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“You Can’t Recover If You’re Dead”

Drug overdoses are killing Americans in staggering numbers. Overdose-prevention spaces have been saving lives for years in Europe, Australia, and Canada. Will they—or can they—ever be accepted in the United States?

Ringer illustration

Carol Katz Beyer was willing to try almost anything. Two of her three children, Bryan and Alex, couldn’t stop using opioids. The health care marketing consultant brought her sons to outpatient programs and inpatient programs, counseling, 12-step meetings near their New Jersey home. Nothing stuck. The substance use problems that had troubled their teenage years followed them into their young adulthood.

“When my boys began this journey of experimentation with drugs, I really didn’t find a lot of support, not in a way that made sense to me,” Beyer told me this year. “At the time it was just tough love and you have to not enable.” She sent Bryan, her eldest, to a rehabilitation program in Florida. He graduated into a sober living home, but then, like the majority of people with substance use disorder do at least once and usually many times, he relapsed. Bryan cycled back into detox and more rounds of rehab and stints in jail, a demoralizing pattern that would last for several years. It wasn’t all bad times: Bryan found love, got married, and started paying Beyer back for the steep costs of his rehab trips. But he died at the age of 28 in 2016, after taking heroin and fentanyl.

Beyer’s middle son, Alex, struggled with drugs alongside his beloved older brother. Panicked after Alex, too, got in trouble in his teens for substance use, Beyer sent him to a boarding school. Then, like Bryan, he followed a typical American treatment program and went to rehab in Florida. He had bad phases—months in jail for drug possession—and good phases, proudly graduating from college. But, like his brother, he relapsed too. Alex overdosed and died at the age of 27, in 2017. He had heroin and fentanyl in his system.

Beyer had followed all the expert advice, but it did not save her sons. She is not alone in this regard. Families and friends of people who have died of overdoses across the country are confronting the vast inadequacy of the current approach to drug treatment. “As parents, we were taught hit bottom, let go, let God, and all the kinds of tough-love models that are prevalent in the United States,” Beyer said. “But they’re not working.”

I’d contacted Beyer because she is on the vanguard of a movement to fundamentally rewire the way people think about drug use in the United States. As the cofounder and president of an organization called Families for Sensible Drug Policy, she has been sharing her story to urge other people to reconsider their beliefs about drug users and treatment. “This is not the way we treat people with other health conditions,” she said. It is also not effective. Drug overdose is the country’s leading cause of death for people younger than 50. It kills more frequently than car crashes.

There was another, more selfish reason I wanted to talk to her. By 2018, nearly everyone I knew in my age group and younger had lost someone to an overdose, myself included. The year before, the White House declared a federal public health emergency. While recent Centers for Disease Control estimates suggest a slight drop in overdose deaths from 2017 to 2018, polysubstance overdoses are on the rise, including deaths involving stimulants, and in many states people are still dying at the same decimating pace. No corner has been turned. Despair is a rational response. And yet Beyer had endured the heaviest personal losses imaginable from this crisis and still decided that things could change. Her pragmatic but insistent optimism felt like a tonic.

Along with a swelling number of doctors, counselors, activists, and ordinary people touched by overdose deaths, Beyer says that sustained relief from the overdose crisis will require a change in how addiction is understood. Beyer was gutted by what she saw at some of her sons’ treatment centers. “There was so much mocking and shame,” she said. She views harmful drug use as a compulsive behavior that desperately needs evidence-based treatment, not punishment.

As part of this mission, Beyer is an advocate for overdose-prevention spaces. (They are also commonly called supervised-consumption sites or safe-injection facilities.) In these spaces, which operate legally in Europe, Canada, and Australia, people are permitted to take drugs with medical staff on hand to prevent overdose and the spread of contagious diseases like HIV and hepatitis. For decades now, researchers have studied whether they help stanch death and infection. The consensus: They do, although some researchers say that further study is needed to determine exactly how helpful they are.

