Harm Reduction in Focus: How Canada Embraces SIFs while the U.S. Holds Back
- Leah Rose
- 2 days ago
- 8 min read
For many who struggle with addiction, it is a private battle fought in alleys, bathrooms, or behind locked doors. Supervised injection facilities (SIFs) offer a controversial but evidence-based alternative. As specialised facilities where individuals can use drugs under medical supervision with access to sterile equipment and emergency care, SIFs save lives.
While both Canada and the United States (U.S.) have faced escalating substance use crises in recent years, their approaches to harm reduction diverge sharply: Canada has largely embraced supervised injection facilities, with 39 currently operating nationwide, while the U.S. remains largely resistant and has only three: two located in New York City and one in Providence, Rhode Island. Distinctions between federal and subnational legal frameworks have been pivotal in shaping the contrasting implementation and legality of supervised injection facilities in Canada and the United States, with cultural attitudes also contributing to these disparities.
While Canada’s harm-reduction-oriented government policy – bolstered by relatively favourable public attitudes toward supervised injection facilities – has fostered an enabling environment for their implementation, the United States maintains rigid federal drug laws and a punitive, abstinence-focused approach to substance use, which hinders the expansion of such sites despite similar drug-related challenges.
When properly established, evidence shows that SIFs reduce the risk of accidental overdose, public drug use, and the spread of infectious diseases. The ongoing surge in fentanyl-related overdose deaths across the United States and Canada draws attention to the broader risks associated with unregulated drug use, including unsafe injection practices, lack of immediate medical intervention, and the absence of supportive health services, all problems which SIFs are designed to address.
From March 2020 to February 2025, supervised injection facilities in Canada recorded over 3 million visits, managed 48,152 non-fatal overdoses, and reported zero fatal overdoses – a powerful testament to their effectiveness in preventing overdose deaths. Yet despite the drug overdose epidemic that was exacerbated by the 2020 COVID-19 pandemic, the U.S. response continues to exclude supervised injection facilities. Instead, it remains limited to less comprehensive harm reduction approaches, such as needle exchanges and fentanyl test strips. SIFs represent a critical, yet underutilised, tool in addressing the substance use crisis in the United States due to their proven ability to prevent fatal overdoses. To fully grasp why Canada has successfully established nearly forty SIFs while the three in the U.S. continue to face significant legal and political resistance, it is essential to explore the distinct legal frameworks and cultural attitudes that underpin each country’s approach to harm reduction.
Key legislation and Supreme Court decisions enabled the establishment and sustainability of SIFs in Canada. Insite, Canada’s first supervised injection facility, opened in 2003 in Vancouver’s Downtown Eastside under a Section 56 exemption of the Controlled Drugs and Substances Act, which allowed it to operate legally despite federal drug possession laws. Consequently, the Vancouver Police Department was able to refrain from enforcing criminal code provisions on site, and the facility’s public health work proceeded uninterrupted. In 2011, the Supreme Court of Canada ruled that the newly appointed federal Minister of Health’s refusal to renew Insite’s exemption violated Section 7 of the Canadian Charter of Rights and Freedoms, which sets forth the right to life, liberty, and security of person. The Court ordered a continuation of the exemption, ruling that denying access to a life-saving health service like Insite was unconstitutional. This decision established a crucial legal precedent that has shaped the regulatory framework governing SIFs in Canada ever since.
While future Section 56 exemptions remain at the Minister’s discretion, criteria were outlined for the assessment of SIFs, including community need, regulatory oversight, public support, and crime impacts. Initial federal legislation responded to the Court’s decision with the inhibitory introduction of Bill C-65, which increased the criteria that had to be met for an exemption to be applied. However, 2017’s Bill C-37 removed these restrictions and simplified the application process, thereby enabling more cities to respond to the substance use crisis. Municipal and provincial governments were also crucial as they provided operational funding, coordinated public health services, and worked with local law enforcement to ensure community buy-in.
