Could Prescription Heroin And Safe Injection Sites Slow The Opioid Crisis?

TERRY GROSS, HOST:

This is FRESH AIR. I'm Terry Gross. The opioid epidemic is the deadliest drug overdose epidemic in U.S. history. Drug overdoses are now the leading cause of death for Americans under 50. We're going to talk about how the epidemic reached this point. We'll also hear about some of the innovative harm reduction approaches to preventing people addicted to opioids from overdosing or getting sick through dirty needles and approaches to making quality addiction treatment more accessible.

My guest German Lopez is a senior reporter for Vox and has been covering drug policy since 2010. One of the cities hard hit by the opioid epidemic is Philadelphia. Later in the show, WHYY reporter Bobby Allyn will tell us about how and why some local officials and public health advocates are trying to make Philadelphia the first city in the U.S. to open a legally sanctioned safe injection site. As you can guess, it's a controversial move.

German Lopez, welcome to FRESH AIR. Give us an overview of the scope of the opioid epidemic. The CDC recently released a report. What did you learn about the scope of the epidemic from that?

GERMAN LOPEZ: So the CDC report found that there were nearly 64,000 drug overdose deaths last year in the U.S., meaning in 2016. So to put that in context, that's more than gun deaths. That's more than car crashes. It's more than HIV/AIDs during the peak of that epidemic. Another way of looking at it is it's more deaths in the U.S. from drug overdoses than there were U.S. casualties during the entire Vietnam War. It's now the biggest drug overdose epidemic in U.S. history. There seems to be a slight increase so far in 2017 as well. So it just - it seems to just keep getting worse.

GROSS: So, you know, you've written in part about the hidden effects of the opioid epidemic and of all the overdoses that we've been seeing. You've written about, like, morgues that have run out of room and children who have been orphaned. Tell us one of the stories that you found related to these kind of hidden effects.

LOPEZ: Yeah. So I think the most striking story along these lines last year that I found was this morgue that - they'd run out of room. And what they ended up having to do is rent out extra space in these trailers, I think it was, to hold the bodies - the extra bodies that they were getting from drug overdose deaths. And this is something that we need to look at in terms of the overdose crisis. It's just - obviously, the amount of death is a tragedy on its own. But it's really having these rippling effects through society.

Another example that you mentioned there is these kids who have been orphaned as a result of their parents overdosing or their parents becoming addicted and therefore not being able to take care of the kids anymore. And it - that will forever transform these kids' lives. They're no longer going to be able to rely on their parents. They'll have to move in with their grandparents. There are many quotes by now in newspapers all over the country of grandparents saying, I didn't think I'd be taking care of kids again at this age. And part of that is because, well, they might not want to. And that'll affect the grandparents as well.

So you see this ripple effect here in terms of, it's now causing all these financial costs for, say, these morgues. It's changing the lives of these children. It's changing retirement plans for these grandparents, and on and on. And that's really one of the things that I think is most pronounced about addiction is that it's not just a disease that kills people. It is definitely that, and that's obviously an awful part about it. But it's also a disease that starts really - it really becomes an epidemic, as it's called, because it affects all aspects of people's lives and not just their own lives but other people's lives as well and really becomes this public health issue.

GROSS: So this is a crisis that's spread way beyond people who started on opioids as a medical way of treating chronic pain.

LOPEZ: Right. I mean, that's usually pinned as the initial catalyst for the crisis - is doctors overprescribing these drugs. And to be clear here, the problem isn't just that pain patients who got the painkillers got the drugs and started getting addicted to them and started overdosing. It's also that because they had so many excess pills, it was also easy for, say, their kids to go to their parents' medicine cabinets and take an extra stash of opioids and use them illicitly or sell them or whatever. So that really led to the proliferation of these painkillers.

But over time as we've - what we've seen is that there is this transition to heroin and fentanyl. And a lot of that is just because heroin and fentanyl are far cheaper in the illicit market than painkillers. Some of that is also just these people - some of the people who were addicted to painkillers, they've now lost access to painkillers either because they lost their prescriptions or they just became expensive. And that has led people who are addicted to opioids to resort to fentanyl and heroin. And this is one way to avoid withdrawal symptoms or keep getting high or whatever it is that they're using the opioids for. And that has also caused the drug overdose deaths to spike.