There are no legal overdose-prevention spaces in the United States, and even the suggestion of opening one provokes impassioned criticism and major legal challenges. The federal government is currently suing the Philadelphia nonprofit Safehouse to prevent it from opening this kind of facility. The Trump administration is bullishly opposed. “They are very dangerous and would only make the opioid crisis worse,” then–deputy attorney general Rod Rosenstein wrote in The New York Times last year. The logic of overdose-prevention spaces clashes unpleasantly with several dearly held American notions about substance use. It undermines the importance of rock bottom, of finding grace from a gutter and pulling yourself up by sober and newly clean bootstraps. There’s something unsettlingly resigned and European about monitoring people who are using illegal substances instead of arresting them or conducting a spontaneous intervention. It sounds a bit like throwing someone who can’t swim into the deep end of a pool and simply standing by with a life preserver.

When she first heard about overdose-prevention spaces, Beyer found the concept disorienting too. “It seemed so radical to me,” she said. “We want our loved ones to stop using drugs. Why would we have a place to have them be able to go there and continue to use?” An encouraging, wry person, she more closely resembles a stereotype of a kindly suburban mom than an unflinching crusader. But she is both. “As a parent who lost two children, I want to impart upon other parents that the likelihood of your child relapsing is more apt to happen than not,” she said. “If it does happen, where would you like them to go?”

Policymakers are starting to seriously contemplate this question. So many children are dying that they are willing to risk inevitable scandal. Over 20 cities in the United States are considering overdose-prevention sites. “This is one of those issues where the science and the data are so crystal clear that the more you learn about this issue, the more supportive you are,” said California state Senator Scott Wiener, a Democrat, who has introduced legislation to open these spaces. “That was true with me.”

The recovery industry is still largely abstinence focused, but overdose-prevention spaces are creating apostates within the field, galvanized by grief. “An overdose-prevention space is about beginning a journey of wellness,” social worker Devin Reaves said in April, during a conference in Ewing, New Jersey, about the potential for these spaces that I attended with Beyer. Reaves advocates for these spaces as part of a larger harm-reduction strategy. “It’s about changing our entire perspective,” he said. “It’s coming along in the recovery community, because we’ve been burying our friends.”

As the Safehouse lawsuit looms, it is not clear whether any overdose-prevention program will open in the United States this year. “No city generally wants to be first, right?” Shilo Jama, the director of Seattle’s People’s Harm Reduction Alliance, told The Ringer. Threatened with harsh punishment from federal law enforcement, cities on the brink of opening these spaces have even more reason to hold off and hope someone else will step up first. Jama is frustrated by the fear surrounding this treatment. “The science is there, but, to be perfectly honest, I don’t think we’re a science-based country.”

The first legally sanctioned overdose-prevention space opened in Bern, Switzerland, in 1986. That decade, Switzerland’s cities had grown infamous for crowded outdoor drug markets. In crisis, the nation reassessed its approach to drugs. “Our public attitude changed from viewing heroin addicts as criminals, to an image of patients in need of appropriate treatment,” Ambros Uchtenhagen, the president of Zurich University’s Addiction Research Institute, told The Local in 2012. “Switzerland is a very conservative country. But we are also pragmatic.” By the ’90s, the country had opened a series of overdose-prevention spaces. It also began a prescription heroin program, and offered a variety of other medication-assisted treatments to people in need. Fewer people died. Other cities in Germany, Italy, and Greece followed this example, liberalizing their laws and shifting focus to treatment too.

As Western Europe continued to expand its offerings, Canada and Australia opened spaces. Today, there are around 120 legal overdose-prevention spaces around the world. In Canada, the first space opened in Vancouver’s Downtown Eastside neighborhood, a Skid Row–like community with high rates of homelessness and drug use, in 2003. As their neighbors died, activists decided they couldn’t wait for permission. “We opened an illegal site,” activist Ann Livingston told The Ringer. “No one arrested us.” Instead, they persuaded policymakers that overdose-prevention spaces were a public good, and received a temporary constitutional exemption to drug laws. Insite, the first sanctioned space, was born. “We had a lot of local support,” coordinator Russ Maynard said.

Since its opening, Insite has sent 400 people a year into treatment. Its neighborhood’s problems haven’t gone away, but people take refuge and connect to social services within its walls. The once-renegade nonprofit is no longer a political hot potato—unless you are one of the people who oppose it. “You can’t win a civic election in this city unless you support injection sites,” Livingston said.

