On September 14, 2023, Philadelphia City Council voted to block the opening of a potential safe consumption site (also known as a safe injection site or overdose prevention site) in nine out of the ten districts in the city. Technically it’s not a true ban: the September city council bill enacted tougher zoning laws such that opening a site would require jumping through additional bureaucratic hoops and accumulating community buy-in. But approval, if obtained, would likely take years. This ban-in-all-but-name was vetoed by the then-mayor on September 27, but the mayor’s veto was overruled by City Council the following day.
This vote took many harm reductionists across the country by surprise, given that in 2020 Philadelphia had been on track to open the country’s first civically authorized, official safe consumption site. The South Philadelphia site had run into trouble in 2020 when it faced pushback from neighborhood groups from areas surrounding the proposed site. These groups had mobilized to put pressure on the owner of the building, resulting in the site’s lease being rescinded before it could open. Since then, the organization that had planned to open the site (Safehouse Philadelphia) had been tied up in legal battles. But even as resistance to the idea of a safe consumption site had grown, it had seemed unlikely that the city itself would pass such a harsh ruling against safe consumption.
I am a harm reduction nurse and researcher, and I was at City Hall when City Council voted on September 14. I was there that day to testify in support of safe consumption sites and against the ban. I’ve also attended many community meetings about safe consumption sites over the years and have watched the debate evolve as the evidence about safe consumption as an effective overdose prevention tool has grown. My interest is in health services research—research focused on how people access health care and the barriers that get in the way.
My training as a researcher taught me that generating enough evidence could sway governmental and public opinion toward effective treatments and solutions for substance use disorders and overdose. However, I am increasingly faced with the reality that a mountain of scientific evidence supporting the effectiveness of harm reduction approaches has not led the public to embrace these new approaches. In fact, as mistrust in researchers and scientists builds—and is stoked by vote-seeking politicians—public opinion may be shifting away from the evidence we work so hard to generate. Our training as researchers does little to prepare us for this reality.
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Other scholars have written eloquently in Inquest and elsewhere about the pitfalls of the “evidence-based obsession” many of us find ourselves in. In the criminal legal reform space, these approaches can lead to painfully slow, incremental approaches that ultimately hinder real change. As stated by Jonathan Ben-Menachem in this publication, “better research won’t get us out of our crisis of mass incarceration.” Likewise, more peer-reviewed publications about the benefits of safe consumption sites likely won’t meaningfully change the deep-seated stigma and mistrust fueling the current backlash against proven harm reduction strategies.
Rigid definitions of “evidence” that require findings from multiple randomized controlled trials also ignore many other important ways of knowing—including qualitative research and expertise accumulated from years of working in the field. Community members can and should have an important role in shaping policy that will impact their neighborhoods. However, when it comes to neighborhood resources, we do not generally poll community members about things like which types of cancer treatments should be offered at the local hospital. Acquiescing to NIMBY (“not in my backyard”) attitudes about what types of services should and shouldn’t be available in which neighborhoods has historically been reserved for those services addressing and serving stigmatized conditions and people—such as methadone clinics, mental health care, low-income housing, and homeless shelters.
Unfortunately, the current anti-safe-consumption-site fervor is fueling a paranoia inspiring people to do things such as protest the construction of a desperately needed primary care health center due to fear that it will secretly house a safe consumption site. As stated by Christopher Moraff, Philadelphia “has a long history of fluctuating between historic reform and the kind of regressive populism common in old strongholds for ward-style machine politics.” It seems we are in a period of the latter, at least with regards to how we’re attempting to address our overdose crisis.
To win the fight for safe consumption sites in Philadelphia—and likely elsewhere—Philly’s harm reduction community will need to convince a lot of NIMBYs, community members and local politicians alike.
The logic behind safe consumption sites is quite simple: People are more likely to die of an overdose when they use alone, with no one around to administer naloxone. Providing a space where people can use under the watchful eye of trained overdose responders means that someone will notice an overdose and intervene before it becomes fatal. People who use drugs have used this technique successfully at “unsanctioned sites” for years before health-care workers and researchers started talking about it. There is even a peer-led telephone version called Never Use Alone, which has been operating since 2019. In addition, many sanctioned, government-funded safe consumption sites exist in Canada and Europe, and in 2021 OnPoint opened the first two officially permitted safe consumption sites in the United States, both in New York City (in Harlem and in Washington Heights).
Of course, logic and decades of expertise are unfortunately often not enough to win approval for something like this. Sometimes they can even backfire. Most researchers lack training in how to effectively engage with and translate our findings for the public, and our lack of experience doing community-driven work can sometimes—and rightfully so—worsen mistrust among laypeople, who may view us as “outsiders” not entitled to provide input as fellow community members.
In addition, even if people buy the argument that using potentially fatal substances in a communal, monitored space seems safer than using alone, there are other potential consequences that need to be addressed. Many people worry that safe consumption sites will bring crime to a neighborhood or increase the amount of syringe litter surrounding the site. Others argue that safe consumption sites condone drug use and discourage people from entering treatment.
To address these concerns, substance use and drug policy researchers have conducted numerous studies examining how safe consumption spaces impact fatal overdose rates in addition to neighborhood-specific concerns such as crime and syringe litter. Study after study has found that safe consumption sites prevent fatal overdoses, decrease syringe litter around the site, and do not lead to an increase in crime. In addition, because many safe consumption sites also offer substance use disorder treatment and other types of health care (such as HIV testing), use of a site may actually increase the chances that people who use drugs will engage with needed care.
