The headlines certainly made it seem like a spectacular, bold and controversial announcement: Philadelphia will be the first city in the country to offer a safe clean space for people to inject themselves with heroin.
But behind the headlines was the real story: Philly, which at 1,200 overdose deaths in 2017 has the highest number of opioid overdoses in the country, is opening its door to the idea of a so-called safe injection site, if some private health or social services organization out there is willing to do the work and take the risk. It’s still not clear if and when that might happen.
But what is clear is the need for something to address the horrors of opioid abuse in Philadelphia—not just for the individuals with addiction and their families, but also for the neighborhoods hit hardest by the scourge. As of last May, there were an estimated 70,000 heroin users in the Philadelphia area, with some 50,000 people who overused prescription pain killers in the last year. The 1,200 deaths are likely a fraction of the number who overdosed and survived; even that number is around 300 more than in 2016, which was the worst year to date. And there is reason to think that the problem is going away any time soon.
What the city is calling a Comprehensive User Engagement site was one of 18 recommendations by the Mayor’s Opioid Task Force, which completed its work last spring. If it happens, it will join about 100 such sites in 66 cities and 11 countries—including Canada and Australia—around the world. In all the talk about safe injection sites being a good way to save lives, or a bad message to send to users, or a good way to clean up a neighborhood, or a bad way to advertise Philly as a place to live and work, the details of what it actually means have been lost.
Here, an attempt to answer the important questions:
What is a safe injection site?
It is what it sounds like: A place where people who use illicit substances—particularly heroin—can go to get a clean needle and “safely” take their drug of choice, rather than hidden away in alleys, or in abandoned houses or lots. People cannot get their drugs here; no one helps them to prepare, or use the drugs; and they are not allowed to sell, give drugs to or help each other.
Do safe injection sites save lives?
Yes. Though, not as many as we need to save. A study commissioned by the city last year found that a safe injection site is likely to save 25 to 75 lives per year. That number is an estimate based on 2016’s 900 deaths; it would be higher given the 1,200 in 2017. But it’s still a drop in the bucket. Still, that does not tell the whole story. Over the last 10 years, the Vancouver site most often studied reported an average of seven overdoses in its facility every day—but none of them fatal. Not all of those would have resulted in a death, of course; but that’s still more than 3,500 overdoses caught and controlled by health care workers on site.
Do safe injection sites save lives? Yes. Though, not as many as we need to save. A study commissioned by the city last year found that a safe injection site is likely to save 25 to 75 lives per year.
Besides that, Philly’s study—done by the Lankenau Institute for Medical Research—says a safe injection site could prevent up to 230 new HIV and Hepatitis cases annually, and could keep users from experiencing common skin infections which can balloon into blood and heart ailments that send them to the hospital. All of this can also save a lot of money—several million dollars annually between ambulance, emergency room, hospitalizations and the costs of overdose deaths. That money—at least in theory—could be used to fund other health and treatment options for reducing addiction.
Do we really want to be the first in the nation to do this?
Well, hold on: The city hasn’t opened anything, or even made any concrete plans for opening anything beyond inviting a private organization to step forward. Meanwhile, the city of Seattle set aside $1.3 million in municipal funds last fall to open a site there; that also triggered headlines proclaiming it the “first,” but it too has been delayed, because of legal challenges. (The controversy in Seattle has dwarfed any debate so far in Philly.)
San Francisco, Denver, Vermont and Pittsburgh have said they are thinking about it; in New York City, the police are spearheading talks with the health department to consider opening a site. Any of those cities could be the first to open an official safe injection site. And there is already at least one unofficial site in a California city that has opened its doors and offered itself for study; its results mirror those in Canada, Australia and Europe.
What happens in these places?
They vary, but in the most talked about sites in Canada, users walk in, take a number and have a seat in a waiting room. When their number is called, they go into a room divided into office-like cubicles that are visible to a health care worker. There, they can prepare their injection with a clean needle, taking their own time, which cuts down on the chance of mistakes. After they use, the nurse is on hand to make sure they are not overdosing or experiencing any other adverse reaction. Then, they go on their way.
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Philly’s Commissioner of the Department of Behavioral Health and Intellectual DisAblity Services David Jones says this simple “harm-reduction” model is not what the city is looking for here. Philadelphia is calling its initiative a “Comprehensive User Engagement Site” because it is supposed to be about more than just injections. Staff will be on hand to treat wounds and other infections prevalent among IV drug users before they become critical; check for and treat transmitted diseases like HIV and Hepatitis; and do a general health assessment. The operator there would also offer wrap-around services to users who walked in the door—referrals to a social worker for psychological and emotional needs; to housing for those who need it; to welfare benefits; to dealing with arrest warrants; to, of course, treatment for their addiction.
Philadelphia’s initiative is about more than just injections. Staff will be on hand to treat wounds and other infections prevalent among IV drug users; check for and treat transmitted diseases like HIV and Hepatitis; do a general health assessment, and offer wrap-around services.
That last bit may be what everyone is hoping to hear about. But it is also the hardest to accomplish. In Canada, sites have claimed 10 to 30 percent of clients have gone into recovery, though those facilities tend to be pretty hands-off when it comes to offering treatment options. Supporters of safe injection sites have made the argument that the longer we can keep drug users alive, the greater the chance they’ll eventually give up their habit. Opponents make the opposite case: Why give up if it’s easy, accepted and clean? As Amir notes, “A lot of individuals in addiction don’t immediately and readily accept treatment.” That’s true no matter where or how they’re using.
Are safe injection sites legal?
