Behind supervised injection sites: A controversial solution to overdose deaths

Drug overdose deaths are up by more than 40% over the past two years.

In an effort to reduce overdose deaths, more than a dozen countries around the world have opened supervised injection sites. Advocates say they more than work.

"Fears we had that this might draw drug dealing to a community, you know the research we have to date says that that turns out not to be the case," Peter Davidson, associate professor in the Department of Medicine at UC San Diego, says.

But there are only two sites in the U.S. — both in New York City.

"We have to do something better," Ronda Goldfein, co-founder of Safehouse, says. "To lose more than 100,000 Americans in the last 12 months from overdoses, and not to say, What can we do better?"

Today, On Point: A controversial solution to overdose deaths.

Peter Davidson, associate professor in the Department of Medicine at UC San Diego. Co-author of Evaluation of an Unsanctioned Safe Consumption Site in the United States.

Ronda Goldfein, co-founder of Safehouse, a non-profit focused on overdose prevention in Philadelphia. She’s also the executive director of the AIDS Law Project of Pennsylvania.

Syderia Asberry-Chresfield, co-founder of the Greater Harlem Coalition.

John Lally, his son Tim died of a heroin overdose in 2016.

KIMBERLY ATKINS STOHR: On June 17th, 1971, President Richard Nixon gave a historic speech that set the country's drug policy for decades to come.

RICHARD NIXON [TAPE]: America's public enemy No. 1 in the United States is drug abuse.

ATKINS STOHR: It was the start of America's so-called war on drugs. Just two years later, the Nixon administration created the Drug Enforcement Administration, a law enforcement agency charged with targeting illegal drug use and distribution. In the 1980s, amid public concern about a surge in crack cocaine, the Reagan administration expanded the war on drugs even further. The focus was put on criminal punishment over treatment or rehabilitation.

In 1986, President Reagan signed the Anti-Drug Abuse Act, which upped mandatory minimum sentences for various drug offenses, and created the so-called crack house statute, making it a federal felony punishable up to 20 years in jail for operating a space or building that allowed illegal drug use.

RONALD REAGAN [TAPE]: Drug use is too costly for us not to do everything in our power, not just to fight it, but to subdue it in concrete. The magnitude of today's drug problem can be traced to past unwillingness to recognize and confront this problem. And the vaccine that's going to end the epidemic is a combination of tough laws like the one we signed today and a dramatic change in public attitude. We must be intolerant of drug use and drug sellers.

ATKINS STOHR: Meanwhile, that very same year over in Europe, Switzerland was having a growing drug problem as well, but policy makers were doing the exact opposite. Instead of becoming more intolerant of drug use, they were becoming more tolerant.

NEWS BRIEF [TAPE]: Around 100 people every day use this drug consumption room. They buy their own drugs on the black market and can take them inside without fear of arrest by the police.

ATKINS STOHR: These drug consumption rooms, also known as supervised drug injection sites, are places where drug users are supplied with clean needles and can use illegal drugs under the supervision of medically trained professionals. The goal is to prevent drug overdose deaths and reduce the spread of HIV. Switzerland was the first country to try this.

And at the time, it was a pretty radical idea that some thought would encourage drug use. But in the years that followed, the opposite happened. Between 1990 and 2002, the number of new heroin users went from 850 to 150. Between 1991 and 2004, the rate of drug related deaths declined by more than 50%. And within ten years, levels of new drug related HIV infections were eight times less. And by 2010:

AMBROS UCHTENHAGEN [TAPE]: About 70% of our injectors are in some kind of treatment.

ATKINS STOHR: That's according to public health and addiction professor Ambros Uchtenhagen of Zurich University. Meanwhile, in the U.S., overdose deaths kept going up and up from 1979 to 2020. Overdose deaths doubled every eight years, and incarcerations for nonviolent drug offenses soared from 50,000 in 1980 to 400,000 in 1997. And those most impacted by this were Black and brown communities. Outside of the U.S., other countries began to open supervised injection sites, including Germany, in the mid-1990s, Spain in 2000, Australia in 2001, and then Canada in 2003.

