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.