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.