Still, Insite’s road to acceptance had obstacles. Two years after the Conservative Party came to power in 2006, it refused to renew the exemption, leading to a battle in Canada’s Supreme Court. The court unanimously sided with Insite, and found that it saved lives without any negative impact on public safety or health. The ruling paved the way for dozens of additional sites across the country. But these spaces remain precarious. The Ontario provincial government recently defunded two sites in Toronto, citing residential concerns as part of the decision-making. “If I put one beside your house, you’d be going ballistic,” Ontario premier Doug Ford said at a news conference. Toronto’s sites haven’t stirred the public into any outward displays of ballistic fury. Inside these spaces, though, anxiety is high.

“It’s been stressful,” nurse Jen Ko said as she gave me a tour of the Moss Park overdose-prevention space, Toronto’s first location. Moss Park is an easy walk from Toronto’s downtown, though its location and stock of stately historic homes have attracted an influx of affluent new residents. Volunteers had launched the space out of tents in its namesake park, which sits in a neighborhood known for high rates of crime and overdoses. While the police looked the other way, the guerrilla nature of the project meant it was barebones. “It was so cold and windy,” Ko said as she led me through the newer, sanctioned facility. “I don’t miss not having bathrooms.” Approval and funding allowed the team to move indoors, to a loftlike site across the street from the park. Rows of oxygen tanks are stationed near rows of metal injection tables, while safety equipment like naloxone kits and needles sit in bins stacked along its walls. There’s a hang-out room with coffee and snacks; apart from the actual consumption area, it looks like a publicly funded community center. A little dingy, but certainly not a bacchanal of right-wing nightmares.

Uncertainty over funding means that the people who work at these sites don’t know how long they’ll have jobs—and it also means that people who rely on their services may be abruptly cut off from the care they’d begun to trust, a source of worry for health care workers. “There’s a moral obligation to continue a service you start,” Ko said. “It’s a basic principle of health care.”

And these spaces provide significant care. “We have a psychiatrist, we have a primary health care physician, a nurse here five days a week, HIV and hep-C rapid testing, housing workers, drop-ins like showers and meals and laundry, mental health case management and harm-reduction case management,” Tyler Watts, the site coordinator for St. Stephen’s Community House’s overdose-prevention space, another Toronto site, told me when I visited this spring. “Detox is referral-based, and it’s hard to get into, but we have a lot of community connections so we’re able to do those things quicker than most folks.”

One of the most repeated criticisms of these spaces is that they might destroy neighborhoods. But, as Watts emphasized, they exist in places where people already tend to use drugs in the open. “Prior to the space being opened, folks would use in our washrooms, and it just wasn’t safe,” Watts said. St. Stephen’s staff had already been responding to health emergencies based on drug use on a regular basis; in fact, the frequency of those responses was exactly why it opened the space in the first place. This is a common scenario. “People say, ‘Well, I don’t want that in my neighborhood to attract the users.’ The users are already there,” Daniel Ciccarone, a professor of community medicine at the University of California San Francisco, told The Ringer. The sites “will bring the problem indoors.”

St. Stephen’s sits across from a microbrewery in the touristy enclave of Kensington Market. It’s a historically tolerant area, known for its car-free summer Sundays and support of immigrant-run businesses. “We haven’t heard a single negative comment,” Watts said, showing me hand-painted posters neighbors made for a community-organized rally. Still, the government pulled its funding—Watts doesn’t understand why—and the program is relying on donations in the lurch. “As it stands right now we can operate until the end of the year,” Watts told me in an email. “If we were to close down the situation would only get worse. People will move back into the washrooms of surrounding businesses, parks and alleyways where they often can’t be helped before it’s too late.”

Even in progressive areas, people striving for reform often endure prolonged battles for painfully incremental wins. “We’re doing everything we can to remain open despite the funding cuts,” Watts said, “because we believe that the lives of people who use drugs are valuable and we won’t abandon them during a crisis.”

