Before the turn of the year, the editorial staff at Infectious Disease Advisor compiled a list of predictions in medicine for 2019 and beyond. Among them, we forecasted that the first supervised injection site would open in the United States. We revisit the debate over the efficacy and legality of these facilities and assess where our prediction stands midway through the year.

Supervised Injection Sites: The Basics

Also known as safe injection sites and overdose prevention centers, supervised injection sites provide drug users a space to inject illicit drugs while under the watch of trained medical staff. A form of harm reduction, these facilities are intended to prevent overdose and HIV transmission. Staff members provide sanitized needles, medical care, safety advice, counseling, and referrals to treatment programs.1 They are present to administer naloxone and other lifesaving procedures when necessary, but they do not inject users or provide illegal substances.2

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Proponents say supervised injection sites save lives and curb addiction by reducing needle sharing and steering drug abusers toward treatment. Critics argue that they perpetuate and facilitate an illegal and harmful activity. We asked our readers whether they would be in favor of legalizing safe injection sites in the United States: slightly more than half (51%) said yes, 37% said no, and 11% weren’t sure.

Where Things Stand

As of the time of this writing, no sanctioned supervised injection site has opened in the United States, although at least one unsanctioned facility opened in 2014 and may still be in operation.3

Legal Roadblocks

Numerous cities have set in motion plans to open an aboveboard supervised injection site only to encounter legal obstacles. Notably, in Philadelphia, a nonprofit organization called Safehouse incorporated with the goal of opening the nation’s first safe injection site. The organization was sued by federal prosecutors in February and a legal battle is ongoing.4,5 “This is in-your-face illegal activity using some of the most deadly, dangerous drugs that are on the streets,” said William McSwain, US Attorney for the Eastern District of Pennsylvania. “We have a responsibility to step in.”4

The Department of Justice had promised to crack down on attempts to open safe injection sites. In 2018, then-US Deputy Attorney General Rod Rosenstein called the facilities “taxpayer sponsored havens to shoot up” that are clearly prohibited by federal law.2

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Research: A Possible Workaround

Some advocates argue that establishing overdose prevention centers for research purposes would help build an evidence base that, in time, will influence policymakers to reconsider their hardline stance. In a JAMA Viewpoint, legal scholars note that United States Code 823(f) allows states to seek research exemptions for government-funded public health studies. Registered health professionals may allow research participants to use schedule 1 drugs in the public’s interest.2

Moving Forward

Because of the legal uncertainty surrounding safe injection sites, efforts to open a facility thus far have stalled. However, due to public opinion and local government support,6 Philadelphia might be the most likely candidate to break through. A Drexel University poll of residents and business owners in Kensington – the neighborhood with the highest drug mortality overdose rates in Philadelphia – found that 9 in 10 residents and 63% of business owners would support opening a supervised injection site.7


  1. How supervised injection sites work. Boston Globe. February 27, 2019. Accessed June 26, 2019.
  2. Gostin LO, Hodge JG Jr, Gulinson CL. Supervised injection facilities: legal and policy reforms. JAMA. 2019;321(8):745-746.
  3. Kral AH, Davidson PJ. Addressing the nation’s opioid epidemic: lessons from an unsanctioned supervised injection site in the US. Am J Prev Med. 2017;53(6):919-922.
  4. Allyn B. US prosecutors sue to stop nation’s first supervised injection site for opioids. NPR. February 6, 2019. Accessed June 26, 2019.
  5. As Philadelphia stalls on supervised injection, other places take up the debate. Even congress. The Philadelphia Inquirer. June 17, 2019. Accessed June 26, 2019.
  6. Allyn B. Supporters sue to open safe injection site in Philadelphia, citing religious freedom. NPR. April 13, 2019. Accessed June 26, 2019.
  7. Roth AM, Kral AH, Mitchell A, Mukherjee R, Davidson P, Lankenau SE. Overdose prevention site acceptability among residents and businesses surrounding a proposed site in Philadelphia, USA. J Urban Health. 2019;96(3):341-352.