After the California state Senate passed a bill last week that would allow San Francisco to start a safe injection site under a three-year pilot program, Deputy Attorney General Rod Rosenstein wrote a New York Times op-ed arguing that such sites were “very dangerous and would only make the opioid crisis worse.”
Safe injection sites, or spaces where people can inject pre-obtained drugs under medical supervision in hygienic facilities, are a controversial idea in the United States. While federal law prohibits safe injection sites, cities such as New York, Philadelphia and Seattle are considering sites modeled after ones in Canada, Europe and Australia, even in the face of threats from Rosenstein and the Department of Justice to crack down on any site that does open.
In his op-ed, Rosenstein argued that safe injection sites pose a danger to the neighborhoods they open in, expose medical staff and bystanders to fentanyl, and normalize drug use, sending a message to teenagers that illegal drugs can be used safely.
Harm reductionists, researchers and drug policy experts took issue with the op-ed, which they believe misrepresented the available evidence about safe injection sites and trafficked in incorrect claims.
“We should view evidence-based policy and the task of confronting problematic drug use using the tools of public health and medicine as effectively one and the same,” explained Kathleen Frydl, historian and author of the book The Drug Wars in America. “Mr. Rosenstein’s editorial flies in the face of both.”
Frydl invited Rosenstein to “make claims on safe-injection sites only after he’s familiarized himself with the evidence, or shows an interest in doing so.”
Harm-reduction advocates ― who promote strategies that limit risks associated with drug use ― have long argued that safe injection sites have health and safety benefits. They say those include reducing needle-sharing and associated infectious disease transmission and lowering the risk of fatal overdoses, since there are trained medical staffers and naloxone on site. There’s also the opportunity for people who use the sites to connect with health care services, including addiction treatment.
“I find it frankly appalling that the Justice Department is threatening to go after cities and states that are trying to implement policies to save lives,” said Maria McFarland Sánchez-Moreno, executive director of Drug Policy Alliance, an advocacy group.
“He did so without offering any reason to believe that his proposed approach, which is enforce, enforce, enforce, would actually work. It’s quite the opposite,” she said.
“When you criminalize drug use, you drive people who use drugs underground. It makes it harder for them to access meaningful support, services, treatment if they want it and more likely that they will get sick, contract infectious disease, share needles, overdose and die,” McFarland Sánchez-Moreno said.
While experts roundly found Rosenstein’s critiques misleading, a recent review of literature on safe injections sites pushed back on some of the favorable claims that harm reductionists have touted as evidence for promoting safe injection sites.
The review, which was published in the International Journal of Drug Policy this month, examined a relatively small pool of studies — eight in total — that the researchers considered rigorous enough to include. Those eight studies examined four facilities.
While the review did link safe injection sites with slightly lower drug-related crime, it largely showed just how much we don’t know about the efficacy of safe injection sites, in the opinion of Keith Humphreys, professor of psychiatry and behavioral sciences at Stanford University.
“The most rigorous studies of safe drug consumption rooms do not show a benefit in terms of mortality, needle sharing or street heroin injection,” he explained. “Neither the claim that these are remarkably effective nor remarkably destructive are supported by this careful scientific review of the evidence.”
The Rosenstein op-ed, however, didn’t portray those nuances. Instead, his claim that sites were “very dangerous” was based on impressions of one city council member from Washington state, who visited Vancouver’s safe injection site there and described it as “a war zone” with “drug-addled, glassy-eyed people strewn about.”
Experts similarly described Rosenstein’s warnings about bystanders or staff being “gravely harmed” by skin contact with fentanyl as overblown. (Despite fearful headlines, it’s difficult to absorb fentanyl through the skin and unlikely to lead to overdose. The American College of Medical Toxicology called the exposure risk to emergency responders “extremely low.”)
“There is no evidence for the destructive effects that Rosenstein is citing,” Humphreys said.
Incomplete research doesn’t mean we shouldn’t try safe injection sites
Other experts had concerns about the new review, and thought that pooling quantitative results from only four facilities didn’t allow for a meaningful picture of how effective the sites are ― or could potentially be in the future.
Sheila Vakharia, policy manager of the office of academic engagement for the Drug Policy Alliance, pointed to qualitative research that she thought was more telling in understanding the benefits of safe injection sites, including a research article about an unsanctioned safe injection site in the United States, which was published in the American Journal of Preventive Medicine last year.
Staff at the site asked each program participant where they would have injected that day if they weren’t at the site, and Vakharia thought the answers were telling. Thirty-five percent of participants said they would have injected in a public bathroom, and 57 percent said they would have injected in a street, park or parking lot if they hadn’t had access to the safe injection site.
Rosenstein is basically saying he wants to keep people who use drugs out on the street, Vakharia explained, noting that safe consumption sites create a point of contact for health care and health services for the highest-risk users.
Vakharia also took issue with Rosenstein’s assertion that safe injections sites send the wrong message to children, noting that it flies in the face of identifying addiction as a disease.
“What kind of message does it send to help people who are sick or who are struggling with a health condition?” she asked. “You are making drug use seem like a deviant immoral act, when the people who are going to be using supervised consumption spaces are people with substance use disorders.”
And as Leo Beletsky, associate professor of law and health science at Northeastern University noted on Twitter, the “bad news” about safe injection sites is that there are too few of them, which not only makes them hard to study, but also means that they’re not operating at a large enough capacity or sufficiently equipped to maximize their functionality.
The study authors themselves made a few suggestions for enhancing the impact of safe injection sites, including extending hours of operation and partnering with syringe exchange programs or drop-in centers for the homeless to expand coverage.
Perhaps most importantly, safe injection sites should be considered as part of a web of potential solutions to the opioid crisis ― including medication-assisted treatments like buprenorphine and methadone, and harm-reduction strategies like needle exchanges and expanded access to the overdose antidote naloxone ― rather than a standalone fix.
“We’ve only proposed [them] as part of a larger multifaceted, multi-pronged approach to addressing the overdose crisis,” Vakharia said. “No one was going to attribute the ending of the overdose crisis to a single intervention, such as a supervised consumption space.”