It’s unclear, really. U.S. Attorney General Jeff Sessions (of course) has declared war on yet-to-be opened injection sites, and Pennsylvania AG Josh Shapiro said that the sites likely violate state and federal laws. But that doesn’t mean operators will be arrested or prosecuted. Philly’s new District Attorney Larry Krasner (of course) has come out in favor of the sites, and Commissioner Richard Ross said that after visiting Vancouver, he has “an open mind” about the idea.
Former Mayor Ed Rendell compared a safe injection site to the needle exchange program his administration okayed during the height of the AIDS crisis. At that time, the idea of distributing clean needles to drug users—one way to stop the spread of the disease—was to many a calamitous signal that the city was encouraging intravenous drug addiction, and some said it violated the law against the distribution of drug paraphernalia. Rendell’s administration made the case that the law was intended to target head shops and drug profiteers—not public health workers. No one challenged that interpretation, and Prevention Point has been swapping out needles and helping IV drug users to survive for more than 25 years now.
Burris says the same argument could be made for safe injection sites. The so-called federal ”Crack House” statute says that you can’t maintain premises for the purposes of illicit drug use. But like with needle exchange, the city could make an argument that the law is not intended to prevent health workers from saving lives. “And no one wants to be seen arresting doctors and nurses who are helping people stay healthy,” says Burris, a former Prevention Point board member who helped launch the needle exchange
On the other hand, he notes one striking difference: Prevention Point was housed in a city building, and the needle exchange was funded with city money, through the health department. That’s what most cities—from Seattle to New York—are looking at. “It looks more like a public health measure when the city health department is doing it, than when it’s a private organization,” Burris says. “This is a little like the city looking for some private entity to take all the risks while the city stands on the sidelines clapping.”
Amir, essentially, did not dispute that. She says the city doesn’t know the answer to the legal question and can make no guarantees.“We have made clear that they wouldn’t necessarily have protections,” she says.
Won’t it make Philly—particularly Kensington—even more of a drug destination?
Councilwoman Maria Quiñones-Sanchez, whose district encompasses the hardest hit Philly neighborhoods, is skeptical about the idea of a safe injection site—at least without a better plan for taking care of her community. She points out—rightly—that the city has allowed drug encampments to take over corners of the neighborhood for years, shifting users from one place to another. Meanwhile, the crisis shows no sign of abating.
“Now we rush to make headlines as the first American city to open an injection site, but we are abdicating our responsibility to address both the health crisis of addiction and the community crisis that these encampments have created in the Barrio,” she said when the city announced its plans. “Opening an injection site without a real plan in place will further entrench the crisis in Kensington.”
Of course, the entrenched crisis in Kensington is the reason why that neighborhood may be the only place in the city where this idea makes sense. The users are there—and come there—already. Neighbors in Kensington/Fairhill have become unfortunately accustomed to living in a drug zone; their call for help is partly why Amir says the city decided to consider an injection site. That would not mean the problem will go away, at least not right away; but it could put much of the behavior indoors, away from public—children’s—eyes. “It can make Kensington look like a place with a lot less drug use,” Burris notes. And studies of other sites have found no increase or decrease in crime near a safe injection site.
Is it legal? “It looks more like a public health measure when the city health department is doing it, than when it’s a private organization,” Burris says. “This is a little like the city looking for some private entity to take all the risks while the city stands on the sidelines clapping.”
But without a carefully-developed plan, as Quiñones-Sanchez has pointed out, an injection site solves one very real problem—people using drugs in plain view of the public, or hidden away where no one will see them if they overdose—and leaves a host of others that the Councilwoman argues are more important to focus on first. In Kensington, most obviously, there’s the issue of homelessness. Drug and/or alcohol addiction is the leading cause of death for homeless people in Philly. Once an individual leaves the injection site, where will they go? Back to the encampment? To a street corner, to await their next visit to the site?
The key word here perhaps is plan. As of now, the city doesn’t have one, because it is waiting to hear from private providers about how this might come about. To Burris, that leaves open possibilities to serve many needs: A social impact bond could encourage hospitals to pay for the safe injection site if they could prove a reduction in expensive hospital stays because of infections; or a “housing first” model that would give people no strings attached shelter, and also offer a place to get services, including a safe space to inject.
What else is the City doing to fight this epidemic?
The Mayor’s Task Force report last May made 18 different recommendations, many of which the City has started to enact, with mixed results. In particular, DBHIDS Director Jones says it has increased by about a third the number of slots that provide people with medication assisted treatment—prescribing methadone or buprenorphine to treat cravings and withdrawal symptoms—along with pschyo-emotional therapy. (Though weirdly controversial, this has been scientifically proven the most effective treatment for opioid use disorder.) Currently, the city is at 75 percent capacity, which means there are 2,200 slots still open for patients—something Quiñones-Sanchez has pointed to as a failure of proper outreach.
The city is also piloting a program at Temple University Hospital-Episcopal to immediately connect overdose patients with community resources, including the possibility of treatment. It has provided Prevention Point with a mobile unit to not only provide clean needles and wound care—as it has long done in encampments—but also the other social services and referrals that it offers in its Kensington storefront. And, it has so far trained 1,000 local residents in how to use Narcan, the overdose blocking drug, with several more trainings scheduled for the next six months.
Jones says he doesn’t know the number of people who overdosed, and survived, last year, but in 2016, the health department reported, 6,400 people visited hospitals with OD-related complaints, and it’s likely that number was significantly higher in 2017. Which means the city’s efforts are hard to call a resounding success so far, and a safe injection site—though perhaps addressing other concerns—is not going to turn the tide
So who is going to open this safe injection site?
No one yet. Amir says no organization has yet stepped forward to sign up, ask questions or express interest. Could it be because there’s still so much up in the air? Could it be the legal issues? Could it just be that no one has yet had time to think it through?
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