Skip to Main Content

In the late 1980s and early 1990s, cities struggling with the AIDS crisis began considering a then-radical idea: give drug users sterile needles and syringes so they wouldn’t spread HIV, the virus that causes AIDS. Underlying the idea was the acceptance that some drug use was inevitable and a belief that this kind of program could reduce its harms. Opponents saw it as declaring defeat. Syringe exchange programs, they said, would only encourage drug use, worsening the HIV epidemic. But cities like Philadelphia, where I now work, were desperate for solutions, so they opened syringe exchange programs anyway.

We face a similar situation today with the opioid crisis. In 2017, more than 70,000 Americans died of drug overdoses, 20,000 more than died from AIDS at its peak in the mid-1990s. In Philadelphia alone, on an average day the city morgue accepts three or more overdose victims, making the city’s overdose death rate about triple its homicide rate.


The roots of the opioid crisis are clear: decades of doctors over-prescribing opioid painkillers (under the heavy influence of opioid manufacturers); aggressive street marketing of heroin by illegal drug traffickers; and drug cartels’ new ability to produce and deliver super-potent fentanyl to the street market. Philadelphia is responding by getting doctors to prescribe fewer painkillers, going after illegal drug dealers, dropping barriers to drug treatment, and flooding the city with the opioid antidote naloxone. Each of these actions is helping.

But they aren’t enough. Many individuals who inject drugs eventually recover and stop using, but it typically takes years. In the meantime, they continue to risk death daily by injecting heroin or heroin and fentanyl. So as an additional harm-reduction solution, activists and health experts like me are proposing to open sites where drug users who are not yet in treatment can inject these drugs under medical supervision.

The logic for overdose prevention sites is simple. Opioids kill by shutting down the brain’s respiratory center. Breathing slows, then stops. An individual who has overdosed on opioids will die from lack of oxygen in a matter of minutes. That’s plenty of time for a trained person on the scene to administer naloxone, which re-starts breathing immediately. But it isn’t enough time for an ambulance to arrive after a 911 call.


Overdose prevention sites, also known as supervised injection facilities, offer a clean, safe environment in which people can inject drugs they have purchased elsewhere under the supervision of medical staff, who act much like lifeguards do at a swimming pool. Staff members are always on the scene and armed with naloxone, which they can readily administer if needed so no overdose becomes a fatality.

At the same time, the staffers make connections with people who are using drugs that can become the first step to recovery from drug addiction. These sites also provide sterile injection supplies, offer basic medical care, and serve as an entry point into drug treatment. In all, the facilities keep people alive during the drug-using phases of their lives, while also offering them a hand up to a new and better life.

The Netherlands, Switzerland, and Germany have had overdose prevention sites since the 1990s, and there are now more than 100 such facilities in Europe, Australia, and Canada. We know they reduce overdose deaths.

Insite, the first overdose prevention facility in North America, opened in Vancouver, Canada, in 2003. Since then it has managed thousands of drug overdoses without a single fatality on site. One study showed about a 30 percent reduction in the rate of drug overdose deaths in the neighborhood immediately around the facility.

Insite also serves as a gateway to drug treatment. Among 1,000 users of the facility who had been injecting drugs for an average of 17 years, about half entered a drug treatment program within two years of beginning to visit the site. Because it moved drug use indoors, the facility also improved neighborhood conditions, cutting the number of littered needles and people injecting in public by about half.

An overdose prevention site is not a pretty solution to the opioid overdose crisis. No one likes the idea of someone watching people use dangerous drugs. But we must recognize that despite our extensive efforts at outreach and education, many people will continue to risk their lives by doing that regularly anyway.

If one of the lives saved at such a site was your daughter’s or son’s, you would think it was worth it. And every person using drugs is someone’s child.

A quarter-century after syringe exchange programs began, they are widely accepted as a successful way to reduce the spread of HIV. They are even endorsed by the federal Centers for Disease Control and Prevention. In Philadelphia, the number of annual cases of HIV infection among injection drug users reversed itself the year the syringe exchange began, and has since fallen by 97 percent.

Syringe exchange programs have taught us that harm reduction works. To apply the concept to combating today’s opioid crisis, I firmly believe that the creation of overdose prevention sites is the next logical step.

Thomas Farley, M.D., is commissioner of the Philadelphia Department of Public Health.

  • i want no more from people who do not understand or care about whats the real problem I want no more from stat i get comments about people wanting you info. i don’t need it and i am not an addicted person on drugs never were. i fight for the rights of people who suffer not the others who want to judge please stop all comments i wont write again.

    • Another stat article that fails to mention all the many thousands of us pain patients who have found relief from opioids without any of the problems they always mention with drug abusers and addicts. Seems that they are just not able to ignore us much longer though, because the fda and cdc are just releasing more updates that are warning doctors and insurers about the dangers of force tapering, etc. They are finally acknowledging the truth it appears, that chronic pain patients overall, are not responsible for the opioid academic, that other groups are..Always wondered why there were always so few articles printed in support of pain patients?..

  • As a recovered addict I do understand the need for such Harm Reduction. But this should not be in the type of place that SafeHouse is looking. These people with Substance Abuse Disorder have a Medical and or Psychological disorder, so this should be done inside of a regulated Hospital system where the focus is healing the mind, body, and soul of the patient.

  • My suggestion is stop the drug dealers and drug users that use it illegally, just like you did to actual sever pain patients and there doctors. you make thousands of inocent people suffer but what are you doing about the drugs on the street, nothing while people continue to suffer these people don’t take it for the high.But those people do. What is a high, after 26 yr. on pain medicine I had a bunch of what i call idiots who told me to suffer these don’t care from sever pain in bed 24 hrs a day. what is it most doctors care but i have met 4 in my area who broke the hippictatic oath our doctors don’t kill us this illegal stuff kills you and if you get out of it alive your lucky. There is no such thing as pain free with these diseases that people suffer from such diseases.One person as well as other but on a National Pain Network said this girl was tormented from sever pain and died from it. No but who cares do you no you don’t teach your children to say no to drugs if you don’t face the consequences because you will. unfortunately we are to busy for protecting our children. God gave you them to instruct them not this government they do not care or have time. you must do it your self. if i don’t care i would be like others and do nothing. And that’s a fact

  • Changing the name from safe injection sites to overdose prevention sites is like putting lipstick on a pig. We are prolonging lives of suicide through despair. Surely we can do better than to provide a place that for the moment may prolong a life until the next time they inject. The interval between injections is shorter w fentanyl than heroin. Expand, lengthen and enhance treatments.

  • As a student in Utrecht in The Netherlands in the late 1970’s I turned from being a critic of the Methadon buses parked throughout the city to a strong believer. The 2-fold merits of these safe user sites were vast reduction of overdose deaths, and also of user numbers as staff gained trust and guided to effective programs for “cleaning up”.
    It is unbelievable that in the USA it takes aother 30 years to open up to the success of such safe sites & programs. The USA seems foolishly too stubborn to learn from other (more civilised and advanced) nations. It renders the leadership of the big USA third-world style if it only acts when problems have escalated to epidemic proportions. Let’s hope the USA now peddles hard to catch up and really deals with the opioid crisis in the effective way proven by other countries. To let real patients scream in agony is definitely a brain-dead approach.

Comments are closed.