MARK TOWNSEND [Tape]: This room is the only thousand or so square feet in the whole of North America where you can legally inject heroin or cocaine in a safe way.

ATKINS STOHR: That was Mark Townsend, co-founder of Canada's first supervised injection site in Vancouver. These facilities have been studied quite exhaustively over the past two decades. A 2014 review of 75 studies concluded that such sites promote safer injection conditions, reduce overdoses and increase access to health services. But here in the U.S., the idea has met with strong resistance. There are only two officially sanctioned, supervised injection sites in the entire country, both in New York City and less than a year old.

And just last month, California Governor Gavin Newsom vetoed a bill that would have allowed Los Angeles, San Francisco and Oakland to open sites as part of a pilot program. It's the second time such a proposal has been vetoed in the state. So today, why is a public health tool that has been deemed effective so controversial in the U.S., even in a state like California? Joining us today is Peter Davidson.

He's an associate professor in the Department of Medicine at UC San Diego. He studied opioid overdose prevention since 1997. Peter is joining us from San Diego. Welcome to On Point, Peter.

PETER DAVIDSON: Hello. Happy to be here.

ATKINS STOHR: So you have personally researched sites like this. What have you found?

DAVIDSON: Basically, we were interested in seeing if all the research from elsewhere in the world played out similarly here in the United States. You know, as we all know, there's some differences between the U.S. and places like Canada. And when we had an opportunity to study a site that was up and running here in the U.S., we basically jumped at it to look at things like, What was the impact of that site on crime rates in the surrounding neighborhood? What was the impact on reducing overdose deaths among the people who use the site, and other outcomes like that?

ATKINS STOHR: And how did this underground site come about?

DAVIDSON: Basically, a small community-based organization that was already providing the services to people who use drugs were seeing many, many of their services as diverse. And when they looked around, they saw safe injecting facilities or overdose prevention sites in Canada and elsewhere in the world. And they said, we really need that here. And if we wait for the legal legislative process to grind its way through to allowing us to do that, everyone we serve will be dead by then. So they made the decision to just open the facility.

ATKINS STOHR: And in your study of this, did it track with what the results in these other countries were finding?

DAVIDSON: Basically. I mean, it's a fairly small site. It only serves about 50 people at a time, partly out of concerns for the legality. But we saw crime rates in the neighborhood around the facility actually decline somewhat, to our surprise. And we saw them save hundreds of people's lives by intervening successfully in overdose events. And we saw people being connected to drug treatment and other positive health outcomes like that. So, yeah, basically all the research said this works the same here as it does in other countries.

ATKINS STOHR: So why do you think it has taken so long to get the sites like the two that just opened in New York City up and running here in the United States?

DAVIDSON: I think there's a lot of reasons for that. I mean, the big legal one you mentioned in the beginning of your show, the federal crack house statute. You know, on the face of it, that seems like a bit of a a solid impediment to anyone opening one of these facilities. There's also a lot of stigma around people who use drugs in this country. And it makes people, it makes policymakers reluctant to sort of leap in and do something controversial.

And finally, we've got a huge amount of inertia in the way that we deal with drug use in this country. You know, as you said, President Nixon declared the war on drugs in 1971 and would set up a lot of infrastructure, and a lot of things oriented towards that very specific way of dealing with drug use. And turning that battleship around on a new course is a little bit difficult.

ATKINS STOHR: And so in recent years, we have seen an increased focus here in the United States, particularly on the growing opioid crisis. And Rhode Island legalized safe injection sites in July of 2021, the only state to do so. And that state is planning to open sites soon as a pilot program. And as we mentioned earlier, there are the two sites in New York City. Now, two sites may not seem like a lot. But for advocates who have been fighting for these sites, it is a big deal. Peter, why do you think there is this shift, even if small, in U.S. attitudes in terms of opening these sites?

