Top Philadelphia officials are advocating that the city become the first in the U.S. to open a supervised injection site, where people suffering from heroin or opioid addiction could use the drugs under medical supervision.
But the controversial proposal aimed at addressing the city's deadly drug crisis must first overcome resistance from top city police officials, community residents and the federal government.
It's a divisive idea: People bring their own drugs to shoot up under the watch of medical staff, in a facility that provides clean needles and other equipment. Advocates say the goal is to provide a bridge to treatment.
There are about 90 such official facilities around the world. Though some U.S. cities — including Seattle, San Francisco and Denver — are talking about establishing this sort of city-sponsored site, there are none in the United States, so far.
Philadelphia may be unusually well-positioned to be the first; its opioid crisis is mostly concentrated in one neighborhood, where some of the purest, cheapest and most deadly heroin in the nation can be purchased.
The city's new district attorney, Larry Krasner, has promised he would not prosecute users at the safe-injection site.
"Supervised injection sites are a form of harm reduction," says Krasner, who was sworn into office just last week.
The rise in opioid deaths in Philadelphia reflects a nationwide epidemic; the size and lethality of the problem, Krasner says, should be shifting the conversation away from the country's long history of responding to drug users with criminal punishment.
"The only way to get people to turn their lives around," he says, "is to keep them alive long enough so they can do that. And we're going to do that."
Philadelphia's Mayor, Jim Kenney, says he soon will make a public announcement on the topic of establishing a supervised injection site — but, so far, he has not provided details.
Sources close to Kenney say he is still working to bring skeptical members of his administration and other opponents on board.
Kenney has been working on Philadelphia's drug problem for months, first launching a task force to combat the opioid crisis, then creating a new position in city hall to coordinate so-called harm reduction initiatives.
Other plans underway include establishing rules for doctors to more safely prescribe opioids; public education campaigns aimed at combating the stigma around usage of the drugs; and ensuring that those whose overdose is reversed in an emergency room are put directly into treatment — what's known as a "warm handoff."
The idea of a safer place to use heroin appeals to people like Johnny, a 39-year-old electrician from Philadelphia's suburbs. (Because he is using an illegal drug, NPR is using only his first name.)
"I would absolutely go there," Johnny says, adding that he recently relapsed after being sober for seven years.
"Every shot — you never know what's going to happen," he says. "It can always be your last one."
On his lunch breaks from work, Johnny says, he often travels to Philadelphia's Kensington neighborhood — the epicenter of the city's opioid crisis — to use drugs.
Recently, a sprawling open-air drug market and homeless encampment in Kensington along decommissioned train tracks was cleared out, prompting droves of opioid users to regroup in smaller pockets under bridges, in alleyways, on the streets and in abandoned buildings.
Under one of those bridges recently, there was a row of tents. Many people live there, and some visitors, like Johnny, use the tents as a private place to do heroin.
He says he would rather inject his drugs in a medically supervised facility, and he thinks Philadelphia residents would prefer that, too.
"People are not going to be shooting up on your front stoop" he says, "or in your back yard, hiding. It will cut down on people dying in abandoned houses around here — or even here." He motions to the tents. "They come down here and get high and die here under a bridge."
But some law enforcement officers have a different view. Philadelphia's police commissioner, Richard Ross, has been skeptical about designating a legal place for the use of an illegal narcotic.
And even if local police can be convinced, the proposal is likely to provoke a standoff with the federal government, which has promised to aggressively crack down on similar plans in Vermont.
Patrick Trainer, a special agent with the Drug Enforcement Administration's Philadelphia field office, says he is no fan of the model.
"The concept, for us, with safe injection sites, is just not a concept we can get behind," Trainer says.
Such a site could attract street drug dealers and increase their sales, Trainer worries. More than that, he says, the federal government is leery about looking the other way in the face of drug use, worried about where that first step might lead.
"Is it going to stop with a safe injection site?" he asks. "Are we going to do that and then, next year and the year following, are we then going to be talking about, OK, there are still overdose deaths, so maybe we need to look into government-supplied drugs?"
Jen Bowles, a researcher now at the University of California, San Diego, who has studied opioid use in Kensington, says research in other cities has shown that safe injection sites actually decrease fatal overdoses and do not cause a spike in crime.
"There's a tremendous fear that says, 'If we create a space in which drug users can more safely consume drugs, that may somehow be encouraging drug use,' " Bowles says. "But that conflicts with the science that finds that not to be true."
Still, evidence-based studies don't change all minds. No Kensington residents agreed to speak out publicly for this story, since the exact proposal is still being hashed out. Some, though, say the idea of a safe-injection site makes them uneasy. Winning the support of the community will likely be another battle.
Nonetheless, the statistics are creating new urgency.
Opioids were the main driver in what officials believe were 1,200 drug overdose deaths in Philadelphia last year.
That's four times the city's murder rate.
Standing along the row of tents, Johnny thinks he has a good counter-argument for those troubled by the notion that opioid injections by people like him can and should be made to be safer, and that the city should play a role in making that happen.
"Someday their children could be out here using," he says. "Wouldn't they want their children to be in a safe environment if they're not able to beat the disease?"
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