GROSS: I think one of the ways that policies have tried to crack down on the opioid epidemic is to restrict, to regulate the number of prescriptions that a doctor can write for a patient for opioids. Am I right about that?

LOPEZ: So in general, it's not that the government is setting a specific quota or number for individual doctors. The DEA sets a quota for opioid painkillers overall in terms of how many companies can manufacture and produce and sell. But individual doctors - they're being told to just watch their prescriptions. And they've also been given these guidelines.

So one example is doctors are being told, with some exceptions, try to avoid prescribing opioids for chronic pain. And that's because we've seen in the science that opioids aren't even good for treating chronic pain in the first place because of the way people become tolerant to the drugs. And because over time, if you take opioids, you can actually become more sensitive to pain. So in some ways, opioids can make you actually feel that pain more.

And it seems to me the general sense is that doctors are now supposed to be thinking of this not as a first-line treatment but sort of as a limited way to address pain in certain situations instead of the way they were approaching it before, which was, hey, this is a first-line treatment for all sorts of pain.

GROSS: So what impact has that had on people who were using opioids for chronic pain and were already addicted?

LOPEZ: If a patient is cut off from opioids - first of all, it's, at the very least, very, very unpleasant to be immediately cut off from your entire supply of opioids because that'll cause withdrawal. And withdrawal is - it's really - just imagine the worst stomach bug imaginable, and then compound that with crippling anxiety. It's really terrible to go through. So people will go through great strides to avoid that, and that's why some people will start buying opioid painkillers in the illicit market or they might start resorting to heroin and possibly fentanyl as a result.

And that's why, in general, one thing that experts have told me is that if you are going to reduce the amount of painkillers somebody is taking, you want to taper them off, so slowly reduce their dose over time. But also, you want to talk with this patient and see, are they stable on opioids? Are they actually misusing the drugs? Is there evidence that they're putting themselves at risk? And these are, like, some of the things that doctors should consider when beginning to taper them off these drugs because otherwise, there is this risk that they'll start resorting to the illicit market, and that can heighten their chances of overdose.

GROSS: What is fentanyl, and why is it so dangerous?

LOPEZ: So fentanyl is this synthetic opioid, and it was originally produced for treating very intense pain. The common treatment that it was used for was cancer pain. So we're talking about patients who - many of them were terminally ill. And the risk of addiction when you're terminally ill is obviously much lower because you're thinking, well, we want to give this patient some sense of pain relief in their last few weeks, months, years of life. And that's how fentanyl was commonly advertised. It's, hey, this is a really potent opioid, and we should be giving it to these really terminally ill patients.

But over time, it turns out that it's actually pretty - relatively easy to produce in a lab. And that has led to its production in places like China, where it's now shipped through Mexico, through Canada, into the U.S. And the biggest risk here is that very often, fentanyl is sold as heroin. So if you're somebody who uses heroin, you think, OK, I'm going to take the dose I've always taken on this drug. But then it turns out you're taking fentanyl, which is multiple times as potent as heroin. And because you don't know that you're actually taking a higher dose - you can't see it based on what you are doing - it increases your chances of overdose without you even knowing it. And that's really what the risk has been, is that as fentanyl has increasingly been sold as heroin or increasingly laced into heroin, the chances of overdose have spiked dramatically. And that's one of the reasons we've seen this rise in deaths.

GROSS: Why is it being sold as heroin or being laced in heroin?

LOPEZ: So the common theory here is that it's just cheaper than heroin. So because it's cheaper than heroin, that makes it - there's a financial incentive there for drug traffickers, drug dealers to essentially cut their drug. So the idea is, well, if you put your fentanyl into heroin, you can put a little more kick into that heroin without actually paying for better-quality heroin. And that means that you can simply sell a stronger product for a lower price or you can sell it for the same price and just make more money in the end.

GROSS: So why is fentanyl cheaper than heroin?

LOPEZ: The simple reason seems to be that it is easy to produce in a lab compared to heroin. So heroin requires getting an opium poppy and then converting that into actual heroin. Fentanyl can just be produced synthetically in a lab. So it's kind of like - I've heard this comparison before of comparing it sort of to producing meth, which is also relatively cheap and easy to make. It's not quite as easy to produce as meth, but that gives you the same general idea of just how easy this is to make in a lab. So that's really the big reason. It's just simply much more easy to produce.