DAVIDSON: I think a number of things have happened across the last decade or so that have made this more palatable. And unfortunately, probably the biggest one is just the opioid crisis has gotten worse and worse. And it went from being perceived as something that only really affected poor people of color, and in the city areas, to something that affects pretty much everyone in the United States in some way, shape or form. You know, most people know someone who has been affected by opioid use, and that makes pragmatic approaches to dealing with it much more palatable, when you're thinking about people you know and you love, who need a service like this to stay alive.

ATKINS STOHR: And is it the criminality that has changed as well? We have seen in some states and localities an effort to decriminalize the use of drugs as opposed to other things, distribution and other things. Do you think that is making it easier for sites like this to open?

DAVIDSON: Yeah, definitely. I think, you know, people are looking around very carefully. If, you know, they're seeing an incredible number of people dying in their communities, and they're looking very hard at what the alternatives are to the way we currently do it. And that's led to the ... kind of openness to at least considering and piloting things like overdose prevention sites or safe consumption sites.

ATKINS STOHR: Now, there's still a lot of people and policy makers in the United States that are opposed to these sites. It continues to be a campaign issue, as we go into elections with people on both sides of this. As a researcher, what pitch would you make to policymakers in the United States when it comes to convincing them that these sites are worth trying?

DAVIDSON: I would say fairly simply that tens of thousands of your own constituents are suffering from this epidemic and are dying because of this epidemic. And we have an intervention which has been well tested around the world, and even well tested in the United States. That works for reducing deaths and for increasing access to drug treatment. And if you care about your constituents in the community that you serve, you should be willing to at least try one of these in your community.

If you care about your constituents in the community that you serve, you should be willing to at least try one of these in your community. 

ATKINS STOHR: In November of last year, New York City opened up two supervised injection sites, one in Washington Heights and one in East Harlem. The only two sites in the entire country, according to the organization that runs these sites, On Point NYC. No connection to this program, they prevented over 390 potential overdose deaths through August of this year. And that alone decreased public drug use.

But many in the local community are not happy to have the facilities in their neighborhood. Syderia Asberry-Chresfield is co-founder of the Greater Harlem Coalition. She lived in Harlem for more than 30 years, and she says one of the biggest problems she has with the site is that the community was never given a chance to have a say.

SYDERIA ASBERRY-CHRESFIELD: We were in an uproar because the commissioner had just gone to community board 11 a week before to say that they were just considering placing one of these sites in Harlem. They never said where. They just said that they were considering it. And then one week later, they had their opening. So Harlem has always been in the dark about what's going on. No one has ever asked us, what it is that we want. They just dump on us.

ATKINS STOHR: Syderia says 20% of the city's drug treatment facilities are in East and Central Harlem, despite making up only 3.5% of New York City's population. She says her neighborhood, which is predominantly Black and brown, is, quote, oversaturated with drug treatment facilities.

ASBERRY-CHRESFIELD: And when we look at the statistics of who's using drugs, it's equal across the board. Black, brown, white are all using at the same pace. So why are they in Black neighborhoods?

ATKINS STOHR: She says, according to the statistics, people are coming from all over the city and beyond to use these facilities. As a result, Syderia says crime in her neighborhood is on the rise.

ASBERRY-CHRESFIELD: There are more robberies. There are more items being stolen from the local stores. We now have police officers that are stationed in front of some of the retail outlets because people just run in, grab as much as they can, and then they just run out. And then we have local restaurants that have closed. There are people that are using our staircases as bathrooms. I mean, we've never had this type of problem ever. In the past 30 years I've been here, we've never had this type of problem.

ATKINS STOHR: Syderia isn't necessarily opposed to supervised injection sites in New York City, but she is definitely against them in Harlem.

ASBERRY-CHRESFIELD: If you really want to do some justice to the people in the community for our users, then make it fair. Put these facilities throughout New York City. And why do they have to be in a specific community? Why can't they be located in hospitals? Why can't they put them in City MDs? You know, there's no reason to oversaturate a community with a service like this.