Another neighborhood called Kensington is at the center of a fight about overdose-prevention spaces. In February, William McSwain, the U.S. attorney for the Eastern District of Pennsylvania, sued Safehouse, the nonprofit preparing to open a space in Philadelphia’s Kensington neighborhood. It’s a working-class area that has experienced gentrification in recent years, like its northern namesake, but the area contains an open-air drug mart known as “the Walmart of heroin.” The federal government’s civil suit argues that Safehouse would violate a section of the Controlled Substances Act known colloquially as the “crack house” statute, and is asking a judge to decide whether the nonprofit would be breaking the law if it opened.

Safehouse has filed a countersuit against the government, arguing that it wants to oversee legitimate medical interventions. “At the core of all board members’ faith is the principle that the preservation of human life is paramount and overrides any other considerations,” the response reads. Some Safehouse supporters say that the crack house statute—which makes it a felony to operate a space devoted to the illegal drug trade—does not apply to overdose-prevention spaces. “The federal crack house statute is about stopping criminal enterprises attempting to profit off the illegal drug trade,” medical sociologist Peter Davidson said. “Having a department of public health open a public health facility to deal with a medical emergency has nothing whatsoever to do with crack houses, or profiting off of the drug trade.” Former Pennsylvania governor Ed Rendell, who is on Safehouse’s board, said he is ready to be arrested over the issue and that the nonprofit isn’t backing away from its mission. But an opening that once looked imminent is now in limbo. “We still are optimistic that we will open in 2019, but there are many pieces that have to fall into place for that to happen,” Safehouse vice president Ronda Goldfein told The Ringer. An evidentiary hearing on how Safehouse would run its space is scheduled for the end of August, while an oral argument about its legality will take place at the beginning of September.

Even if Safehouse triumphs in court, it will still need local support. Unlike the Canadian Kensington, the Philadelphia neighborhood has many local dissenters. At a meeting about Safehouse this spring, attendees were “overwhelmingly opposed” to its opening. Philadelphia Mayor Jim Kenney, who has supported Safehouse in the past, issued a statement this April urging a slowdown. Safehouse is now taking time to drum up more local support, and hopes to open locations in several neighborhoods to take the pressure off Kensington.

The backlash in Philadelphia isn’t an anomaly. Overdose-prevention spaces are “legal drug dens,” according to the oft-sensationalist New York Post. Opponents argue that the sites will make surrounding neighborhoods dangerous, although there is no evidence that they lead to increased crime. Another common criticism is that they corrode society by making drug use safer. “Should we also create safe places to play Russian Roulette; jump off buildings; or perhaps to eat Tide Pods?’” wrote right-wing radio commentator Karen Kataline, in a blog post typical of conservative commentators’ opinions on the subject. “Why don’t we make it safer for alcoholics to drink themselves into a stupor?”

Not all opposition to these sites is driven by fear. Since the facilities can serve only a limited number of people in a specific geographic area, they cannot easily be scaled up. When service providers face a limited budget for drug treatment programs, the sites don’t always make the most sense to prioritize. As people aren’t likely to drive in order to use drugs, rural communities may not benefit from them. These sites are a specific form of harm reduction, not a panacea, and work best in cities with dense populations. They primarily serve people who would otherwise use drugs in places like public bathrooms or the streets, or “a very specific group of people who live around the facility and don’t have some other residence, or have difficulty accessing safe equipment,” said medical epidemiologist Jay Unick. Among that group of people, Unick observed, it’s been proved that overdose-prevention spaces prevent death.

While there are unsanctioned spaces currently operating in the United States, this hostile legal climate has driven them deeper underground. Peter Davidson, who has studied one of these sites, has stressed their desire to remain hidden for now. They want to “keep their heads down and keep the people they serve alive,” he said. And meanwhile, despite the opposition, people are still fighting. This winter, I saw a white-haired man in a priest’s collar and cowboy hat get arrested while barricading New York Governor Andrew Cuomo’s door during a protest agitating for overdose-prevention spaces in the state. “We are doing something that is holy!” he shouted before being led away in handcuffs. A few weeks later, I met Charles King, now in a dapper suit and tie, at his office in downtown Brooklyn. King is the CEO of Housing Works, a New York City institution focused on ending AIDS and homelessness. He was disappointed by the government’s lack of action. “We felt that there was a ripe moment,” King said. “Where sanity would prevail instead of the ideological nonsense.”

