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September 27, 2022

A new era of harm reduction: Will the US finally embrace safe drug consumption sites?

Safe consumption sites are seeing fresh support in states across America, but what challenges do they face to go nationwide?

By katharine swindells

In November 2021, New York City opened OnPoint NYC, the first government-sanctioned overdose prevention centres in the United States. These centres are facilities where people can consume and inject illegal drugs with trained healthcare professionals available nearby, as well as other support such as counselling, showers and laundry services for the users. In September 2022, they announced they had saved 500 lives from overdose in the facilities.

Safe consumption sites like these have existed globally for decades, most prominently in Canada, while the US has had “underground” drug consumption sites in the past, but the New York opening marked the first successful government-authorised site in the country. Almost a year on, what does OnPoint NYC mean for other cities that are trying to open similar facilities?

A man uses the narcotic consumption booths at a safe injection site at OnPoint NYC in New York. In 2021, New York City opened two supervised drug injection sites in the Harlem and Washington Heights neighbourhoods in an effort to address the increase in overdose deaths. (Photo by Kent Nishimura/Getty Images)

The opioid epidemic has been a defining crisis in the US public health landscape over the past decade. Almost 109,000 people died of a drug overdose in the US in 2021, and 82,000 of those were connected to opioids – 3.5 times the number of opioid-related deaths that occurred in 2011.

Since 1999, opioid overdose deaths in the US have risen tenfold. In 2020, as the world grappled with the Covid-19 pandemic, opioid deaths increased by 37% in a single year.

Balancing safe consumption sites and community engagement

In Somerville, a small city in the greater area of Boston, Massachusetts, harm reduction and addiction experts have been working for years to try and get a supervised consumption site (SCS). Massachusetts is among the states with the most severe drug overdose death rate: in 2019 it ranked eighth in the US, with 32 deaths per 100,000 of the population. 

“When they're in their most vulnerable moments, when they're at most risk of overdosing and dying, we can't be with them,” says Carl Sciortino, an executive vice-president at Fenway Health and author of the recent feasibility report into a Somerville SCS. “People are dying in our streets every day because they're being forced to hide in back alleys or bathrooms or wherever they can find a corner of the city to use because of the stigma and the legal status of drug use. We could be there, ready to administer the most basic life-saving interventions, but we’re not allowed. That to me is both unethical and lacks common sense.”

With the support of the city government, Somerville has spent the past three years in a lengthy process of in-depth community engagement, speaking to local residents, business owners and community leaders.

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“The whole point was not to sway or persuade, it was just conversation to see how we can help people understand for themselves what this is and give them information that they need,” Sciortino says. “Some people would say ‘we're going too slowly, just open it tomorrow,’ but it's really important to take the steps to get this right. The biggest risk is doing it haphazardly and making mistakes.”

Ultimately Sciortino says that although people’s concerns are valid, all of them see how important this work is, since they come into contact with the reality of the opioid epidemic every day – in the bathrooms of their restaurants and cafés, in the streets and public areas, and among their own friends and families.

“Somerville is a city with an openness to innovation and new, progressive ideas,” Sciortino says. “It's also a community that has been dealing with overdose deaths for many, many years and has lost a lot of people in the community. And those families and friends are still here, mourning the loss of their loved ones.”

How New York led the way in supervised drug consumption facilities

But Somerville is far from the only place looking to follow in New York's footsteps on safe consumption sites to tackle the epidemic of drug deaths in their area, albeit with mixed success. In the summer of 2021, Rhode Island became the first US state to legalise a pilot programme for the sites, though hasn’t yet opened one, while California governor Gavin Newsom recently vetoed a bill to trial sites in San Francisco, Oakland and Los Angeles. Advocates hope that the successes of the New York overdose prevention centres (OPCs) will help them make their case in their own cities.

OnePoint NYC, which has locations in East Harlem and Washington Heights, opened at the end of November 2021, with 613 individuals using the service 5,975 times in the first two months. Trained staff intervened 125 times to mitigate overdose risk, including administering oxygen or naloxone, and individuals were transported to emergency departments three times. Crucially, however, there were no fatal overdoses.

Of the 613 users, over a third (37%) were living on the street, and a further 18% were in a homeless shelter or provided housing. Users experiencing homelessness were even more common at the Washington Heights location, where they accounted for half of all reports.

“This first description of OnPoint NYC suggests not only that OPCs are feasible, but also that individuals who were unhoused, who are at extremely high risk of overdose death, were willing and interested in using OPCs,” writes Elizabeth Samuels, assistant professor of emergency medicine at Brown University and consulting assistant medical director for the Rhode Island Department of Health’s drug overdose prevention programme.

In fact, over three-quarters of people who visited OnPoint centres said that, had the centres not been an option, they would have used drugs in a public or semi-public location, such as the street, park, subway station or restaurant bathroom.

What challenges do safe consumption sites face?

But what does it take to open a safe consumption site? Dr Miriam Harris, an addiction expert at Boston Medical Center and professor at Boston University, who trained alongside safe consumption services in Canada, says that while New York's success is bringing momentum, efforts to create safe consumption sites are still hyper-local.

“The two sites in operation in New York City are not operating with state or federal support. They came into fruition because of private and community-based organisation partnerships, but that model is really difficult to be sustainable,” Harris says. “So I think what we're going to see in the United States is rather a cascade of new safe consumption sites being opened, using very local approaches that find workarounds to the current unsupportive federal and state policies.”

Even states like Rhode Island, which have passed legislative support, still will likely face opposition from communities near where the sites are suggested, Harris says, so campaigners will have to engage in extensive local engagement.

“We really have to do it in partnership with communities so that after opening, they maintain their success and are able to stay open,” she says. “That’s why we are seeing hyper-local efforts like what’s happening in Somerville, which, while exciting, is also slow.”

But safe consumption sites are only the first step in a long way the US has to go towards a progressive drug policy. In Canada, they have existed for 20 years, and now there are clinicians exploring more drastic methods like prescribing opioids to addicts to ensure their supply is clean. Harris says when she first came to the US, she was shocked by how purportedly liberal cities like Boston and New York could be so far behind Canada when it comes to treating substance abuse. Ultimately, she says, clinicians and policymakers need to be centring the people at the heart of their work.

“We need to do a much better job of empowering people who use drugs to be the leaders of the solutions,” she says. “We have to really resist just making the same mistakes over and over again, of investing in the war on drugs, and investing in coerced models of forced treatment, which are not effective and likely dangerous.”

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