Several American cities are rallying around a new response to the opioid epidemic: safe spaces for using heroin.

The concept has gained traction in New York City, Philadelphia, San Francisco, and other cities across the US. The thinking is to allow supervised drug consumption sites where people can use drugs with sterile injection equipment and the supervision of trained staff, who are ready with the opioid overdose antidote naloxone if anything goes wrong. The sites may also link people to addiction treatment on request.

The idea: While in an ideal world, no one would use dangerous and potentially deadly drugs, many people do. So it’s better to give these people a space where they can use drugs with some sort of supervision. It’s a harm reduction approach.

The US Department of Justice, under President Donald Trump, has become a vocal opponent of supervised consumption sites (also known as safe injection sites, medically supervised consumption sites, and many other names). This year, the Justice Department sued Safehouse, the nonprofit spearheading a safe injection site in Philadelphia, to stop it.

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On Wednesday, a federal judge ruled that Philadelphia’s safe injection site did not violate federal law. The federal government argued that the site would violate the federal law by promoting illegal activity, citing the federal “crackhouse statute” that targets properties where drugs are used. Safehouse argued its goal is, in fact, to help people who use drugs and over time get them to reduce risky behaviors and perhaps get into addiction treatment.

US District Judge Gerald McHugh agreed with Safehouse. “The ultimate goal of Safehouse’s proposed operation is to reduce drug use, not facilitate it,” he wrote in his opinion.

The move means Safehouse can, barring appeals, move forward with its plan. It also signals to other cities that their proposals for safe injection sites may be on sturdy legal ground too.

Advocates of safe injection sites argue they have the evidence on their side, citing some studies from sites in Canada, Australia, and Europe that found the sites can lead to major public health benefits.

There’s a cultural battle, too. After decades of the war on drugs, much of America’s drug policy is colored by a criminalized, stigmatized approach to addiction — one that demands shunning and shutting down all drug use, and trying to make sure that nothing is perceived as even remotely enabling or allowing drug use. Under this view, the idea of giving people a safe space to use drugs seems downright counterintuitive.

Now advocates are challenging the criminalized framing, arguing that if the goal is to save lives from addiction and overdose, a more compassionate approach is necessary.

In the middle of an opioid crisis, some cities are coming around to the new perspective. Drug overdose deaths in 2017 reached a record 70,000, around two-thirds of which were linked to opioids, according to data from the Centers for Disease Control and Prevention. With the death toll mounting, policymakers are desperate for anything that may help.

Cities’ embrace of safe injection sites is triggering a broader culture war

Several cities have released plans to open a supervised consumption site, including New York City, Philadelphia, San Francisco, and Seattle. Others, such as Denver and Ithaca, New York, are considering the sites. It’s not clear when any of these will open.

It’s worth noting, however, that none of these cities would be the first in the US to open a supervised drug consumption facility should they move forward with their plans, because unsanctioned facilities have been operating in the country for years. Some of the sites are makeshift, set up where people commonly use drugs. At least one, though, is secretly run by a harm reduction group that provides other kinds of services to people who use drugs — as has been documented by some studies.

One reason these older sites have never been officially sanctioned is public opposition. There’s a widespread not-in-my-backyard (NIMBY) sentiment with these kinds of services; essentially, people are worried that if a supervised consumption site opened in their area, it would attract people who use drugs to their neighborhood, and that could cause a rise in general crime and social disorder.

Critics also worry that supervised consumption sites would lead to more drug use, because they would remove a barrier — and perhaps some of the stigma — to drug use.

The Justice Department made this exact argument about Vermont: “Such facilities would also threaten to undercut existing and future prevention initiatives by sending exactly the wrong message to children in Vermont: the government will help you use heroin. Indeed, by encouraging and normalizing heroin injection, [supervised consumption sites] may even encourage individuals to use opiates for the first time, or to switch their method of ingestion from snorting to injection, the latter carrying greatly increased risk of fatality and overdose.”

It’s no coincidence that the Justice Department is making this argument. Law enforcement officials are some of the biggest opponents of supervised consumption facilities — and these officials can be particularly persuasive for politicians at the local and state level, where police hold a lot of sway over any policy related to public safety. In Philadelphia, for one, a key turning point seemed to be Police Commissioner Richard Ross going from being, as the Associated Press put it, “dead-set” against supervised consumption sites to “keeping an open mind if they can truly save lives.”

It’s that reformed perspective — one focused on saving lives — that advocates of harm reduction and supervised consumption sites focus on. It’s not that the public and society should embrace or enable drug use or addiction, but that strategies should instead take people who use drugs seriously, listen to why they’re doing what they’re doing, and try to minimize the harms of what they’re doing as much as possible.

The argument: While ideally, people would not use drugs and those with addiction would get into treatment, the reality is that many people aren’t ready to stop using. By meeting people where they are, governments and providers can mitigate some of the harms until someone is ready to stop using — and potentially save lives in the process.

So if people are at risk of transmitting HIV or hepatitis C through reused syringes, maybe a program can give them a supply of sterile needles so that they don’t need to reuse syringes. If people are at risk of overdose, maybe a program can provide them with naloxone — or create a space where they can be supervised in case they overdose and need medical aid. In concert with these services, providers can also lay the groundwork for treatment in case people decide they’re ready for it.

It’s similar to the thinking around teen pregnancy: Perhaps parents would prefer that their teens don’t have sex at a young age, but, acknowledging the reality that teens might, it’s better to provide them condoms and other forms of birth control.

As Jonathan Giftos, an advocate and doctor focused on addiction, said on Twitter, “No one is arguing that [supervised consumption sites] are THE answer to our overdose crisis, but they would fill an enormous gap in current care model — engaging a highly marginalized group of patients — and ultimately save many lives.”

