Rogue public health workers in an unnamed U.S. city are operating a space where injection drug users can safely inject their drugs under medical supervision. Even under its unsanctioned status, the site is showing public health benefits.

It’s Time to Bring Supervised Injection Sites Above Ground

In 1986, at a community HIV prevention meeting in New Haven, Connecticut, an injection drug user spontaneously brought a bundle of clean syringes to freely hand out. By this time, the correlation between injection drug use and HIV had been made. This gave Jon Parker, a former injection drug user hosting the meeting, an idea.


Parker knew that community programs that distributed clean syringes in Europe had been having success at preventing HIV transmission. But in the U.S., the notion of giving drug users sterile instruments to inject their drugs was met with resistance by both high-ranking government officials as well as local community leaders. From their perspective, supporting what became known as needle or syringe exchange programs also meant supporting — or even encouraging — injection drug use. Government funds couldn’t go near such heresy, despite evidence showing that such programs do not increase drug use.

Fed up with watching members of their community wither away from a preventable illness, Parker, along with other activists and injection drug users, went rogue by starting one of the first underground syringe exchange programs on U.S. soil. They refused to wait idly while local public health departments hammered out the law and politics. There was no time to waste.

The same brave work is being done today. Only instead of distributing clean syringes, which is status quo in most major cities now, public health workers and harm reductionists in an unnamed U.S. city are operating an illegal, unsanctioned supervised injection site: a space where injection drug users can safely inject their drugs under the watch of medical professionals. Even under its unsanctioned status, the site is showing public health benefits, according to a qualitative study published in late December in the International Journal of Drug Policy.

It’s time to bring this site, and possibly other secret sites on U.S. soil, above ground.

In 2016, over 60,000 people in the U.S. died from drug overdoses, according to the Centers for Disease Control and Prevention. For context, that’s more people dead than during the peak of the AIDS epidemic in 2005. Having reported on the overdose crisis for years, I fear these deaths aren’t being comprehended. These aren’t just numbers from a government report. Just two weeks ago in Chicago, my friend Mike, a 27-year-old getting his master’s in social work at the University of Chicago, died from an overdose. He’ll be counted as one among tens of thousands who died in 2017, which is expected to surpass the death rate from 2016.

What if Mike wasn’t alone? What if he had a space to safely use? A space where he wasn’t judged and shamed; a space where he could talk about why, after years of recovery, he went back to the needle?
The opioid crisis is indeed the AIDS epidemic of our time. People from all walks of life are dying preventable deaths — more than 100 every day — at the peak of their lives. And yet, just as with the AIDS epidemic, the government has been slow to implement public health policies that could save these lives. And as with syringe exchange programs, government officials and community members fear that supervised injection sites will encourage people to use drugs. This is despite dozens of empirical evaluations of over 100 supervised injections sites across 10 European countries showing that these spaces save lives, reduce public injection, and function as a gateway to other vital services, including addiction treatment.

People opposed to supervised injection sites will often argue that Europe and America are too different, and that such studies are not relevant. But this is precisely what makes the work of Peter Davidson, Andrea Lopez, and Alex Kral — veteran harm reduction researchers — all the more novel. Since 2014, they’ve been collecting survey data from users of an unsanctioned injection site in the United States, and they’re finding similar results as studies in Europe.

“One of the things that came out of these interviews over and over again was the enormous relief of not having to shoot up in public, possibly in front of kids,” said Davidson, who is the lead author of the new qualitative study — the second of two studies on the unsanctioned site.

“Everyone was enormously grateful that this place existed,” he added, “and there was a fairly strong sense of protecting this place and the people who are sticking their necks out providing it.”

Interviewees also discussed relief from what’s called the “micro-risk environment,” Davidson told me. That means “being able to do the things you need to do in a clean, well-lit space where you’re not rushed makes a massive difference,” he said. “Lots of bad things happen when people are rushing shots, it can lead to soft tissue infections, which are fairly expensive to treat. So the financial impact is in everyone’s interest.”

That’s also what Sarah Mars, qualitative project director for a longitudinal National Institutes of Health/National Institute on Drug Abuse study called Heroin in Transition (HIT), said about supervised injection sites. She called them a “win-win for all members of the community.”

Along with Dr. Daniel Ciccarone, principal investigator on HIT, Mars and her colleagues study the heroin market in various urban hotspots. “Our research among injecting heroin users on the East Coast has shown an intense awareness of overdose as an imminent threat due to the highly unstable adulterated supply,” Mars said. Supervised injection sites, she added, “offer some protection from these risks.”

The number one driver of overdose deaths in America isn’t prescription painkillers or even heroin; it’s illicitly manufactured fentanyl, a super-potent opioid several times stronger than heroin. Ciccarone has told me that we’re no longer in the midst of an “opioid epidemic,” so much as what he calls a “poisoning crisis.” The heroin supply is more dangerous than it’s ever been, which makes the need for safe injecting spaces all the more urgent.

There are glimmers of hope. Harm reduction activists in cities across the United States are fighting hard for supervised injection sites in their communities. “We’re feeling very optimistic about our progress in Denver,” said Kat Humphries, director of programs and data evaluation at the Harm Reduction Action Center. Located across the street from Colorado’s State Capitol building, Humphries and her colleagues distribute needles, naloxone, and other vital, lifesaving services to injection drug users in Denver. They’re trying to turn a storage room at their facility into Colorado’s first supervised injection site. Other cities, including Seattle and San Francisco, along with the state of Vermont, are in various stages of the legislative process for a sanctioned supervised injection site.

 “Most encouraging has been the outpouring of support from local businesses and organizations,” Humphries said, “who are taking a stand to provide people who use drugs a safe space to use and to prevent further public injection in their bathrooms and in other spaces like alleyways and parks.”

Despite conservative opposition, there are hundreds of syringe exchange programs legally operating nationwide. These programs exist because activists used data and told human stories showing their benefits. The fight for supervised injection spaces can be won using these tactics.

While morally entangled American policymakers debate the politics of saving human lives, rogue activists and researchers are busy saving them anyway.

Zachary Siegel is a freelance journalist covering public health and criminal justice. He is currently a Guggenheim Justice Reporting Fellow at John Jay College of Criminal Justice at the City University of New York.

Zachary Siegel is a freelance journalist living in Chicago. His work covering public health and criminal justice has appeared in WIRED, The New York Times Magazine, and The Atlantic, among others. He is currently a journalism fellow at Northeastern University’s Health in Justice Action Lab.