One year since Gov. Andrew Cuomo voiced his imminent approval of a pilot program to establish overdose prevention centers in New York, it’s been nothing but radio silence, according to a coalition of drug prevention advocacy groups.

Research for a Safer New York, the group behind the proposal, which is made up of five nonprofits and syringe exchange providers, said it has Mayor Bill de Blasio’s approval but has been locked in a back-and-forth with Cuomo about getting the program up and running since the proposal’s inception three years ago.

In the past decade, the rise of drug overdose death rates in the U.S. has led several states to try to establish safer drug consumption spaces in order to save lives. Three years ago, New York appeared to be one of them. Today, it’s not so apparent.

In 2016, the AIDS Institute, part of the State’s Department of Health, released official guidelines for syringe exchange programs that acknowledged drug overdoses in the facilities’ restrooms could happen. It recommended implementing a variety of safety measures for emergencies, including an intercom inside each restroom to communicate with staff and a door that swings outward.

The same year, New York’s City Council paid for a study on the feasibility and benefits of overdose prevention centers, which are not legal in the U.S., but are common throughout Europe and Canada. In them, participating users may consume drugs under the supervision of trained medical personnel.

The International Drug Policy Consortium has published findings on the efficacy of the sites at reducing the number of overdose deaths and transmission rates of infectious diseases. They have also won the support of organizations like the American Medical Association and the American Public Health Association.

The Washington Heights Corner Project, a nonprofit syringe exchange program in Northern Manhattan, pioneered the idea in N.Y. off-the-radar, quietly allowing program participants to administer drugs in their restrooms.

Other nonprofits, like St. Ann’s Corner of Harm Reduction in the South Bronx, provide thousands of clean syringes for shooting galleries where users convene to do drugs, said Van Asher, syringe access program manager at St. Ann’s. According to Asher, the organization has been advocating for overdose prevention centers for years, long before Research for a Safer New York came to be.

The South Bronx suffered worse overdose death rates than the rest of the country behind West Virginia in 2017, Newsday reported, with an average fatal overdose rate of 21.3 deaths per 100,000 people. Pockets of the Bronx also have trouble managing collection of dirty syringes, a reporter found for The Bronx Ink.

There is nothing new about a drug overdose crisis in the Bronx, said New York State Senator Gustavo Rivera, chair of the Senate health committee, co-chair of the Opioid, Addiction and Overdose Prevention Taskforce and a staunch supporter of overdose prevention centers.

“Unfortunately and tragically, the current way that we have organized a lot of our drug policy is based on this idea that it is a choice,” said Rivera. “And if you’re making it, there’s something wrong with you.”

The way forward, according to Rivera, is with an approach known as harm reduction, a concept that was popularized as the AIDS epidemic raged through the U.S. and Europe beginning in the 1980s. This novel approach is a gentler alternative to abstinence-only public health interventions, aimed at de-stigmatizing drug addiction in society and reducing, rather than entirely eliminating, drug use, recognizing the latter is not possible.

The first overdose prevention center was born in 1986 in Berne, Switzerland. Today, approximately 100 facilities around the world are in operation. 

In 2016, five New York-based nonprofits rallied to propose a pilot program of four overdose prevention centers in the city and one in Ithaca, N.Y. The pilot would start as a two-year program that could eventually expand. Housing Works—a nonprofit that provides housing, health care and legal assistance to people affected by HIV/AIDS—along with four other unwavering sponsors of syringe exchange programs in the state formed a new entity: Research for a Safer New York. The proposal was set to go; all that was needed was city and state approval.

In October of the following year, State Health Commissioner Howard Zucker embraced the proposal, according to Housing Works CEO Charles King. Research for a Safer New York began working with the department’s AIDS Institute to develop protocols for operation and received legal counsel determining the proposal did not violate federal law.

That December, the group received word that Cuomo would sign off on the proposal if it first received de Blasio’s support, said King, who was in direct communication with the Governor.

