Should California Legalize Supervised Drug Injection Sites?
Should California Legalize Supervised Drug Injection Sites?
San Francisco wants to open a facility where people could use illegal drugs, but Governor Newsom just vetoed a bill that would have authorized such centers. Would such sites reduce overdose deaths?
Today’s Debate
Supervised injection sites (SISs), also known as safe drug consumption sites, are facilities where people can use illegal drugs under the supervision of trained staff who can intervene in case of overdoses. The main goals of these sites are to reduce drug-related deaths, prevent the transmission of infectious diseases, and connect drug users with health and social services.
Currently, it is illegal for a city in California to open and operate a SIS. However, reporters exposed San Francisco last year for turning its Linkage Center - originally designed to link people to needed social services - into a SIS. Controversy erupted, ultimately leading the city to shut down the Linkage Center in December 2022.
Senate Bill 57 would have changed the legal status of such sites in California, allowing Oakland, San Francisco, and Los Angeles to trial supervised drug injection sites through January 1, 2028. However, Governor Gavin Newsom vetoed the bill in August 2022:
“I have long supported the cutting edge of harm reduction strategies. However, I am acutely concerned about the operations of safe injection sites without strong, engaged local leadership and well-documented, vetted, and thoughtful operational and sustainability plans. The unlimited number of safe injection sites that this bill would authorize - facilities which could exist well into the later part of this decade - could induce a world of unintended consequences.”
While California is the in early stages of exploring legalizing supervised injection sites, other places around the world have been running such centers for years - and several cities around the United States have or are moving forward with their own projects - despite a federal ban on such facilities. New York City opened of 2 injection sites in November 2021 and Philadelphia, Boston, and Seattle have all taken steps to open similar sites.
The debate over open injection sites reflects the urgency of addressing the opioid crisis that has claimed thousands of lives across the country. Overdose deaths in California have increased by roughly 3 times in just the last 5 years.
San Francisco has reportedly renewed efforts to create a SIS in the city. The Board of Supervisors passed a motion last month that changes permitting laws to make it easier for a facility of this type to be created.
Argument in Brief
Should California legalize supervised injection sites?
Case For:
Supervised injection sites save lives by preventing overdose deaths
Supervised injection sites increase access to addiction treatment
Normalizing drug use reduces stigma, increasing usage of supportive services
Case Against:
Supervised injection sites increase drug usage and worsen addiction
Supervised injection sites make the surrounding community drug-infested and crime-ridden
Supervised injection sites violate federal law
My Assessment:
While it can be difficult to prioritize any action that jeopardizes a human life in the interest of achieving an alternative outcome, I believe it is more important to avoid fostering the creation of a population of people who are increasingly addicted to mind-altering substances. My most serious concern regarding SISs is the potential they have to encourage and normalize drug use.
Is it possible to authorize SISs without creating a larger, more seriously addicted population in California? It’s hard to say, but even if it could, the scientific evidence on both sides of the arguments below is quite weak.
As a result, like Governor Newsom, I don’t believe California is ready to even experiment with the opening of such sites. First, we need to ensure we have a full continuum of care set up to ensure that we are effectively pushing drug users into treatment and out of addiction. If we can satisfy these conditions, then we could move forward with some small-scale experiments, but importantly, we should still restrict usage of such facilities to those using illicit drugs as a sort of palliative care or to those suffering from the most extreme cases. The use of SISs should be a rare exception within a dominant anti-drug culture.
Case For:
Supervised injection sites save lives by preventing overdose deaths
The primary goal of supervised injection sites is to prevent overdose deaths. Senator Scott Wiener, who authored SB 57, explains this goal:
“We know that we are experiencing a crisis of overdose deaths, and these are preventable. This is one way to help keep people safe and to actually help people get into treatment.”
Democratic Assemblyman Miguel Santiago threw his support behind such sites after seeing the open-air drug use in Los Angeles’ Skid Row:
“It is an attempt to create a safe place for people to use (drugs), to help them when they are at their lowest, and to prevent the worst from happening.”