ATKINS STOHR: That was Syderia Asberry-Chresfield. She's the co-founder of the Greater Harlem Coalition, and lives just blocks from one of only two supervised drug injection facilities in the country.

Under the Trump administration, it became pretty clear that the federal government did not support the opening of these so-called supervised drug injection sites. Here's former U.S. Deputy Attorney General Rod Rosenstein in an interview back in 2018.

ROD ROSENSTEIN [TAPE]: I'm not aware of any valid basis for the argument that you can engage in criminal activity as long as you do it in the presence of somebody with a medical license.

ATKINS STOHR: Rosenstein said, In any city or town planning to open one, they should understand it is against federal law. And a federal prosecutor might go after them. And that's exactly what happened on February six, 2019. U.S. attorney William M. McSwain sued the nonprofit Safehouse for trying to open a supervised drug injection site in Philadelphia.

WILLIAM McSWAIN [Tape]: Normalizing the use of deadly drugs like heroin and fentanyl is not the answer to solving the opioid epidemic.

ATKINS STOHR: Safehouse is still wrapped up in a legal battle with the federal government. And as a result, has yet to open one of these sites. I want to introduce Ronda Goldfein. She is the co-founder of Safehouse, the nonprofit in Philadelphia that was sued by the federal government for trying to open up one of these drug injection sites or overdose prevention centers. She's also the executive director of the AIDS Law Project in Pennsylvania. She's joining us from Philly. Welcome to On Point.

RONDA GOLDFEIN: Thank you, Kimberly.

ATKINS STOHR: So start off by telling us why Safehouse wanted to open up these sites in Philadelphia in the first place.

GOLDFEIN: You know, we see increasing overdoses in Philadelphia and in the nation. We looked at the literature across the across the world. You know, we've heard these sites have been in operation, some version of them for 30-plus years, and they work. You know, it's an evidence-based initiative. And so we thought we're seeing so much death in the streets in Philadelphia, we have an idea that this can make a difference.

We also had an idea that the city would support us. Because they convened a task force, thought that it was worth trying, and announced that they would support and encourage any provider that tried to open up a site. So we thought, this is our opportunity. We should do this.

ATKINS STOHR: And what response did you get from community members when you were contemplating doing this?

GOLDFEIN: No community can be defined broadly. So overwhelmingly tremendous support. Lots of loud opposition, sure. I think that people are so afraid of a new initiative, or in some areas feel that their neighborhoods are so saturated, that they're so angry that they can't hear that we're offering a potential solution. For the folks who don't want to see consumption outside, we're saying, Well, bring it inside. For folks who don't want to see drug related litter outside, We'll bring it inside. The idea is to try something different.

ATKINS STOHR: And as you heard earlier from Syderia, she has a site open in her neighborhood in Harlem, and she's not happy about it. How should these centers address concerns from the community like her, to make sure they're not just providing the service to the people who need them, but also that this can benefit the community.

GOLDFEIN: I mean, I think that outreach to the community is always essential. And we want, in Philadelphia, we want to hear what people have to say. We want to have productive conversations. And I think in any setting that that can happen, we can listen to people's concerns. We can address their concerns with how it will be handled.

ATKINS STOHR: And Peter Davidson, what has your research told you about the interplay between these safe injection sites and the communities in which they exist?

DAVIDSON: I think the typical path is that there is almost always initially some concern. When you talk about opening one of these facilities, it's just the same as a facility serving any stigmatized population. We see it with facilities, too, to deal with mental illness. We saw it back in the '80s and '90s with facilities to provide care to AIDS patients. And we certainly see it with any facility providing services to people who use drugs.

But I think what the research consistently shows is if the operators of the site are very communicative with the community around about what they're doing, why they're doing it, and there's some parts of the community that come to them and say, hey, this is the side effect that's happening and people work together to address it. Then it tends to work extremely well. I would also agree with Syderia that only having one or two of these sites and having them be fairly large sites is not necessarily what the research suggests.

