摘要：Safe injection facilities (SIFs) have shown promise in reducing harms and social costs associated with injection drug use. Favorable evaluations elsewhere have raised the issue of their implementation in the United States. Recognizing that laws shape health interventions targeting drug users, we analyzed the legal environment for publicly authorized SIFs in the United States. Although states and some municipalities have the power to authorize SIFs under state law, federal authorities could still interfere with these facilities under the Controlled Substances Act. A state- or locally-authorized SIF could proceed free of legal uncertainty only if federal authorities explicitly authorized it or decided not to interfere. Given legal uncertainty, and the similar experience with syringe exchange programs, we recommend a process of sustained health research, strategic advocacy, and political deliberation. INJECTION DRUG USE HAS been a public health problem in the United States for many decades. 1 , 2 It accounts for the cause of one third of this country’s cumulative AIDS cases. 3 Injection drug users (IDUs) are at high risk of acquiring hepatitis and HIV. 4 – 7 Skin abscesses and endocarditis can result from unsterile injection. 8 A recent wave of fentanyl-related overdose deaths has called attention to the high number of fatal overdoses among IDUs. 9 – 11 Many of the harms associated with injection drug use stem from the scarcity of sterile injection equipment and users’ fear of the criminal justice system. 12 – 15 Anxiety about social rejection and arrest deter use of health and preventative services and force IDUs into hidden locations that are poorly suited for hygienic injection. 14 , 16 – 20 The likelihood that IDUs will contract a blood-borne disease increases significantly when they inject in public spaces or “shooting galleries” (structures such as homes—privately owned, abandoned, and otherwise—that are frequented by IDUs for the purpose of injecting). 18 , 21 Although opiate overdose is typically reversible through the administration of naloxone (an opiate antagonist), witnesses often hesitate to summon first responders out of fear of legal consequences. 22 , 23 Lack of proper syringe disposal facilities and legal disincentives to safe disposal increase the risk that used syringes will be improperly discarded, creating public anxiety and some risk of accidental disease transmission. 24 Syringe access and disposal, outreach, and drug treatment programs help reduce these risks. 25 – 28 These interventions do not address the lack of a safe and hygienic setting for injection, nor are they sufficient to overcome the behavioral influence of relationships and other factors present in informal injecting milieus. 29 , 30 Recognizing this unmet need, some 40 cities worldwide have introduced safe injection facilities (SIFs) as one way to address unsafe drug consumption environments. 31 , 32 A SIF is a place supervised by licensed health personnel where IDUs inject drugs they obtain elsewhere. Facility staff do not directly assist in injection, but rather provide sterile injection supplies, answer questions on vein care and safer injection methods, administer first aid, and monitor for overdose. 33 , 34 SIF staff also offer general medical advice and referrals to drug treatment and other social programs. 31 , 35 Some SIFs extend services to drug users who do not inject. 31 In addition to reducing the health risks of drug use and serving as a bridge to other services, SIFs are intended to reduce the externalities of public drug use in the communities they serve. 36 – 39 They generally target high-risk, socially marginalized IDUs who would otherwise inject in public spaces or shooting galleries. 31 Laws and law enforcement practices have chronically complicated the implementation and limited the impact of harm reduction programs in the United States. 40 – 42 Without at least a reasonable claim to legality, a SIF would be vulnerable to police interference and could have difficulty obtaining funding. Clients could be arrested for drug possession, and staff members might fear arrest or discipline by professional licensing authorities. Following the example of syringe exchange, health activists might open “underground” SIFs to meet IDU’s needs and push the policy agenda. 43 , 44 Over time, however, official authorization and public funding would be needed to allow SIFs to be properly evaluated, let alone to operate effectively and at scale. State legislation authorizing politically controversial harm reduction interventions is not unprecedented; since the beginning of the HIV epidemic, 19 states have passed laws authorizing syringe exchange programs, pharmacy syringe sales, or both, and syringe exchange programs have been authorized by city or county governments in two additional states. 45 Unlike a syringe exchange program or pharmacy, however, a SIF openly provides a place for consumption of controlled substances. Federal law enforcement agencies may view this as a direct challenge to national drug laws. A SIF authorized by a state or local government therefore has the potential to trigger a complicated legal and political conflict between state health powers and federal leadership in the war on drugs. We offer an initial assessment of the main legal issues surrounding SIFs and place them in the context of other drug policy conflicts.