A 2014 review of 75 studies suggested that these sites do reduce overdoses. An evaluation of North America’s first SIS - Insite in Vancouver - beginning in 2003 and published in 2016 reported that no overdoses resulted in death. Further, the report concluded that overdose deaths in the area surrounding the center fell by 35% during the 2 years after the center opened, compared to a 9% reduction across the city of Vancouver.
The New England Journal of Medicine found similar results in their evaluation of an unsanctioned SIS that reportedly opened in an undisclosed U.S. city in 2014:
“In total, there were 10,514 injections and 33 opioid-involved overdoses over 5 years, all of which were reversed by naloxone administered by trained staff. No person who overdosed was transferred to an outside medical institution, and there were no deaths.”
One analysis conducted in San Francisco estimates that for each dollar spent on supervised injection sites, $2.33 would be saved in emergency medical, law enforcement, and other costs, yielding a yearly savings of $3.5 million.
However, some dispute these findings, even the research on Vancouver’s Insite facility:
“The report by Brandon Marshall and colleagues (April 23, p 1429), in which it is claimed that the opening of a supervised injection facility on Sept 21, 2003, in Vancouver, BC, Canada, was associated with a 35% decrease in overdose deaths in its immediate surrounding, contains serious errors. The claim that all overdose deaths in Vancouver declined between 2001 and 2005 is strongly affected by the highly questionable inclusion of the year 2001—a year of much higher heroin availability and overdose fatalities than all subsequent years.”
The RAND Corporation performed a systematic analysis of studies on the topic, finding that on average sites were associated with reductions in overdoses deaths, but it warns that:
“The scientific evidence about the effectiveness of SCSs is limited in quality and the number of locations evaluated.”
Many of the studies contained in these reviews are focused on the one site in Vancouver. Keith Humphreys, an addiction researcher and psychiatry professor at Stanford University, issues a similar warning:
“Nobody should be looking at this literature making confident conclusions in either direction.”
For example, authorities in another Canadian town report vastly different results to those cited in Vancouver:
“In Alberta, public health authorities released a bombshell report that showed the sites did not reduce overall overdose deaths or opioid-related emergency calls.”
Despite these data concerns and limitations, Dr. Sharon Larson, a professor at Thomas Jefferson University, thinks we can move forward:
"It does not give me pause about developing these injection sites. What it tells me is if we want to demonstrate that this is an effective strategy for harm reduction, one of many, that we ought to be very thoughtful about how we develop data to answer the important questions."
Supervised injection sites increase access to addiction treatment
Even critics of SISs may grant supporters the argument that they save lives, arguing that they do so at the cost of increasing addiction. But if visiting these facilities makes drug users more likely to participate in addiction treatment, critics’ argument may be severely weakened. This would be harm reduction at its best: meet people where they are and from there, journey with them into greater levels of health.
In addition to employing staff trained to administer naloxone to reverse overdoses, most sites also offer a range of other social and medical services, including substance use treatment. A New England Journal of Medicine study cited research suggesting SISs do this effectively:
“Several studies suggest SISs improve the health of people who use the sites by facilitating access to general health and social services.”
A 2014 review of 75 studies reached the same conclusion.
When it comes to addiction treatment specifically, studies have found an “increased uptake of drug detoxification and addiction treatment” and “significant improvements in access to addiction treatment programs.”
For example, in one study, 185 people – 18% of those in the study - began a detoxification program during follow-up. Another study of 50 people reported anecdotal evidence for this claim:
“IDU (Injection drug users) narratives indicate that the SIF (supervised injection facility) serves to facilitate access to health care by providing much-needed care on-site and connects IDU to external services through referrals. Participants’ perspectives suggest that the SIF has facilitated increased uptake of health and social services among IDU.”
However, at San Francisco’s Linkage Center (also known as the Tenderloin Center), referrals to treatment programs were minimal as of June of last year:
“The Tenderloin Center doesn’t have great numbers on getting people into addiction treatment — 53 people have been referred to substance abuse treatment so far and there’s no information on the outcomes.”