Still, not everything is seamless: driven by community concerns surrounding the proximity of SIFs to schools and child-care centres, nine provincially funded supervised injection facilities in Ontario were shut down beginning March 31, 2025. The facilities were converted into Homelessness and Addiction Recovery Treatment (HART) Hubs, which are prohibited from offering drug consumption services. This leaves only one active SIF in the province, the privately funded Kensington Market site, still operating despite facing ongoing legal challenges. Today, although three-tiered governmental support has enabled Insite to be joined by 38 other supervised injection facilities across Canada, harm reduction efforts continue to face significant political and legal challenges even as the federal government affirms that these sites save lives and are essential public health measures.
The graphic above shows each SIF in Canada represented by a black dot. It should be noted that this data is from February 2025, prior to the closure of all but one SIF in Ontario.
The legal and policy framework that enabled supervised injection facilities to take root in Canada was reinforced by a significant cultural and political shift in how addiction was understood. In the late 1990s and early 2000s, rising overdose deaths, the public spread of HIV/AIDS, and widespread injection drug use in public spaces catalysed a shift away from narratives framing addiction as a criminal justice issue and towards an understanding of it as a medical and social problem. The declaration of a public health emergency in Vancouver’s Downtown Eastside in 1997 marked the beginning of this transformation, highlighting the increasing recognition that punitive drug laws were failing. When the 2000 Vancouver Agreement committed all three levels of government to addressing addiction, it simultaneously formalised its status as a public health issue. By 2001, the cultural tide had turned so decisively that not supporting SIFs had become politically riskier than endorsing them.
Community-based activism – particularly from peer-led movements, healthcare professionals, and coroners – was instrumental in sustaining the public pressure essential to legitimising government action, and it ultimately paved the way for legal exemptions and institutional support. Insite opened in 2003 in response to this belief that addiction is a medical issue that should be addressed in a care-based, humane, harm reduction-oriented way, providing a safe space that prioritises health and dignity over criminalisation. Nonetheless, the recent closures of supervised injection facilities in Ontario were welcomed by many who felt these sites posed safety concerns for nearby schools and child-care centres. Thus, harm reduction continues to be divided across Canada and lack of community support can impact SIF operation to the point of closure.
While federal law in Canada has enabled the expansion of supervised injection facilities, in the United States, it creates a major barrier. Although some states and municipalities have attempted to authorise SIFs under local law, these facilities remain vulnerable to federal interference under the Controlled Substances Act, particularly Sections 844 and 856, the former which prohibits drug possession and the later otherwise termed the “Crack House Statute.”
Designed to prevent environments that facilitate drug misuse and endanger public health, this statute makes it a federal crime to knowingly maintain a site for drug consumption and thereby creates a significant legal hurdle for local efforts aimed at harm reduction.
The strength of this barrier was exemplified by the 2019 legal battle in which the first Trump administration filed a lawsuit to block Safehouse, a nonprofit, from opening a SIF in Philadelphia. While a district court initially ruled in Safehouse’s favour, concluding that their goal was "to reduce drug use, not facilitate it," the decision was later overturned by the Third Circuit Court in 2021, which stated that the planned opening of Safehouse “will break the law.”
However, the Safehouse decision did not resolve the broader legal ambiguity surrounding SIFs at the federal level. In the continued absence of any national law or policy explicitly addressing these facilities, fear of federal prosecution remains a major deterrent. In 2021, mayors from six cities emphasised this concern, stating that “the threat of federal enforcement is one of the greatest disincentives to opening and operating these lifesaving programs.” The conflict between local and national authorities has intensified more recently when, in February 2025, U.S. Representative Nicole Malliotakis called on President Trump to shut down New York City’s two city-approved SIFs, citing violations of the Crack House Statute and public disorder. Community groups echoed this pressure, urging the Department of Justice to intervene. Without explicit federal authorisation or a clear directive not to enforce federal drug laws against SIFs, state and local efforts continue to be blocked and threatened.