GROSS: Sure, so you don't have to rely on poppy-producing countries like you do for heroin.

LOPEZ: Right. That's exactly right.

GROSS: So a lot of the fentanyl in the U.S. comes from China. Why is it coming from China?

LOPEZ: Apparently the biggest reason there is just, they have the most lax regulations for these kinds of labs, so that has let a lot of this illegal drug trade really just take off there. China is now taking some steps, supposedly, working with the U.S. to crack down on that. We still have to see how well that works out because China has kind of struggled to crack down on these labs before because there are just so many of them.

And there's also a question of well, OK, if China does this, will these labs just move to another place that's loosely regulated, such as India? And then the fentanyl production might take off there. So we're still seeing how that will shake out. But that's generally the reason, is just - it's very loosely regulated there. And the laws that do exist are very loosely enforced.

GROSS: Well, let's take a short break here, and then we'll talk some more. If you're just joining us, my guest is German Lopez. He's a senior reporter for Vox and has been covering the opioid epidemic. We'll be right back. This is FRESH AIR.

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GROSS: This is FRESH AIR. And we're talking about the opioid epidemic. And we're also talking about the medical model - the public health model - for dealing with it as opposed to the punitive model. My guest is German Lopez. He's a senior reporter for Vox who focuses on drugs, guns, criminal justice, race and LGBTQ issues. He's been reporting on drug policy issues since 2010.

So one way of dealing with drug epidemics is punishment. You know, you put people in prison, and maybe you put them in prison for a really long time. There're some really bad effects when that happens. So you've been looking into alternatives to prison and into places that are creating alternatives to the punitive model of addiction. And one of the things you write is that we have to stop seeing addiction as a moral failure and think of it as a real medical problem. Describe those two conflicting points of view.

LOPEZ: For a long time in America, we have criminalized drug use. We have seen it as kind of this moral failure. I mean, whenever I write about the opioid epidemic, I get emails to this - that basically voice this argument all the time that - I mean, some of these emails are really awful, saying that, like, these people should be allowed to suffer and die because it's their fault that they're in the mess they're in. And the problem with that is there's just no evidence that that's a good way to deal with addiction.

And increasingly, if you talk to experts, if you talk to addiction specialists, they will tell you that this is a chronic, relapsing disease. And what they mean by that is that this is a disease that will need a lot of medical care over time, and that's how you properly treat it. The problem with the criminal justice approach is that when you put people in these prisons for their drug use, you're shutting them off from their communities, you're shutting them off from their families. You might be cutting them off from care because sometimes prisons are very poorly equipped to deal with drug addiction.

And if you think about what causes drug addiction, a lot of that simply works against this person going into recovery. So one thing that causes drug addiction is simply a lack of access to treatment. So if a prison doesn't have that, obviously, that's going to cause the addiction to get worse. But the other is just a general sense of despair. There are many studies out there linking addiction with other mental health issues and also linking addiction to just a general sense of existential despair.

So when you're cutting somebody off from their families and their communities, you're isolating them, you're making them feel worse about their lives. And if you're in that position, some people might become more motivated to quit drug use, but a lot of people will simply become worse as a result of that. They're going to be less happy, and that might give them more reason to use drugs because it might be their escape. And that's really the major way I view this criminal justice approach as not being a good idea. When you put people in prison for these drugs, you're cutting them off from the things that will, over time, probably help them get better.

GROSS: So you've looked into various approaches for harm reduction. Would you explain what harm reduction is?

LOPEZ: Harm reduction is this idea that a lot of people are going to use drugs, no matter how much treatment is available, no matter what you do to prevent drug use in the first place. So if you want to avoid people getting addicted and dying from drugs, one way to do that is just mitigating the risks of these drugs. So a popular - and, really in the research, uncontroversial in terms of the evidence behind it - is these clean needle exchanges.

And what these places do is essentially give people who want to get these needles - they can go to the - these stations. They obtain new needles, new syringes. And then they can use those for whatever drug it is that they're using. And the idea is - yeah. To some degree that means that they now have a source for these syringes. But it also means that these syringes are clean in that they aren't contaminated by, say, HIV or hepatitis, which can also obviously cause death by themselves. So that's one way of harm reduction.