As the leader of Housing Works, King works intimately with people who use drugs, and he described a scenario similar to what had been happening to Watts’s staff in Kensington Market before it was able to open its overdose-prevention space. “We know that people are using our bathrooms,” King said. “While we have panic cords and we have timers and all the rest of that, we still could run the risk of somebody having a cardiac arrest that’s irreversible.”

In between King’s arrest and our meeting, the Safehouse suit had been filed; King suspects it spooked New York officials. “I think the governor’s office decided that it gave them an excuse to sit this out and see what happens,” he said. (Jonah Bruno, the New York State Department of Health communications director, noted that the state is taking the federal lawsuit seriously. “We have been in active dialogue with advocates and the City on the proposal while addressing potential law enforcement concerns and the threat of legal challenges,” he said in a statement.)

The Safehouse lawsuit is having a definite chilling effect elsewhere. In Colorado, Democratic state Senator Brittany Pettersen, who had planned to introduce a bill supporting the creation of overdose-prevention spaces, told the Denver Post that rhetoric against the sites had given her second thoughts. This March, the Seattle mayor’s office cited the Safehouse suit as a reason to hold off on opening a space, even though the City Council had already allocated more than $1.4 million in the budget to do so.

Overdose-prevention spaces do not have many prominent political champions. Few of the Democratic presidential candidates have taken a public stand. Long-shot candidate Andrew Yang favors decriminalization of opioids and cannabis; among the crowded field of more likely nominees, Elizabeth Warren is closest to taking a stand, having said in 2018 that she would support safe-injection facilities if it’s proved that they save lives. (When The Ringer asked whether that statement reflected her current position, her press office referred us back to her previous comments. None of the other major candidates offered comment for this story.) The Trump administration’s hostility isn’t unique. “Would a Democratic administration take a hands-off approach? Possibly,” said Leo Beletsky, the director of Northeastern University’s Health in Justice Action Lab. “But Obama wasn’t very progressive on harm-reduction issues.”

But American attitudes toward drugs often shift more quickly than its laws. Support for cannabis legalization, for example, has jumped from the hippie fringe to the mainstream over the past few decades; although cannabis remains illegal at the federal level, it has gained unprecedented social acceptance. “We have a whole industry operating right now that sits squarely outside of the law,” Beletsky said—meaning that if the federal government felt so inclined, it could arrest everyone working at cannabis dispensaries and grow operations across the United States. But a federal crackdown would be politically disastrous. Two out of three Americans now believe cannabis should be legal, whereas less than one in three felt the same way 20 years ago. A recent study suggests that the drug became more accepted as it was perceived as a medical issue and not a moral one.

It’s not only cannabis undergoing an image overhaul: Denver recently voted to decriminalize psilocybin mushrooms, which have been the subject of renewed interest among researchers for their potential medicinal and psychological benefits. Meanwhile, skepticism about punishment for drug use has been increasing. Greater awareness of the way black and Latino people are arrested and incarcerated for drug use at disproportionately high rates and for longer sentences has made the inhumane and frequently racist logic of many drug laws harder to ignore. In a time when drug norms are rapidly crumbling and reforming, there’s an opening for changes that would’ve seemed outlandish just a few years ago. For overdose-prevention sites, it’s a critical moment. “The Philadelphia case will be a bellwether,” Beletsky said.

Cannabis legalization is just one example of how dramatically American norms can evolve; the embrace of naloxone is another. Harm-reduction advocates have successfully pushed the easy-to-administer medication, which can reverse or mitigate the effects of an opioid overdose, into mainstream use. In Connecticut, for example, equipping state troopers with naloxone led to nearly 300 overdose reversals in three years. There are critics of naloxone, who say that it gives people who use drugs a false sense of security, but the U.S. surgeon general has gone all in on the treatment. The office’s official advisory reads, in part: “BE PREPARED. GET NALOXONE. SAVE A LIFE.”

Another mantra popular with naloxone advocates has turned into a rallying cry for supporters of overdose-prevention spaces: You can’t recover if you’re dead. During the conference I attended with Beyer this fall, several speakers repeated variations of this slogan, which sums up the idea behind harm reduction. The goal of administering naloxone overlaps with that of passing out needles, which overlaps with the mission of fighting to bring overdose-prevention spaces into the treatment fold. Keeping people alive is treatment. “If we’re willing to go hand out needles to people and we know that they’re going to go inject, there’s no real difference between that—which we have a huge evidence base for and is now widely accepted public health intervention—and having somebody sit there with them as they inject to make sure they don’t overdose,” said Jay Unick. “It’s not like you’re crossing a moral chasm.”

