Can supervised drug-injection centers stop the relentless crush of overdose deaths?

After just six weeks of operation, the nation’s first two government-authorized centers where people can safely use illegal drugs have logged nearly 5,000 visits, reversed at least 114 overdoses, and raised hopes among harm reduction advocates that more communities will adopt this controversial model.

Opened in New York City in late November, the centers are supervised by trained medical staff and offer sterile syringes, overdose-reversal drugs and information on treatment options to people who come in with heroin and other drugs. The sites operate in a legal gray area, technically barred by a federal statute that prohibits maintaining any place for the purpose of distributing or using a controlled substance, but backed by Bill de Blasio in one of his final acts as mayor. 

He promised there would be no “enforcement action” against the providers. So far, the police have honored that commitment. The new mayor, Eric Adams, has signaled he wants to open more centers as part of a widening harm reduction strategy aimed at reducing overdose deaths.

More than 100,000 people nationwide died of an overdose from May 2020 to April 2021, according to the Centers for Disease Control and Prevention, an all-time high. The agency projected that overdose deaths in New York City would skyrocket 35% from June 2020 to June 2021, compared with a 21% increase nationwide. The toll has been relentless, as the powerful synthetic opioid fentanyl infiltrates the illicit drug supply. The COVID-19 pandemic has further accelerated the trend, the CDC says.

Advocates around the country are watching New York as they seek not only to open their own centers, but also to build on the momentum for harm reduction more generally. In January, New York City health officials announced a plan to open vending machines throughout the five boroughs that will dispense overdose-reversing drugs, syringes, toiletries, and safe-sex kits for free. Programs that distribute sterile needles and other supplies to people who use drugs, once anathema, have become commonplace; the North America Syringe Exchange Network lists 441 syringe service programs in its directory.

Rhode Island recently passed legislation to start a safe consumption center pilot program in the coming weeks. California’s Senate Bill 57 would pave the way for a similar pilot in San Francisco, Oakland and Los Angeles City and County. The bill, passed by the California Senate last year, is now in the Assembly.

Most strikingly, the Substance Abuse and Mental Health Services Administration has authorized an unprecedented $30 million for harm reduction efforts, signaling the Biden administration’s support.

Broadening government acceptance is a departure from the outright hostility that harm reduction has faced over the years. In 1990, eight activists in New York were charged with criminal possession of hypodermic needles while trying to distribute them to drug users to slow the spread of AIDS and other diseases. While they were acquitted the following year, needle possession was decriminalized in New York State only last October, despite the fact that millions of syringes were already distributed through state-funded public health programs each year. 

Because legislative progress in harm reduction has been slow and community opposition has been fierce, advocates are guarded, though hopeful that the winds may finally be shifting.

“A lot of this depends on what happens in New York,” said Darren Willett, director of the Center for Harm Reduction with Homeless Health Care Los Angeles who has long sought to open a safe consumption site on Skid Row. He said he is “optimistic that our country is taking a turn and beginning to understand the public health benefit.” 

In selling the idea of supervised drug use, officials often focus on the sites’ potential to stop overdoses. New York City officials refer to the facilities as “overdose prevention centers,” or OPCs. California’s SB 57 is titled, in part, “overdose prevention program.”

Willett, however, says that term “is a bit limiting.” 

Harm reduction, according to the National Harm Reduction Coalition, is a set of principles and strategies designed to reduce negative consequences associated with drug use — not only overdose, but also infection, arrest, incarceration and societal disenfranchisement.

“The actual benefits of these facilities goes far, never mind the fact that they become a service access point for other things, for people who otherwise don't access services a lot of the time,” Willett said.

The primary barrier his team faces in establishing a facility on Skid Row is the real threat that they could end up in jail, he said. His team is ready to act as soon as it becomes legally feasible to do so.

Other advocates identified different barriers, including what they see as incomplete media coverage and, relatedly, community perception and pushback. Joshua Miller, a state senator in Rhode Island who sponsored the successful bill to open centers in that state, believes in talking directly with those who argue that supervised injection sites — or even needle exchanges — encourage drug use and threaten neighborhood safety. 

“One of the important things to do when you start off with that conversation with people who've been less involved in the issue is to bring them up to date on how the underground drug supply is now saturated with fentanyl. That's the first thing I do, is explain it to them,” he said. “And then I go to the evidence and the research.”

Those sorts of conversations will play a big role in the development of programs in the state. The Rhode Island Department of Health draft regulations released in December require proposed centers to receive community approval and state licensing in order to open. The state is now taking public commentary and should be ready to accept applications from providers by March. 

Before he brought his bill to the Legislature, Miller said he researched harm reduction centers around the world. He often points to centers in Canadian provinces because he finds people are more receptive when he draws parallels between similarly sized U.S. and Canadian cities.

Miller recalls studying how neighbors and business owners worried about increased crime, drug use and vagrancy before the sites opened. “None of those things came to be. In fact, it was quite the opposite.”

Harnessing compassion for people who use drugs helped him change minds, too: “Tragically, it became easier as fentanyl became more prevalent because that was the first thing people understood because they had friends or neighbors or loved ones that died of overdose,” he said.

Mike Selick, associate director of capacity building for National Harm Reduction Coalition, is less interested in trying to promote compassion among opponents of safe consumption sites. Instead, he encourages detractors to consider how they themselves will benefit.

“Regardless if people do or don't care about people who use drugs — and ideally, we would like them to care, especially because 100,000 people died from overdose last year; it should have been humanized by now — but if that's not what's going to make people care and support this, then do because you don't want to have to deal with it,” he said. “Let them be safe somewhere else because the current situation is bad for everybody. People who use drugs don't want to be injecting in the parks and getting arrested, and people in the parks don't want to find needles or watch people inject in public.”

Selick works to advance harm reduction throughout New York, Vermont, Connecticut, Massachusetts and other Northeastern states. He sees growing support at all levels of government. 

For now, though, all eyes remain on New York, where the centers are exceeding expectations.  A Department of Health feasibility study released in 2017 found that supervised consumption sites could save up to 130 lives a year. The new centers, in Manhattan’s Washington Heights and East Harlem, are on pace to surpass that in their first three months.

“If the feds don’t intervene in New York, we’re going to have a lot of confidence that our federal government decided to do the right thing and take care of people who use drugs,” Willett said. “That will determine how much this arm of harm reduction spreads and how quickly it’s going to get hung up in court.”

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