Jan. 3—NEW YORK — Sitting before a large mirror in a cubicle in East Harlem, a man in his mid-40s tied a length of elastic around his arm and began searching for a vein.

He made no effort to hide his next step: injecting himself with illicit fentanyl — an often deadly opioid, far more powerful than heroin.

A medical worker watched the man's reflection from a desk in a room set up like a call center — but for the strategically placed mirrors, the neatly stacked sterile syringes and crack pipes, the "crash cart" with oxygen tanks and overdose-reversing medication.

The man, who asked not to be identified to protect his privacy, has been addicted to opioids since 2019. He used to use alone, in his car, sometimes blacking out and then waking up to find he'd been robbed. But here in the supervised consumption site at OnPoint NYC, when he overdosed, he woke up with an oxygen mask on his face. He credits his life to OnPoint, the first officially sanctioned place in America where people in addiction can use drugs under medical supervision.

Today, testing his drugs at OnPoint, he discovered a higher dose of fentanyl than he expected. Staff had shown him how to divide his drugs into smaller doses and inject slowly to avoid an overdose.

"It makes me feel good that I can test it out, and definitely safer," he said. "People who are [using drugs] — it's not something that we choose. But this is where we're at."

The concept of supervised drug consumption is on shaky legal terrain in the United States. Federal courts so far have blocked a years-long effort to open such a facility in Philadelphia, which has some of the nation's highest urban overdose death rates. But just 90 miles north, New York City — in a different federal judicial district where the recent court rulings do not apply — has launched two sites, in East Harlem and Washington Heights.

The results: Since November 2021, the sites together have served more than 2,100 experienced drug users more than 50,000 times, with 672 overdoses treated. No one has died at the centers. Without these facilities, many of these overdoses would have been deadly unless somebody with a dose of Narcan happened to be present.

New York's program is a testing ground for one of the most controversial responses to an overdose crisis that killed a record 106,000 people nationally in 2021.

In Philadelphia, settlement talks that could pave the way to a supervised injection site opening here continue in a lawsuit between the government and Safehouse, the nonprofit that has proposed opening such a facility.

But political and community concerns still loom. Pennsylvania's incoming governor, Josh Shapiro, opposes the facilities. Intense community opposition kept a site from opening in South Philadelphia in 2020, and skeptical neighbors in Kensington, another possible location for a site, have asked for more say in discussions around a site opening.

New York's sites have also faced controversy, with some neighbors worrying that the sites are overburdening neighborhoods that already deal with heavy drug use and dealing.

Meanwhile, staff and clients at OnPoint say they are proving that an approach used in dozens of countries can also be an effective tool against the U.S. overdose crisis. Supporters stress that the goal of such facilities is to keep drug users alive in a deadly overdose crisis — so that they can act with autonomy, including pursuing addiction treatment. (Research continues on the long-term impact of supervised consumption sites in the United States. But the limited research on forcing people into drug treatment rather than waiting for them to choose it suggests that the practice is often ineffective and potentially dangerous.)

"What we have now is a health intervention that keeps people alive," said Sam Rivera, OnPoint's executive director. "And it should be all over the country."

'An overdose in here doesn't look like an overdose out in the community'

As temperatures dropped on a recent afternoon, OnPoint's drop-in center was bustling with clients looking to get out of the cold. Some went to the health clinic on 126th Street, just off Park Avenue in East Harlem, to exchange used syringes for clean ones at the front desk; others sat in armchairs sipping coffee.

To the handful lined up to use the consumption facility, a staffer provided a list of questions: What kind of drugs did they plan to use today? How did they plan to consume them?

For six years before the site opened here in what had been a traditional syringe exchange, health clinic staff used to set timers on the bathrooms for a few minutes at a time. Clients would go in alone to use drugs. After the timer went off and a client was still behind closed doors, staff would check on them.

Now, with support from former New York Mayor Bill de Blasio and his successor, Eric Adams, clients can use drugs within direct view of staff specially trained to spot an overdose. At the East Harlem clinic, mirrors and bright lights even help clients to more accurately find veins.

A sealed-off room with a two-door airlock system and air filters to dispel smoke is particularly popular among an older crowd that uses stimulants such as crack, a smokable form of cocaine.

Participants who inject their drugs receive sterile syringes; those who smoke get sterile pipes and rubber mouthpieces to prevent burns and the spread of diseases.

There are safety rules. For example, clients must tell staff at the front door if they plan to split a dose with another participant.

None of the participants are first-time drug users. But staff do offer safety tips, like avoiding injecting in the neck or in other large arteries.

