Amidst Opioid Crisis, Safe Injection Sites Considered by Philadelphia`s Mayor

"We have seen the costs of inaction on epidemics in the past and cannot let that happen again," Mayor Kenney said at a City Hall news conference held with Gov. Wolf.

City health commissioner Thomas Farley, a physician and task force co-chair, emphasized that there is evidence supporting protected injection sites. He also said his profession must accept its share of the blame due to the many users who started on opioids via legal prescriptions. "What is different about this epidemic is how much it is due to the medical community," he said.

Broadening access to medication-assisted treatment was a major theme of the report, as was expanded distribution of the overdose-reversal medication naloxone. "We want people to stay alive before they get into treatment," Farley said.

Mayor Kenney announced the task force on Jan. 11 and it began meeting one week later. Meanwhile, overdose deaths continue accelerating, according to the Medical Examiner's Office. If the current pace continues, 2017 will see nearly 30 percent more than the 907 fatalities recorded last year, which was 30 percent ahead of 2015. The increase is being driven largely by fentanyl.

Last year's statewide increase was similar, according to the U.S. Drug Enforcement Administration, which is collecting statistics from coroners around Pennsylvania.

Task force co-chair Arthur C. Evans Jr., former commissioner of the city's Department of Behavioral Health and Intellectual disAbility Services, said there was broad agreement on many issues, including the role of stigma in the opioid crisis.

"That really complicates our ability to deal with this problem," he said in an interview before the report was released. "Ninety percent don't come into treatment, 80 percent of them don't believe they need treatment," said Evans, who now is CEO of the American Psychological Association.

Attitudes also get in the way of opening new treatment centers, Evans said, noting that overdose rates in Northeast Philadelphia are comparable to those in the rest of the city but that it took seven years to place a methadone program there because of neighborhood opposition.

Education about the dangers of opioids was another item all members agreed on. The city has already begun "Don't Take the Risk," an advertising campaign on cable and broadcast television and social media that features people who have been addicted to prescription painkillers or lost family to overdoses. The tagline: "Prescription opioids: heroin in pill form."

Task force members decided early on that they "wanted to be aspirational but also have actionable items," Evans said. That goal helps explain why the final report recommended exploring, but not immediately acting on, a subcommittee's recommendation to create safe injection sites where users could inject heroin under medical supervision to protect against overdose. The concept behind this "harm reduction" measure is similar to a hypodermic needle exchange program, something Philadelphia already does: Because not all users are ready to get off drugs, help keep them safe in the meantime.

The final report was not distributed until shortly before the news conference and inclusion of the safe injection locations--dubbed "comprehensive user engagement sites"--was a surprise to some on both sides of the issue.

Safe injection sites were "vehemently discussed," but raised big questions for law enforcement, said Patrick J. Trainor, a DEA special agent who attended many of the meetings. "Say somebody goes to a safe injection site, gets in a car, is driving home on I-95 and overdoses and kills a family of six," Trainor said in an interview beforehand. "You can't discuss safe injection sites and not include that conversation."

Such sites are highly controversial and illegal in the U.S. but operate in Vancouver and some European cities. Omitting a positive recommendation from Philadelphia's report was a disappointment to Scott Burris, director of the Public Health Law Research Center and a professor at the Temple University Beasley School of Law.

In an email from Denmark, where he is attending a policy conference, after the report was released, Burris wrote: "There will never be a better time to do it: we have a need--a crisis; we have a solid evidence base; we have a nucleus of community support; it even looks like we will have a sympathetic DA."

Trainor, Burris, and more than 100 others, including some subcommittee cochairs, were not formal members of the task force but gathered information and made recommendations to the full panel.

Burris was an early national advocate for widespread use of naloxone, the opioid-overdose reversal medication, which has been credited with saving thousands of lives in recent years. Gov. Wolf has said the state will pay $200,000 to supply more than 5,000 additional doses of the emergency medicine to city police. The task force's subcommittee on overdose prevention and harm reduction strongly recommended that the city make it more available to the community of users.

Despite the concentration of filth and addiction hidden along the Conrail tracks in Kensingon and Fairhill--"I just walked into hell," Dr. Mehmet Oz told his TV audience during a taped tour last month--just 2 percent of last year's overdose deaths were at the encampment. "Which means that the naloxone distribution that we have going on down there works. Those guys are reversing themselves, they are trained in it, and we are down there giving them supplies every week," said task force member Jose Benitez, executive director of the needle exchange organization Prevention Point Philadelphia and co-chair of the harm reduction subcommittee.

The report did not mention the encampment, which the Kenney administration has vowed to clean up. That effort is faced with major challenges, chiefly where the homeless community there would go.

A subcommittee charged with examining data recommended setting up an early warning system that would allow public health officials to identify overdose surges in real time.

"Last Friday the Fire Department responded to seven overdoses before noon, all in 19134, and our staff responded to three in addition. So we are on the phone talking to each other, because they know to call us, we know to call them, but the reality is there is no sort of early warning system," Benitez said in an interview.

Another subcommittee urged lowering barriers to "warm handoffs" to get users directly into treatment from emergency rooms, where police and paramedics bring people who have been revived after overdosing. Emergency physicians often complain that even making a referral is difficult because of regulatory red tape.

Health insurers were urged to provide more coverage for alternatives to opioids to help patients who are in pain. Insurers also were encouraged to continue checking into routine prescriptions for medicines containing opioids. "Insurers are writing policies requiring prior authorization," Caroline Johnson, acting deputy city health commissioner, said Thursday, shortly after getting off a conference call with health insurance companies.

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