Safe consumption sites: Study identifies policy change strategies and challenges

A new qualitative study from the Johns Hopkins Bloomberg School of Public Health identifies several key lessons from early efforts to establish sanctioned safe consumption sites in five U.S. communities. The results offer insights on one approach some localities are exploring to address the escalating drug overdose crisis in the U.S.

Through interviews with key informants, the researchers identified strategies for organizing around this issue and engaging the community, as well as facilitators and barriers to progress.

The study was published online February 13 in the journal Psychiatric Services.

"We wanted to understand the environment in which these policy change efforts are occurring," says lead researcher Alene Kennedy-Hendricks, Ph.D., assistant director of the Johns Hopkins Center for Mental Health and Addiction Policy Research and a faculty member in the Bloomberg School's Department of Health Policy and Management. "Study participants emphasized the importance of engaging diverse partners to organize around safe consumption sites, elevating the voices of people who use drugs in these discussions and framing the need for this harm reduction approach in terms of racial justice."

Safe consumption sites, also known as overdose prevention sites or supervised injection facilities, are places where people can use pre-obtained drugs under the supervision of trained staff who can intervene and prevent fatal overdoses. No sanctioned safe consumption site exists in the U.S. but policymakers in at least six states, including Maryland, California, Colorado, Massachusetts, New York and Vermont, have introduced legislation to establish safe consumption sites, and at least two cities—Philadelphia and Seattle—are working to establish these sites without state legislation. These policy discussions have been controversial within the communities where they are being considered and potentially conflict with federal law. For example, federal prosecutors are currently suing to stop plans in Philadelphia to open a site.

For the study, the researchers interviewed 25 participants from five jurisdictions over the phone from April to July of 2018. Study participants were asked about their strategy for changing policy to sanction safe consumption sites, organizing efforts, community engagement, facilitators of progress and barriers to adoption. Participants included community organizers, harm reduction advocates, local government officials and health and social service organization leaders from jurisdictions considering implementing safe consumption sites. The researchers identified initial study participants in each jurisdiction and then recruited additional participants on the basis of initial interviews. Researchers identified common themes that emerged in the interviews.

One of the most commonly reported barriers to establishing these sites was developing an approach to respond to federal action, given federal law prohibiting the operation of spaces for the use of drugs. This concern also has created challenges in identifying the right location and physical structure for the site. Financing remained a challenge, although at least one community had allocated public funds for this purpose. Several communities emphasized efforts would only be successful if trust was built among communities of color, given the precedent of racially discriminatory drug policies in the U.S.

Participants from communities that already had well-established harm reduction programs, such as syringe services or scaled up naloxone distribution programs, said that those programs gave them a solid foundation on which to build support for safe consumption sites. These communities seemed to have an advantage since existing policies, programs and partnerships had been established. Researchers also found that securing political and community champions was critical in advancing policy on this issue. Community members who were trusted and respected by their neighbors and championed safe consumption sites helped improve local residents' understanding of the purpose of these sites. Visits to safe consumption sites in areas outside the U.S. (specifically Vancouver, British Columbia) by local government officials and key community members helped to reduce opposition.

Most jurisdictions reported that engaging a diverse set of community allies helped in building a broader coalition and stronger connection to policymakers. The community leaders who participated in the study all viewed establishing safe consumption sites as part of a broader, comprehensive strategy to respond to the devastating scale of the opioid epidemic. Co-author Colleen L. Barry, Ph.D., MPP, professor and chair of the Bloomberg School's Department of Health Policy and Management, notes that advancing harm reduction measures, including safe consumption sites, is viewed as an important strategy for connecting people who use drugs with evidence-based treatment, social services, housing support and other services to make positive changes that reduce the risks associated with using drugs.

Participants reported that organizing people who use drugs and involving them in policy efforts is critical, and some locations were involving drug-user unions in these efforts. Pressuring policymakers to take a stand on safe consumption sites during campaign events was viewed as an effective strategy.

"This study brings to light the realities of how such an innovation could be implemented, the nature of the stakeholders and the complexity and uniqueness of each city's process," says Susan Sherman, Ph.D., MPH, professor in the Bloomberg School's Department of Health, Behavior and Society and the paper's senior author. "It provides insight into the community-specific distinctions and important commonalities across these jurisdictions."

"We have an approach here that other countries have found helpful in reaching a marginalized population that faces high rates of mortality," says Kennedy-Hendricks. "A key question now is which jurisdiction will open the first sanctioned safe consumption site in the U.S. Their experience as an early adopter will inform efforts around the country."