
==== Front
Lancet Reg Health Am
Lancet Reg Health Am
Lancet Regional Health - Americas
2667-193X
Elsevier

S2667-193X(24)00216-3
10.1016/j.lana.2024.100889
100889
Comment
Supervised safe consumption sites — lessons and opportunities for North America
Zhu David T. davetzhu@gmail.com
a∗
Bajaj Simar S. b
Kerr Thomas cd
a Medical Scientist Training Program, School of Medicine, Virginia Commonwealth University, Richmond, VA, USA
b Harvard University, Cambridge, MA, USA
c British Columbia Centre on Substance Use, Vancouver, BC, Canada
d Department of Medicine, University of British Columbia, Vancouver, BC, Canada
∗ Corresponding author. Medical Scientist Training Program, Virginia Commonwealth University School of Medicine, 1201 E Marshall St, Richmond, VA, 23298, USA. davetzhu@gmail.com
11 9 2024
11 2024
11 9 2024
39 1008897 6 2024
15 7 2024
29 8 2024
© 2024 The Author(s)
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open access article under the CC BY-NC license (http://creativecommons.org/licenses/by-nc/4.0/).
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pmcIn the United States, over 80,000 people die of opioid overdoses every year.1 In February 2024, Rhode Island opened the first state-sanctioned supervised safe consumption site (SCS) to combat the state's rising opioid overdose rates.2 Joining two other SCSs in New York City, Rhode Island's initiative reflects a broader global movement, with Canada, Belgium, Germany, Australia, and others also hosting SCSs to curb the opioid epidemic.3

SCSs offer safe, non-judgmental spaces for people who use drugs (PWUD), where they can consume previously obtained substances under the supervision of healthcare professionals. Their primary aim is to reduce overdose deaths with immediate medical intervention. Additionally, these sites provide sterile equipment to minimise infection risks and link PWUD with essential health and social services, such as housing support and addiction treatment. Recent systematic reviews indicate clearly that SCS meet these objectives without producing unintended consequences.4, 5, 6

Despite these benefits, SCSs face significant legislative and regulatory hurdles. For instance, federal laws in the US prohibit the operation of facilities allowing the use of opioids and other controlled substances. Some organisations, like New York City's OnPoint, have negotiated agreements with local governments to continue operating as SCSs, but others, like Philadelphia's Safehouse, face legal sanctions that prevent their implementation. Given the burgeoning opioid epidemic, these restrictions underline the need to explore new avenues for implementing SCSs in the US.

Firstly, health officials must address community resistance rooted in stigma and misinformation (Panel 1). Community members often fear that SCSs will increase crime, devalue property, and contribute to a “negative image” of their neighbourhoods.2 Successful community engagement is crucial for improving public acceptance; for example, in Vancouver, Insite invested heavily in community outreach and public education regarding SCS to facilitate implementation.7 While political backlash often centres around “enabling drug use and crime,” research consistently shows that SCSs do not exacerbate public disorder or crime.4,5Panel 1 Priorities for the implementation of supervised safe consumption sites in North America

Domain 1: overcoming community resistance to SCSs

• Proactively engaging community members through public hearings and community forums to provide harm reduction education and dispel misinformation

• Empowering trusted community members, including religious leaders and nurses, as harm reduction champions for SCSs

Domain 2: forming legal partnerships to facilitate SCS implementation

• Leveraging empirical and quasi-experimental evidence demonstrating the public health impact of SCSs in lobbying efforts

• Seeking legal exemptions to pilot SCS programs, integrated within local and state public health strategies to combat the opioid epidemic

Domain 3: designing accessible, low-barrier SCS facilities

• Addressing structural barriers to SCS accessibility by implementing low-barrier programs connected to existing services used by PWUD

• Co-designing community-centered SCS spaces with social services aimed at addressing social disparities experienced by PWUD

While public hearings, town hall meetings, and community forums are useful for educating community members and dispelling misinformation, such consultations should not be mandatory; requiring community approval for SCS approval creates an exceptional status that hinders implementation. Trusted community figures, such as church leaders and healthcare professionals like clinicians and nurses, can be engaged as pragmatic harm reduction allies through proactive harm reduction education.

