Understanding Morals Is Key to Accepting Safe Injection Sites

The United States is in the midst of a long-running opioid epidemic that has killed nearly one million people since 1999 and cost over $1trillion in health care, law enforcement and social services since 2001. Safe injection sites, also known as supervised injection sites and opioid prevention centers, are places where people who use injectable, but illegal, opioids such as heroin, can do so without fear of overdose, prosecution or spreading disease. While these sites do not provide drugs, do not degrade neighborhoods and do not promote crime, opposition to opening them across the country has been fierce, as well as misguided.

The first program in the U.S. opened in New York in November 2021, inside existing medical facilities offering multiple services. By August 2022, Onsite NY’s centers had intervened in over 390 overdoses, preventing injury and death.

Internationally, safe injection sites have reduced the risk of overdose, death and the spread of infectious diseases, increased public safety and decreased public drug injection or nuisance. Sites link people to medical care, expedite social services that help them quit using, and aim to reduce the stigma associated with drug use that often prevents people from seeking help.

Despite efforts by advocates to instill the more affirmative term “opioid prevention centers,” it’s been hard to gather widespread support for these programs. In one national study in 2018, only 29 percent of Americans supported legalization of safe injection sites.

So how do we get support?

Proponents of safe injection sites can employ common techniques of persuasion, which require some form of understanding and acknowledgement why people oppose them. Through understanding and acknowledgement, speakers show they are aware of both sides of the issue, building credibility. This may sound like a straightforward task, but it’s often hard to pinpoint people’s underlying fears and true nature of their opposition. Here is where a little-known theory, called moral foundations theory, comes in. 

Moral foundations theory—which says several universal values underlie how humans determine what they believe is right and wrong—helps to explain, and even predict, the strong opposition to safe injection sites, despite robust evidence for their success. There are five lenses in the theory: care for others, fairness, authority, purity and liberty. The opposition to safe injection sites involves the first four lenses more than liberty. To better understand how the overall theory applies, consider this basic statement, which rests on the moral value of harm versus care: people harm themselves through substance use, but safe injection sites allow others to care for them.

The theory seeks to explain how people weigh fundamental values against each other, which ultimately determines their opinions of right or wrong, support or dissent. Using moral foundations theory to understand a societal dilemma has precedent. In a recent paper in the journal American Psychologist, researchers found that moral values accurately predicted COVID-19 vaccination rates in counties across the U.S. Individuals who prioritize fairness and loyalty to the group were more likely to be vaccinated, whereas those who prioritize moral concerns of purity were less likely to have been vaccinated.

As in the case of vaccination status, we can use moral values to better pinpoint the main reservations of the opposition to safe injection sites. To increase support for sites, we need to be able to speak to, and refute, the counterarguments associated with the prioritization of other moral values beyond care for others: fairness, authority and purity.

When federal funding is in question, the moral value of fairness often rises to the top. Opponents of safe injection sites argue that people with substance use are unfairly receiving free services: clean needles, drug testing and medical supervision. They suggest that taxpayers would be subsidizing illicit drug use. However, safe injection sites are fairer to American taxpayers, as it’s far more costly to allow injectable drug use to go unaddressed and untreated. Sites are estimated to save millions over time, with New York City estimating $7 million in annual savings across four proposed sites.

There also remains the question of authority. There is no consensus on who the primary authority over substance use is: the criminal justice system, the health care system, religious institutions or the recovery community. The war on drugs has historically placed the criminal justice system as the prevailing authority on illicit drug use. But this is changing. As we learn about the biological and neurological basis of addiction, the high costs of incarceration, the rise in opioid overdoses, and the disproportionate harm draconian drug laws have on minority populations, health care is emerging as the most equipped system and central authority to best manage the myriad physical and mental conditions experienced by people who misuse injection drugs. It is an important distinction that safe injection sites do not circumvent the authority of the criminal justice system by letting drug use “off the hook.” Instead, sites seek to designate a new authority: trained medical professionals.

For opponents prioritizing the moral value of purity, drug use is a moral failing, and the self-contamination of the human body and spirit. But research shows that substance use disorder is a chronically relapsing brain disease connected to inherited genetic factors.

Other ways in which the moral value of purity can present is in the “purity” of the community. Fears about increases in strangers, crime and litter persist, even when objective data on safe injection sites refute these concerns. No community is free of drug use, so these sites, especially those built into preexisting medical facilities, give local residents safe and private places to manage their disease, instead of in public places like parks.

By identifying the moral lens through which safe injection sites are viewed we can identify reservations and opportunities for agreement, to provide this much-needed form of health care. Despite its successes, Onsite NYC is funded through private philanthropy. City, state and federal officials across the country have continued to refuse to provide funding for such programs. In August, California Governor Gavin Newsom vetoed legislation that would have allowed opioid prevention centers in some cities.

While safe injection sites may initially seem counterintuitive, safe spaces for individuals with substance use challenges provide access to treatment and recovery resources in a way that is nonjudgmental, compassionate and effective. Understanding moral values can help us prevent exchanges where we fail to acknowledge or refute the reservations of the opposition; a critical component to garnering support. In successfully opening dialogue around safe injection sites and the underlying values that determine their acceptance, we can begin to bridge political divisions and make such sites a more widely used strategy to save lives.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.

