Philadelphia, where another 1,100 people died of an overdose in 2018, is slowly navigating toward opening a supervised injection site, a move that has prompted a debate among harm reduction advocates and law-and-order types about the best way to address the overdose crisis. Safehouse, a nonprofit, has been incorporated with the sole purpose of opening a site to save lives. After incorporating, the U.S. attorney sued Safehouse, arguing that the site is illegal, in an attempt to prevent them from opening. The suit is currently in court, but Safehouse has made progress. In March they announced a potential location.

While Philadelphia’s alarming overdose rate adds urgency to this initiative, the city doesn’t need to reinvent the wheel. There are already about 120 supervised injection sites around the globe.

The Inquirer wanted to hear from people on the ground who made some of these sites a reality (or are trying to do so) with the hope that as Philadelphia moves forward, those involved can learn from the hard work of people who have already been through the process. Here are my takeaways from these discussions, followed by a deeper reflection from the people doing the work to launch and operate these sites.

Dublin, Ireland

How a painstaking legal process can provide political clarity

What Philly can learn from Dublin:
  • Patience is key: For supporters of supervised injection sites, it can feel like Philadelphia’s process is moving too slowly. But Dublin’s story is a reminder that even with legal approval, opening a site can take a very long time.

  • Bureaucracy can help define roles: Because the government took ownership over Dublin’s site, it set clear guidelines for what needs to happen to open it. The government chose the model, location, and provider. Those with grievances can complain to their public officials. This is something Philadelphia should consider, given that Mayor Kenney has expressed disapproval toward Safehouse’s proposed location.

In January 2012, because of serious harm caused by street-based injecting that Dubliners witnessed on a daily basis, Ana Liffey Drug Project, an Irish harm reduction charity, began to advocate for mobile supervised injecting facilities (SIFs) in Ireland’s capital city.

Building political support took time. It wasn’t until 2016 that the Irish minister of state allocated funds to support the establishment of a pilot SIF in Dublin’s downtown area. Then, in May 2017, President Michael D. Higgins signed into law the Misuse of Drugs (Supervised Injecting Facilities) Act 2017, which created a legal framework within which an SIF could operate, a victory celebrated by harm reduction advocates.

Once the law was changed, the Health Service Executive (HSE), Ireland’s state health-care body, invited organizations to submit proposals to become the provider of a pilot, non-mobile SIF in downtown Dublin. The HSE designed the service requirements similar to the successful model of a SIF in Sydney, Australia.

Through this process, Merchants Quay Ireland, the provider of a busy needle and syringe program, was identified as the preferred provider for the SIF service, with their premises in the heart of Dublin assessed as the best location.

But there were still more legal steps before the SIF could become reality.

In November 2017, Dublin City Council ruled that planning permission would be required to re-purpose Merchants Quay’s premises to allow for the SIF. Merchants Quay applied for planning permission in September 2018 — and the application met with almost 100 objections from local residents and businesses.

Currently, Merchants Quay Ireland is still working through the planning process and no realistic commentator thinks that (even assuming there are no additional planning hurdles to overcome) any service could be operational before the second half of 2020.

In the interim, there is still a significant problem with street-based injecting in Dublin. While we await the implementation of supervised injecting in Ireland, the related harms continue to impact people who inject drugs, their families, and the people who live in, work in, or visit the capital.

Tony Duffin is the CEO of the Ana Liffey Drug Project, a harm reduction charity in Dublin. @tonyduffin

Toronto, Canada

How an illegal supervised injection site can speed up the legal process

What Philly can learn from Toronto:
  • Show, don’t tell: Sometimes the best way to show people how something will work is just to do it. While Toronto’s police worked closely with the people behind the unsanctioned site, Philadelphia advocates shouldn’t necessarily expect similar treatment, considering that federal law enforcement has already taken action against Safehouse. If they choose this route, they must be prepared for some risk.

In 2004, the city government of Toronto developed a strategy for dealing with its drug problems. The strategy recommended an evaluation of Toronto’s need for a supervised injection site.

Fast forward to 2010, when a group of researchers released a study that said that the city needed three sites at minimum. There was quite a bit of public support at that time. But the process with the federal government required a lengthy application process to get an exemption under the law.

While activists, including myself, were waiting during that process, some of us went into a park and opened Toronto’s first overdose prevention site. We opened it in the area that is the epicenter of the overdose crisis. No organizations wanted to take on the role of advocating for supervised injection sites in this area because it was so political and challenging. In August 2017, we just went and opened one up — illegally.

People in that area were so happy that we were there because they were so burdened with reversing overdoses and seeing people die. The police were very open to this, too. They were saying things like, “You guys are here for the preservation of human life, and we also have a responsibility to preserve human life, so we are going to allow you to be here even though it’s not legal.” They let us operate from 4 p.m. to 10 p.m. We picked those hours because we all worked in the daytime.

By November 2017, the sanctioned sites started to open, but we stayed in a park for about another eight months. We reversed 251 overdoses while we were there and we received about $250,000 in donated funds from people in the city of Toronto. And then we moved inside and became a legally sanctioned funded overdose prevention site as part of South Riverdale Community Health Centre.

The illegal site added pressure to get the sanctioned sites open sooner. It put pressure on other harm reduction organizations to open a site in a neighborhood where no one wanted to open one at the time. Now, we have four in that neighborhood.