The following May, after the citystudy’s findings were published, de Blasio signed off on the proposal. Cuomo, however, did not reciprocate. 

“The governor became suspicious that the mayor had delayed until this point,” King said, “and had issued the report with a lot of publicity in order to make it a big issue in the governor’s reelection campaign.”

Indeed, the topic came up in a gubernatorial debate between Cuomo and Republican opponent Marcus Molinaro. Cuomo said the centers are “very complicated” and the “the federal government is decidedly against them,” but that the state is “working on” it nonetheless.

After a campaign appearance at the Pride Parade was threatened to be disrupted by Research for a Safer New York, Cuomo indicated to the group he would approve the proposal “imminently” after the gubernatorial election in November, according to King, who also serves as chair of the board of the organization. 

Nearly one year later, Cuomo has not followed through on his promise.

“The governor got cold feet, decided to go back on his word and not move forward on this,” King said. 

Because Cuomo has not given his authorization, the hands of the health department, which originally agreed to the pilot, are tied. The years-old proposal hangs in limbo.

“We have been in active dialogue with advocates and the City on the proposal while addressing potential law enforcement concerns and the threat of legal challenges,” a spokesperson for the agency said.

New York is not alone in this uphill battle. Safehouse, a nonprofit in Philadelphia, was on track to establish the nation’s first overdose prevention site until February of this year, when federal prosecutors sued the organization, claiming it violated a federal drug law called the Controlled Substances Act.

At the heart of the debate is a stipulation known as the “crack house statute,” which prohibits using or maintaining any place to manufacture, distribute or use controlled substances. Though prosecutors believed Safehouse violated the statute, the organization’s lawyers argued in a brief it was “plainly far removed” from it, The Philadelphia Inquirer reported.

Under the Trump administration, the Department of Justice has strongly opposed overdose prevention sites, with Deputy Attorney General Rod Rosenstein writing an aggressive op-ed decrying the spaces in The New York Times.

Safehouse fought back. And won. Last week, a judge ruled the nonprofit’s plan to open and operate the site does not violate federal law. The federal government is expected to appeal the decision.

Members of Research for a Safer New York speculate Cuomo has been waiting with bated breath for the judgement from Philadelphia in order to move forward. Nevertheless, advocates have been and continue to call on Cuomo to approve the sites.

“With over 20,000 overdose deaths under Governor Cuomo’s tenure, his legacy will be marked by his choice to either stand with New Yorkers or stand in the way of their survival,” Vocal-NY, one of the five groups belonging to Research for a Safer New York, said in a statement. “Every day that we wait on his approval, the Governor has blood on his hands.”

Without making headway with Cuomo, Research for a Safer New York has been working with local elected officials Rivera and Assemblywoman Linda Rosenthal, who has proposed the Safer Consumption Services Act to rally for the research pilot. Each has been a  “champion” for the cause, Research for a Safer New York said.

Rivera believes in approaching the crisis as a public health issue, “not a criminal justice one.” Establishing overdose prevention centers in N.Y. would make the state a “leader in the country,” he said.  

“Nobody has ever died in any of these facilities from an overdose,” Rivera said, while admitting it is “a fairly controversial approach.”

In the meantime, Rivera said, the best alternatives are “evidence-based practices” like Medication-Assisted Treatment, decriminalizing the possession of syringes and making naloxone, a drug that treats overdoses in emergencies, widely accessible.

Syringe exchange programs like St. Ann’s in the South Bronx train volunteers on how to properly administer the drug and certify them to carry it with them at all times. St. Ann’s trains more than 1,000 people a year, Asher said.

For many advocates, overdose prevention centers are the only feasible next step forward in attempts to curb the crisis. 

“I think that the people that are against the idea don’t understand the shortcomings of our current approaches,” said Ken Robinson, executive director of Research for a Safer New York. “Law enforcement can’t fix this problem. In fact, law enforcement makes it worse.”

Cuomo was expected to meet with King last Friday to resume talks about the proposal. King said the Governor’s counsel postponed the meeting until Oct. 22.