WHEN Brian Abernathy was first asked about setting up a supervised place for people to take drugs, his response was “Hell, no.” The first deputy managing-director of the City of Philadelphia, who looks after public safety, says he still feels very uneasy about shooting galleries sanctioned by the city. But a visit to Vancouver, where safe-injection sites have operated since 2003, and to Seattle, which is considering the idea, persuaded him that the help they provide outweighs the risks of encouraging lawbreaking.

The idea is counterintuitive: in the next year the city will permit an NGO to provide a place for drug users to go and inject themselves with potentially lethal drugs, while trying to encourage them to seek treatment for their addiction. Staff will hand out clean needles and administer naloxone, a drug that temporarily reverses heroin’s effect on the brain and jump-starts breathing in those who overdose.

The experiences at more than 100 injection sites in 66 cities around the world, including some in Canada, Switzerland and Germany, speak for themselves. Safe-injection sites reduce overdose deaths by as much as one-third in the immediate vicinity and lessen injection-related infections and the transmission of diseases such as HIV and hepatitis C and B. They help addicts to seek treatment for their addiction and other medical problems, as well as providing a point of access to municipal housing and social services. And they make neighbourhoods ravaged by drugs safer, by reducing drug use and the disposal of drug equipment in public places.

Philadelphia, with its fine-art museums, grand avenues and imposing statues of heroes of the war of independence, is perhaps the most cruelly affected of big cities by the opioid epidemic. In 2016 deaths from drug overdoses increased from 702 in the previous year to 907, or 60 deaths per 100,000 residents, more than three times higher than in Chicago and four times more than New York. Around 80% of overdose deaths involved opioids, pain-relieving drugs that include both prescription painkillers such as OxyContin and illegal ones such as heroin. Most of the victims of opioids were men (nearly three times more than women), white (double the rate of African-Americans) and aged between 35 and 59. Last year was even worse: the city estimates that around 1,200 people died, four times the number of murders in a city once nicknamed “Killadelphia”.

City officials do not have an answer to why the opioid scourge is hitting Philly so hard. Poverty is one reason. After decades of manufacturing jobs leaving the city, around a quarter of the population live below the federal poverty line. Availability of drugs is another. Philadelphia’s dealers sell the cheapest and purest heroin on the east coast, perhaps even in the country. It is piped in by Sinaloa, the Mexican “cartel” led until recently by Joaquín “El Chapo” (Shorty) Guzmán, who is awaiting trial in a jail in Manhattan. Addicts travel to Philadelphia from New York and New Jersey and even states in the Midwest to stock up on white-powder heroin and fentanyl, a synthetic opioid, which is around 50 times more potent than heroin and 100 times more powerful than morphine.

Jim Kenney, Philadelphia’s progressive mayor, is trying to use every tool he can to get the epidemic under control. Last summer the city and Conrail, a railway company, cleared out El Campamento, an open-air heroin market and shooting gallery beneath sunken railway tracks in the Kensington neighbourhood that every day saw scenes of pain and desolation reminiscent of a painting by Hieronymus Bosch. He set up a task force that came up with 18 recommendations to fight the scourge, including the introduction of supervised injection sites, a media campaign about the risks of opioids and more education about access to and use of naloxone.

The voices of friends

In January Philadelphia filed a lawsuit against manufacturers of prescription opioids seeking to halt the companies’ “deceptive” marketing practices and to get them to pay for the rocketing cost to the city of treating addicts. According to the city’s health department, one in three adults has received a prescription for opioids in the past 12 months and one in seven, or some 168,000 residents, are now taking them.

The introduction of safe-injection sites, which has also being announced in San Francisco and discussed in Baltimore and New York, was by far the most controversial of the mayor’s recommendations. The state’s attorney-general, Josh Shapiro, opposes them because he says they are illegal. On the other hand Larry Krasner, the city’s district attorney, promises not to prosecute users or staff at the sites as he considers them helpful. Yet the best argument for such spaces, says Eva Gladstein of Philadelphia’s city government, is that they could save up to 76 lives a year. Moreover, they could contain the cost of the epidemic, estimated at $26m a year, by saving up to $1.9m a year in costs related to treating skin infections and hundreds of thousands of dollars thanks to fewer trips to hospital and a reduced use of ambulances and emergency rooms.

Supervised drug-use sites are not a silver bullet, but they help to keep needles clean and off the streets. No one has ever died in a legal shooting-gallery. And most crucially, says Susan Sherman at Johns Hopkins University, one of the authors of a report on the costs and benefits of such sites, they connect people to recovery. Between 2003 and 2006 46% of drug users at Vancouver’s Insite, North America’s first legal safe-injection site, entered rehab.