supervised injection site supervised injection site supervised injection sites (sis) are medically supervised facilities designed to provide a hygienic environment in which people are able to consume illicit recreational drugs intravenously and prevent deaths due to drug overdoses. the legality of such a facility is dependent by location and political jurisdiction. supervised injection sites are part of a harm reduction approach towards drug problems. the facilities provide sterile injection equipment, information about drugs and basic health care, treatment referrals, access to medical staff, and, at some facilities, counseling. most programs prohibit the sale or purchase of recreational drugs at the facility. cubicles for drug injection at a supervised injection site in strasbourg terminology supervised injection sites are also known as overdose prevention centers (opc), supervised injection facilities, safe consumption rooms, safe injection sites, safe injection rooms, fix rooms, fixing rooms, safer injection facilities (sif), drug consumption facilities (dcf), drug consumption rooms (dcrs), and harm reduction centers. facilities australia "shooting galleries" (the term "shooting" is slang for injecting drugs) have existed for a long time; there were illicit for-profit facilities in sydney, australia during the 1990s. authors differentiated the legally sanctioned sites in australia from those examples in the care they provide. while the operators of the shooting galleries exemplified in sydney had little regard for the health of their clients, modern supervised injection facilities are a professionally staffed health and welfare service. the same journal describes the same facility in australian context as "in general" may be defined as "legally sanctioned and supervised facilities designed to reduce the health and public order problems associated with illegal injection drug use" the legality of supervised injection is handled on a state-by state basis. new south wales trialed a supervised injection site in sydney in 2001, which was made permanent in 2010. victoria also opened a supervised injection site in melbourne in 2018 on a trial basis; in 2020 the trial was extended for a further three years and a second site approved. the second site in melbourne has now been delayed pending a review. the second site was slated to be placed in a building on flinder's street which had previously housed yooralla. europe the first professionally staffed service where drug injection was accepted emerged in the netherlands during the early 1970s as part of the "alternative youth service" provided by the st. paul's church in rotterdam. at its peak it had two centers that combined an informal meeting place with a drop-in center providing basic health care, food and a laundering service. one of the centers was also a pioneer in providing needle-exchange. its purpose was to improve the psychosocial function and health of its clients. the centers received some support from law enforcement and local government officials, although they were not officially sanctioned until 1996. the first modern supervised consumption site was opened in berne, switzerland in june, 1986. part of a project combatting hiv, the general concept of the café was a place where simple meals and beverages would be served, and information on safe sex, safe drug use, condoms and clean needles provided. social workers providing counselling and referrals were also present. an injection room was not originally conceived, however, drug users began to use the facility for this purpose, and this soon became the most attractive aspect of the café. after discussions with the police and legislature, the café was turned into the first legally sanctioned drug consumption facility provided that no one under the age of 18 was admitted. during the 1990s additional legal facilities emerged in other cities in switzerland, germany and the netherlands. in the first decade of 2000, facilities opened in spain, luxembourg, and norway. naloxone, a drug on hand at clinics used to administer in cases of opioid overdose whereas injection facilities in europe often evolved from something else, such as different social and medical outreaches or perhaps a homeless shelter, the degree and quality of actual supervision varies. the history of the european centers also mean that there have been no or little systematic collection of data needed to do a proper evaluation of effectiveness of the scheme. at the beginning of 2009 there were 92 facilities operating in 61 cities, including 30 cities in the netherlands, 16 cities in germany and 8 cities in switzerland. denmark passed a law allowing municipalities to run "fix rooms" in 2012, and by the end of 2013 there were three open. the united kingdom opened one (officially unsanctioned) facility in glasgow in september 2020. it was opened by peter krykant, a local drugs worker; however, lack of funding and support led to its closure in may 2021. ireland has legislation to permit the opening of a service (as of may 2017) in the misuse of drugs (supervised injecting facilities) bill 2017, however, has been halted by planning concerns. to date in july 2022, according to european monitoring centre for drugs and drug addiction belgium has one facility, denmark five, france two, germany 25, greece one, luxembourg two, netherlands 25, norway two, portugal two, spain 13, and switzerland 14. canada there are 39 government authorized scs in canada as of july 2019: 7 in alberta, 9 in british columbia, 19 in ontario, and 4 in quebec. an exemption to controlled substances law under canadian criminal code is granted inside the facilities, but drug possession remains illegal outside the facility and there is no buffer zone around the facility. canada's first scs, insite in downtown eastside of vancouver, commenced operation in 2003. in august 2020, arches lethbridge in lethbridge, alberta, the largest scs in north america, closed shortly after alberta revoked their grant for misuse of grant funds. shortly after opening in february 2018, arches lethbridge found itself repetitively necessitating police intervention and/or emergency medical services for opioid-related issues; indeed, three weeks after its closure, the city noted a 36% decline in opioid-related ems requests. expenditure the average per-capita operating cost of government sanctioned sites are reported to be cad$600 per unique-client, with the exception of the arches lethbridge which had a disproportionately high cost of cad $3,200 per unique