JUST SAY MAYBE — Last week New York City became home to the first two sites in the country where drug users can take illegal drugs under the supervision of staff trained to reverse overdoses. Rhode Island plans to open a similar site next year, under a two-year pilot program. And about a dozen localities are considering the controversial idea, which advocates say can lower overdose deaths but which critics say promotes illegal drug use. The Trump administration vocally opposed such supervised injections, saying they violated the "crack house statute" — legislation that Joe Biden crafted as a senator in the 1980s. So far, the Biden administration has remained silent on whether it would allow the sites to operate. But in the coming weeks, a lingering Trump administration case against a proposed Philadelphia injection site called Safehouse could force the Biden administration to decide whether it is willing to quietly condone the practice. The Department of Justice is supposed to file a brief stating its position in the case by Jan. 5 — the department refused to comment to Nightly on its plans. If the Biden administration drops its opposition to Safehouse in court, that would pave the way for more such sites to open up around the country. Supervised injection sites are just the newest example of how the ongoing overdose death crisis is fraying the bipartisan resolve that developed during the first wave of opioid deaths in the 1990s and 2000s. The sites are also testing the Biden administration's willingness to dismantle "war on drugs" policies that often interfere with localities' efforts to lower deaths from drug overdoses. The opioid crisis is worse than it has ever been, but as it has moved from a prescription drug crisis to a street drug one, it's become far more complicated — and controversial — to solve. When the opioid overdose crisis was rooted in the realm of prescription drugs there was an easy, agreed-upon villain. Federal and state officials, Republicans and Democrats alike, wanted to crack down on the doctors and pharmacies running pill mills and to file lawsuits against pharma companies for flooding towns with addictive painkillers. The nation directed its ire — and investigative, award-winning stories, books and documentaries — at the Sackler family. Now, the problem has migrated from brand-name pain pills like Oxycontin to illicit street drugs like heroin and, now, mostly fentanyl. Opioid prescriptions plummeted 44.4 percent between 2011 and 2020, yet overdose deaths soared as people suffering from addiction migrated to deadlier alternative highs. Overdose deaths topped 100,000 between April 2020 and April 2021 — the highest level ever recorded. Deaths are surging among Black and Indigenous populations, in big cities across the country. Policies designed to stop the pharmaceutical drug crisis could now be backfiring, driving people to street drugs, addiction experts say. That approach of limiting access to powerful painkillers has also made medications used to treat opioid addiction, like methadone and buprenorphine, which are forms of opioids themselves, harder to get. "My patients have gotten arrested for buprenorphine that I have prescribed for them," said Daliah Heller, director of drug use initiatives at Vital Strategies. Meanwhile fentanyl is cheap, powerful and ubiquitous, making it a more attractive alternative to someone in withdrawal. The supervised injection sites in New York and Rhode Island fall into a broad category of policy called harm reduction, which adopts the guiding philosophy of just keeping drug users alive so that they have a chance to seek addiction treatment before they die. Addiction experts say these sorts of policies — like supplying fresh needles for heroin addicts and strips that help users determine whether their narcotics are laced with fentanyl — are the country's best shot of reducing deaths from overdoses. The bulk of the evidence is on their side, they say. "It works and it improves outcomes," Nora Volkow, director of the National Institute on Drug Abuse, told Nightly about harm reduction broadly. Volkow was optimistic about safe injection sites but said they still needed to be studied. Even so, backlash to such policies is mounting. The Safehouse site in South Philadelphia is facing opposition in the neighborhood where it was planning to locate. The Biden administration is trying to tread cautiously, though it is the first administration to embrace harm reduction. Biden's drug czar, Rahul Gupta, has been criticized for his role in shutting down the state's largest syringe services program when he ran West Virginia's health department. These are programs that often get their start underground, operating in legal gray areas first, making them politically problematic, said Leo Beletsky, a health law professor at Northeastern University School of Law. It's one thing for policymakers to agree to crack down on overprescribing doctors or misleading pharma companies, but it's far more politically risky for them to take steps that condone illegal drug use. "We're not ambitious enough," said Paul Joudrey, an assistant professor in the Yale School of Medicine who is a drug use, addiction, and HIV research scholar. "We don't propose changes that match the scale of the epidemic." Treating addiction is hard and complicated. The fundamental challenge is dealing with the things that drive people to take painkillers in the first place. People use drugs to cope with loneliness, lasting trauma and other psychological wounds. That is part of the reason why drug deaths soared during pandemic lockdowns, and why the numbers are likely to stay persistently high for years to come, Heller said. "I started my career during the AIDS epidemic," said Judith Feinberg, professor of behavioral medicine and psychiatry at West Virginia University. "This is the same kind of tragedy. It's worse really. It's horrendous." Welcome to POLITICO Nightly. Reach out with news, tips and ideas at nightly@politico.com. Or contact tonight's author at rrayasam@politico.com, or on Twitter at @RenuRayasam.
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