Secondly, health officials should partner with governments and law enforcement agencies — seeking public endorsements and legal exemptions, including non-interference agreements — to facilitate the operation of SCSs (Panel 1). For instance, in Rhode Island, the Harm Reduction Center Act of 2021 proactively addressed potential legal concerns and enabled the implementation of the state's first SCS.8 Such protections are critical since they allow centres to operate without the constant threat of prosecution, providing vital support for both PWUD and staff, who might otherwise fear their license being revoked/removed.

Harm reduction leaders should advocate for legal exemptions to establish pilot SCS facilities, framing them as win–win public health responses to the opioid epidemic. Indeed, recent changes in the illicit drug supply suggest that SCSs could help address the rising polysubstance crisis driven by fentanyl and synthetic adulterants like xylazine. Given the latter's intense sedative effects, SCSs offer safe havens for PWUD who would be at risk for assault and robbery when injecting in public, while also providing non-stigmatising spaces to treat xylazine-related skin ulcers.9

Thirdly, ensuring the accessibility of SCSs is vital (Panel 1). Long travel times, limited operating hours, and overcrowded facilities are well-documented barriers, leading some PWUD to experience withdrawal and leave without accessing SCS services.10 Correspondingly, SCS should be implemented as low-barrier programs within housing environments or operating out of temporary or mobile facilities where drug users congregate, drawing from the success of British Columbia's model.7 These sites should balance privacy for safe injection practices with inclusive, welcoming physical spaces that foster a sense of community while avoiding overcrowding. Specialised SCS services can also help reach vulnerable subpopulations; for example, Vancouver's women-only SisterSpace offers gender-specific, trauma-informed programming and peer support networks. SCS organisers should seek to co-design facilities with people with lived experiences of substance use to meet their unique social needs. In particular, referrals to addiction treatment and primary care are imperative to ensure a comprehensive continuum of care.

As the North American opioid crisis intensifies, SCSs represent an important pillar of harm reduction, aimed at decreasing overdose mortality and linking PWUD with essential health and social services to reduce the harms of opioid use. Considering the growing body of empirical research on the public health benefits of SCSs, renewed efforts to widely implement and scale up these sites are long overdue.

Contributors

DTZ drafted the original manuscript, SSB and TK reviewed and revised the manuscript.

Declaration of interests

The authors all declare no competing interests.

Acknowledgements

No funding was received for this work.
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References

1 Provisional data shows U.S. drug overdose deaths top 100,000 in 2022 2023 National Center for Health Statistics https://blogs.cdc.gov/nchs/2023/05/18/7365/
2 Prevent Overdose R.I. Overdose death data https://preventoverdoseri.org/overdose-deaths/
3 Ivsins A. Warnock A. Small W. Strike C. Kerr T. Bardwell G. A scoping review of qualitative research on barriers and facilitators to the use of supervised consumption services Int J Drug Policy 111 2023 103910
4 Levengood T.W. Yoon G.H. Davoust M.J. Supervised injection facilities as harm reduction: a systematic review Am J Prev Med 61 5 2021 738 749 34218964
5 Kennedy M.C. Karamouzian M. Kerr T. Public health and public order outcomes associated with supervised drug consumption facilities: a systematic review Curr HIV AIDS Rep 14 5 2017 161 183 28875422
6 Magwood O. Salvalaggio G. Beder M. The effectiveness of substance use interventions for homeless and vulnerably housed persons: a systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder PLoS One 15 1 2020 e0227298
7 Kerr T. Mitra S. Kennedy M.C. McNeil R. Supervised injection facilities in Canada: past, present, and future Harm Reduct J 14 2017 28 28521829
8 State of Rhode Island General Assembly Harm reduction center pilot program to combat overdose deaths becomes law https://www.rilegislature.gov/pressrelease/_layouts/RIL.PressRelease.ListStructure/Forms/DisplayForm.aspx?List=c8baae31-3c10-431c-8dcd-9dbbe21ce3e9&ID=371925 2021
9 Zhu D.T. Public health impact and harm reduction implications of xylazine-involved overdoses: a narrative review Harm Reduct J 20 1 2023 131 37700329
10 Petrar S. Kerr T. Tyndall M.W. Zhang R. Montaner J.S. Wood E. Injection drug users' perceptions regarding use of a medically supervised safer injecting facility Addict Behav 32 5 2007 1088 1093 16930849