What we learned is that somebody has to go ahead and just do it. These are just sites. There is no big deal about opening a site and saving someone’s life. We went ahead and did it and the sky did not fall. Actually, it did the opposite: It changed everybody’s minds.

Zoë Dodd is a co-organizer of the Toronto Overdose Prevention Society. @ZoeDodd.

Ottawa, Canada

What happens on opening day of a supervised injection site

What Philadelphia can learn from Ottawa:
  • Day 1 isn’t everything: Philadelphia shouldn’t expect a supervised injection site to be full on the first day. It may take time for people to feel comfortable to use there. But at some point that is likely to change. Safehouse should be prepared for a scenario in which they get more clients than they can accommodate.

  • Building coalitions: The success of a site depends on the comfort of clients. Working with the police and the community is of utmost importance to ensure a welcoming environment. If potential clients know that the police and/or angry neighbors are waiting outside the site, they won’t use it.

After the opioid overdose deaths in Ottawa, a city of about a million people, increased from 40 in 2016 to 64 in 2017, harm reduction advocates had an urgency to open a supervised injection site. An unsanctioned site opened in August 2017. It was just a tent in a park. The first legal site opened in October 2017. A few months later, the site in the Sandy Hill Community Health Centre, where I now work, opened. There are now four sites in Ottawa.

On the first day that our site (which was the third site overall in Ottawa) opened, there was no line outside the door. We had maybe five people come in.

Prior to opening the site, we didn’t do a big outreach campaign. We just spread information by word of mouth in our needle distribution center. We told people who came to get needles, “Here’s the room and you can have a look at it.”

There was very low interest from people who use drugs at the beginning. We still had people coming in to get needles, but they weren't ready to use the site yet.

The issue for many people was comfort level. They wondered: What is going to happen in that room? How is this going to work?

It took them a long time to feel comfortable. It’s like going to a new bar. That feeling when you walk in, who else is going to be there? Some people can’t go to a new place without 10 of their friends coming with them. Some people needed to hear how it was from their friends who went before them.

As the months went on, more and more people came. Now, on our busiest day, which was about two weeks ago, we had 96 visits in a 12-hour period. Our numbers far exceed what we planned in the beginning and we are probably over capacity. We had to impose a time limit on staying in the site because if we don’t, we simply don’t have the space to serve the amount of people who want to use it.

When a site in Philadelphia opens, I think it will be slow at the beginning. People will have to trust that the staff knows how to respond to overdoses, that they won’t be bothered by people injecting drugs in front of them, that they will be nonjudgmental, and that the cops are not going to sit outside. There won’t be a line outside the door in the first day, and that’s probably a good thing because it will let the community around the site get used to it.

Taliesin Magboo Cahill is a registered nurse. She works at the supervised injection site at the Sandy Hill Community Health Centre in Ottawa, Canada. @tmc_RN.

Mexicali, Mexico

How permits, not laws, can get in the way

What Philadelphia can learn from Mexicali:
  • The work is never done: Philadelphia should anticipate and plan for an evolving situation. As long as supervised injection sites are not explicitly codified in law — which is a federal issue — the sites are at risk.

  • Pay attention to permits: Community support might matter, but at the end of the day, having the proper permits to open can be the difference between staying open and being shut down. This is especially interesting in light of a recent City Council attempt to block Safehouse through the use of zoning.

In October 2018, Verter, a harm reduction organization in the border city of Mexicali, the capital of the Mexican state of Baja California, opened a supervised injection site, which they called a safe consumption room, in a community health center. The site was unique because it only served women, unlike most of the co-ed services that Verter provides. Verter did not advertise the site and kept it discreet, even though under Mexico’s law there is no explicit prohibition of supervised injection sites. A few weeks after the site opened, someone tweeted about it. The tweet went viral and made national news. A few days later, the city shut down the entire community center, arguing that Verter did not have the proper permit. Since then, Verter has gotten a permit to operate a community health center but not an injection site. The fight continues. The Inquirer talked to two board members of Verter about how community inclusion might have helped or hindered their process.

Quotes have been edited lightly for style and clarity.

Jaime Arredondo Sánchez Lira, professor at the Drug Policy Program at the Centro de Investigación y Docencia Económica (CIDE) in Aguascalientes, Mexico:The lesson from Mexicali is to try to keep it under the radar for a little bit longer in order for us to share some information about how the world is not going to end [because of a supervised injection site]. If we were able to, for example, provide that service for three months or six months and show that nobody died and the community didn’t decay since the introduction of the service, [we could’ve proved] to decision makers in the community that nothing went to hell and they didn’t even notice. We were already giving it, and there were no negative consequences ... or maybe they noticed it because there are fewer dropped syringes on the streets or fewer people using drugs on the streets. Would it have been better to do this more with community consultation? My first step would have been to prefer to keep it under the radar for a little bit longer, but knowing what I know now, would [doing more community consultations] have made a difference? No.”

Said Slim, coordinator of projects and founding member of Verter: “The community around us thinks that the problem is the project [the supervised injection site]. That we started the [drug] problem in the area. But the truth is that the problem existed before we came here. We hosted two meetings with neighbors and businesses. Only two or three people came to these meetings. Most people don’t view the relevance and the benefits to start supervised consumption services in a safe space. They only want to call the police and arrest other people. I’m optimistic because we have a large number of clients. Always. As long as the people in this area need these services, we promise to continue with our project. In the future, if we don’t have clients ... we’ll close down."