The idea of giving drug users clean syringes was initially met with the same sort of revulsion currently directed at overdose-prevention spaces. “Throughout most of the ’90s, it felt like there was a pattern set where harm-reduction talk was framed as a polarizing, controversial issue primarily mapped onto partisan lines,” said the Harm Reduction Coalition’s Daniel Raymond. “Liberals supported harm reduction. Conservatives didn’t.” There is still pushback to needle exchange, which is banned in many states. But while it was once unthinkable for conservative politicians to support progressive drug policy, there are now GOP converts. In Florida, Missouri, Iowa, and Arizona, new legislation to make needle exchanges legal have been either sponsored or cosponsored by Republicans. Overdose-prevention spaces have also found champions within the libertarian movement. “Look at it from a pure cost-benefit point of view,” Cato Institute senior fellow Jeffrey A. Singer told The Ringer. He says that overdose-prevention spaces will shrink spending on disease, as well as first-responder budgets.

Even ideologues can course-correct during a crisis. As a U.S. representative, Vice President Mike Pence voted to uphold a needle exchange ban, which contributed to a deadly outbreak of HIV. Later, as governor of Indiana, Pence signed an order to create a needle exchange program in a rural area of the state beset by an HIV outbreak. “The arguments against it were always that you were enabling people,” said Steve Rabinowitz, former director of downstate field operations for the New York State Office of Alcoholism and Substance Abuse Services. Rabinowitz, who started his career during the beginning of the AIDS crisis, noted that the opposition he saw then against needle exchange reminds him of the opposition faced by overdose prevention advocates. “The kind of arguments you heard then are the kind of arguments people are putting forward against safer injection facilities.”

Medication-assisted treatment is often called the “gold standard” of addiction care. Its success rate is so compelling that major treatment centers have moved away from abstinence-only strategies to offer medication-assisted treatment as well. Even the Food and Drug Administration under Trump has revised its stance.

Familiarizing people with what actually happens at harm-reduction centers often dispels fears about them. “People were fearful and opposed to needle exchanges 30 years ago. Thirty years later, needle exchanges are widely accepted as a life-saving public health strategy,” Seattle City Councilmember Teresa Mosqueda observed. “They are a benefit to our city, and many people don’t even realize that they are there.”

“We don’t have 30 years to wait on this crisis,” Mosqueda said.

There is a specific model that drug policy reform advocates return to when they offer possible solutions for this crisis. “There are only so many more deaths the people are going to take before the public is going to say, ‘OK, we’re open to trying something else,’” the Cato Institute’s Jeffrey A. Singer said. “That was the story of Portugal.”

Understanding the story of Portugal is crucial to understanding why strategies like overdose-prevention facilities are worth testing. The small country offers a remarkable model for an evidence-based approach to the overdose epidemic. It is, arguably, the most advanced nation in terms of drug policy in the world. “It beats them all,” said UC–San Francisco’s Daniel Ciccarone.

In the 1980s and 1990s, heroin gripped the country, resulting in the highest HIV infection rate in the European Union. One out of every 100 people in Portugal used the drug. Faced with an unprecedented health crisis, the government tried something unheard of, and decriminalized drug possession and consumption in 2001. The country flipped how it spent money on addiction, moving the majority of funds formerly spent on criminal punishment into treatment, and gave its health ministry responsibility for drug-related issues rather than law enforcement. This led to a shift in how people thought about one another. “Those who had been referred to sneeringly as drogados (junkies)—became known more broadly, more sympathetically, and more accurately, as ‘people who use drugs’ or ‘people with addiction disorders,’” a 2017 Guardian article about Portugal’s policy noted. Portugal opened an overdose-prevention center only recently, but not because of ideological opposition—because it has already come so far in reducing overdose deaths that the spaces were less urgently required. The results of Portugal’s drug policy when compared to the results of the United States’ drug policy are staggering. In Portugal, 27 people died of drug overdoses in 2016. The country is on track to whittle its overdose deaths to a single digit. In the United States, more than 60,000 people died of drug overdoses in 2016. The next year, the last with comprehensive data, was no better. “We lost 70,000 of our loved ones in 2017,” Beyer said.