The common criticism of harm reduction is that there is this fear that it will lead to more drug use because they're thinking that if you mitigate the risks of drugs, then people will feel less threatened by drugs and therefore be more willing to use them. But again, there has been a lot of research into this through needle exchanges. And they have found time and time again that there does not seem to be this increase in drug use. What does happen when you make these needle exchanges available is there's lower incidence of HIV, lower incidence of hepatitis. And, therefore, there's less death overall caused by drugs.

GROSS: So in your attempt to visit places that are using harm reduction approaches to dealing with the opioid epidemic, you visited a clinic in Vancouver that deals with prescription heroin. I didn't know this kind of treatment existed. Would you describe this prescription heroin treatment?

LOPEZ: Yeah. When I first approached the story, I was pretty surprised by just what I was finding here. So essentially, the thinking is there is now so much fentanyl out there in the illicit market that drug users don't know what they're going to get. And the thinking is, well, at least if you provide them with prescription heroin, you'll, one, be able to ensure that they get a relatively clean supply of the drug - meaning it won't be laced with fentanyl or something else that will increase the chances of overdose.

The second thing is that you'll be able to supervise them as they're using or injecting the drug. And that will let you respond in case they overdose to ensure that they get medical help immediately. They'll get the opiate overdose antidote naloxone, which helps revive people from overdoses. Or they'll give them an oxygen tank which can help with respiratory problems that come from overdose. So that's kind of why it's phrased as harm reduction because you don't want - I mean, obviously, in an ideal world, you don't want people using heroin. But if people are going to use heroin anyway, here's one way that you can provide it and at least mitigate some of the risks that could lead people to die from it.

GROSS: I'm sure a lot of people listening to this are just thinking the people who administer prescription heroin are just enabling heroin addicts, are just enabling a horrible addiction with a horrible drug instead of helping them get off the drug.

LOPEZ: Right. And quite frankly, when I first started looking into this, I was deeply skeptical of it. But then I started talking to experts and looking into some of the research about this. And one thing to be clear about is this is not going to be for everyone who uses heroin. The way that this is administered in Vancouver is that after someone has gone through other treatment avenues - so say medications - other medications for opioid addiction or other traditional treatments that we think of in the U.S. - once somebody has gone through that, then prescription heroin will be made available to them. Ultimately, they estimate about 10 to 15 percent of people addicted to opioids will end up needing to use this. And the other thing is that with the research - when you actually look at this, it does seem to lead to better outcomes.

GROSS: My guest is German Lopez, a reporter for Vox who covers the opioid epidemic. We'll continue the conversation after a break. And we'll talk with Bobby Allyn, a reporter at WHYY in Philadelphia about how some public health advocates and Philadelphia city officials are trying to make their city the first in the U.S. to have a legally sanctioned safe injection site, which just to be clear, is not the same as offering prescription heroin. I'm Terry Gross. This is FRESH AIR.

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GROSS: This is FRESH AIR. I'm Terry Gross back with German Lopez, a senior reporter for Vox who's been covering the opioid epidemic. When we left off, we were talking about one of the approaches to harm reduction practiced at a clinic in Vancouver. They selectively offer prescription heroin to users who have had no success with any approach to getting them off the drug, including rehab.

You spoke with people who were using prescription heroin in Vancouver. Tell us one of the stories you heard.

LOPEZ: So I think the biggest example of this is John Pinkney (ph). He's one of the people I talked to at Vancouver. He actually passed away last year due to unrelated health issues. But his story was really inspiring to some degree. This was someone who has struggled with illicit drug use for decades. He linked the beginning of his drug using to his teens. He had a horrible family situation. His parents were abusive. He was homeless for some time and on and on.

I mean, really, this guy went through some horrible, horrible things throughout his life. And he used illicit drugs for a decade. Then he found this prescription heroin clinic. And the way he put it to me is that he felt he had finally gotten his life back because he felt that now he can maintain a job. He was a security guard. Now he had a stable housing situation. So he had an apartment. I mean, he bragged to me about having furniture and a TV in his house.

And these are some of the things that, like, a lot of us would take for granted. But for somebody who had been struggling with drug use all his life, this was a really monumental step for him. Seeing how this man, after decades of drug use, managed to turn his life around - it really showed to me that, at least for some people, this really can work. This was someone who really had become a productive member of society as a result.