Accepting this view, however, requires rethinking how America approaches drugs. As Sarah Wakeman, an addiction medicine doctor and medical director at the Massachusetts General Hospital Substance Use Disorder Initiative, has told me, “For 100-plus years as a society, we’ve punished and criminalized people who use drugs.” The harm reduction view asks that America move away from that criminalized approach.

The evidence for safe injection sites is promising, but critics want more

Researchers have been looking into supervised consumption sites for decades (since the first one opened in Switzerland in 1986), with many positive findings so far. But critics aren’t convinced that the evidence is very strong.

Drawing on more than a decade of studies, the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) in 2018 concluded that safe injection sites led to “safer use for clients” and “wider health and public order benefits.” Among those benefits: reductions in risky behavior that can lead to HIV or hepatitis C transmission, drops in drug-related deaths and emergency service calls related to overdoses, and greater uptake in drug addiction treatment, including highly effective medications for opioid addiction.

Despite concerns that the facilities would draw more people who use drugs to an area and cause disorder, the research suggests, according to the EMCDDA, that these facilities lead to less public injecting and fewer syringes discarded in the area — both of which can benefit local communities. The facilities also weren’t linked to higher crime in Sydney, Australia, or Vancouver, Canada — and, in fact, were linked to reduced street disorder and encounters with police.

“These services facilitate rather than delay treatment entry and do not result in higher rates of local drug-related crime,” EMCDDA concluded.

A recent review of the evidence from the RAND Corporation was more cautious. RAND found that there aren’t many well-conducted studies on safe injection sites, and the studies that do exist are too few and far between and have too many methodological constraints and weaknesses to reach hard conclusions about the sites’ overall effectiveness. “It’s not that you can’t learn anything from those studies,” Beau Kilmer, the lead author of RAND’s report, told me. “But you have to be really careful.”

Still, even the RAND review found no evidence that supervised consumption sites lead to more crime and drug use, despite critics’ claims.

One problem with supervised consumption sites may come down to scale. The sites have limits in where and when they’re open, how many people they can serve at once, and whom they serve. For a city dealing with potentially thousands of people using drugs — many of whom use drugs multiple times a day — the sites don’t have enough reach to help a lot of the population. That’s particularly true for rural areas, where many people simply won’t be able to make an hours-long trip every time they want to use drugs.

So even though some studies have been done, critics and skeptics want more.

The US has a lot of room for improvement in its response to the opioid crisis

Beyond supervised consumption sites, there’s a lot the US could do to combat the opioid crisis.

At the top of those other things is treatment — specifically, medications like methadone and buprenorphine. There are decades of evidence behind these medications, showing that they reduce the mortality rate among opioid addiction patients by half or more and keep people in treatment better than other approaches. When France relaxed restrictions on doctors prescribing buprenorphine in response to its own opioid crisis in 1995, the number of people in treatment rose and overdose deaths fell by 79 percent over the following four years.

But these medications, and addiction treatment in general, remain largely inaccessible in the US. A 2016 surgeon general report concluded that only 10 percent of people with a substance use disorder get specialty treatment, in large part due to a lack of affordable and accessible treatment options. And even when treatment is available, other federal data suggests that fewer than half of treatment facilities offer opioid addiction medications.

The US could also do a lot more on the harm reduction front. Consider needle exchanges, where people can pick up sterile syringes and trade in used needles. The decades of research show needle exchanges combat the spread of bloodborne diseases like hepatitis C and HIV, cut down on the number of needles thrown out in public spaces and link more people to treatment — all without enabling more drug use.

Yet needle exchanges remain scarce in the US, as Josh Katz reported for the New York Times: “According to the North American Syringe Exchange Network, 333 such programs operate across the country, up from 204 in 2013. In Australia, a country with less than a tenth as many people, there are more than 3,000.”

Then there’s a more controversial idea: prescription heroin sites.

The idea behind these: Some people struggling with addiction are going to use heroin no matter what. For whatever reason, traditional therapies just aren’t going to work for them — just like some treatments for, say, heart disease or cancer don’t work for some patients. So if that happens, it’s better to give them a safe source of the drug they’re seeking and a safe place to inject it, rather than letting them pick it up on the street — laced with who knows what — and possibly overdose without medical supervision.

Researchers credit the European prescription heroin programs with better health outcomes, reductions in drug-related crimes, and improvements in social functioning, such as stabilized housing and employment. Canadian studies also deemed prescription heroin effective for treating heavy heroin use. A review of the research — which included randomized controlled trials from Switzerland, the Netherlands, Spain, Germany, Canada, and the UK — reached similar conclusions, noting sharp drops in street heroin use among people in the treatment.

The RAND review of the evidence also found solid support for prescription heroin sites, which actually had a much stronger evidence base than supervised consumption sites.

There is no prescription heroin program in the US.

Advocates of supervised consumption sites, though, argue that safe injection facilities provide a unique opportunity that other policy interventions do not.

For example, someone who uses heroin may have had bad experiences with the criminal justice system or health care system in the past. That may make him skeptical of going to these institutions — or any other official institutions — for help. A supervised consumption site, though, can be different, since it’s an environment in which people are less judgmental about drug use. If the people running supervised consumption sites take advantage of this, they could use their better stature with people who use drugs to guide them to treatment and recovery.

There’s some research, as the EMCDDA found, that supervised consumption sites can do this. But more evidence is needed, skeptics and critics argue.

But as tens of thousands die of drug overdoses a year, some local policymakers are desperate to find solutions. So despite the federal opposition, they’re moving ahead with supervised consumption sites.