Increasingly, countries like Canada, instead of just having one or two big sites, have lots and lots and lots of little sites that just serve small numbers of people, which reduces any of the kind of community impacts that she's talking about and also provides much better access to people all through the community who need this kind of service.

ATKINS STOHR: Ronda, I want to ask you about that point, too. Walk us through how you thought about how big the facility would be, exactly where it would be located, and whether there could be more in other parts.

GOLDFEIN: Well, we see this as a city-wide problem in Philadelphia. And certainly our intentions are to make these services available to people in need, but also not to be the one site. I agree with the comments that just one site doesn't address a city-wide need. I think we have to have those difficult conversations about how we provide services to people who use drugs. I was struck by the quote from President Reagan at the beginning that he talked about, you know, the war on drugs and continuing the war on drugs as a past unwillingness to confront tough problems. But that's where we are right now. We have a whole lot of tough problems and we need to talk about it so we can address them throughout the city and provide some relief.

ATKINS STOHR: And what, Ronda, has been the response from law enforcement to the potential of these sites opening in Philadelphia?

GOLDFEIN: We've had overall a favorable response from law enforcement. I think that after so many years of seeing people suffering with drug use, that law enforcement recognizes that locking people up, holding them for some period of time, forcing them into withdrawal only for them to be released to the streets and be at higher risk of a fatal overdose. That's not how we're solving the problem.

The mantra is, you know, we're not going to lock this up. We're not going to arrest away the problem. And so I think that folks who are looking at this in a meaningful way say we must do something better. Here's an initiative that works. There isn't any reason to think that we can't make it work here, as well.

ATKINS STOHR: And the lawsuit that came from the Department of Justice. Was that expected, Ronda?

GOLDFEIN: Not completely unexpected, but it took us by surprise. I mean, no one wants to be sued, let alone by the federal government. But we thought now we will have a forum where we can talk about how our intended activities would not violate the federal law. The law prohibits maintaining a drug-involved premises for the purpose of use storage, transfer, sale, manufacture of drugs, controlled substances.

And we said, Oh, we're not doing any of that. We're maintaining a premises for the purpose of saving lives. And so we thought that we were in the right. We believe we were in the right. We won in the first level in the federal district court. We lost at a subsequent appellate level, and we have been remanded back to court on some of the other remaining legal issues.

ATKINS STOHR: Peter Davidson, how can policy-makers, experts like you, lawmakers, work together to carve out a space for this?

DAVIDSON: I'm not even sure we need to carve out a space. I mean, the federal crack house statute is pretty clearly intended to stop the criminal exploitation of people who use drugs in search of profit. What these facilities are is a public health intervention to deal with a public health emergency. And even though there's some superficialities that, you know, we really don't think the federal crack house statute even remotely applies to this kind of facility. And I think some acknowledgment of that on the part of policymakers would be all that would be needed for other places to be much more willing to just try and do this.

ATKINS STOHR: Ronda, the DOJ mentioned that they are seeking some sort of guardrails for sites like the one you are proposing. Can you tell us what you think they might propose, and if there is some way to to find cooperation here?

GOLDFEIN: We are still in conversation with the Department of Justice about what those guardrails and what a settlement would look like. So I can't go into too much detail, but I can say that we understand that for a site to be effective, it has to be low barrier. There's no point in creating a program that the eligibility requirements are so high that they can't be used. And so we're optimistic that the Department of Justice, that Safehouse and that advocates nationally want the same thing, safer sites where people can use in a non-judgmental, in a trusting way and then make their own decisions about what's next. And maybe that will be treatment. Maybe it will be staying alive until they're ready for treatment. But we remain optimistic.

ATKINS STOHR: There are a lot of people who, even if they support the idea of having a safer place for people to use drugs, that they fall short of actually endorsing that as a policy matter. What pitch would you make to them about the need to have these in communities throughout the country?