For context, from January to May of last year, the city reports that 50,000 guests utilized the center. Opponents of SISs in Alberta, Canada cite similarly meager referral rates:
“Advocates in favor of supervised injection sites assert that they provide connections for those with substance use disorders to find housing and treatment options. However, these sites have a poor record of moving drug users into treatment and recovery, with some referral rates as low as 1%.”
Normalizing drug use reduces stigma, increasing usage of supportive services
SISs can reduce the stigma users of illicit drugs can often feel:
“The safe consumption sites didn’t just offer an escape from death and the unsanitary and dangerous conditions on the street. They offered escape from the stigma that pounds on the ugliness of their addiction until there is no daylight between who they are and what they do. Shame is rarely a long-term motivator.”
In fact, one researcher refers to Vancouver’s Insite facility as:
"a place which is an official healthcare setting which is not judgmental, which does not stigmatize them for their drug use, and which accepts that they are people first and foremost."
Insite’s longtime program coordinator, Darwin Fisher explains the importance of destigmatizing drug use:
"It's about making a space where drug users are allowed to feel like people. We're also mindful that this is a respite from the street and at times it might be difficult for people to leave the only situation that feels vaguely safe for them in a day."
While some supporters of SISs admit that these facilities are “a Band-Aid, not a solution,” they argue that reducing stigma so that drug users interact with staff can make a big difference:
“…every minute he spends getting someone to talk to him — even if they’re injecting fentanyl at the time — is a minute that could lead to change. ‘I just ask that people see the hope in it,’ he said. ‘Because there ain’t a lot of hope out here.’”
However, critics argue that destigmatizing drug use – which normalizes it – shouldn’t be a goal at all:
“Injection sites normalize intravenous drug abuse, encourage a horrible addiction, and let down the people who suffer from it. Promoters of these sites offer addicts little but failure — medical safety at the time of injection but, overall, mere complicity in a nightmarish cycle of addiction leading to death. Perhaps not when the addict shoots up under the careful eye of a medical professional, but one of the hundreds of other times she shoots up somewhere else.”
President Trump’s former Deputy Attorney General Rod Rosenstein makes the same argument against normalization:
“Injection sites normalize drug use and facilitate drug addiction by sending a powerful message to teenagers that the government thinks illegal drugs can be used safely.”
Case Against:
Supervised injection sites increase drug usage and worsen addiction
By facilitating drug use, it would seem logical to believe that SISs would increase drug usage. Stanford School of Medicine professor Keith Humphreys explains this risk:
“If you’re coming into a place that’s supposed to guide you toward the end of seeking treatment and recovery and there are people using drugs around you, that becomes an incentive to keep going. It’s like trying to have an AA meeting in a bar.”
Data from an unsanctioned SIS in the United States suggests that this is the case, at least at the population level. Injection events almost tripled in just 5 years and overdoses per injection event increased by more than 5 times. Far more drugs are being consumed at far greater doses.
Similar data can be seen at Vancouver’s Insite facility where the overdose rate associated with heroin use increased by 4.8 times from 2010 to 2017.
Michael Shellenberger, an independent candidate for governor of California in 2022 and author, argues that the existing structure of SISs leads to continued drug use:
“What they’re proposing is addiction maintenance. … I think that we need to embrace addiction recovery.”
Shellenberger interviewed a senior government official from a European country who has studied SISs. He describes the difference between what happened and is being proposed in San Francisco and the models currently at work in Europe:
“‘These guys point to Europe as these fabulous utopias of using drugs safely, but when European officials visit they are horrified by what they see. They say to us, ‘We require the addicts to maintain their obligations as citizens. You let them off the hook. You don’t require them to take responsibility for their health and their obligations as a member of a community. That’s where you’re going wrong.”
Shellenberger explains that in Europe, police and medical professionals put pressure on law-breaking addicts to quit. This official, in fact, only recommends SISs for those who require some measure of lifelong dependency on drugs:
“‘I don’t disagree with the European model and don’t dismiss that the overdose prevention sites may have utility for a particular population. And there is no question in my mind that there is a very small subset of the addicted/using population whose needs are palliative in nature.”