GROSS: Well, how did prescription heroin help him become productive? Because I think the common image of a heroin addict is somebody who's basically, you know, sitting on the floor, nodding...

LOPEZ: Right.

GROSS: ...And not working and not doing much of anything.

LOPEZ: The thing you need to understand, I think, about heroin use is at a certain point, heroin use becomes more - and this is a term commonly used by people who are addicted - it becomes more about getting straight than getting high. And what they mean by that is that heroin no longer makes them feel this sense of euphoria or whatever that we commonly attach to it. It makes them feel normal. And that's due to just how it works in the brain and how you become tolerant to it.

You do everything you can to avoid withdrawal. And that's really what drug addiction becomes over time - is you really want to avoid this sense of withdrawal. And because of that, when you imagine somebody who is, say, stealing to obtain heroin, it's not just that they want to get high from this drug. For a lot of them, it's that they want to avoid this sickness that comes from dependence to this drug. So when they have a reliable source of heroin, they can go to this clinic and get it two or three times a day. Suddenly, they don't have to worry about how they're going to get their fix that day.

They're going to start thinking about the other things they can do because they know that they will have a reliable supply of this drug. And, you know, it's not going to be something that everybody feels easy with. The people and staff at the clinic that I talked to - they were - to some degree, they seemed uneasy with it. I mean, they were confident in that they think they're saving lives by doing this. But it's - nobody wants people using heroin. Like I said, in an ideal world, that wouldn't be the case.

But this seems to enable them to focus on the other aspects of their lives instead of just focusing on how they're going to get their next supply of the drug. And at least in this clinic, they have had zero people under their care overdose and die, which is remarkable. They have a few hundred patients. And they've been seeing them for years. So that's a really remarkable outcome compared to - if you were having a few hundred people using heroin in the street, you would expect at least some of them to die.

GROSS: So we've been talking about approaches to harm reduction. You were describing the prescription heroin approach that's being tried in some countries, including parts of Canada. That is not a legal approach in the U.S. But you said when you went looking for a state in the U.S. that's taking the opioid epidemic seriously and using a medical model instead of a punitive model, you went to Vermont. What did you find there?

LOPEZ: Yeah. So Vermont has really over the past few years built up what they call a hub-and-spoke system. And it's a fancy term for what they've essentially done - is really integrated addiction treatment into the rest of the health care system. So the hub is the place where you would get intensive care. I like to think of this kind of as this emergency-room-like situation where you go in, and you'll be able to sign up, and you'll get really intensive daily care for your opioid addiction.

And then the spoke is where you go after you sort of stabilize and get better over time. And this is a place where you'll get treatment, say, on a weekly, monthly - some people bi-monthly basis - over time, you'll need to see it less and less. But the key thing that Vermont did with this is they emphasize this as a public health issue. First of all, they leveraged a Medicaid waiver for this to pay for it, to set up these clinics. And then they've really leveraged other aspects of health insurance expansion under the Affordable Care Act, including the Medicaid expansion, to make sure that patients have insurance to pay for all this treatment.

And through this, they've provided these medications for opioid addiction. So some of these medications are Suboxone. That's the brand name for buprenorphine. And then there's methadone. And the idea with these medications is that they stave off withdrawal symptoms without causing patients to get high. And that way, people can focus on improving other aspects of their life that might have led them to drug use in the first place. And so they won't have to worry about withdrawal.

And that's really what Vermont has hunkered down on - is really providing this treatment, which is considered the gold standard for opiate addiction care, and making sure that patients have access to it. And the idea is anyone should be able to go to a hub or spoke and get treatment really quickly - within a few days - because one of the risks is if you have these waiting periods, as some states do, of weeks or months for care, then people are going to keep using drugs. And with each time that they use drugs, they're going to be at risk for overdose.

GROSS: So it is the use of methadone or buprenorphine controversial?

LOPEZ: If you talk to addiction specialists and experts about this, it is not controversial. It is widely considered the gold standard of care. There's research that shows if you get people who are addicted to opioids on these medications, their chances of death will drop by more than 50 percent, which is a really remarkable outcome in terms of health.

