The success of Insite, North America’s only supervised-injection facility, in Vancouver, B.C., has given many cities on this side of the border hope that a similar site might be feasible here. Federal drug laws prohibit illegal drug use, but there are workarounds; as with marijuana, which is illegal under federal law but authorized widely for medical use at the state level, the feds can choose to turn a blind eye to certain forms of sanctioned drug use. With heroin use leaching into the fabric of white, middle-class American life, and directly impacting people with the power to sway policy, cities in the US, from Ithaca, NY to San Francisco, are asking themselves: What if? What if we can’t fix this epidemic with tough love and forced treatment and mass incarceration? What if there was a way to keep people alive until they’re ready to get better and until we have the resources to help them do so? What if users weren’t stigmatized and pushed into back alleys but embraced and supported?

Matt Curtis, policy director at the New York-based harm-reduction group VOCAL-NY, thinks we may be ready to start answering those questions. His group is working to create a safe-injection site in New York City, and he says widespread panic about the heroin epidemic has elevated the issue of opioid abuse to the level of even Republican lawmakers’ attention.

“I don’t know if anyone knows or remembers this, but about 10 years ago, there was a big push toward SIFs (safe injection facilities) in San Francisco, and a bunch of Republicans in Congress flipped out and were like, ‘San Francisco, if you want a SIF, we’re ready to cut off all your federal funding,’ and the city very quickly blinked and nothing happened for 10 years. Now it’s starting up again and something is very different today,” Curtis says. “We want the public health tool, but we also see this as a way of forcing people to contemplate drug users’ humanity and dignity in a different way, and we’re at that moment in the US in general where that’s happening more.”

Support, or at least grudging consideration, for safe-injection sites can also be attributed to the fact that they move drug use from parks and public restrooms to authorized indoor locations, where users can shoot up and dispose their needles outside public view. 

“I hear it all the time, ‘It’s everywhere, there’s needles in the park,'” city council public health committee chair Sally Bagshaw, who is open to the idea of safe-injection sites, says.  The concerns about children stabbing themselves with HIV-infected needles in the park or public restroom may be overblown, Bagshaw says, but “also, they’re real, and they’re real because people see the detritus and are concerned about how widespread it is. And part of the reason people are talking abut it now is it is hitting neighborhoods of affluence. It’s the teenagers of the doctors and lawyers who are becoming addicted.”

Like Seattle, Vancouver residents worried that Insite’s presence would only worsen high crime rates on  the city’s historic “skid row,” East Hastings Street, but crime actually leveled off after the facility opened, and some crimes, including vehicle break-ins, declined in frequency. Meanwhile, public health outcomes in the area improved dramatically; since it opened in 2003, Insite has prevented 35 new cases of HIV each year (saving more than $6 million), has decreased the fatal overdose rate in the area by 35 percent, has led to dramatic decreases in risky needle use and disposal practices, and has caused 30 percent more people to seek inpatient detox services.

Maia Szalavitz, an author and former heroin addict whose book “Unbroken Brain” presents a new theory of addiction, says it’s obvious why users in Vancouver haven’t run roughshod over the nearby neighborhoods—they know what they have is precarious, and that pissing off their neighbors will lead to Insite’s closure. “The people who are going to be there—would you like to have them? Not in your sight, most likely, but if they are given a safe space, they will respect that safe space. This is one of the things I’ve seen again and again and again with needle exchanges. They know that this is a fragile thing and everybody hates them, and if they, to put it crudely, shit where they eat, it’s not going to work out so well. So they tend not to. … When you give people respect and safe spaces, they will typically give you respect and safe spaces back.”

“The research has indicated that supervised consumption spaces decrease what frequently gets called ‘public nuisance behavior,'” Patricia Sully, a staff attorney at the Public Defender Association and the coordinator for the Seattle-based VOCAL-WA, says. “I think there’s an increasing recognition that public health problems are not best dealt with by the criminal justice system. We really need the public health system to deal with public health. So I think there’s a lot of openness to this new intervention.”