client. unauthorized site in alberta in september 2020, a group in lethbridge, alberta led by an arches employee started hosting an unauthorized scs in public places in a tent. the group did not have authorizations to operate an scs or a permit to pitch a tent in the park. the organizer was issued citations for the tent; and the lethbridge police service advised that users utilizing the unauthorized scs would be arrested for drug possession, because exemptions do not apply to unauthorized sites. this opening of this illegal drug consumption tent was controversial and became a subject of discussion at the city council meeting. united states clandestine injection sites have existed for years. a new england journal of medicine study from july 2020 reports that an illegal supervised consumption site has been operating at an "undisclosed" city in the u.s. since 2014 where over 10,000 doses of illegal drugs have been injected over a five-year period. supervised consumption sites with some degree of official sanction from a state or local government have been contemplated, but are rare due to the federal regulation of drugs and the explicit opposition of federal law enforcement to any form of decriminalization. denver (2018) in november, 2018, denver city council approved a pilot program for a safe injection site with a 12-to-1 vote. the drug enforcement administration's denver field office and the united states attorney's office for the district of colorado issued a statement together on the proposed site stating that "the operation of such sites is illegal under federal law. 21 u.s.c. sec. 856 prohibits the maintaining of any premises for the purpose of using any controlled substance." philadelphia (2020) a safe injection site in the united states was projected to open in philadelphia february 2020, under the auspices of the organization safehouse and with the support of the city government. immediate neighbors strongly objected to the site, and the owner of the first proposed location withdraw a lease offer under pressure. united states district attorney william mcswain sued to stop the safehouse project, losing in district court in october 2019, but winning an injunction in january 2021 from a 3-judge panel of the united states court of appeals for the third circuit. safehouse said its proposed operation was "a legitimate medical intervention, not illicit drug dens" and claimed protection under the free exercise clause because "religious beliefs compel them to save lives at the heart of one of the most devastating overdose crises in the country". maine (2021) similar to safehouse, jesse harvey attempted to claim religious freedom protection by forming the church of safe injection in maine. after his death from a drug overdose, the organization obtained a relaxation in regulations from the governor of maine and approval from the maine cdc to operate as an authorized needle exchange in several cities (but not a supervised injection site). new york city (2021) the first government-authorized supervised injection sites that began operating in new york city on november 30, 2021 with the approval of mayor bill de blasio. the new york city department of health and mental hygiene refers to the initiatives as "overdose prevention centers" (opc); they are attached to the pre-existing syringe exchange programme sites. a peer-reviewed study of the first two months of the opc's operation has been published in jama. news media have been allowed access to the opc sites as well. public criticism of the new york city opc's has so far been limited. one problem brought up by the leadership of the metropolitan transportation authority is how use migrates from the centers to nearby new york city subway stations when the opc's are closed. in response mayor eric adams called for the centers to be funded to operate continuously. though sanctioned by the city, the sites arguably remain illegal under federal law, and rely on non-enforcement by federal officials to keep operating. the united states department of justice, during the presidency of joe biden, has signaled some openness and stated that it is "evaluating supervised consumption sites, including discussions with state and local regulators about appropriate guardrails for such sites, as part of an overall approach to harm reduction and public safety." elsewhere local governments in san francisco, seattle, boston, vermont, delaware, and portland, oregon have considered opening safe injection sites as well. plans to open an injection site in somerville, massachusetts in 2020 were delayed by the covid-19 pandemic. evaluations in the late 1990s there were a number of studies available on consumption rooms in germany, switzerland and the netherlands. “the reviews concluded that the rooms contributed to improved public and client health and reductions in public nuisance but stressed the limitations of the evidence and called for further and more comprehensive evaluation studies into the impact of such services.” to that end, the two non-european injecting facilities, australia’s sydney medically supervised injecting centre (msic) and canada’s vancouver insite supervised injection site have had more rigorous research designs as a part of their mandate to operate. the nsw state government has provided extensive funding for ongoing evaluations of the sydney msic, with a formal comprehensive evaluation produced in 2003, 18 months after the centre was opened. other later evaluations studied various aspects of the operation – service provision (2005), community attitudes (2006), referral and client health (2007) and a fourth (2007) service operation and overdose related events. other evaluations of drug-related crime in the area were completed in 2006, 2008 and 2010, the saha international cost-effectiveness evaluation in 2008 and a final independent kpmg evaluation in 2010. the vancouver insite facility was evaluated during the first three years of its operation by researchers from the bc center for excellence in hiv/aids with published and some unpublished reports available. in march 2008 a final report was released that evaluated the performance of the vancouver insite against its stated objectives. some posit that safe injection sites help reduce improperly discarded needles in public. this was found to be the case in a report by the canadian mental health association in 2018. prior to the establishment of a supervised injection site in vesterbro, copenhagen in denmark in 2012, up to 10,000 syringes were found on its streets each week. within a year of