But in much of the public discussion, these drugs have been maligned and stigmatized. One common frame that people tend to view this as is that it's replacing one drug with another because you're giving up, say, heroin or opioid painkillers and simply replacing that with another opioid like buprenorphine or methadone. In fact, our former secretary of Health and Human Services, Tom Price - he actually made an argument like this last year. But experts caution that this is not how you're supposed to view these medications because the problem with addiction is not that somebody is using drugs - I mean, I'm sure a lot of people listening to this show will have had a cup of coffee this morning. That has caffeine, which is a drug. I'm sure a lot of people will have had a few drinks maybe last night or over the weekend.

And they'll think, you know, I'm fine with that. And that's generally what you want to think. It's like, the problem is not the drug use, per se. The problem was when that drug use leads somebody to do things that aren't good for society or themselves - say, they might be stealing. They might be putting themselves at risk of overdose. And what these drugs enable is that they make it possible to not have to worry about withdrawal. They make it so you get a clean source of these medications, so you do not have to worry about overdose. And in that way, you can get your life back in order. And while you still are technically using opioids, you're doing it in a much more stabilized environment.

GROSS: Well, let's take a short break here and then we'll talk some more. If you're just joining us, my guest is German Lopez. He covers the opioid epidemic for Vox. We'll be right back. This is FRESH AIR.

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GROSS: This is FRESH AIR, and if you're just joining us, my guest is German Lopez, a senior reporter for Vox. He focuses on drugs, guns, criminal justice, race and LGBTQ issues. And as part of that, he's been covering the opioid epidemic.

When candidate Donald Trump was running, he promised to address the opioid epidemic and, you know, presented the message that he knew how to do it. What has he done?

LOPEZ: So the biggest thing he's done, and really, the only notable thing he's done so far, is he declared a public health emergency. This is a very limited change in that it might unlock some extra resources, although it's unclear how many, to deal with opiate addiction. Experts are deeply skeptical about this because it seems to be just so limited. So one of the funds that this unlocks only has around $50,000 in it, which is simply not enough to deal with an opioid epidemic of this scale. And otherwise, it's not clear what else this declaration will do.

The other things he's done are, for the most part, just investigating this issue more thoroughly. So he appointed an opioid commission led by New Jersey Governor Chris Christie to look into this issue, and they made a bunch of recommendations. And he's also had one of his chief advisers, Kellyanne Conway, lead what they call an opioid cabinet into this issue. But so far, there's been a lot of investigation, but it's not really clear if any specific action is being taken. It seems to be a lot of talk but not nearly as much action to accompany that talk.

GROSS: So Trump has said he would do what he can to end the opioid epidemic. At the same time, he's pledged to end Obamacare. What has Obamacare contributed to the treatment of addiction?

LOPEZ: The basic way to understand this is that Obamacare dramatically expanded access to health insurance in the U.S. It also enforced some laws requiring that insurers treat addiction treatment as well as they do, say, physical treatment or surgery. These are called parity laws. They basically require that insurers treat addiction treatment just as seriously as they would treat any other illness. So those are the two ways that Obamacare has really had an impact here. It's dramatically expanded access to health insurance, which lets people pay for addiction treatment, and then it's also made sure that this health insurance will have to cover addiction treatment.

So going back to Vermont, they really leveraged the Affordable Care Act by, one, getting a waiver through the law that let them set up clinics and hubs and spokes. And two, just the fact that more people within the state now have federally funded health insurance has allowed the state to pay for these programs that they otherwise would not have been able to afford before. And through those two avenues, it has really let Vermont build up this hub-and-spoke system, which is what's let it essentially expand treatment to - for addiction.

GROSS: So since you've been writing about addiction-related issues since 2010, I'm wondering if addiction has hit you close to home, if people who you are close to have been - have become addicts, if you've seen it firsthand in that way.

LOPEZ: Yeah, so I'm from Ohio, which is now the state with the second highest drug overdose death rate in the country, so I've definitely seen this firsthand in my family and friends. I still have friends from high school that have been struggling with addiction. I have family that has struggled with addiction. So I've seen this firsthand. And I had a friend overdose on drugs a couple of years ago, and that's one of the things that led me to start looking at this issue much more seriously. And I think if you live in some of these states that have been really hard hit, it's almost inescapable how much damage this does.

