In January, the City of Philadelphia announced plans to open safe injection sites in an effort to combat the opioid epidemic, a decision that was met with impassioned responses on both sides. Here, Sarah Bauerle Bass, associate professor of social and behavioral sciences and director of the Risk Communication Laboratory, relates the discussion over safe injection sites to an earlier debate—syringe exchanges at the height of the AIDS crisis—and explains why the injection sites would provide a similar public health victory.
A quarter of a century ago, the activist group ACT-UP urged Philadelphia officials to establish a syringe exchange to address the exploding HIV infection rates among people who inject drugs. The concept was simple and the public health imperative clear—provide clean, new needles in exchange for used ones, because more than half of the HIV cases were due to drug use.
Though the idea of syringe exchange was unpopular politically and socially, then-Mayor Ed Rendell signed an Executive Order in 1992 legalizing the possession of syringes in Philadelphia, overriding both state and federal law. Politicians argued that it would make people who didn’t use drugs suddenly want to use, and neighborhoods were concerned that it would increase drug use and crime. Supporters were threatened with arrest, but they bravely established a syringe exchange that is now one of the largest in the country.
The effect? The latest statistics from the Philadelphia Department of Public Health show only 5.5% of new infections are among people who inject drugs, with no increase in crime in areas of syringe exchange. Clearly, a public health win.
Today, we face a new public health emergency that requires similar courage. With 1,200 overdose-related deaths in 2017—a dramatic increase from around 450 just four years earlier— Philadelphia is suffering some of the worst effects of the nation’s opioid crisis. Fueled by pure grade heroin that has often been cut with fentanyl, a synthetic opioid up to 100 times more potent than morphine, this rate is four times the city’s homicide rate in the same time period and four times the overdose rate of New York City. It is even more than the 953 AIDS deaths in 1994, at the height of that crisis. Every day, at least three Philadelphians die of an overdose, and many more overdose but are saved by the use of the overdose reversal drug naloxone. These people are our brothers and sisters, mothers and fathers, and children.
So, the time again calls for a bold public health strategy: safe injection sites. This approach would establish locations where people could go to inject drugs under medical supervision so that overdoses could be responded to immediately and resources such as treatment could be provided. This, like syringe exchange, is a form of “harm reduction,” a public health strategy that acknowledges that in the absence of stopping a negative health behavior, it’s important to provide resources that help people to engage in that behavior safely. In short, harm reduction acknowledges the obvious: We must keep people alive if we are to have any hope of helping them.
In January, the City held a press conference with the heads of the public health, health and human services, police, and fire departments; the mayor’s office; and the District Attorney to announce the findings of the Mayor’s Task Force to Combat the Opioid Epidemic and to support the establishment of a safe injection site in Philadelphia. The plan places us at the forefront of efforts to address this epidemic. In fact, if the safe injection site is opened in the short timeframe the city is urging, Philadelphia could be the first in the country.
The City’s announcement was an extraordinary development, but the backlash was immediate. Pennsylvania House Speaker Mike Turzai called it a “stark violation of federal law” and urged Governor Wolf to send the city a cease-and-desist order. PA Attorney General Josh Shapiro has expressed his opposition, and, while no word has come from the US Attorney’s office yet, it would not be surprising if local officials were again threatened with arrest if they proceed with the plan. It seems we don’t learn from our own history.
But let’s look at the facts. A recent report by Larson et al. estimated that if established in just one location in Philadelphia, between 24 and 76 potential deaths from overdose would be averted in one year, saving between $12 and $74 million in costs. Presumably, multiple sites would increase those numbers. And evidence from Vancouver, where the Philadelphia reps visited recently, shows that there has been no increase in crime but a 35% reduction in overdose related mortality within 500 meters of the facility. More importantly, it has increased the number of people referred for drug treatment and provided medical care and potentially life-saving education on blood borne diseases like HIV and Hepatitis C.
Harm reduction, though sometimes hard to swallow, works. It meets people where they are and ensures that if and when they are ready to stop using, they can—and they aren’t six feet under because of a drug overdose. At the press conference, the fire chief said he had gone to Vancouver believing safe injection sites were a bad idea and came back thinking they were an important answer to the opioid problem. He said that if any city can make it work, Philly can.
This is a city that can make it work, like we did 25 years ago, by adopting a bold, life-saving public health strategy to address the opioid epidemic. But it takes perseverance and a belief in the importance of saving lives. If history repeats, the public will warm to the idea of safe injection sites, as they have to syringe exchange. In the meantime, it’s time to support the city’s bold vision to establish a safe injection site and have the courage to stand up to the opposition.