While Oren Gur was performing research on death records at the Montgomery County Coroner’s Office in Pennsylvania, he was struck by a recurring theme among overdose victims.

“In each of these case files you have pictures of people who have overdosed and died, along with comments from their family members, and lots of them were people who were dying alone,” recalled Gur, an assistant professor of criminal justice at the Penn State Abington campus. “A big part of the problem is people using alone, and therefore nobody was there to help them.”

In addition to the legal issues, the heavy stigma around heroin and other opioids driving the nation’s overdose crisis can push individuals into the shadows where they are most vulnerable. Officially, at least 91 die people every day from opioid overdose nationwide, a number that likely undershoots the true total due to underreporting.

Aiming to stem the ever-rising number of deaths is a push for supervised injection facilities, spaces where people can test their drugs, use them in a clean and safe area, and access medical and addiction services if necessary or desired. “Having a place where people can go to use with other people and provide each other with supervision and help would address a big part of the problem,” Gur told me.

There are still no sanctioned injection facilities (though at least one exists in secret), also known as comprehensive user engagement sites, in the United States, despite more than 100 examples of success in Europe, Australia, and Canada. Seattle is making strides toward opening the first, with other cities such as San Francisco, New York, and Philadelphia tentatively poised to follow.

“These are platforms where people can make different or better decisions about their health,” said Sarah Evans, former manager of InSite in Vancouver, the first supervised injection facility in North America, at a recent meeting in Philadelphia. “These people are outside. We need to bring them inside.”

Since its opening in 2003 through the end of last year, clients had injected drugs at InSite 3.6 million times and experienced 6,440 overdoses—and zero deaths. In addition to effectively eliminating fatalities on their premises, injection sites have shown a number of other benefits, including reducing transmission of HIV and Hepatitis C as well as lowering the chances for bacterial infections and abscesses caused by non-sterile injection.

Evans said many of the fears people in Vancouver originally expressed about the facility never came to pass—the site didn’t lead to an increase in crime or drug use in the community, nor did it entice new users to start injecting. “Harm reduction and treatment and recovery are all on a continuum,” she added. “They aren’t opposites.”

The issue is especially acute in Philadelphia, where overdose deaths are projected to hit an all-time high of 1,200 for the year, largely driven by the prevalence of fentanyl products, opioids 50 times (or more) as powerful as heroin. This year, the city closed a number of areas where people gathered to use drugs—most notably, “El Campamento,” a makeshift camp along old railroad tracks in the Kensington neighborhood on a landscape strewn with garbage and needles. When the media published reports on other spaces where drug users congregated, such as a library lawn and an abandoned church, they were swiftly shut down as well.

While the gathering spots were an embarrassing look for the city, advocates say they were also places where people could keep an eye on each other, not to mention where outreach workers could make contact and offer services. Notably, only 17 of the city’s 907 overdose deaths in 2016 were near El Campamento, despite its reputation as the epicenter of injection. Now drug users are more dispersed on the streets, many sleeping under bridges, seeking out privacy where they can inject from the public eye. That means alleys, bathrooms, and abandoned tracks, where they are extra vulnerable to theft, attack or lonely death.

Prevention Point, a harm-reduction organization in Kensington, has filled some of the need for life-saving services by training hundreds of community members on the administration of naloxone, the medicine that reverses opioid overdose, as well as having staff serve as de facto first responders when an overdose occurs in the neighborhood. “If we don’t address this issue in a harm reductionist kind of way, we’re going to continue to see an increase in overdose deaths,” said Jose Benitez, the group’s executive director, in an interview with VICE earlier this year. “As far as safer injection sites, we think they would save lives.”

Where Philadelphia goes next is an open question. A special task force earlier this year suggested that the city continue to explore user engagement sites, among numerous other recommendations, but officials have not committed yet. Alicia Taylor, a spokesperson for the city’s Department of Health and Human Services, said in an email, “We are actively working to consider the feasibility of such a site as quickly as we can,” noting that a team of city officials had recently visited Vancouver to explore the InSite facility.

“A secure consumption facility (SCF) raises a host of challenging legal and law enforcement issues, and no American city has been able to implement one yet, but we are committed to fully exploring the possibility,” Taylor wrote. “We are seeking an independent party to do a review of the challenges and opportunities, and we will be consulting with national experts.”

A number of obstacles loom—reluctance by some officials, opposition by residents in the neighborhoods hardest hit by the epidemic, and a legal gray area that could put operators in danger of violating federal law. While injection facilities are not explicitly banned by the US government, they could possibly violate certain sections of the Controlled Substances Act, depending on how they are interpreted.

Temple University law professor Scott Burris, however, said during the meeting in Philadelphia that given the immediate need, the city should plow forward anyway, just as it did for a needle exchange program more than 25 years ago despite its prohibition under state law. “I think we should dare the feds to shut it down and not worry about their legal opinion one bit,” Burris said. “Tell Jeff Sessions to bring it on.”

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