In parts of the country hit hard by addiction, some public health officials are considering running sites where people can use heroin and other illegal drugs under medical supervision. Advocates say these facilities, known as supervised injection sites, save lives that would otherwise be lost to overdoses and provide a bridge to treatment.
There are at least 13 efforts underway in U.S. cities and states to start an official supervised injection site — with advocates in several cities saying they want to be the first. And the forms vary. Seattle is planning a safe injection van; Philadelphia is considering portable structures; some elected officials in places like Denver, Vermont, Delaware and San Francisco, are trying to gather support for proposals.
Harm reduction advocates hope supervised injection sites can follow the path of needle exchange programs which have gained wider acceptance over the years, thanks to their role in containing the spread of HIV and AIDS. There are now needle exchange programs in 39 states.
But many safe injection site proposals seem to be waylaid in community debate and legal uncertainty.
Scott Burris, director of Temple University's Center for Public Health Law Research, says municipalities are worried about a showdown with Jeff Sessions' Department of Justice.
"You can talk about cities racing to be first," Burris says. "But my guess is that you have a lot of cities who are actually racing to be second."
When officials with the Justice Department are asked where Sessions stands on the issue, they offer a statement issued late last year by a U.S. attorney in Vermont saying health workers at a supervised injection site would be vulnerable to criminal charges and the property could be at risk of being seized by federal law enforcement.
Burris says there could be a public backlash to Justice Department lawyers asking a judge to sign warrants for the arrest of social workers and nurses working to save lives in the facilities, but the fear of a hardline response is still giving local officials pause.
In Philadelphia, where overdoses kill four times as many people as murder, it has been six months since top city officials, including the mayor and the city's district attorney, announced they were advancing the idea of a supervised injection site. Now, city officials say they are still searching for private funders and launching new outreach efforts in many neighborhoods to help make the controversial concept more palatable.
Eva Gladstein, deputy managing director of the city's Health and Human Services, says it's time to act.
"We estimate that we would save up to 75 lives in one year, and if any of those 75 people are a member of your family, you would, I think, agree that that's something that's desirable," she says.
In a survey Gladstein's department conducted in Philadelphia's Kensington neighborhood, seen as ground-zero of the city's opioid crisis, more than two-thirds of drug users said they would go to a supervised injection site.
"In communities that have been living with this addiction," she says. "Everybody knows someone or has a family member who is affected."
Philadelphia-based federal prosecutor Louis Lappen is more skeptical. "You're talking about an extremely dangerous situations with people injecting these drugs into their veins," he says. "That is killing them at rates we have never seen before in the history of the world. So, it's not something we can just say, 'Wow, that's a really great idea.' "
It is not just prosecutors who are unsettled by the concept. Massachusetts state Sen. Will Brownsberger sponsored a bill to jump-start a safe injection site there, but some Boston elected officials and residents remained leery that a supervised injection site would enable and even exacerbate drug use.
"If we had a place where people were ready for it, then we could probably get it done. But we don't have that right now," says Brownsberger.
While the issue has recently heated up in the U.S., in Canada, the city of Vancouver has run a safe injection site called Insite for 15 years. It navigated its own legal challenges. The Supreme Court of Canada ruled in 2011 that the facility should be granted an exemption from federal law since, the court wrote, saving lives outweighs any benefit of prohibiting the use of illegal drugs at the site.
In the U.S., where all official supervised injection sites remain pending, the issue has never been tested in the courts. Still, legal scholars are already gearing up for future legal fights by considering federal drug law loopholes or novel arguments that could persuade a judge to rule in favor of harm reduction.
Yet before the courts weigh in, a site has to open.
In May, New York City Mayor Bill de Blasio endorsed a proposal to open four safe injection spaces. The plan still needs the blessing of the state Department of Health. Some drug users say they would embrace such a facility. Take Jeff, who says he has been struggling with addiction for more than 25 years.
"This thing is not a joke. It really isn't," Jeff says. (NPR agreed to use just his first name since he uses illegal drugs.)