Leaders from a grassroots San Francisco-based nonprofit, Mothers Against Drug Deaths, say “safe spaces make addictions worse.”
Shellenberger and his associated organization, California Peace Association, argue that the philosophy of harm reduction is fundamentally flawed:
“But many proponents of harm reduction misunderstand the nature of addiction by avoiding any measures requiring abstinence. Many addicts will not stop using voluntarily. By supplying housing and other services with no strings attached, San Francisco misses an opportunity to incentivize addicts to get better.
While some harm reduction measures are positive, they are not enough to stop addiction, as skyrocketing drug deaths show. We need to provide real incentives to drug users to break their addiction, including contingency-based housing predicated on abstinence and the introduction of mandatory treatment as an alternative to incarceration.”
However, other researchers argue that SISs do not lead to increased drug use. Specifically, conclusions from a long-term study of Insite suggest the opposite, according to the lead researcher:
“They found no signs of a so-called "honey pot effect," at Insite, meaning it didn't increase or encourage drug use.”
A review of 75 studies – almost entirely focused on SISs in Vancouver and Sydney – also suggest that SISs do not lead to increased drug use:
“SISs have largely fulfilled their initial objectives without enhancing drug use or drug trafficking.”
Supervised injection sites make the surrounding community drug-infested and crime-ridden
The authorization of illicit drug use in SISs is likely to attract drug addicts and their dealers and, by extension, all the challenges – including crime – associated with a street drug market:
“These consequences should surprise no one: If you’re a drug dealer looking for customers, an injection site is where you’ll find them. If your neighborhood hosts an injection site, drug addicts will go to your neighborhood. The City of Vancouver dropped the speed limit on the street next to Insite to about 20 miles per hour because addicts might wander into traffic.”
Others echo this argument:
“The activists like to keep the argument narrowly focused on the addict and overdose deaths. They don’t want to look at the impact of the [supervised drug] sites on crime rates or their devastation on communities and small businesses. It’s folly to think you can attract all those drug users without attracting all the problems of concentrating addicts. You will see drug traffickers moving into control the area.”
John Lovell, testifying on behalf of the California Narcotic Officers’ Association, echoes this sentiment:
“There is a magnet effect so that people come into the area.”
Specifically, Vancouver’s Insite reportedly resulted in challenges for the surrounding community:
“The presence of the site increased public disorder in Vancouver’s Downtown Eastside to the point that one official called it “a war zone.” Within a year of its opening, Vancouver Police posted four officers at the site and an additional 40 in the surrounding neighborhood.”
Officials in Alberta reported similar complaints:
“Drug traffickers appear to be openly conducting their business unabated near the SCS sites, due to a burgeoning client base. Drug users purchase their drugs from these individuals, as it reduces the need to transport an illicit substance over a distance, thus reducing the potential of being arrested for possession of an illicit substance. The police are placed in the untenable position of determining how to appropriately engage with clients of the SCS while clients engage in illegal activities such as theft, prostitution and break-and-enter to pay for their drugs.”
However, some health officials in Alberta claimed the previously cited report is biased and doesn’t include any of the science evaluating supervised consumption sites:
“Our observations and data indicate that these facilities, collectively, have not increased crime or disorder in the surrounding community.”
A systematic review of 22 studies of overdose prevention sites – again, primarily focused on Vancouver’s Insite facility – similarly claims there was not an increase in crime or nuisance activities in the surrounding neighborhoods.
Supervised injection sites violate federal law
Federal law – known as the “crack house statute” - currently prohibits operating, owning, or renting a location for the purpose of using illegal substances. The Justice Department, under the Trump administration, invoked this statute in 2019 to stop a supervised injection facility in Philadelphia from opening.
While the Biden Administration has not explicitly endorsed SISs, officials from the city of Philadelphia have reportedly had “productive conversations” with the Administration about authorizing one or more sites in the city. At the same time, New York City has authorized the opening of 2 facilities – despite the national ban on such facilities.