The underlying idea motivating Portugal’s policymakers and the people fighting for overdose-prevention spaces is the same: People who are addicted to drugs should be treated as people in need of medical care, and it shouldn’t be against the law to be sick. “We came to the conclusion that the criminal system was not best suited to deal with this situation—that incarcerating drug users or organizers who provide those services was not the best option,” Dr. João Goulão, the national drug coordinator for Portugal, explained in a 2015 interview with the Multidisciplinary Association for Psychedelic Studies. “The Portuguese approach stands on the assumption that, even when users keep using drugs, we are still trying to provide them with conditions for a longer life and a better quality of life. In our model, we don’t give up on people.” Had he trotted this argument out on Intervention, Goulão may have been chided as a delusional enabler. But the rejection of tough love and penalization has not turned Portugal into a substance-addled cesspool. Drug use is down.

There is evidence that people in the United States could come around to Portugal’s approach. Carol Katz Beyer, among many others, say that its life-saving results have the capacity to change minds about harm reduction. “The families learned about Portugal,” she said, tracing how she and her fellow grieving parents and spouses came to change their views on drug use. “We awoke.”

The argument over these spaces boils down to the idea that harmful drug use is a medical issue. In Philadelphia, where the Safehouse lawsuit has pushed the issue into the news, two recent polls asked slightly different questions to gauge support. The Philadelphia Inquirer found that only 22 percent of people approved of “an area where those who wish to inject themselves with illegal drugs are allowed to do so, free from the risk of arrest.” Meanwhile, when Pew asked more directly if they would approve of a “safe site” where people could take drugs under medical supervision, 50 percent said they were in favor, suggesting that people tend to warm to the idea when it is seen as a health care intervention. The most recent survey, published in June, which polled people in the Kensington neighborhood, found that 63 percent of business owners and 90 percent of residents wanted an overdose-prevention space opened in their neighborhood.

As overdose deaths have increased in the United States, there has been a push for additional “war on drugs” approaches, including a wave of drug-induced homicide laws. These laws punish people who give or sell drugs that cause an overdose, treating it as one human killing another. Instances of prosecutors treating accidental drug overdoses as homicides has doubled between 2015 and 2017. I’ve seen part of this push up close; at a funeral, I witnessed women pass out bracelets advocating for these laws, calling on their neighbors to join their crusade against drug deaths. The impulse to punish drug dealers often stems from the same search for justice and change that people like Carol Katz Beyer are undergoing—these women, I knew, were just trying to make the world safer. And yet drug-induced homicide laws often punish vulnerable people, and do nothing to stop people from dying.

A 2017 investigation by a Wisconsin Fox affiliate examined 100 recent local cases and found that most people prosecuted were friends or family of the deceased, or low-level street dealers and others with substance use disorder. “The war on drugs, at this point—not all of us will agree, but any empirical evaluation will conclude that it has failed. It’s probably as good an example of folly as anything at this point,” said Ricky Bluthenthal, professor of preventive medicine at USC. “It doesn’t reduce drug use, it doesn’t protect drug users, it doesn’t get people into drug treatment, it doesn’t do anything that it’s supposed to do, and in fact it makes lots of things worse.”

The fight over overdose-prevention spaces is, at its root, a fight over what it means to have a drug problem. People who want these spaces to exist do not intend them as sweeping fixes to the overdose crisis at large. These spaces are intended to be a single part of a much larger, multifaceted strategy for treating harmful drug use as a medical issue. “We need every approach we can get,” said behavioral neuroscientist Judith Grisel, who recently wrote Never Enough, a book about addiction. “I don’t think it’s a solution to the addiction problem, but it’s a humane response to the addiction problem.”

“We’re not trying to address and resolve all of the problems related to opioid use,” said Safehouse’s Ronda Goldfein. “We’re trying to do a really small thing, which is save some lives while some of these other issues are being worked out.”

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