COMMENTARY

America's Forgotten History of Supervised Opioid Injection

Jonathan S. Jones

April 29, 2021

Over the past year, a Philadelphia nonprofit, Safehouse, has been making headlines with its controversial plan to open the U.S.'s first supervised injection site. The proposed facility would allow Philadelphians with opioid addiction to inject drugs like heroin under the watchful eye of nurses equipped to intervene in accidental overdoses. The clients would provide their own opioids, but the nonprofit would supply needles, provide kits to test drugs for dangerous levels of fentanyl, and connect clients to treatment services.

Supervised injection sites are similar to buprenorphine treatment programs and methadone clinics, where doctors dispense medicines to help clients stay in recovery from opioid addiction. But proponents of supervised injection say that existing programs are difficult to access and too few in number, and that there is need for alternatives.

Safehouse's backers point to strong scientific evidence that supervised injection sites — one of a broad range of strategies to mitigate the risks associated with drug use known as harm reduction — can prevent overdose deaths, slow the spread of Hepatitis C and HIV/AIDS, and connect the most vulnerable people who use drugs with rehabilitation programs and social services. Similar facilities are already proving effective in Canada and Europe. If Safehouse succeeds, it might pave the way for supervised injection sites in cities across the U.S.

But in January, the 3rd U.S. Circuit Court of Appeals blocked Safehouse's plan, ruling that it would violate the "crackhouse statute" of the Controlled Substances Act, which makes it illegal to provide a space for people to use drugs. Former U.S. Attorney William McSwain, who helped bring the lawsuit, applauded the ruling, saying it ensures Philadelphia, the birthplace of American democracy, won't also be known as "the birthplace of heroin injection sites."

Read between the lines, and McSwain is clearly suggesting that Safehouse would represent an unprecedented about-face on U.S. drug policy, which for the past half century has criminalized narcotics through a $1 trillion war on drugs. But McSwain has the history all wrong. In reality, there is a well-established historical precedent of government support for supervised injection sites.

Understanding that support and how it came about requires a close look at America's first opioid crisis, during the Gilded Age in the late 19th century. Opioid addiction had become a major public health problem. Physicians were trained in medical school to dole out opioids for even minor aches and pains, and in the Civil War's aftermath, tens of thousands of disabled veterans got hooked on opium and morphine. Careless doctors overprescribed morphine and later heroin, escalating the problem to crisis levels in the early 1900s. Opioids were largely unregulated, and Americans bought the medicines over the counter at local pharmacies. $1.50 could buy two bottles of heroin and a syringe kit from Sears.

A cartoon illustration of a drugstore from the magazine Puck, published in 1900. At that time, opioids and needle kits could be bought over the counter.

Desperately, doctors tried to clamp down on addiction. Reformers called for limiting the number of opioid prescriptions, the main cause of addiction. Other pioneering doctors created the earliest drug rehabs, then called "inebriety clinics." These scattered medical reforms met with some success by the turn of the century, reducing the number of Americans addicted to prescription opioids. But the larger problem of addiction persisted. Even while opioid prescriptions trended downward overall, some doctors bucked the trend and kept prescribing huge volumes of addictive opioids.

By the 1910s, anti-drug activists became convinced that the sporadic medical reforms were not enough to tackle the addiction crisis. Instead, they urged the government to ban the sale of narcotics. In 1914, the federal government responded with the Harrison Narcotics Tax Act, which, for the first time in U.S. history, essentially banned sales of all narcotics except those prescribed as part of a bona fide medical therapy.

Opioids were largely unregulated, and Americans bought the medicines over the counter at local pharmacies.

Many, if not most, Americans then addicted to opioids had lived relatively stable lives until the Harrison Act. Historical accounts are filled with stories of people who spent most of their lives as functional morphine users, some starting as early as age 12. Suddenly cut off from legal opioids, however, addicted Americans faced the agonizing, potentially fatal prospect of withdrawal or risked being thrown in jail for buying on the black market.

A medical therapy exemption loophole in the Harrison Act left the door open for a compassionate solution to this dilemma: a practice that became known as morphine maintenance.

In the 1910s, dozens of city and state governments across the U.S. began operating "morphine maintenance clinics," the forerunners of modern methadone clinics and supervised injection sites. The clinics provided opioid-addicted Americans with free or discounted prescription opioids to use in plain sight, on the government's dime. Some clinics also tried to help patients taper down dangerously high doses and even quit opioids altogether. But the primary goal then, as now, was to prevent avoidable overdose deaths and stem the flow of dangerous black-market heroin.

The first clinic opened in Jacksonville, Florida in 1912­, and dozens of clinics serving thousands of patients were in operation by the early 1920s. Morphine maintenance clinics saved lives and kept people out of jail, a boon for local communities. In its heyday, the New York City Health Department's massive clinic treated 800 people a day who might have otherwise languished in jail cells or suffered early deaths.

In New Haven, Connecticut, a clinic opened in 1918 that was serving 91 regulars by the time it was shut down in 1920. Decades later, researchers reviewed death certificates of 40 of the clinic's patients and found that few had died from an overdose or another clearly drug-related cause, fates that commonly befell other opioid users.

The primary goal then, as now, was to prevent avoidable overdose deaths and stem the flow of dangerous black-market heroin.

Morphine maintenance was popular and effective. But it became exclusionary as, against the backdrop of alcohol Prohibition, federal authorities shuttered clinics in the early 1920s. Increasingly, Black and poor Americans who used drugs were pathologized by doctors, labeled "junkies" and "dope fiends" by police, and formally excluded from maintenance programs. White people of means who used drugs had access to legal morphine doses, while Black, poor, and urban drug users were forced to buy opioids through the illicit market, where they got caught up in police dragnets and sensationalized in lurid news exposés.

The racist stereotyping of Black and urban drug users as criminals soon dominated media coverage, and the misleading narrative stuck. Individual doctor-patient morphine maintenance continued through the 1960s, but it eventually fell out of favor with younger physicians who, influenced by negative media coverage, frowned upon the practice.

So when critics of Safehouse assert, as former U.S. Attorney McSwain did, that history is on their side and that facilities like Safehouse run counter to "Congress's intent to protect American neighborhoods from the scourge of concentrated drug use," they are conveniently overlooking the government's historical support for the forerunners of today's supervised injection sites. They are choosing to ignore how effective those sites were at preventing accidental deaths, keeping people out of jail, and encouraging the sick to seek help.

Safehouse has vowed to appeal the Circuit Court ruling, and legislative efforts are underway to legalize supervised injection sites in multiple states, including Illinois, New Mexico, and Rhode Island. All of these proposals face steep climbs to becoming law, but as the battles play out, the largely forgotten history of early-20th century morphine maintenance clinics provides much-needed context. The fact that the government once supported facilities like Safehouse should dispel some of the myths around supervised injection and foster a more productive conversation about the public health benefits of harm reduction.

Jonathan S. Jones (@_jonathansjones) is a historian of American medicine. He is currently a postdoctoral scholar at Penn State University's Richards Civil War Era Center, where he's writing a book on opioid addiction in the Civil War era

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