In New York State, illegal drug use in the bathrooms of syringe exchange sites is something of an open secret – the state even issued a protocol on how to safely manage the practice years ago. But John Barry, executive director of the Southern Tier AIDS Program in Ithaca, NY, seeks an alternative: a facility where drug use is allowed to happen out in the open, in stainless steel booths. There, no one has to hide their drug use, and help is on hand. Barry believes that if he had such a facility, his team would be able to respond more effectively to overdoses and provide better care.
"Instead of having to essentially break into a bathroom, we could be there in real time with a person, talk to them about their injection technique so that they don't get abscesses, and give them a more nuanced intervention," Barry says.
Facilities like the one Barry is describing already exist In New York City. It’s called a supervised injection site (SIS). Also known as overdose prevention or safe consumption sites, the facilities enable people who use drugs to do so safely, providing access to clean needles, on-site medical care, and connections to social and health care services. While offering a space for drug use is federally illegal, New York City opened two SISes last November – the first such facilities in the U.S. – after getting authorization from then-mayor Bill de Blasio, the Department of Health, the NYPD, and four district attorneys. The Department of Justice has so far declined to shut them down. A bill authorizing safe consumption statewide passed the Assembly Health Committee in May but had not advanced further as of June 2.
Advocates say that more such sites are needed. “This is a kitchen table issue. The overdose crisis has impacted districts across New York State,” says Jasmine Budnella, director of drug policy organizing and campaigns for VOCAL-NY, a nonprofit advocacy and services organization.
New York City’s sites, led by OnPoint NYC, are located in East Harlem and Washington Heights, which have the city’s highest rates of overdose death. The sites are having outsized impacts and are looking to extend their hours. A city Department of Health feasibility study done before the facilities opened predicted that four sites would prevent between 67-130 overdoses in a year, but the two sites had already averted 314 overdoses since they opened, according to an OnPoint representative. OnPoint NYC’s facilities, which have been used 20,708 times by 1,252 registered participants, are not “just a bunch of people using in a room,” says Budnella. Rather, the sites offer various medical and mental health services and provide showers, laundry, and meals. Acupuncture and meditation are also available to visitors.
A Growing Body of Research in Support of Safe Consumption
Decades of research from SISes outside the U.S. – including in Canada, Europe, and Australia – shows that they reduce overdose deaths. Supervised injection is a harm reduction strategy, which strives to support rather than criminalize people using illegal drugs. The approach has been gaining momentum with the rising death toll from opioid overdoses – a crisis that only intensified during the pandemic. The U.S. surpassed a record 100,000 overdose deaths in 2021, leaving communities across the country desperate for new solutions.
"Not just in New York, but in many cities there's been a groundswell movement to try to open sites," says Sarah Evans, division director, drug policy, global programs at Open Society Foundations. Other hotbeds of SIS advocacy include Baltimore, Denver, Ithaca, NY, Philadelphia, and San Francisco, according to Evans, who previously spent a decade managing North America’s first SIS, Insite in Vancouver. As for why the approach is so compelling right now, experts point to their capacity to save lives.
“There's never been an overdose death that has occurred within one of these consumption sites. That's really powerful,” says Barrot H. Lambdin, a senior epidemiologist and implementation scientist in RTI International’s Behavioral Health research division.
Lambdin has been involved in several years of research from an unsanctioned SIS, which opened in 2014 in an undisclosed urban location in the U.S. Led by an unnamed community-based organization, the site has trained staff to monitor sterile injections but lacks any official authorization. A 2022 study demonstrated how the site reduced hospitalizations and emergency department visits and helped providers intervene before problems (like abscesses) became life-threatening.
Opponents of SISes sometimes cite a lack of research from within the U.S. But compared to studies done abroad, research at the unsanctioned site has produced “the same types of results,” says Lambdin; the 2022 study’s findings supported the use of SISes to reduce the burden on the health care system. “There’s really nothing unique about our context that would suggest that it wouldn’t work here.” While the U.S. medical system does pose distinct challenges, Evans points out that evidence for the effectiveness of safe consumption has come from a variety of places. Nearly 200 SISes exist across 14 countries, and meta-analyses of multiple sites show that they don't increase drug use in neighborhoods or fuel crime, according to Evans.
Still, harm reduction proponents in some conservative states have faced pushback in recent years, including opposition to needle-exchange services in North Carolina and West Virginia. And in New York City, neighborhood groups have complained that East Harlem already has too many social and health services, while Washington Heights city council member Carmen De La Rosa has described a lack of community outreach to locals. Given the decades-long War on Drugs, which concentrated open-air drug use in disadvantaged areas, their hesitation to sanction drug use is understandable. But community approval tends to grow the longer the site is open, according to Evans, who experienced as much at Insite, “because in fact, it makes the neighborhood more stable.”
The Prospects for Supervised Injection Sites Beyond New York City
The proposed New York State legislation would let local jurisdictions choose to allow supervised injection and get government dollars for those services (New York City’s sites rely on private donations). But the bill’s passage would not necessarily pave the way for sites to open statewide. Organizations would still need approval from local leaders and law enforcement – an uphill battle in certain communities “given the conservative nature of upstate,” says Barry. Moreover, nonprofits may lack enough staff to provide safe consumption services. “It is a great idea and I would love to do it, and nobody wants to give me any money to do it. And the resources that I currently have are stretched to the breaking point,” Barry says.
In Sullivan County, NY, which has the highest rate of overdose deaths of any county statewide, the lack of health care services overall could prevent an expansion of harm reduction services, according to Patricia Strach, PhD, a SUNY Albany professor and a Fellow at the Rockefeller Institute of Government. “They certainly don't have the doctors talking about harm reduction just because they don't have the doctors in general,” she says. Sullivan County ranks 61 out of 62 counties statewide in quality of health. The issue has been drawing more services and political attention recently, however. In April, a new harm reduction program led by Hudson Valley Community Services expanded to Sullivan County, and Sen. Chuck Schumer proposed a plan aimed at combating overdoses in Sullivan County that includes funding for harm reduction.
Meanwhile, other states and cities in the U.S. are pushing ahead with efforts to open their first supervised injection sites. A bill that would allow several California jurisdictions to authorize safe consumption sites passed a California Assembly committee on June 1 and is headed to the full Assembly. The Philadelphia organization Safehouse is in talks with the Department of Justice that could lead to a SIS opening. Rhode Island became the first state in the U.S. to legalize supervised injection in July 2021 and has begun working toward opening its first site.
But all this momentum hasn’t come without costs.
“Sadly, I think it has taken the holes in people’s hearts from grief and loss – and lots of education and public awareness – for us to get to this moment,” Budnella says.
