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Painted in bland neutral tones and outfitted in IKEA basic, the modest office space that opened last week in downtown Providence, Rhode Island, is almost self-consciously boring. Curious visitors might even mistake it for a dentist’s office.
That’s the idea. It’s a drug policy reformers’ version of a real-estate agent’s model home. It’s also a model of what an intervention that could help solve the U.S. drug overdose crisis, which killed a record 93,000 people last year—an increase of nearly 30 percent from 2019, according to preliminary data released last week from the CDC.
On July 7, Rhode Island became the first state in the U.S. to legalize “safe injection sites,” places where people can use drugs, with oversight from medical professionals trained to administer medicines like naloxone to reverse overdoses in case something goes wrong. There, users can also meet with case workers to connect them with services like housing and job training, no matter what happens.
Also known as safe-consumption sites or harm-reduction centers, roughly 120 such places exist in 11 countries throughout the world. Despite their rarity, the research shows they work. Overdose-related ambulance visits dropped by 68 percent and fatal overdoses dropped by a third in areas near North America’s first safe-injection site, according to a 2017 study published in the journal Canadian Family Physician. Another study, examining the efficacy of a safe-injection site in Australia, found opioid-related deaths decreased by 70 percent.
“What we know is that no one has ever died of an overdose in one of these facilities,” said Dr. Brandon Marshall, an epidemiologist at Brown University in Providence, who has studied the opiate crisis in depth. “It shows that an overdose death is entirely preventable.”
They work, and opiate users want them. But every attempt to open one in the U.S. over the past half decade has been met with stiff resistance, mostly—but not exclusively—from federal law enforcement.
Neither the Biden administration nor the U.S. Attorney in Rhode Island has made a public statement on the plans for the Providence site. Whether the government moves as aggressively now as it did under Trump is an open question. But the feds might not need to lift a finger; a revolt from noisy neighbors could spook city councils, local zoning boards, or planning commissions into rejecting a safe-injection site or banning them in their town or city outright—just as they’ve done to other, far less controversial innovations like legal cannabis dispensaries.
“The barrier to this is not the science proving that this is helpful,” said Dr. S. Bobby Mukkamala, an ENT specialist who sits on the American Medical Association board of trustees and chaired the AMA’s Opioid Task Force, which strongly supports safe-injection sites. “It’s the stigma associated with drug use and opiate use disorder.”
“What we know is that no one has ever died of an overdose in one of these facilities”
In 2018, the California Legislature authorized a pilot program in San Francisco—where, last year, drug overdoses killed more than three times as many people as the COVID-19 pandemic did. Following a threat from the Trump Justice Department, then-Gov. Jerry Brown vetoed the bill and put out a statement that dismissed safe-injection sites as “enabling,” while baselessly casting doubt on their efficacy.
After a Philadelphia nonprofit called Safehouse announced plans to open a safe-injection site in 2019, the Trump DOJ sued to stop it, arguing that harm-reduction centers violate a mid-1980s federal drug law nicknamed the “crack house statute.” A lower court sided with Safehouse, but after the feds appealed and the Court of Appeals for the Third Circuit ruled 2-1 in the feds’ favor in January. In their opinion, the justices noted that “Congress has made it a crime to open a property to use drugs.” After that, Safehouse gave up.
Rhode Island has already made more progress merely by passing a statewide law. But the showpiece in Providence is still a deliberate attempt to demonstrate that if there was a safe-injection site in your neighborhood, it would be muted and modest. Residents might never know it was there.
“We’ve got to make it as plain as possible that this is a medical facility,” said Haley McKee, a former intravenous-drug user who now co-chairs the Substance Abuse Policy, Education and Recovery PAC, which lobbied in favor of the bill. The group now has to ensure neither the U.S. Department of Justice nor agitated NIMBYs can portray spaces like this as a menace.
In Rhode Island—home to one million people—fatal overdoses killed 396 last year. That’s an average of more than one per day. Ambulances, conspicuous reminders of this statistic, appear almost every day at McKee’s apartment building in south Providence, she said. In this small state, opiate overdoses may have hit a critical mass.
“If someone was murdered in your community every day, and your state police, and your FBI, and your local police, were totally ineffective—in fact, you had more people murdered, not less—what resource would you leave behind?” asked state Sen. Joshua Miller, one of the legislation’s sponsors. He runs group homes, where he’s had a client overdose, and has been trying to pass a safe-injection bill since 2019.
Miller drew another analogy. Picture an airport serving a city of 1 million people, where, right on schedule, a couple of Boeing 737s crashed every year, killing everyone on board—and nobody did anything except book more flights.
“Everybody can do that math,” he said. “These are the statistics we’re working with.”
