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Rhode Island (SIFs) or "harm reduction centers" in the U.S. last week, but many states still face an uphill battle to opening their own sites.

The bill calls for launching a which would permit harm reduction centers or SIFs to serve as a community resource, providing a place where people can legally consume or inject pre-obtained illicit drugs under medical supervision to prevent overdose. Each site will also provide referrals to counseling or other medical treatment that might be needed for a visitor to the site.

The law will take effect on March 1, 2022 and is slated to expire on March 1, 2024.

, , and have all come close to launching their own safe injection sites, but encountered barriers either from the local community or .

AMA and NIDA Weigh In

Organized medicine and even top scientific government officials have offered their support for studying safe injection sites.

The American Medical Association (AMA) announced its support for .

And in an email to MedPage Today, Bobby Mukkamala, MD, chair of AMA's Opioid Task Force, said that Rhode Island was "taking an important step to save lives from drug-related overdose and deaths ... These facilities are designed, monitored, and evaluated to generate data to inform policymakers on the feasibility, effectiveness, and legal aspects of reducing harms and health care costs related to injection drug use."

Without explicitly stating support for Rhode Island's plan, Nora Volkow, MD, Director of the National Institute on Drug Abuse, applauded the idea of increasing harm reduction research, citing the effectiveness of similar measures such as needle-exchange programs in preventing HIV, reducing high risk injection behaviors, and improving the quality of life for those who use drugs.

"Supervised injection facilities -- also known as overdose prevention centers -- have shown some promise in reducing harms and social costs associated with injection drug use, and have not been associated with increased crime or drug use in surrounding communities," Volkow wrote in an email to MedPage Today.

"However, far more research is needed. As the opioid overdose crisis continues to worsen, it is crucial to enhance harm reduction research and implementation of evidence-based harm reduction practices. If demonstrated to be effective, overdose prevention centers could be another valuable and innovative tool to support and care for people with substance use disorders."

Making the Case for Safe Injection Facilities

James "Jim" Baker, MD, MPH, immediate past chair of the Massachusetts Medical Society's Committee on Mental health and Substance Use, supports safe injection facilities.

Baker's son, Max, died from a heroin overdose on December 28, 2016. He was 23.

Max hid his addiction from his father for years and he, even as a physician, didn't know anything about addiction or how to find his son the help he needed.

When he told his own primary care doctor, "a caring educated physician," of his son's addiction all his doctor could do was to sympathize with him and say, "I hope he finds help."

With few exceptions for certain progressive institutions that can immediately refer people to treatment, that response hasn't changed, Baker said.

"[T]he overwhelming majority of people who are suffering from addiction do not have an avenue of care where they can turn ... They're going to use in a locked bedroom or a locked bathroom or a public restroom and die and that shouldn't happen."

Often, Baker said, people with substance use disorders aren't ready to accept help. But his son sought it out. He found treatment on his own and was sober for a little more than a year before relapsing after he was given opioids following a surgery.

If there had been a safe, supervised facility where his son could go when he knew he was relapsing, where there were medical professionals and Narcan, Baker believes things might have turned out differently for Max.

"He could have been safe instead of being found dead on the floor in his own home," he said. "As unpalatable as that concept is to families who don't understand addiction, for families who have lost someone like mine, that could have saved his life."

Proponents of safe injection facilities argue that the sites prevent disease, offer health screening, serve as a link to recovery and rehabilitation services, and lower the risk of injection drug users dying from an overdose.

Peter Davidson, PhD, of the University of California San Diego, said a couple of decades worth of research from 150 authorized sites around the world has found that sites "reduce overdose deaths amongst people who have access to [them] in the immediate community, they reduce unsafe disposal of needles on the street in the surrounding community, [and] they connect people to addiction treatment more rapidly."

They have a broad range of positive public health outcomes without having shown, to date, "any unintended negative consequences."

Davidson's research with Alex Kral, PhD, an epidemiologist at independent, non-profit research institute, RTI International, on . resulted in similar findings: such sites don't increase crime in the surrounding neighborhood, and reduce syringe sharing.

Davidson said that he'd like to see a site opened in the U.S. so that it can be properly studied, since conducting research on an unauthorized site is more challenging because confidentiality must be the foremost concern.