And I think people will see the drug overdose statistics, and they'll see some of that. But what's really shocked me about this is just how addiction is all-consuming in people's lives. So I've had friends who ended up not being able to finish school, whether that's high school or college, because of their addiction. That'll forever change their lives. I've had friends who just ended up homeless or ended up not being able to chase the career that they wanted all their lives. And when I see the impact that this has had personally on my communities, it just - it has, of course, moved me to cover this issue more seriously.

GROSS: Well, German Lopez, thank you so much for talking with us.

LOPEZ: Yeah, thanks a lot for having me. I really appreciate it.

GROSS: German Lopez is a senior reporter for Vox who covers the opioid epidemic. Coming up - how some Philadelphia public health advocates and city officials are trying to make their city the first in the U.S. to have a legally sanctioned safe-injection site. This is FRESH AIR.

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GROSS: This is FRESH AIR. Although in several countries, people addicted to opioids can go to legally sanctioned, medically supervised safe injection sites, there are no such legal facilities in the U.S. Many public health experts in Philadelphia would like to make their city the first. Last week, WHYY reporter Bobby Allyn broke the story that now some top city officials are actively pursuing the idea. And the controversy it's generating in Philly exemplifies some of the obstacles to creating such a site in America.

Bobby, thanks for coming on FRESH AIR. How bad is the opioid epidemic in Philadelphia?

BOBBY ALLYN, BYLINE: It's pretty devastating. Officials say when the final count is totaled that there will have been 1,200 lethal overdoses in Philadelphia last year. And for context, that's quadruple the city's murder rate. And Philadelphia is a quite violent city. And it's not that drug use rates in Philadelphia just went up astronomically, but, really, the death rate went up astronomically. And one of the biggest drivers for that is that a lot of heroin that's being bought on the streets is being laced with very potent synthetic fentanyl. And that's made the reaction to using it very unpredictable and sometimes deadly.

GROSS: So in Philadelphia, there are public health advocates and some officials as well who want to see a safe injection site in Philadelphia to help deal with this overdose epidemic. So describe what that might look like if it ever comes to be.

ALLYN: So how a safe injection site typically works is, someone will come from off the streets into this facility, and they will bring their own drugs. If the user wants, the drugs can be tested for fentanyl, that very potent synthetic. And it's done very quickly. They have these fentanyl test strips, and they could do it almost instantly and know whether or not there's any fentanyl in that dosage.

Medical staff are sort of waiting, watching, supervising and providing clean, sterilized equipment. So they're providing, you know, all the things you need to do heroin. There's this thing called a cooker. They're given needles. They're given clean swabs. And this way, the people who are using won't contract infectious diseases like hepatitis C or HIV. And nurses are standing by watching people essentially shoot up with oxygen and the overdose-reversing drug naloxone. And when they're done, they go into what's known as this chill area. And there, their breathing is monitored, and other vital signs are monitored. And from that point, they're kind of released back onto the streets.

Now, during this process, if they want, they can be directed toward detox and other drug treatment programs. And that's been a big selling point for the advocates, the so-called harm reductionists who are very much in support of these safe injection sites. They say they can be a bridge to treatment services for people who wouldn't necessarily find it on their own. And that's why advocates don't like to call these sites safe injection sites but comprehensive user engagement sites. That sort of speaks to how people come there, they come to use, but, hopefully, it's a way to turn their life around.

GROSS: What's the status of this now in Philadelphia?

ALLYN: So Mayor Jim Kenney of Philadelphia is in support of safe injection sites. He made a new position in Philadelphia City Hall known as a harm reductionist. He started this task force with dozens and dozens of experts that issued a number of recommendations about how to combat the opioid crisis.

And one of the most critical factors is our new district attorney in Philadelphia, this guy named Larry Krasner, who is a career defense attorney - he was actually just sworn in recently. He's in his first days as a prosecutor. And he campaigned on this platform of upending the local criminal justice system. He's against mass incarceration. He's against the death penalty. And he is for safe injection sites. And he has said once this starts in Philadelphia, he's not going to have his prosecutors charge the people who are using illegal drugs with any crimes.

GROSS: And when Krasner, who's now the DA in Philly - when he was a defense lawyer, he advocated on behalf of harm reduction.

ALLYN: Exactly. So Krasner's advocacy of harm reduction goes back to the '90s when the city and the country was having a debate about needle exchanges. And there was one called Prevention Point in Philadelphia that was involved in a lot of litigation. And Larry Krasner, Philadelphia's current district attorney, represented Prevention Point. So going back decades, this DA has really believed in interventionist strategies like harm reduction, like needle exchange, like safe injection sites.

