Seattle, King County, United States - Shilo Murphy sat in his small, cluttered office inside the United Methodist Church in Seattle's University District where he has distributed clean syringes in the back alley for more than 16 years.
The 41-year-old local is a heroin user himself and now directs the needle exchange, People's Harm Reduction Alliance, where he connects drug users to community support, clean injection equipment, infection testing, and education for safer drug use.
After record-high fatal heroin overdoses in King County in recent years, the city of Seattle asked for Murphy's input on how to address opioid addiction in the area.
A decision was later reached by Seattle and King County to build the nation's first safe injection facility (SIF), a clean and safe space where users can consume drugs under medical supervision.
"I've watched my family and friends die a very preventable death through overdose," Murphy says. "[SIFs] are going to promote a culture of safety and a culture of people not dying ... they get people off the streets and also connect people to services."
At least two pilot sites - also referred to as safe consumption sites or Community Health Engagement Locations - will be implemented pending decisions on funding and location, alongside a number of harm reduction methods including increased access to buprenorphine, an opioid medication used to treat opioid addiction, and expanded distribution of naloxone (also known as Narcan), a drug that reverses overdoses.
Such methods emerged from the belief that the world would never be drug-free, and have successfully reduced the harms associated with drug use globally. While unprecedented in the US, SIFs have been implemented elsewhere since the 1980s with about 90 locations in Europe, Australia, and Canada. Many SIFs have reduced fatal overdoses, increased access to healthcare and treatment for people addicted to opioids, and saved financial resources. Introducing the sites, however, has been laden with controversy and, in the Seattle area, has spurred debate around whether the sites will be effective, or legal under federal law.
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|Murphy stands in a back alley in Seattle's University District where he runs a needle exchange [Emily Mulder/Al Jazeera]
Safe space for drug users
Many locals look to North America's first and only SIFs across the border in Vancouver, Canadaas a sign of what they might look like in King County. Critics depict the Vancouver site as a honeypot for drug sellers and focus on harrowing scenes of street corner overdoses, fearing a mirror image in their localities.
Seattle's Kris Nyrop has worked on SIF projects worldwide and says they look different depending on their environment. He says the county's sites would be likely to emulate the unassuming or "low-footprint" models of Hamburg or Amsterdam rather than the oft-referenced site in Vancouver's Downtown Eastside, a highly impoverished neighbourhood where drug users are highly concentrated.
Noting local concerns around the sites, the Seattle Police Department's public affairs director Sean Whitcomb says it would be "absolutely" possible to establish SIFs without harming public safety.
"Look at what we have now: public injection sites all over the city," Whitcomb says. "The needles in your park? Hopefully, they'll be gone because they will be safely disposed. The person who died in the restroom? Hopefully, that won't happen."
Harold* is a man in his early 20s who pays regular visits to Murphy's needle exchange. He is currently homeless and says he would be "excited and glad" if there was a clean and safe space where he could use drugs, listing Seattle neighbourhoods he thought would benefit from SIFs.
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Opposition to SIFs
State Senator Mark Miloscia opposes SIFs out of fear they will set a nationwide precedent for federally facilitated heroin use.
In early March, Miloscia successfully passed a bill in the state Senate to ban the sites. The bill is now under review by the state's House Health Care and Wellness Committee.
Speaking over the phone from the Senate floor, Miloscia equated heroin use with criminal acts such as domestic abuse and assault.
"We need to stigmatise the people hooked on heroin who refuse to go into treatment, to save their lives," Miloscia told Al Jazeera. "We need to push people into treatment, with cultural values and cultural pressure."
The concept that drug use alone results in addiction - and should, therefore, be criminalised and stigmatised to keep people safe - is what physician Gabor Mate called "one of the bedrock fables sustaining the so-called war on drugs".
A lot of people use drugs every day because they're in trauma. I think we should be trying to focus on healing that trauma.
Julie Hannah, co-director of the International Centre on Human Rights and Drug Policy at the University of Essex in the UK, argues that criminalisation and societal prejudice around drug use and addiction lead to the erosion of the human right to health.
"There's plenty of evidence showing that when you're criminalised, it drives you away from services. It drives drug use underground, which leads to more unsafe injection, and it keeps people in need of real healthcare and support completely disconnected from those services," Hannah says.
Fear of illicit drugs and addiction spurred on by decades of a war on drugs mentality has led to other rights abuses, Hannah adds.
"The heavy policing of poor communities in the US, the corresponding number of drug-related arrests, and the disproportionately racist mass incarceration for drug offences emerge within this [war on drugs] context," she says.
Hannah commended Seattle's move towards SIFs, hailing harm reduction approaches that "embrace evidence, health, and dignity, instead of this ideological fear-mongering".