"We have a lot of very convincing data from elsewhere in the world but the U.S can be a little bit different in terms of its drug market ... So it's possible that it wouldn't work out to be a good idea here."

He added that there are other differences between the U.S. and other countries that have piloted SIFs, for example, the U.S. has more guns and law enforcement here may be less supportive.

"If the police are opposed to it ... [and] act on the ground in opposition to it, that could make it work not very well at all," he said.

Kral said he has heard rumbling from law enforcement who will say things like, "I've already saved that guy one time, he's just going to go out and use again."

No one's ever argued that for a person who's had a heart attack and then continues to eat poorly. "They only come up with that type of argument when it comes to drug use," he said.

It also isn't true that someone who uses heroin will continue to do so for life, Davidson said. The median time people use opioids is less than ten years, he said.

"I think these facilities ultimately meet people when they're in the worst period in their life," Davidson said. "They help them stay alive very successfully and they help them enter that path that will lead them to not having this be the central driving force in their life... and I think that's worth doing."

Questions Remain

While there are extreme arguments in either direction, suggesting that consumption sites will either "destroy the world and normalize drug use," or "reverse the overdose crisis," there's no real evidence to support either claim, said Keith Humphreys, PhD, of Stanford University.

Importantly, the literature to date, in support of SIFs or consumption sites is "really weak," said Humphreys, who is a former Obama administration senior drug control policy advisor.

At one point, roughly 80% of the research was being conducted at two sites -- one in Vancouver and the other in Sydney and by people who worked at those sites or helped to launch them.

Another drawback is that compared to buprenorphine, methadone, or needle-exchanges, consumption sites or SIFs aren't "big population coverage interventions ... People are not going to drive in from the suburbs to inject drugs in front of a nurse," he said.

And because the substance use system has only a finite amount of resources, there are tradeoffs to opening these sites.

Opening a consumption site could "impoverish other services in the system that are more effective" and could lead to missed opportunities to get people into recovery.

"With the same resources, [if] you could carry another fifty people in your methadone clinic, you're probably, on net, increasing overdoses." On the other hand, "if you could do it very cheaply then you're not," he said.

"I just think we should give people things that we know work," Humphreys added.

The only thing that would change his view of these facilities would be a rigorous study Humphreys said, but it would have to be by "somebody who's not pre-committed in advance" to their success.

Barriers to Implementation

In city after city, safe injection sites have met roadblock after roadblock.

The Controlled Substances Act, a Nixon-era law makes it illegal to use certain drugs the government decides are prohibited, Kral said. And the "Crack House" Statute, which was part of the Anti-Drug Abuse Act of 1986, punishes building owners who know drug use is happening in their building by forcing them to forfeit the property.

Seattle approved three or four years ago for safe consumption sites. But advocates are still trying to find a site where the community will allow a facility to be run, said Kral. In October, city council members floated a new proposal that would allow the services to be delivered in existing social service and healthcare sites, according to .

In Philadelphia, lobbied for a safe consumption site alongside Safehouse, a Philadelphia nonprofit, but a federal court ruled in January that opening such a facility , according to NPR.

New York also for developing a facility, with then Mayor Bill de Blasio pledging his support in 2018. But Gov. Andrew Cuomo, who appeared committed to the plan, .

And Mayor London Breed of San Francisco, along with several other mayors in April, calling on the Biden administration to relax drug enforcement activities around proposed safe injection sites.

Kral noted that Garland has yet to respond.

The prevailing attitude around safe injection facilities has been one of "profound resistance" among constituents, said Baker who has himself lobbied lawmakers to try to establish the facilities.

But the issue is "radioactive" a "nonstarter" among even lawmakers who are compassionate and committed to finding solutions.

Sometimes, he said, "there's an actual visual recoil" when he mentions the idea of launching such a facility.

"These are leaders who I know care and they're looking for answers, but at the same time they represent their constituents," Baker said.

Davidson said his "slightly pessimistic take" on the chances, of opening a site is that he anticipates "a couple more hurdles before they actually get to open the doors on an actual facility."

But Baker remains optimistic.

"To me it's not an issue that can't be surmounted. I think it can be achieved."

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