GROSS: What do the Philadelphia police think of that?

ALLYN: The Philadelphia police are far less excited about that prospect. And Philadelphia's police commissioner has said, it's kind of awkward to have beat cops rolling around a facility where people are using heroin and not make arrests. And if there is a incident report, if somebody calls the cops and says something happened at one of these facilities, they're going to have to investigate, and that might result in an arrest.

Now, if that arrest makes its way to the DA's office and the DA's office says, we're going to drop it, that's - that might happen. But nonetheless, there is likely going to be tension between the facility workers and the users in that facility and members of Philadelphia's police department.

GROSS: Well, that might also mean that users would be discouraged from going to a facility knowing that it could lead to prosecution.

ALLYN: Absolutely. And so that's why the stage of this in Philadelphia requires the buy-in from local law enforcement. Before this is going to become official, the department head, the police commissioner in Philadelphia and the, you know, 6,000-plus rank-and-file police officers have to agree that this is something that the community needs. And that's going to be an uphill battle.

GROSS: So even if, on a local level, all the officials and police found a way to work it out and agree to the safe injection site, what about on a federal level - law enforcement on a federal level?

ALLYN: It's an interesting question. In Vermont, some lawmakers are proposing a similar safe injection site. And the response from federal law enforcement has been, if you do open a safe injection site, we will muster all of the resources of the federal government to come after you. The U.S. attorney in Vermont released this very unambiguous statement saying this. There are federal crimes that will happen here. We will seize your assets, and we will make arrests not just of the supervisors but even the workers in the safe injection site. So that is kind of setting the stage for what will likely be a really intense standoff between - even if local police agree - between local officials and the federal government.

GROSS: Another issue is if a safe injection site was open, would there be protests in the community that it was opening in? Would there be a not-in-my-backyard effect?

ALLYN: I think the not-in-my-backyard - NIMBYism - effect is going to be fierce. It's going to be swift. If you look at a number of other cities across the U.S. that have proposed - and proposed is key because there are more than 100 facilities around the globe - safe injection facilities - none of them are in the United States.

A number of proposals here. But none of them have been successful. There have been efforts in Seattle. They're pretty far along. San Francisco, New York, Denver's talking about it. But no U.S. city has been able to accomplish it. And the big - a big reason is because of the community backlash. So people who live in the heart of the epidemic in Philadelphia want it off their streets. They're sick of seeing people overdosing in public bathrooms, in alleyways, you know, shooting up or, you know, dozing off as they're waiting for the bus. They want that to be addressed somehow. That's a consensus.

They're sick of seeing the piles of syringes. Everyone in the community knows that stakeholders, that elected officials have to do something. But the idea of a safe injection site is just not - there's no clear consensus on that yet. And it's because it's very visceral. When you think about a bunch of people who are often chronic drug users congregating to one place and coming in and out and maybe interacting with you as you're on your way home from the grocery store, interacting with your children or interacting with you as you're walking your dog - I mean, a lot of these are fears that are based in the perception that people who are using opioids are dangerous people who may hurt you and your family.

I mean, that's really what it is. It's an emotional fear, and it's a real fear. And, I mean, there are people who just say, this notion kind of freaks me out to have that many drug users that close to my home.

GROSS: Well, Bobby, thank you very much for sharing your reporting with us.

ALLYN: Thanks for having me, Terry.

GROSS: Bobby Allyn is a reporter at WHYY in Philadelphia, the station where FRESH AIR is produced. Tomorrow on FRESH AIR, an auto repair shop founded by a woman with women mechanics. My guest will be Patrice Banks. She started the shop, so women wouldn't feel ashamed when they take in their cars for maintenance and repair.

PATRICE BANKS: The shame of not knowing how to take care of their car and being afraid to ask a question because they're going to feel stupid.

GROSS: Banks is the author of the "Girls Auto Clinic Glove Box Guide." I hope you'll join us.

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GROSS: FRESH AIR's executive producer is Danny Miller. Our technical director and engineer is Audrey Bentham. Our associate producer for online media is Molly Seavy-Nesper. Roberta Shorrock directs the show. I'm Terry Gross.

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