Murphy also rejects stigma and criminalisation-based approaches to curbing opioid addiction.
"The number one thing that helps our participants to heal and grow is telling them that they're loved … A lot of people use drugs every day because they're in trauma. I think we should be trying to focus on healing that trauma."
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Shilo Murphy who directs a needle exchange in Seattle believes the planned safe injection facilities will promote a culture of safety and prevent deaths among drug users [Emily Mulder/Al Jazeera]
Opioid addiction under the Trump administration
Seattle's controversy comes amid increased focus nationwide on the country's growing opioid crisis, to which many are looking to see how this White House will respond.
Chair of the Department of Psychology at Columbia University Dr Carl Hart anticipates that the Trump administration will stray from science-based approaches to public health policy when it comes to opioids.
"Drug use and drug addiction have to be separated," Hart says, pointing to evidence that most people who use opioids do not become addicted, and that the majority of opioid-related deaths result from mixing opioids with other drugs. Discussion of science around addiction is lost in what Hart referred to as the US' historically "draconian approach to drugs".
The US president pledged on the campaign trail and in his February 28 address to Congress to expand the use of drug courts, naloxone, and opioid treatment, but his rhetoric has weighed heavy on stopping the supply of opioids entering the country, using law enforcement.
Certainly, the preliminary signal we've gotten from the administration ... is an attitude of taking a much more law enforcement-based approach to drugs.
"Certainly, the preliminary signal we've gotten from the administration ... is an attitude of taking a much more law enforcement-based approach to drugs," Wendy Parmet, director of Northeastern University's programme on Health Policy and Law, told Al Jazeera.
"We need a more holistic science-based approach. If the response is a look-tough-and-get-tough-approach, I'm worried that that may not be effective," Parmet says.
Trump administration policy could be destructive for Americans addicted to opioids, according to Richard Frank, professor of health economics in the Department of Health Care Policy at Harvard Medical School.
The Affordable Care Act (ACA) marked the first time insurance companies were required to cover substance use disorder and mental health treatments, Frank says, giving people with drug addiction the purchasing power necessary to access treatment.
"If the Trump administration works to undermine the coverage expansions in the ACA then they would put at risk the gains that occurred," Frank told Al Jazeera.
Frank estimates that of the 2.8 million Americans with substance use disorder who rely on the ACA for health insurance coverage, 222,000 could lose access to opioid addiction treatment if it were repealed.
House Republican leaders and the White House still aim to repeal the ACA despite withdrawing legislation to do so in March. Frank told Al Jazeera that the president's plans around opioids still remain unclear.
"His [Trump's] budget and policy announcements seems to at once call for more attention to opioids while making major cuts in SAMHSA's [Substance Abuse and Mental Health Services Administration] budget," Frank says.
Brad Finegood of the King County Department of Community and Human Services says that a "significant portion" of the county's population with opioid addictions were low-income and currently receive treatment services from Medicaid through ACA.
Seattle Mayor Ed Murray's office, meanwhile, says Trump's proposed budget includes deep cuts in federal funding to cities which would affect the city's ability to address the opioid crisis.
"For decades, the federal government has slashed funding for public health, including substance use treatment - and with President Trump in the White House, cities are on their own," the office said in a statement to Al Jazeera.
The Department of Health and Human Services and the White House press office did not respond to requests for comment.
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Pioneer in public health
Seattle advocates, however, remain hopeful that their local public health policy will continue improving support for residents addicted to opioids.
Senator Miloscia requested Attorney General Jeff Sessions for federal intervention in SIFs, but power over public health has traditionally been given to state and local governments.
ACLU-WA's Mark Cooke told Al Jazeera that King County and Seattle were "well within their local authority to use their public health powers" when it comes to SIFs.
While no legal precedent exists for SIFs in the US, Cooke refers to analogous situations such as marijuana policy and needle exchanges, which come under state jurisdiction. Both are against federal law, but as neither have received federal intervention, Cooke believes this could be the case for SIFs.
Cooke added that King County has long pioneered harm reduction approaches in public health. In the late 1980s, local activist Dave Purchase was one of the first people in the nation to start needle exchanges during the HIV/Aids epidemic. The West Coast has historically been home to proactive public health movements.
Mayor Murray has pledged to call for more support from federal and state partners "to help the city try new approaches to save lives".
Back at the University District needle exchange, Murphy says that while he believes in the need for SIFs, he criticises the city for dragging its feet on planning funding.
"I have hope for [the SIFs], but politicians are politicians. What happens if Mayor Murray doesn't get re-elected? What happens when Trump pulls out money? ... Words are nice, but words are not going to stop people from dying in this neighbourhood," Murphy says. "I want real commitment."
*Name changed for privacy
Source: Al Jazeera