GOLDFEIN: My pitch would be similar to Peter's. We have to look at the number of lives lost and we have to do better. We have a very good evidence based initiative in front of us, and there's no reason to not try that. I mean, we can continue the war on drugs and we see it hasn't worked. We flood the streets with Narcan. We saturate neighborhoods with treatment centers. But that's not working. So we need to look at initiatives that do work. And all the evidence suggests this does work.

ATKINS STOHR: And Peter, if Safehouse is ultimately successful with this lawsuit, in that there is a way for it to open, with the blessing of the DOJ, what significance would that have for other jurisdictions thinking about opening similar sites?

DAVIDSON: I think any jurisdiction that successfully opens and operates one of these facilities sort of basically sends a message to the rest of the country that, look, the sky didn't fall. And people's lives are being saved, that the feds didn't come and arrest everyone. You can do this, too. There was a half joke for several years that everyone was racing to be second on this, because they wanted to see what happened to the first people to open. And now New York has done that, and the sky hasn't fallen and they've saved 300 and something lives. And let's move forward and carefully try this in other places and carefully look for potential negative effects that need to be addressed. But let's just do this.

ATKINS STOHR: And Ronda, in just a few seconds before a break, are you looking to be that kind of model for other jurisdictions?

GOLDFEIN:  We're hoping that we can reach an agreement that will provide federal authority for any jurisdiction that wants it. But while still supporting folks that just say time is now when we're opening.

ATKINS STOHR: I want to bring in now the perspective of John Lally, an On Point listener from Ellington, Connecticut. He's a retired psychiatric nurse practitioner who's worked in addiction and mental health for 34 years now. He called to tell us about his son, Tim, who he lost to a heroin overdose in 2016 when Tim was 29 years old.

JOHN LALLY: The sad part is he had gone through treatment very recently and was doing better, and was living in what we call a sober house. But he relapsed. For some reason he knew that he felt the need to, and he relapsed and they kicked him out. Someone took him in and let them stay in their basement. But my son, because of the stigma and shame he felt, my wife and I would have taken him home until we can get him back on track.

But he was too ashamed and felt like a loser, which ... is part of the stigma of drug use. And people feel like, you know, they're worthless people. And he started to believe that about himself, and was too ashamed and embarrassed to tell his mom and I that he had relapsed. And so he was living in this guy's basement. And unfortunately, he was alone when he took that last dose.

ATKINS STOHR: When Tim died in 2016, there wasn't a single safe drug consumption site in the country. So John can't help but ask.

LALLY: Would my son be alive today? Possibly. That final dose he took, if that was in a safe consumption site, he would have lived through it. No one has ever died in a safe consumption site. It's 100% safety, as far as overdose deaths go. You know, he didn't want to die from this. He struggled with his addiction. He went through treatment a couple of times, and he felt good when his mind was clear. But like opiates often do, they sneak up on you again. And the addiction sneaks up and the cravings come back and the person finds himself in a relapse before they even realize it. So we want to keep them alive until they can get treatment. That's the point.

ATKINS STOHR: John said his son Tim struggled with depression and anxiety since high school. They tried many psychiatrists and therapists to treat his mental health, but nothing worked until he had his first dose of opiates. So he self-medicated and eventually he turned to heroin. From there, it became an addiction and something his son tried desperately to beat. He just needed more time, John says.

LALLY: And people say reducing harm is wrong. It's [the attitude of] you need to let people reach rock bottom. I'm sure we've all heard that. To me, that's the most ridiculous idea, because for my son, rock bottom was his death. Should we have not done anything or wait until he hits rock bottom? People who struggle with addiction, you can't tell what it's going to take for them to find the way internally and externally to make the changes that they need to do. So we need to be working with them all through the way.

ATKINS STOHR: John knows there are a lot of people out there who don't support these safe drug consumption sites. His pitch to them is simple.

LALLY: Think about this, if this was your child, if this was your child, if this was your wife, your spouse, and they were going to use a drug despite the fact that, you know, it's not good for them. But they were going to use it, would you rather them chance using alone and dying, or have a place where if they're going to use someone was there to save their life?