In New York, where VOCAL-NYC launched a campaign last fall to drum up support for safe injection, Curtis says the movement has been slowed down by the cargo ship of bureaucracy that is New York City and state government. VOCAL has been pushing for a state preemption law that would allow a safe-injection site to operate without the threat of a law-enforcement crackdown, but Curtis says it may be faster to change rules at the city level, where the council has already proposed an impact study for a theoretical safe injection site. Curtis’ hope is that a critical mass of cities will decide simultaneously to open safe-injection sites, so that “you have kind of a medical marijuana situation, where maybe the federal government isn’t approving of it, but they’re kind of confused and they can’t crush everybody.”

To build a critical mass, however, some city needs to be the first, and right now, Curtis says, New York is “not as far along as Seattle” in laying the groundwork for safe injection.  Nor is Ithaca, a small town in upstate New York that saw 14 fatal overdoses in 2014. Ithaca’s mayor, Svante L. Myrick, has embraced the idea of supervised injection, but Curtis says the city is waiting for a change in state law that will grant them a waiver from enforcement before moving forward. Other jurisdictions that are discussing safe injection include San Francisco and New Mexico, but no discussions are as far along as Seattle’s.

So will Seattle be the first? That depends on many factors—not just whether the opiate task force recommends supervised-injection or -consumption facilities, as seems likely, but on whether state lawmakers try to crack down on Seattle by passing legislation that preempts the city from opening a safe-injection site, and how willing neighborhood activists are to not just acknowledge but embrace the notion of their neighborhoods as hubs for semilegal drug activity.

Convincing neighborhoods that they’re better off without people using drugs in their parks and public spaces will require convincing neighborhoods that safe-injection sites won’t bring even more drug users and crime, and at a certain point, facts and statistics fail. You can talk all day about how safe-injection spaces reduce crime, get more people into treatment, connect people to services, and improve public health for the entire community, all of which they do, but at some point, the debate comes down to this: Do you believe that drug users should be given the tools to stay alive while they decide if they want to get better (spoiler alert: Most of them do), or do you believe in the tough-love approach to drug use whose failure can be seen in needle-strewn parks and restrooms across the city?

Sully says there will always be “some subset of the population that really opposes [safe-injection sites] in the same way that there is a subset of the population that really opposes methadone clinics and syringe exchanges. There are some people we have not reached and who we’re likely to never reach.” But, she adds, “there is also this movable middle, and in Seattle we have a really large group of people who want a better option and who are really willing to come and listen and learn and shift their opinions.”

Brad Finegood, the assistant director of King County’s Behavioral Health and Recovery Division, told Bagshaw’s public health committee earlier this year that as the brother of someone who died of a heroin overdose, “I was vehemently opposed, as a family member to the idea of a safe injection facility. It was something that just didn’t sit real well with me.” About a  year and a half ago, however, Finegood toured Insite, and described it as “really a transformative process. I was able to see what happened [there] and to see how people are treated. What Insite does is not a lot different tha n what we do here at our needle exchange services, except that here, what happens when people get their needle exchanged is we kick them out the door and tell them to go shoot up in a back alley.”

Sully says Seattle may have another advantage: The Seattle Police Department already has a program in place to connect low-level criminal offenders, called Law Enforcement Assisted Diversion, that was just as controversial at its start as safe injection is now. That program is now widely heralded as a success at reducing crime, connecting people to services, and getting substance abusers into treatment—so successful, in fact, that neighborhoods outside the initial pilot area for LEAD, Belltown, are clamoring for its expansion. That program comes with a set of police officers who are already familiar with the concept of harm reduction, putting them well ahead of other cities that still have a throw-away-the-key attitude to petty crime. It also created relationships between sometimes adversaries like the Public Defender Association and SPD, so neither has to reinvent the wheel.  And not for nothing, Sully says, but the city has a history of “being early adopters”—not just of LEAD but of harm-reduction strategies like syringe exchanges, which were started in Seattle in response to another epidemic, AIDS, in 1989. Harm-reduction proponents hope that willingness to be a pioneer will translate into a pilot safe-injection site in the city soon.

Actually, not just a pilot site—more like pilot sites. And not just a safe-injection site, but safe coke snorting, and crack smoking, and meth smoking, too. But don’t worry—I’ll get into all that in the final installment of this series, coming up later this week.

Read part 1 and part 2 of this series. And if you enjoy my work and would like to help keep it going, please consider becoming a supporter at Patreon; your monthly contributions help me pay for expenses like my recent trip to Vancouver to visit Insite and the Downtown Eastside.