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Prevention Centers Save Lives, But Only Radical Change Will End the Overdose Crisis

Confronting the overdose crisis will require a society-wide transformation in how we approach the issue of drug use.

A client assembles overdose kits for distribution at the Center for Harm Reduction in Los Angeles, California, on September 28, 2021.

A pair of legally sanctioned overdose prevention centers — in which people can use illicit drugs under medical supervision — began taking clients in New York City in late November, potentially opening the door for similar facilities in other cities. The announcement has been a rare bright spot in the increasingly terrifying media coverage of the overdose crisis. The prevention centers are a hopeful step toward addressing the crisis, but they are not a panacea. Even if more centers are established beyond New York, experts warn that overdose prevention centers alone cannot stem the staggering tide of death.

In overdose prevention facilities (also known as safe consumption sites, safe injection sites and supervised consumption centers), people use drugs, often by smoking or injection, under the supervision of health professionals equipped with clean syringes and naloxone, the opioid antidote that reverses overdose and saves countless lives. The facilities provide a number of harm reduction services in a safe indoor setting, along with pathways to health care, addiction treatment and other vital resources. The centers have faced right-wing pushback, but experts say the controversy is seriously overblown. People are using drugs regardless of whether such centers exist, both inside and out on the street. Harm reduction services such as syringe exchange and innovative forms of drug checking and supervised consumption have existed in some hard-hit communities for years. Creating overdose prevention centers gives users and providers a medical office and a safe place to be inside.

Reams of research on overdose prevention centers in other countries and at least one unsanctioned site in the U.S. show they are clearly saving lives. Policy makers are finally taking notice as rates of fatal overdose shatter records nationwide.

However, even if more overdose prevention centers are authorized — a crucial step — experts say they must be one component of a larger program. The impact of such facilities would be limited to small geographic areas in big, liberal cities that accept them, and by the number of people who are both able and choose to show up.

“I never would have used the safe consumption site, I know that for a fact,” Morgan Godvin, a former heroin user who was incarcerated before becoming an advocate and fellow at Northeastern University’s Health in Justice Lab, told Truthout. “But I tried to get on the methadone twice and couldn’t surmount the red tape.”

Methadone is an effective prescription treatment for opioid addiction, but methadone patients and programs remain under strict state surveillance, which made the medication impossible for Godvin to access. Godvin and other experts say both overdose prevention centers and bolder policies are urgently needed to intervene in a chaotic drug supply that is fueling the overdose crisis. This includes a “safe supply” of drugs, and the “medicalization” of addiction treatment with medications such as methadone, hydromorphone and amphetamines that can replace powerful synthetic drugs obtained on the street.

As usual, the necessary changes to law and policy are not keeping up with activists and drug users on the front lines. Federal prosecutors have not said whether they would target overdose prevention centers for drug violations, and President Joe Biden has so far ignored calls for broader drug decriminalization, which can also prevent overdose deaths. Under President Donald Trump, the Justice Department blocked an embattled push for an overdose prevention center in Philadelphia in court, which created legal uncertainty for aspiring programs elsewhere.

“There’s obviously a dire need for these sites across the country, especially in areas with concentrated drug scenes getting hit with overdoses, and it’s a really important move in New York to open these sites,” said Ryan McNeil, director of harm reduction research at the Yale Program in Addiction Medicine, in an interview. “We’ll likely see similar action across the county. Now, I think one thing that’s going to hold that up is the verification about potential legal repercussions, and one would hope that we’ll get that from the Justice Department.”

Advocates for overdose prevention centers are reading the Biden administration’s tea leaves with the hope that similar facilities can quickly and legally be established beyond New York, including in San Francisco and Seattle. Rhode Island recently passed legislation legalizing “harm reduction centers” as well.

Simply put, people don’t overdose and die when they use drugs at prevention sites. Still, Godvin and McNeil said the facilities are not a “silver bullet.” The overdose crisis in changing rapidly, and it could be years before more brick-and-mortar harm reduction centers overcome stigma and political opposition to break ground.

Across the West, Godvin said, opioid use patterns are shifting from heroin injection to smoking blue counterfeit pain pills that contain the powerful synthetics driving sky-high overdose rates. These drug users may see little need for facilities also known as “safe injection sites,” especially if they are not numerous and conveniently located near to where they live.