Lawmakers like Miller and advocates like McKee, along with supporters including epidemiologists and public health experts from Brown University, the Ivy League school a short walk from the statehouse, have already met with public health officials and state Attorney General Peter F. Neronha to work on writing explicit regulations—and to ensure that if the Justice Department sues, like the feds did in Pennsylvania, state elected officials will be there in support.
For now, backing from some elected officials appears tepid. Even though Rhode Island Gov. Daniel McKee signed the bill into law July 7, he did it quietly, without issuing any public statement (and without even telling Miller, who found out that the bill was signed via the Providence Journal).
As for the feds, nobody can say what they plan to do. Lawmakers like Miller haven’t heard anything one way or the other, he told VICE News, and the DOJ’s District of Rhode Island did not return a call seeking comment.
In one way, some advocates hope the feds do mount a challenge, so they can win—and then use that win elsewhere. Rhode Island is not served by the Third Circuit, so a court challenge may encounter friendlier justices who could issue a precedent-setting ruling in support that other cities and states could use to quickly open up safe-injection sites of their own.
Or, since U.S. Attorney General Merrick Garland has said the opioid crisis is a “high priority,” the federal DOJ could do what it did under the Obama administration with cannabis: issue guidance indicating that safe-injection sites operate under state authority and should not be meddled with, a sort of “Cole Memo” for the overdose crisis.
In Rhode Island, safe injection won’t use any federal or state funding. The exact cost hinges on variables like whether the site can be added to an existing nonprofit service provider or has to be built from scratch. But a mystery “private donor,” whom McKee declined to name, has committed to writing whatever check is necessary.
Safe-injection sites also won’t be on state property and will be able to open only in areas zoned for medical facilities, in areas with an existing high level of overdoses. That means “multiple communities across the state might meet those criteria,” as Brown University’s Marshall said. But in addition to overdoses, they’ll also have to have
explicit buy-in from the local city council and the local zoning or planning board, and they’ll have to have support from local merchants and homeowners’ associations.
In that way, a proven opioid-crisis solution boils down to a land-use issue. And if NIMBY property owners are convinced that a safe-injection site will crater the value of their real-estate, the opiate crisis will continue to worsen, and a commonsense, proven solution seen in other countries won’t happen here.
“It happened in Pennsylvania,” the AMA’s Mukkumala said. “And the ‘not in my backyard’ phenomenon will likely happen in Rhode Island.’”
In fact, it’s already happening. State Senate President Dominick Ruggiero, a Democrat who represents the town of North Providence, voted for the legislation—but said on a popular talk radio show that a safe-injection site would not “be conducive to be in my district.” And that was from a supporter. State Rep. Arthur Corvese, a Democrat and one of the nine “no” votes on the injection state in the state Legislature, conjured visions of state-funded opium dens. “But yet we will say, you want to chase the dragon or shoot up, here’s the place to do it,” he said, according to local station WBUR. A call to the city council in Providence, the city probably most likely to benefit from a safe-injection site, was not immediately returned.
Like advocates for desperately needed services with proven value like homeless shelters, cannabis dispensaries, and affordable housing can tell you, a vocal minority in opposition can be enough to halt everything.
“The complexity is that you have communities who already feel besieged by drug use and drug dealing. Then we say, ‘Hey, we’re going to put these in your neighborhoods, too,’” said California state Senator Scott Wiener, a San Francisco Democrat who authored the rejected 2018 bill. “Our job is to say to them, ‘There’s already drug dealing and drug use in your neighborhood. Isn’t it better to use inside, in a controlled setting, than on the sidewalk as you walk by, or as your kids walk by?”
In the abstract, most people do seem to get it. A recent survey of residents in Somerville, Massachusetts—like Providence, a New England college town with elite universities nearby as well as a mix of gentrification and urban problems, including steadily worsening overdose deaths—conducted by researchers at Brown as part of a feasibility report to see if safe-injection sites would work there, found “more than half’ supported safe consumption sites. Of course, that doesn’t mean they won’t say, “‘That sounds good–but I don’t need that near my house,” as the AMA’s Mukkamala observed. That could still be a problem.
“Now we get to the harder part, about the logistics,” Mukkamala said. “Pennsylvania didn’t even get over that hurdle. Now we will get to that other challenge.”
By the abject standards of America’s drug war and overdose crisis, even this limited, qualified success is seen as a win. Lawmakers in other states want to capitalize. Wiener said he plans to re-submit a bill to introduce safe-injection sites in California—and he expects it to become law this time.
“We don’t know what the Biden administration position is, but we’re reasonably confident they will not act like neanderthals, in the way that the Trump administration did,” he said. If the president, an acknowledged architect of the drug war, doesn’t want to endorse it, “at the minimum, we’d love a hands-off approach,” he added.