Why Did Supervised Use Sites Lose Momentum? It’s a Matter of Head and Heart.

Director of Legislative Services Allie Morgan co-authored this blog post.

After months of negotiation and efforts by advocates to drum up support for a bill to permit supervised use sites in Colorado, legislators and key proponents said they do not have the necessary political backing to pass such a bill in 2019.

Colorado had been one of several states considering authorizing supervised use sites as a way to prevent drug overdoses. At a supervised use site, people can inject pre-obtained illegal drugs under the supervision of someone who is trained to administer Narcan, an overdose reversal drug. Countries from Canada to Luxembourg have created such sites, but they are not currently legal anywhere in the United States.

The argument in favor of supervised use sites is that they save lives and keep people with substance use disorders around long enough to get treatment by preventing the spread of disease and offering protection against fatal overdoses. The argument against: The facilities act as a haven for illegal drug use and can introduce crime and safety concerns to neighborhoods.

A bill introduced last session, Senate Bill 18-040, failed in the legislature. And supporters do not plan to try again this year: Senator Brittany Pettersen (D-Lakewood), who would have sponsored the bill, said she “lost hope, day by day, as it continued to be a political target.”

Why did the effort to pass a supervised use site bill in Colorado stall in 2019 despite having early momentum?

As with all policies involving substance use, the answer involved both the head and the heart. One way to understand what happened is by considering four concerns that play into policy decisions involving substance use: evidence, politics, context, and values.

(For more on this framework for understanding substance use policy, check out this presentation (webinar and slides) developed by Alex Caldwell and Jalyn Ingalls for CHI’s 2018 Hot Issues in Health conference.)

Evidence: Do safe injection sites work to reduce overdose deaths?

Research into these sites is limited, especially in the U.S., where they are illegal. However, there is some evidence available.

No deaths have been reported at any of the 120 or so supervised use sites that operate around the world, mainly in Europe, Canada, and Australia. And a literature review found that supervised use sites in other countries were able to reduce deaths and increase access to other health services such as substance use disorder treatment, and they did not increase crime or drug use.

This week, a new report about the potential costs and benefits of a supervised use site in Denver was released by the Drug Policy Alliance, a reform organization, in conjunction with the Colorado Fiscal Institute, Harm Reduction Action Center, and Law Enforcement Action Partnership. The report found that such a site “could generate annual net savings of $6.9 million” for the city. The authors point to a strong return on investment, saying that each dollar spent on the facility would generate nearly $5 in savings in addition to providing health benefits.

Politics: Does necessary political support exist to pass (and sign) a bill?

Colorado currently has a “blue trifecta,” with Democrats in control of the state House, Senate, and governor’s office. Though there was some bipartisan support for last year’s supervised use site bill, the new political landscape seemed to be more friendly to such a bill. The timing also seemed good after Denver’s City Council approved a supervised use site pilot last November.

Early in the session, it seemed that Democrats had enough votes to pass a bill, and there were discussions about having enough Republicans on board to allow a few Democratic legislators in swing districts to take a pass on what was sure to be a controversial vote. But support began to erode within the party. The final straw was when House Republican leadership said that Democrats who supported the bill could face recall elections. (Curious about how recalls work in Colorado? Check out this Durango Herald article.) The friendly political environment was no longer there.

Context: What other discussions or media coverage are happening related to this issue?

Authorizing these sites raises questions both about funding and about federal oversight. Proponents indicated that supervised use sites would be paid for by private funders if they became legal, but opponents suggested that tax dollars might fund the sites — an unpopular idea.

Federal agencies and officials, including the Deputy Attorney General, said that cities that operated a supervised use site would face legal action. This context gave pause to many in Colorado. Marijuana remains illegal at the federal level, but the state has been allowed to continue operating its recreational and medical markets. However, it’s not clear if this would hold true for a supervised use site, where people would be injecting other drugs.

Proponents of supervised use sites point to a different piece of context: the many people dying from drug overdoses. Headlines are full of their stories, and many Coloradans have a family member, friend, or other connection who has personally been affected. The opioid epidemic has been cited as a leading cause for a surprising recent decrease in Americans’ life expectancy. Such declines, according to the Commonwealth Fund, are “rare in the developed world outside of periods of war or national crisis.”

Values: How do philosophical beliefs or emotional appeals influence the supervised use site debate?

It is impossible to ignore the role that values, beliefs, and emotions play in policy decisions. They often go head to head with the evidence.

Strong rhetoric is used by proponents and opponents to describe supervised use sites. People bring personal beliefs around drug use and treatment to the conversation.

Some examples of emotional appeals voiced on both sides of the debate in Colorado:

  • Opponent: “These injection centers are slow-motion suicide.”
  • Proponent: “I can’t get people into treatment if they’re not alive.”
  • Opponent: “This is the equivalent of having a separate lane for those who choose to drink and drive.”
  • Proponent: “This isn’t going to change whether or not they use. This is going to change whether or not they live.”

Ultimately, in the case of the supervised use sites, strongly held values and political shifts led to the decision to pull the draft bill. With the threat of recall elections in the public conversation, proponents decided not to move the proposed legislation forward. They believed it would be a futile effort that would increase stigma for people who inject drugs by creating space for people to air disapproving views in committee hearings and media coverage.

Though the debate seems to be over for now, we anticipate that supervised use sites will be proposed again in Colorado. Other cities are looking to open such sites, which may lead to more evidence about their effectiveness and more familiarity among policymakers. And as the number of overdoses continues to climb in Colorado and nationally, calls for solutions are likely to continue.

But the context, evidence, and politics — and maybe even the values — surrounding supervised use sites will continue to shift. Here are three key questions to keep in mind going forward:

  • The federal government has filed a lawsuit against the City of Philadelphia, which is attempting to open a supervised use site. What will the outcome of the lawsuit be, and how will the decision affect other cities’ and states’ decisions to move forward (or not) with supervised use site legislation?
  • Are there better ways to evaluate the impact of supervised use sites abroad so policymakers can have a clearer understanding of the evidence around these facilities?
  • Democrats will remain in control of the Colorado legislature and governor’s office in the 2020 session, which begins next January. Will political support for a supervised use site increase between now and then, and if so, how?

Stay tuned. The political battle over supervised use sites in Colorado is far from resolved.

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