Sometimes, staff will help clients find a vein, as missing a vein is one of the most common causes of infections among people who inject drugs. Participants, however, must push the syringe's plunger themselves, said Rayce Samuelson, the morning manager at the East Harlem site, which is officially called the Overdose Prevention Center.

After clients use their drugs, staff watch closely for signs of an overdose: eyes rolling back in the head, discoloration of the face or mouth, arms extending downward, or the head sagging.

Acting swiftly saves lives and also results in better treatment. Some 85% of overdoses at the clinic were treated with only oxygen, which has fewer side effects than the reversal drug naloxone.

Naloxone is most commonly delivered via a nasal spray in 4-milligram doses — lifesaving, but also high enough to send a drug user into severe withdrawal. That painful experience often leads to more drug use and potential overdose. When clients do need naloxone at OnPoint, staff usually deliver a lower dose by injection into a muscle.

"An overdose in here doesn't look like an overdose out in the community," Samuelson said. "We know how long someone's been out. There's no question about how long they haven't been breathing."

Philly's legal fight

Four years ago, New York and Philadelphia both started exploring the supervised injection site concept.

In New York, city leaders helped to pick a site. DiBlasio suggested the Washington Heights clinic — already offering syringe exchange services — as a potential location in an area where drug use and fatal overdoses were frequent. His health department ran community outreach operations, but the program's landlord at the time revoked the program's lease even before any such operation could open. (The Washington Heights facility has since found a new lease.)

In Philadelphia, city officials said they would allow — but not fund or operate — a supervised consumption site. When legal challenges began, city officials wrote a friend-of-the-court brief supporting the sites but directed most questions to Safehouse, the nonprofit that's been fighting in court to open one.

The Philadelphia location question was more complicated than in New York. Syringe exchanges are not legal in Pennsylvania, and the few providing such services do so only at the discretion of local officials.

Still, in late 2018, advocates in Philadelphia announced that they were forming Safehouse, and were swiftly sued by the U.S. Department of Justice in a case argued by then-U.S. Attorney Bill McSwain. The Trump appointee argued that such facilities violated the so-called crackhouse statute — a 1980s-era law, sponsored by then-Sen. Joe Biden, prohibiting maintaining places for the consumption of drugs.

Safehouse scored an early legal victory when a federal judge ruled the proposed site wouldn't violate the statute because its primary goal was preventing overdose deaths and not providing a place for drug users to inject. The nonprofit identified a medical facility in South Philadelphia in February 2020 for a site.

But when residents protested, Safehouse's landlord pulled its lease before the site could open — much like in Washington Heights. Later that year, a federal appellate court encompassing Philadelphia ruled that the sites were illegal, though the legal battle continues.

New York, which is in a separate judicial district, moved ahead with its plans, and two clinic locations opened late in 2021. This time, with Biden in the White House, the federal government did not sue. The sites exist in a legal gray area — with the government making no efforts to prosecute staff, but no definitive ruling on its legality in its own judicial district.

Around the country, the concept has advanced slowly, often with similar controversy.

In California, Gov. Gavin Newsom vetoed a bill last April that would have legalized supervised injection sites there. In Rhode Island, the state legislature passed a law permitting supervised consumption sites in 2021; they are expected to open next year, funded by settlements in lawsuits against opioid manufacturers.

OnPoint had hoped to use opioid settlement funds as well, but earlier in December, New York Gov. Kathy Hochul rejected the idea, leaving it to rely on private donations.

'People deserve to be alive'

A year after the sites' opening, not all residents are happy with the operation. Neighbors in East Harlem have complained that open-air drug use has increased in the area, a claim that Rivera rejects. After all, he points out, clients were using drugs in OnPoint's bathrooms for six years when it was only a clinic offering syringe exchange.

In Washington Heights, commuter advocates have asked whether the site can stay open for longer to encourage more people to use drugs inside instead of on subway platforms. (East Harlem's site is open five days a week from 6 a.m. to 8 p.m.; the Washington Heights site has similar hours during the week and accepts participants from 6 a.m. to 4 p.m. on weekends.)

Mayor Adams has said he wants to open more sites in the city.

Rivera is struggling to keep OnPoint funded, however, and wishes he could stay open round the clock. In recent weeks, he said, two regular participants died from overdoses while a site was closed.

"We haven't lost one person in the overdose prevention center. But we get the calls on Monday mornings when we return here, saying we lost another participant because the site wasn't open. It's just brutal," he said. "People deserve to be alive."

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