The United States is in the midst of a long-running opioid epidemic that has killed nearly one million people since 1999 and cost over $1trillion in health care, law enforcement and social services since 2001. Safe injection sites, also known as supervised injection sites and opioid prevention centers, are places where people who use injectable, but illegal, opioids such as heroin, can do so without fear of overdose, prosecution or spreading disease. While these sites do not provide drugs, do not degrade neighborhoods and do not promote crime, opposition to opening them across the country has been fierce, as well as misguided.

The first program in the U.S. opened in New York in November 2021, inside existing medical facilities offering multiple services. By August 2022, Onsite NY’s centers had intervened in over 390 overdoses, preventing injury and death.

Internationally, safe injection sites have reduced the risk of overdose, death and the spread of infectious diseases, increased public safety and decreased public drug injection or nuisance. Sites link people to medical care, expedite social services that help them quit using, and aim to reduce the stigma associated with drug use that often prevents people from seeking help.

Despite efforts by advocates to instill the more affirmative term “opioid prevention centers,” it’s been hard to gather widespread support for these programs. In one national study in 2018, only 29 percent of Americans supported legalization of safe injection sites.

So how do we get support?

Proponents of safe injection sites can employ common techniques of persuasion, which require some form of understanding and acknowledgement why people oppose them. Through understanding and acknowledgement, speakers show they are aware of both sides of the issue, building credibility. This may sound like a straightforward task, but it’s often hard to pinpoint people’s underlying fears and true nature of their opposition. Here is where a little-known theory, called moral foundations theory, comes in. 

Moral foundations theory—which says several universal values underlie how humans determine what they believe is right and wrong—helps to explain, and even predict, the strong opposition to safe injection sites, despite robust evidence for their success. There are five lenses in the theory: care for others, fairness, authority, purity and liberty. The opposition to safe injection sites involves the first four lenses more than liberty. To better understand how the overall theory applies, consider this basic statement, which rests on the moral value of harm versus care: people harm themselves through substance use, but safe injection sites allow others to care for them.

The theory seeks to explain how people weigh fundamental values against each other, which ultimately determines their opinions of right or wrong, support or dissent. Using moral foundations theory to understand a societal dilemma has precedent. In a recent paper in the journal American Psychologist, researchers found that moral values accurately predicted COVID-19 vaccination rates in counties across the U.S. Individuals who prioritize fairness and loyalty to the group were more likely to be vaccinated, whereas those who prioritize moral concerns of purity were less likely to have been vaccinated.

As in the case of vaccination status, we can use moral values to better pinpoint the main reservations of the opposition to safe injection sites. To increase support for sites, we need to be able to speak to, and refute, the counterarguments associated with the prioritization of other moral values beyond care for others: fairness, authority and purity.

When federal funding is in question, the moral value of fairness often rises to the top. Opponents of safe injection sites argue that people with substance use are unfairly receiving free services: clean needles, drug testing and medical supervision. They suggest that taxpayers would be subsidizing illicit drug use. However, safe injection sites are fairer to American taxpayers, as it’s far more costly to allow injectable drug use to go unaddressed and untreated. Sites are estimated to save millions over time, with New York City estimating $7 million in annual savings across four proposed sites.

There also remains the question of authority. There is no consensus on who the primary authority over substance use is: the criminal justice system, the health care system, religious institutions or the recovery community. The war on drugs has historically placed the criminal justice system as the prevailing authority on illicit drug use. But this is changing. As we learn about the biological and neurological basis of addiction, the high costs of incarceration, the rise in opioid overdoses, and the disproportionate harm draconian drug laws have on minority populations, health care is emerging as the most equipped system and central authority to best manage the myriad physical and mental conditions experienced by people who misuse injection drugs. It is an important distinction that safe injection sites do not circumvent the authority of the criminal justice system by letting drug use “off the hook.” Instead, sites seek to designate a new authority: trained medical professionals.

For opponents prioritizing the moral value of purity, drug use is a moral failing, and the self-contamination of the human body and spirit. But research shows that substance use disorder is a chronically relapsing brain disease connected to inherited genetic factors.

Other ways in which the moral value of purity can present is in the “purity” of the community. Fears about increases in strangers, crime and litter persist, even when objective data on safe injection sites refute these concerns. No community is free of drug use, so these sites, especially those built into preexisting medical facilities, give local residents safe and private places to manage their disease, instead of in public places like parks.

By identifying the moral lens through which safe injection sites are viewed we can identify reservations and opportunities for agreement, to provide this much-needed form of health care. Despite its successes, Onsite NYC is funded through private philanthropy. City, state and federal officials across the country have continued to refuse to provide funding for such programs. In August, California Governor Gavin Newsom vetoed legislation that would have allowed opioid prevention centers in some cities.

While safe injection sites may initially seem counterintuitive, safe spaces for individuals with substance use challenges provide access to treatment and recovery resources in a way that is nonjudgmental, compassionate and effective. Understanding moral values can help us prevent exchanges where we fail to acknowledge or refute the reservations of the opposition; a critical component to garnering support. In successfully opening dialogue around safe injection sites and the underlying values that determine their acceptance, we can begin to bridge political divisions and make such sites a more widely used strategy to save lives.

This is an opinion and analysis article, and the views expressed by the author or authors are not necessarily those of Scientific American.