ATKINS STOHR: That was John Lally. He lost his 29 year old son, Tim, to a heroin overdose in 2016. It was just five days before Tim's 30th birthday. Ronda, I want your thoughts hearing this story from John.

GOLDFEIN: You know, it's heartbreaking. And my sympathies go out to his family. You know, we hear a lot from a lot of parents, a lot of family members who have lost a child, lost a loved one, and say if only there had been a supervised site my child could use. And I'm always surprised by that, not because I don't believe it could have saved them, but that we don't see parents saying, okay, I've had enough of all drug related things. I don't want to think about this anymore. They're digging deep on their pain and saying, no, we have to spare someone else from experiencing that. And that's what we're looking at with the Overdose Prevention Center we hope to open in Philadelphia. Despair someone else that pain, but to also give somebody an opportunity to get back on a better path, a path of their own choosing.

ATKINS STOHR: And Peter, it seems that perhaps policymakers who oppose these are expecting something different from these sites. So as a researcher, what do you see as a fair measurement of success of these sites? Something that policymakers can look at when they're making their decision about whether it is right or not for their communities.

DAVIDSON: I think the simplest measure is just how many dead people do you have in your community? I mean, I think your listener and his heartbreaking story are sort of really indicative of exactly who these sites are designed to serve. And opioid use is very similar in a way to tobacco use. You know, we all know people who've attempted to commit quit using tobacco. And almost no-one is successful the first time, it usually takes multiple attempts to finally succeed. And these sites help both keep people alive while they're still using. They keep reconnecting them to treatment, and they keep providing more support and a sense of humanity while they're in that place. And increase the likelihood that someone will get through all of this and be alive at the end of it as well.

ATKINS STOHR: And Peter, you mentioned smoking. I think in this case, people, particularly people who use opiates, have a much different stigma attached to them than people who say smoke or excessively drink alcohol. How do you think the stigma affects the policy here?

DAVIDSON: I think the stigma affects both policy and the risk of death. Like if you're using opioids around other people and you overdose, there's someone there to go that doesn't look right, and call 911. But when people, as your listener said, are feeling ashamed because they've relapsed or ashamed just because they're using this hyper stigmatized drug, they're much more likely to use alone. And if they do overdose, they're much more likely to die as a consequence.

And that stigma also affects policymakers. You know, they think, oh, well, those people are worthless or those people are never going to recover. Why should we put all this effort or political capital into doing something to just keep them alive a little bit longer? But we know that 90% of people who use opioids will stop using opioids at some point and go on and have normal, productive lives. And our job is to not let them end up at the medical examiner's office.

ATKINS STOHR: Ronda, explain how you address that issue, the stigma that is associated, particularly with opioid use.

GOLDFEIN: You know, among the reasons why we have pursued a legal path, I mean, we were bit forced into it because we were sued. But we have looked to have an agreement with the federal government is a hope of reducing the stigma. You know, if we can have policymakers say, no, this is this is a medical condition, we're going to provide a health care initiative, we believe, that will ultimately reduce the stigma that people are facing.

ATKINS STOHR: Ronda, how might a change in stance at the federal level from the federal government affect the situation, beyond just the fact that you are still in ongoing litigation with the federal government? But if overall, the messaging from that level changes on safe injection sites?

GOLDFEIN: We're hopeful for a collaborative response from the federal government ... that they listen to Dr. Gupta's words, which sure I would have liked to hear him say specifically. Yes, go ahead, open them. But the fact that he talked openly about harm reduction and about embracing that, I think that's important. I think that's where the shift needs to occur and it's refreshing.

For so long, we have heard, you know, this rhetoric about, Why do people use drugs? Let's do this extensive analysis and think about how we can change that behavior. Different from, Let's try to save their lives today. And so I think this is all movement in the right direction. And I think that there is a momentum that can be felt that, you know, we saw it in Rhode Island, our brave colleagues in New York. I think we are on the right path. We just have to get there a little bit more quickly.