Some are not concerned with violating federal law. In fact, California’s sanctuary state status – as it relates to immigration – demonstrates its willingness to disregard federal statutes when its values don’t align with federal laws.
It’s no wonder, then, that San Francisco has not hesitated to discard California’s existing regulations that also make SISs illegal. Not only did San Francisco secretly operate a supervised injection site, its supervisors have also recently taken steps to streamline the opening of such facilities within the city.
My Assessment
Before assessing the details of the arguments above, I believe it’s necessary, in this case, to start with a discussion of the desired outcome. While it can be difficult to prioritize any action that jeopardizes a human life in the interest of achieving an alternative outcome, I believe it is more important to avoid fostering the creation of a population of people who are increasingly addicted and influenced by powerful and unregulated substances.
We should not normalize a drug-use culture. The authorization and even, facilitation of illicit drug use, will – should it become widespread – have a powerful cultural impact, further increasing our nation’s submission to drugs.
While some drug use can have minimal effects, even moderate ongoing use is associated with severe, long-lasting physical and mental consequences. For example, cocaine has a scary impact on the brain:
“The damage cocaine does to the brain may last the longest. Research from the University of Cambridge found that cocaine may make the brain age unnaturally fast; addicted users “lose twice the brain volume each year,” compared to their non-using counterparts. The brain loses grey matter as part of the normal aging process, which manifests as the usual signs of old age, such as memory problems and declining cognitive abilities.”
In short, widespread drug use is and will create an unproductive, anxious, depressed generation that uses powerful substances to escape reality rather than doing the hard work to achieve internal health so that medication is not necessary. The latter is by no means easy or simple – but it is the path we should be encouraging people to take.
Some also require such assistance to propel them forward on the path to recovery – but this approach should be limited to the most severe cases and limited in the duration over which they are applied.
The push to authorize such sites seems at least in part to be an overreaction to the war on drugs, which led to mass incarceration rather than recovery and rehabilitation. The war on drugs, however, was not wrong in its desire to minimize drug use. It was wrong in its use of incarceration as the primary tool for disincentivizing its use. Portugal’s success shows another way. Keep drugs illegal and disincentivize their use, but punish drug use with mandatory treatment, using incarceration as a way to drive people into treatment.
Is it possible to authorize SISs without creating a larger, more seriously addicted population and without further normalizing drug use in California? It’s hard to say, but let’s assume for a minute that it is. Would it then be a good idea to authorize the opening of SISs in California?
The main challenge in assessing this argument is the discrepancies and shortcomings in the data. As Stanford professor, Humphreys shared with NPR:
“He doesn't think the available evidence points to supervised injection as being harmful, but the research has not strongly demonstrated an overall reduction in overdose deaths over time.
The real problem, he says, is there just are not a lot of good studies, period, on supervised injection. "So I think we should be pretty cautious," he says.”
That said, some of the most concerning and straightforward data available is the number of injection events and overdoses per injection event from the unsanctioned site in the United States and from Insite. Data from both sites clearly demonstrated massive increases in injections and overdose rates. It’s possible these increases were driven by increased utilization of the sites and/or overall increases in drug use in the surrounding areas. Even if these contextual factors can explain some or most of the increase, this data leaves me concerned.
As a result, like Governor Newsom, I don’t believe California is ready to even experiment with the opening of such sites. First, we need to ensure we have the rest of the continuum of care set up to ensure that we are effectively pushing users of the facility into treatment and out of addiction. To do this, we should closely analyze the models used in Portugal and other European countries, being careful to replicate all components of their model, rather than cherry-picking the ones that align with the most permissive environment. And we must also cultivate a culture that discourages drug use and rejects addiction as an acceptable lifestyle.
If we can satisfy these conditions, then we could move forward with some small-scale experiments, but importantly, we should still restrict usage of such facilities to those using illicit drugs as a sort of palliative care or to those suffering from the most extreme cases and using illicit drugs as a short-term strategy to aid withdrawal. The use of SISs should be a rare exception within a dominant anti-drug culture.
This is just my opinion. I’d love to know yours. What do you think?