The Baltimore Health Department has a history of taking risks to help drug addicts. In an effort to prevent outbreaks of HIV and hepatitis, the city was one of the first to open a needle exchange where addicts can swap dirty needles for clean ones. It also made national headlines when the city's health commissioner, Leana Wen, opened the door for any resident to buy naloxone, the life-saving antidote to an opioid overdose.
But there's at least one evidence-based method for helping people with substance abuse problems that Wen is hesitant to propose: supervised injection facilities.
Supervised injection facilities (SIF) are places where addicts can safely use their own illegal drugs under the watchful eye of a medical professional and with clean paraphernalia provided by the city. Also present are people who can connect users with social services, including drug and mental health treatment and housing assistance. Dozens of studies have shown that SIFs reduce overdoses and do not increase drug use or crime in the community.
There are more than 100 of these clinics in Europe and Australia, and one in Canada. In the U.S., however, the idea encounters roadblocks everywhere it goes. But as the opioid epidemic rages on, its supporters don't appear to be giving up, and the country might get its first facility of this kind in 2018.
After overcoming many hurdles, the place closest to opening an SIF is King County, Wash., home to Seattle.
Seattle and King County officials gave the green light to pursue one in 2017, but an opposition group raised enough signatures that would have put the issue on the ballot. The group argued that because the opioid epidemic is a public health crisis, the public should have a say in how it gets handled. A judge, however, shot down the effort in October, ruling that the petition infringed on the decisionmaking power of the King County Board of Health.
There still isn’t a timetable for when it will open, though Jeff Duchin, a health officer for King County, says he’s confident they’ve cleared the biggest logistical hurdles and that the clinic, which will be a pilot project at first, will be well-received.
“If you think people are just weak-willed, it might seem strange," he says. "When you realize this is a chronic disease and you’re engaging them in treatments, it makes more sense."
In the past few months, several more places -- Colorado, Delaware, Philadelphia and a county in Vermont -- have started discussing the possibility of an SIF to address the opioid crisis.
The Colorado General Assembly is expected to take up the issue when they convene for the 2018 session this month. Denver City Council President Albus Brooks already traveled to Vancouver in November to visit the SIF there. In Philadelphia, the idea has the backing of Mayor Jim Kenney. In Crittenden County, Vt., the top county prosecutor is pushing it, but the Vermont Association of Chiefs of Police is opposed, and Gov. Phil Scott remains unconvinced -- although he says the issue should be studied.
There's also an ongoing effort in California. After a bill to allow supervised injection sites in California failed in September, the sponsor immediately promised to propose it again this year.
“While I am disappointed that the bill will not pass at this time, I am committed to finding a way forward next year. The opioid epidemic continues and new solutions are desperately need[ed]," Assemblywoman Susan Eggman posted on Twitter.
It faces an uphill battle: Not one Republican supported the measure, and a few Democrats also voted no or abstained from voting altogether.
At one time, Boston looked like it might be the first U.S. city with a supervised injection site, but a contentious public hearing on the idea in September appears to have killed it for now.
"So we’re going to watch them inject, snort or whatever? And then we’re going to sit by and wait to see whether we have to jump in and render assistance? I think that is absolutely asinine," said Councilor Michael Flaherty during the hearing.
There's a bill to allow the creation of SIFs across the state pending in the Massachusetts Legislature, but it doesn't appear to be a priority for the new year.
One thing holding some cities back from opening a supervised injection facility is the Trump administration. While cities don't need approval from the federal government to establish their own SIFs, U.S. Attorney General Jeff Sessions has shifted the Department of Justice back to a tough-on-drugs operation.
Sessions sent out a memo in May, for instance, encouraging prosecutors to go after "serious drug offenses" and on Thursday, he rescinded an Obama-era memo that urged lax enforcement of federal law in regards to marijuana.
Supervised injection facilities are just too radical a venture to embark on during the Trump administration, says Baltimore's Wen, noting that "80 percent of our funding comes from grants, and many of them are federal. It would just be too tricky. I would require specific guidance from the Department of Justice."
King County's Duchin, however, is hopeful that the DOJ will maintain its commitment to state’s rights in this case.
“This approach is widely recognized in other places, and it isn’t a threat to the federal government,” he says.
Wen also notes that President Trump’s opioid commission failed to recommend any harm-reduction solutions -- including needle exchanges and supervised injection sites -- in its report on how to combat an epidemic that killed more than 33,000 people in 2015.
SIFs not only save lives, they could also save money: A May report from Johns Hopkins Bloomberg School of Public Health found that the opening of one would save the city of Baltimore $6 million.
"In the midst of an epidemic, we should be trying all evidence-based methods," Wen says.