ATKINS STOHR: And the current two sites in New York City have not resulted in any prosecutions during this current administration. I know your civil lawsuit is going on, but they have not resulted and they have not prosecuted anyone for opening these two sites. Ronda, is there a concern on your part that a change of administration in 2024, if it happens, could put these sites in jeopardy?

GOLDFEIN: I'd like to see us have an understanding in place, an agreement in place so that the folks in New York can continue to operate without fear. We can open in Philadelphia without fear. Anyone else who wants to open out of the shadows can do so without fear, and that in the event there should be a change of administration, I'm counting on folks like Peter to collect so much good data that it would become impossible to shut them down should there be a change of heart.

ATKINS STOHR: And Peter, talk about how changes in policy can affect the situation on the ground. For example, there have been changes in terms of recognizing the legality of marijuana use in the states that have chosen to do that. The federal government has flip flopped on that based on who is in office. Talk about the impact that has on drug policy.

DAVIDSON: Marijuana is a really good example. You know, states like California have authorized at the state level commercial operators, operating spaces where people can come and consume marijuana. Marijuana is still a schedule one drug. So here is a facility in which people can come and use the schedule and drug. We're proposing the same thing in a way for a completely different reason. We're proposing that facilities be opened and carefully evaluated so that people can use other Schedule one illegal drugs more safely. .... If there's a few dozen or even a few hundred of these operating successfully around the country, and we have data saying that they reduce deaths and don't cause harm to the surrounding community, at that point, I think it doesn't really matter who's in power at the federal level, that it will just become standard of care.

ATKINS STOHR: And Peter, in Canada, they have not only had these supervised injection facilities for nearly 20 years, but they also now provide fentanyl to people at these sites to ensure the supply is safe. How much of an impact, in addition to accepting these safe consumption sites, if that happens in the U.S., what impact could that have?

DAVIDSON: The Canadians are providing heroin or diacetyl morphine and hydrocodone, I think, to people in order to get around the problem that the drug supply at the moment is basically contaminated with fentanyl. You know, we've handed over control of the manufacture and distribution of drugs to organized crime, which, you know, usually is not a good thing.

And they, following the example of the Europeans 20 or 30 years ago, have found that actually just providing people with pharmaceutical grade opioids reduces the chance of overdose in the first place and certainly reduces the chance of overdose death. That is something they could conceivably try here in the United States. So I think that's another big policy step forward that I don't expect to happen soon.

ATKINS STOHR: Ronda, how much do you think is riding on these two sites in New York City to do well before other sites can open throughout the country?

GOLDFEIN: You know, the folks at On Point, the sites were brave and open because they couldn't stand to see any more death in their community. I don't want to put more pressure on their backs, but I think that they're doing a tremendous job. Their data to date has shown that they're saving lives and there have been no adverse consequences. I think that people will operate based on what's best in their jurisdiction.

You know, the folks in California, at various places, people will operate sites based on what's best for their jurisdiction, and what will fit in their community. You know, in Philadelphia, I hope that a site that has federal approval, people will be encouraged to come. Maybe in more rural areas, there will still be a need to keep things discreet. But I think overall, we keep sending the message that this works, we can save lives. And I think in the end, even the detractors agree, we don't want to see people die unnecessarily. We just have to get to the path to save them.

ATKINS STOHR: And, Peter, the solution to the epidemic of overdose deaths has to be as complex as the problem itself. What else do you think needs to happen besides legalizing safe consumption sites to help combat this problem?

DAVIDSON: I think a whole bunch of things happen. I mean, we've already addressed to some degree over-prescription of opioids in the community. I think the other really big thing is moving to a more consistent focus on evidence based treatment. There's many forms of treatment, both available in the United States. But the most common ones are ones that don't actually work particularly well at the moment.

And so sort of focusing on funding and expanding access to evidence based treatment is probably the other big thing, like so that people have somewhere to go after they've been using a safe consumption site for a while. When they've decided, I've had enough of this and I am ready to stop.