Jeff says using on the streets is risky — especially when using alone. If New York's safe injection sites open, people would bring their own drugs and use them under the eye of trained health care providers, who stand by with the overdose-reversing drug naloxone.
"It's not good to have a person strung out on this stuff. But you definitely don't want them doing this alone," Jeff says. "And you definitely don't want to find out that they died alone."
Elana Gordon contributed to this report.
NOEL KING, HOST:
Here at home, lawmakers in more than a dozen cities are talking about creating spaces where people can use heroin and other illegal drugs under medical supervision. There are about a hundred of these so-called safe injection sites around the world, but no U.S. city has officially opened one. Advocates say these spaces can save lives in the middle of a deadly overdose crisis, but fears over a clampdown from the federal government are keeping many local leaders on the fence. Bobby Allyn has the story.
BOBBY ALLYN, BYLINE: Outside of a needle exchange in Manhattan, we found Jeff. We agreed to use just his first name since he uses illegal opioids. He's been battling addiction for a long time.
JEFF: Over 25 years - this thing is not a joke. It really isn't.
ALLYN: Jeff says using on the streets is risky, which is why he's welcoming New York City's proposal to open four supervised injection spaces. People would bring their own drugs and use under the watch of workers armed with an overdose antidote.
JEFF: It's not good to have a person strung out on this stuff. But you definitely don't want them doing this alone. And you definitely don't want to find out they died alone.
ALLYN: Just as needle exchanges helped contain the spread of the AIDS epidemic decades ago, harm reduction advocates today say allowing people to use drugs in a medical setting can curb fatal overdoses and provide a bridge to treatment. NPR found that there are at least 13 efforts underway to open the country's first official supervised injection facility. And the forms vary. Seattle is planning a safe injection van. Philadelphia is considering pop-up tents. And some elected officials in places like Denver and Vermont are trying to gather support for proposals.
SCOTT BURRIS: You can talk about cities racing to be first. But my guess is that you have a lot of cities who are actually racing to be second.
ALLYN: That's Scott Burris. He leads Temple University's Center for Public Health Law Research. He says municipalities are worried about a showdown with Jeff Sessions' Department of Justice. And what insurance company would cover the site? In Philadelphia, where overdoses kill four times as many people as murder, Eva Gladstein says it's time to act. She's a top official with the city's Health and Human Services department.
EVA GLADSTEIN: We estimate that we would save up to 75 lives in one year. And if any of those 75 people are a member of your family, you would, I think, agree that that is something that's desirable.
LOU LAPPEN: You're talking about an extremely dangerous situation with people injecting these drugs into their veins...
ALLYN: Philadelphia-based federal prosecutor Lou Lappen.
LAPPEN: ...That is killing them at rates we have never seen before in the history of the world. So it's not something that we can just say - wow, that's a really great idea.
ALLYN: It's not just prosecutors who are unsettled by the concept. Massachusetts State Senator Will Brownsberger sponsored a bill to jumpstart a safe injection site movement. But many in the Boston area said, not in my backyard.
WILL BROWNSBERGER: If we had a place where people were ready for it, then we could probably get it done. But we don't have that right now.
ALLYN: To help grapple with some of these issues, city and state leaders have been taking trips to Vancouver, Canada. A safe injection site called Insite has operated there since 2003. There's a table in the waiting room with syringes and bandages. Above it, there's a message on a dry-erase board - drink water. Darwin Fisher works here.
DARWIN FISHER: So now we're heading out of the injection room. We're passing the treatment room, which is where a lot of...
ALLYN: Since the opioid epidemic started to worsen, he says being a tour guide has become a big part of his job. Dozens of city leaders have rolled through.
FISHER: They want the site demystified.
ALLYN: Back in New York, Governor Andrew Cuomo is still puzzling through the issue. Asked about his position on supervised injection facilities, he replied it's complicated.
Bobby Allyn, NPR News.
(SOUNDBITE OF SYNCHOPATHS' "VERY LAST STRAW") Transcript provided by NPR, Copyright NPR.