place. As a reviewer of an earlier version of this article put it, our data show that “rules can be made organically without anarchy.”