None of this evidence seems to matter in much of the public debate. This is partially because many people simply refuse to believe the findings. But it is also because some of those opposed to safe consumption sites don’t really seem to care about these positive outcomes.
At a recent neighborhood meeting, I watched as a supporter of safe consumption sites tried to convince an opponent, who was arguing that a site would “ruin the neighborhood” with an influx of crime. The supporter raised a recently published article (in a leading medical journal) that found no increase in crime in neighborhoods in New York City where safe consumption sites are located. The opponent quickly brushed off the study as “bunk” and refused to engage, even though this paper directly and clearly addressed his purported concerns.
Some opponents of safe consumption sites will fall back on some version of the “tough love/rock bottom” argument, which proposes that any amount of care and tenderness for people with substance use disorders is “enabling” them. According to this belief, only by falling flat on one’s face, alone in the depths of despair, can one finally find the will to change. If you were wondering, there is little evidence to support this. In the most extreme instances of opposition, it almost seems as though the problem with safe consumption sites is that they do work. In other words, I’ve been in spaces where it felt to me that some people weren’t troubled by the fact that their neighbors who use drugs might simply die—that their lives were not worth saving.
This is not to say that all opposition to safe consumption sites is so unsympathetic. Some communities, especially urban communities of color, have been disproportionately harmed by the racist war on drugs. Having seen a previous generation of pols and wonks present hyperpolicing and mass incarceration as data-backed solutions to pervasive drug use, people from these communities are sometimes understandably skeptical of any new strategy being presented as backed by research, especially one as radical as safe consumption sites. It is also certainly true that these types of interventions—focused on the health and safety of drug users rather than on criminalization—were not part of the public conversation during the crack epidemic, and people whose communities have been ravaged by mass incarceration often rightly take offense that public sympathy for people who use drugs increased only when white and suburban people were highlighted by the media as victims of the so-called opioid epidemic. As if to underscore this point, the public’s newfound concern has largely ignored the skyrocketing overdose death rates among Black and brown communities. In Philadelphia and elsewhere, predominantly Black neighborhoods have been largely left out of harm reduction and overdose response efforts.
Charelle Parker was sworn in as Philadelphia’s hundredth mayor on January 2, 2024. She replaced Jim Kenney, who had visited safe consumption sites in Canada and expressed supportive views about opening one in Philadelphia. Unlike her predecessor, Mayor Parker has made clear since the primary campaign that safe consumption sites are not on the table. On the campaign trail she stated: “The first thing I wouldn’t do is to employ the use of a safe-injection site. . . . I refer to that as what I call ‘I know what’s best for youse people policymaking,’ when academicians and others attempt to force a particular strategy on a community.” During her inauguration, she softened her tone a bit, but remained difficult to pin down, stating: “We want to have a data-driven and research-based approach that is put together by the best law enforcement and public health professionals that we can find. . . . But I want you to know everybody is not going to be happy when we make some of these decisions.”
As you can probably imagine, these statements have left Philadelphia harm reductionists frustrated and incredibly concerned. Her opposition toward safe consumption sites is clear, and many fear she won’t be supportive of other harm reduction approaches either. As in her inauguration speech, she has spoken supportively about law enforcement approaches, positioning them as of equal (or greater) authority as public health experts, and she has even proposed calling in the National Guard—regardless of the fact that this type of approach is not what findings of a recent survey suggest that a majority of Philadelphians want. Pennsylvania governor Josh Shapiro, who would need to sign off on this sort of thing, has expressed his unwillingness to deploy the National Guard to address substance use.
Mayor Parker’s language about “academicians” who want to “force a particular strategy on a community” plays up stereotypes that those of us who spend our time building and promoting evidence-based harm reduction strategies are not community members ourselves, but ivory-tower outsiders who should not be trusted. She is not alone in this. The city council member who introduced the anti-safe-consumption-site bill, Quetzy Lozada, has opined that safe-injection-site supporters are outsiders who shouldn’t get to have a say: “It is disturbing to me that the voices of the people who don’t have to deal with the day-to-day trauma that our children and our community have to deal with . . . think that their voices should be louder than those who walk those streets every day.” She made this statement after some Philadelphians who live and work in Kensington spoke in support of safe consumption sites, as well as fellow city councilor Kendra Brooks. Some of these neighbors recounted their own overdoses or the overdoses of loved ones, while others spoke in detail about their frontline work with people who use drugs. Some literally told stories of walking the streets of Lozada’s district, Kensington, and administering naloxone to people unconscious on the sidewalk. To be clear, some of those who spoke at the City Council hearing in opposition to safe consumption sites were also from Kensington—but to suggest that it is only outsiders who support this approach is incorrect.
So what’s going to happen next in the fight against the growing overdose death toll in Philadelphia? Clearly, the staggering amount of suffering that we see on our streets, in our subway, and on the front page of our local papers isn’t enough to convince many of us that we might need to try something radically different from the drug war. I really don’t know what will help, but I’m pretty sure that, at least on its own, more research showing that harm-reduction strategies are effective isn’t going to sway those who oppose them. Despite the explosion of the anti-vax movement, the COVID era also brought us many examples of how thoughtful and sustained community-partnered work can help engender trust in science among previously skeptical people. I am increasingly convinced that those of us who have been trained to generate evidence and publish academic papers about effective substance use treatment and overdose prevention strategies need to commit to engaging in community-partnered work in our local communities if we really want to influence public opinion and impact policy.
Image: Daniel ODonnell/Unsplash