“So, we’re burning political capital on something that might not be viable in five years when we finally get it off the ground, because drug consumption patterns are changing at a breakneck pace,” Godvin said. “Like we’ve never seen before in history.”

Still, for so many of us who have lost friends and loved ones, the stories of untimely death are becoming heartbreakingly familiar, and every tool is important. Sometimes, a victim recently quit drugs or was released from jail and began using again with a much lower tolerance. Sometimes drugs are more powerful than users expect due to interruptions in the supply and powerful synthetics such as fentanyl. At overdose prevention centers, people can test their drugs for adulterants and compare notes with other users and providers.

Facing pandemic isolation and intense social stigma, overdose victims often die after using drugs alone, with no one around to call 911 or administer naloxone. In other cases, they overdose with others nearby, but the people around them fear calling 911, because draconian laws in a number of states allow prosecutors to charge fellow drug users with homicide or other crimes in the wake of a tragic death. At overdose prevention centers, nobody uses drugs alone. Naloxone is always on hand and the police are not involved.

The harm reduction services at prevention centers were developed over decades by activists, researchers and drug users who created informal overdose prevention sites and resource networks operating in legal grey areas. This work continues today, and will continue as long as drugs remain stigmatized and illegal and users are unable to access proper health care through the medical system.

For these drug users and allies, the opening of legally sanctioned overdose prevention centers in New York was the result of years of activism in the face of scaremongering politicians, urban “not in my backyard” campaigners and law enforcement. As the centers began operating above ground for the first time, the death toll from the overdose crisis had surpassed a record 100,000 over the course of a year. In the White House and cities like New York, public health officials are slowly turning toward harm reduction as existing policies fail.

“The opposition to safe consumption sites is purely ideological, and it’s how they make people feel,” Godvin said. “It is not evidence-based or based in science, but mostly people fear abstract concepts much more than they fear tangible things right before their eyes.”

While Biden administration is now using harm reduction-related rhetoric and promoting some harm reduction policies, it has not taken a position on overdose prevention centers after Trump officials rejected them and the basic principles of harm reduction in general. The Biden administration removed a decades-old moratorium on making methadone clinics mobile and made other regulatory tweaks, but officials are also doubling down on drug war policing, mass incarceration and “supply reduction,” which makes the drug supply more dangerous. Plenty of barriers to effective pain and addiction medications remain in place as the government cracks down on the prescribing of opioids and other psychoactive drugs, which is driving demand for counterfeit pills laced with the powerful synthetics behind the record rates of death.

Advocates like Godvin and McNeil want us to know that a legally sanctioned overdose prevention center going up down the street won’t negatively impact neighborhoods, and they will make a positive difference — but they will not put an end to the crisis alone. Prevention centers in Canada and Europe are situated in urban areas where drug use is concentrated, often among a significant population who would otherwise get high outside and struggle to access stable housing.

“For some people supervised, safe consumption’s going to be fantastic,” McNeil said. “They’ll go regularly. And maybe they’ll primarily inject at the sites. Other people won’t go to them at all. And you know, we’ve done this work for so long evaluating sites in Vancouver, for example, that we just know that is the case.”

Other hopeful options exist that could be engaged in tandem with overdose prevention centers. Both Godvin and McNeil pointed to a recent study on hydromorphone, an opioid painkiller, which was provided to people who would otherwise be using heroin or fentanyl and are at high risk of overdose. Researchers found the program reduced the use of street drugs and overdose risk, improved pain management and was associated with better health and economic well-being.

Laws must be changed if hydromorphone is to be prescribed or distributed as part of overdose prevention efforts. Additionally, advocates say people at risk of overdose should be able to easily access so-called “prescription heroin” and other treatments at the doctor’s office or even special vending machines that are now in use in Canada.

Yet public policy has gone in the opposite direction in response the overdose crisis, with opioid prescribing plummeting over the past decade in response. Now, rates of fatal overdose are higher than ever, and medical experts see the connection.

“Let’s use hydromorphone, a very similar compound and very similar effect [to heroin and fentanyl], and let’s push for broad medicalization of it, and pull it all back into the medical system because the drug supply is so toxic,” Godvin said.

Confronting the overdose crisis will take a broad range of strategies and a transformation of the way we approach drug use in policy and as a society. Although the proliferation of prevention centers would be a huge and hopeful development, advocates say they must be viewed as just one step toward a broad and expanding mission to save lives and protect human rights.