A Judgment Free Zone for Drug Use
Does providing safer spaces to use drugs help or hurt?
More than 106,000 people died from opioid overdoses in the U.S. in 2022, according to the CDC—about two-thirds of them after taking fentanyl, the synthetic opioid that has long tainted heroin supplies but is now showing up in meth, cocaine, and counterfeit pills. That same year, 435 Rhode Islanders lost their lives to overdose, the highest number in the state’s history. The State House responded with a law allowing state-supervised overdose prevention centers, or OPCs—the first such law in the U.S. And Brown researchers are leading a federally funded study of the new programs.
OPCs already exist in 14 countries around the globe. Visitors come to the community-based spaces to access drugs in relative safety. They must self-administer and bring their own drugs, but the benefits include clean needles, often fentanyl test strips, staff trained to respond when medically needed, and connections to services that include addiction treatment, medical care, mental health treatment, and social support.
“They’re a highly studied public health intervention,” says epidemiology professor Brandon Marshall, founding director of the People, Place, and Health Collective [PPHC] at Brown’s School of Public Health, who has studied OPCs in Canada and will lead the Rhode Island study. “The first one opened in Switzerland in 1986, so there have been decades of research that have examined their impacts on both those who use them and the neighborhoods in which they’re located.”
It shows “consistently improved health and social outcomes,” says Marshall, as well as “improved neighborhood conditions—fewer people using in public, smaller amounts of drug-related litter, and most studies show no impact or decreasing crime.” The sites also save money through reduced ER visits, according to Marshall’s research. But the U.S. has resisted opening any until recently, opponents arguing that OPCs encourage illegal drug use and are themselves illegal.
A quiet experiment
Legal or not, a number of OPCs have opened around the country. “We’re in the business of saving lives,” says Ju Park, an assistant professor of medicine and epidemiology at Brown and research scientist at Rhode Island Hospital who is studying OPC implementation. “There are people and small organizations willing to risk arrest and incarceration to provide these services that are not controversial in other countries.” Park expects that the number of OPCs will increase rapidly.
Brown researchers, in partnership with a team from NYU Langone Health, are focusing on three sites. Two are in NYC, where in 2022 the city allowed two OPCs—they’re also known as harm reduction centers—to open in Harlem and Washington Heights. The other will be in Providence, where Rhode Island is set to open the country’s first state-supervised site in 2024, staffed by Project Weber/RENEW, a local nonprofit. The four-year study won $5.8 million in federal grants despite significant pushback from both sides of the political aisle. It seeks to enroll 1,000 adults who use drugs—500 from Providence and 500 from the NYC sites.
An interdisciplinary Brown team is examining the impact on both the participants and the surrounding neighborhoods. One prong investigates whether participants experience lower rates of overdoses, drug-related health problems, and ER visits, and whether they are more likely to enter treatment for substance use disorders. Another analyzes the operational costs and potential savings in health care and criminal justice, and measures community impact by assessing changes in overdoses, economic activity, and public disorder such as drug-related litter, arrests, and noise complaints. The first results from NYC, published Nov. 13, showed no increase in crime vs. pre-existing syringe service programs.
Proponents argue there is an urgent need for data to determine how well such centers work in the U.S., with its distinct health care delivery, social policies, and policing practices. OPCs “require us to shift our thinking in how we treat people who use drugs and how we address health issues they face,” Marshall told the New York Times. “So much of the history of the drug war in the U.S. is pushing people into the shadows, criminalizing their drug use. These facilities do the opposite. They say, ‘We want to bring you in and give you a safe environment where you will be respected.’”
A grassroots approach
Jon Soske, who advises researchers doing community-based research at Rhode Island Hospital’s Center for Biomedical Research Excellence on Opioids and Overdose, emphasizes the importance of directly involving community members with research. Soske used drugs for 13 years before going into long-term recovery four years ago.
“Harm reduction was a movement created and led by people who use drugs,” he says. “So if you want to do research surrounding harm reduction, it can’t be a top-down affair. It has to reflect fundamentally that the people who are experts about the dangers of drug use and ways of protecting against those risks today are people in the community.”
The story of recovery is often told as a redemption story, Soske notes. “We see addiction as the fall and recovery as a kind of reentry into society and social acceptability…but told that way the story of addiction is really stigmatizing”—and often minimizes the role of harm reduction, he says.
“For a long time I would have told you there was no harm reduction that was part of my recovery story,” he adds. Rather, he told “a neat redemption narrative…but now when I look back at that narrative, I actually see all kinds of moments where I made small decisions to reduce harm and increase my health that are invisible when I’m telling a redemption story.”
“I don’t believe in silver bullets,” says Alexandra Collins, a Brown epidemiology professor who works with PPHC. OPCs “are one very critical piece that we need to implement, but we also need additional policy change, additional services, and additional housing.”
Collins’s research centers around the intersection of housing and other built environmental factors and drug use patterns. “Housing instability compounds the issues that people who use drugs face,” Collins says. “It increases potential risk of health and social harms, because people are outside and have to use drugs in a space that puts them at increased risk for being arrested and criminalized.”
One solution could be integrating OPCs into homeless shelters, Collins says. “Housing, harm reduction, etc., all operate in silos here…we have to work on integrating these all together because they overlap in many ways.”