In the absence of support from Washington, state and local governments have adopted a range of legal and political strategies to navigate federal resistance. As the “Crack House Statute” continues to prohibit the operations of sites for drug use, reflecting a longstanding national commitment to strict substance regulation, some subnational jurisdictions have attempted to work around restrictions by embedding supervised injection facilities within existing syringe exchange programs. In 2021, New York City opened two SIFs with strong support from city officials. However, despite yearly reports of intervention in hundreds of overdoses without a single fatality, the programs remain vulnerable to shut-down as they continue to operate without explicit state or federal authorisation. Other states, including Rhode Island, Vermont, and Minnesota, have passed laws and allocated funding to support SIFs, aiming to establish legitimacy crucial to long-term operation. Pivotally, in 2024, Rhode Island became the first state to establish a supervised injection facility formally authorised and supported by state law.
This milestone could potentially set a precedent for other jurisdictions considering the same programme. Overall, while federal policy remains unchanged and legal risks persist, these local and state-level efforts underscore the critical role of subnational leadership in advancing harm reduction.
In addition to legal challenges, efforts to expand SIFs in the United States are impeded by deep-seated stigma and cultural resistance. The nation’s long-standing framing of substance use as a moral failing and criminal justice issue has fostered punitive laws that marginalise drug users and deter many from accessing essential health services for fears of arrest or social rejection.
In neighbourhoods hardest hit by the overdose crisis, such as those in Philadelphia where Safehouse was proposed, negative perceptions of drug users have led to fierce backlash from residents who are concerned that SIFs will attract crime. Former Deputy Attorney General Rod Rosenstein argued that SIFs would bring violence and despair into communities, reflecting the widespread scepticism around these facilities. Indeed, in 2018, only 29% of the American general public supported the legalisation of SIFs, although polling indicates growing acceptance and increasing advocacy in areas directly affected by the overdose crisis.
This widespread public unease stems in part from a genuine desire to protect community safety and uphold the rule of law – values that have long shaped American drug policy, even when they conflict with a substantial body of evidence indicating that SIFs do not increase criminal activity and, in fact, improve public health and safety. While cultural resistance plays a role, it is the ongoing legal ambiguity in the intersection of federal and state law – that remains the most significant obstacle preventing U.S. jurisdictions from pursuing supervised injection facilities. Nonetheless, the cautious optimism generated by New York City and Rhode Island’s successful sites shows that change is possible, especially if legal clarity at the federal level is paired with sustained, strategic efforts to confront stigma and build public trust.
Canada and the United States have taken markedly different paths in their legal approaches to supervised injection facilities, influenced by divergent political and legal structures and, to a lesser extent, by varying levels of public support. In Canada, a top-down legalisation approach, bolstered by a Supreme Court ruling and federal health policy, removed ambiguity and gave municipalities the authority and protection to act. This enabled a network of SIFs to grow within a clearly defined legal framework. In contrast, in the United States bottom-up efforts from cities and states have been hindered by federal law – specifically the “Crack House Statute” – which continues to render these initiatives legally precarious.
While legal frameworks have been the primary driver of differences, cultural attitudes have also played a role, though less starkly. In Canada, coordinated public health advocacy and grassroots activism helped shape public support for SIFs, while in the U.S., similar efforts have been more fragmented, hyper-local, and less influential on national policy. Both countries have also faced community backlash, but for different reasons: in the U.S., resistance is largely rooted in entrenched ‘tough on crime’ attitudes, while in Canada, concerns tend to focus on community safety.
Overall, these distinctions highlight how national-level policy, when aligned with provincial and local public health objectives, can empower harm reduction. Further, the absence of such policy can stall harm reduction, even in the face of an urgent overdose crisis. For supervised injection services to expand in the U.S., a fundamental transformation is needed – one that changes federal law, ignites political will, and reshapes how society understands addiction.
Image by n.d. via Wikimedia Commons