The death rates associated with the opioid crisis are so staggering that they can be difficult to comprehend through statistics alone. According to New York State and City health department data, at least 4,181 people died from opioid overdoses in the state in 2020a per capita rate of 20.7 per 100,000. To put that into perspective, this annual rate has more than quadrupled in a decade. More than any other region, the Hudson Valley and Catskills have disproportionately borne the burden of the crisis. Sullivan Countys opioid overdose death rate was triple that of the rest of the state in 2020. While the Department of Healths data for 2020 are still preliminary, opioid overdose is a chronically undercounted phenomenon.
Some of this rapid uptick can be attributed to the emergence of fentanyl, an especially potent and deadly synthetic opioid that has contaminated much of the drug supply. In Sullivan and Ulster counties, 100 percent of reported opioid overdoses in 2020and in Orange County, all but one overdoseinvolved synthetic opioid pain relievers, particularly fentanyl. It has also contributed to New Yorks skyrocketing number of overdose fatalities involving cocaine and synthetic opioids, which increased by 2,000 percent between 2014 and 2019. Additionally, the COVID-19 pandemic has exacerbated this public health crisis nationally, with overdose deaths exceeding an unprecedented 100,000 between May 2020 and April 2021. These numbers are rising fastest among communities of color.
For fifty years, the US has waged the war on drugs by leveraging steep legal consequences for drug possession and sales, with the number of people incarcerated for drug offenses exploding more than tenfold between 1980 and 2019. Were talking in the 50th anniversary year of Nixon declaring the war on drugs, says Melissa Moore, director of civil systems reform for the Drug Policy Alliance. If criminalization and prohibition had been effective policies, we would not be seeing record-breaking overdoses year after year after year.
New York Stateand the Hudson Valley in particularis in need of an aggressive shift in policy and culture to reverse current trends and save lives. But the most effective interventions have often been illegal under federal and state law. That may be changing, with the recent introduction of two overdose prevention centers in New York City that offer the promise of a new model for reducing harm.
For decades, countries such as Canada and Australia have operated overdose prevention centers that have consistently correlated with a significant decrease in fatalities in surrounding communities, and with no known reported deaths. These centers, also known as supervised injection sites, offer multiple services, but most importantly and controversially, they are spaces for safe consumption: community members who access the facility are able to use their substance of choice under the eye of a healthcare provider or other staff member specifically trained in overdose prevention and Narcan administration. There are few requirements for entry, but criteria for participation often include age and a prior history of drug use (so that minors and first-time users are not among the clientele).
In November 2021, New York City became home to the first overdose prevention centers to operate openly in the United States. OnPoint NYCthe organization formed when New York Harm Reduction Educators and the Washington Heights CORNER Project mergedopened two such centers in Washington Heights and East Harlem. As of January 24, the sites had reversed more than 100 overdoses with zero fatalities. This precedent could signal critical change for the rest of the state, and for the rest of the country.
The Effectiveness of Harm Reduction
Despite its novelty in the United States, research on the efficacy of supervised injection is already bearing out. Dozens of scientific studies and peer-reviewed articles have consistently demonstrated that in addition to reducing overdose frequency and mortality, overdose prevention centers are also associated with an array of other positive health outcomes, including access to health care and referrals to treatment. In fact, regular use of supervised injection and contact with counselors at a facility have been shown to be positively associated with entry into treatment and cessation of injection. While most existing data is based on studies from Canada and Australia, it is consistent with findings from unsanctioned sites in the United States.
Still, some residents in Harlem and Washington Heights have protested the new sites, claiming that they will attract users from all over the city and expose children to public injection and dropped syringes. Of course, expanding overdose prevention centers to other parts of the state would decrease the need for clients to travel to the facilities in Harlem. But the research has demonstrated that overdose prevention centers actually decrease dropped syringes in public spaces. Sites in Sydney and Vancouver saw a decline in public injection in surrounding communities, with no increase in crime or drug trafficking. Cost-benefit analyses published in the International Journal of Drug Policy, the Canadian Medical Association Journal, and the Journal of Drug Issues have estimated that overdose prevention centers offer communities estimated net savings starting at $3.5 million.
Supervised injection falls under the category of harm reduction, a set of principles that have been around as a grassroots community service, an underground strategy, and as official public health policy for decades. The basic principle is to meet people where theyre at, including those who are not ready to stop using. A harm reductionist approach to substance use seeks to prevent associated complications like overdose, HIV and Hepatitis C transmission, or wound infections, without condemning or stigmatizing the individual or requiring that they enter treatment to access services. Harm reduction programs may offer syringe exchange, low-threshold housing, Narcan kits and training, or fentanyl test strips, in addition to support groups, holistic health services, or simply a temperature-controlled indoor space. Often, these programs offer clients a level of human dignity they are not afforded in other settings.
Harm reduction is also seen as a more effective foundation for long-term sobriety than traditional programs which demand sobriety as a condition for services. But total cessation is not necessarily the goal of harm reduction programs, which instead seek to improve the quality of life and prevent illness and death among a deeply stigmatized and disenfranchised population.
Joe Turner is the co-chair of the New York State Harm Reduction Association (NYSHRA) and the founder of EXPONENTS, a substance use services organization; he got his start in the field of harm reduction as a lawyer during the HIV/AIDS epidemic. Back then, we could not wait for people to become sober or drug-free in order to receive these life-saving interventions, he says. At the time, the only anti-HIV drug approved by the FDA was expensive, induced caustic side effects, and required around-the-clock administration. So whether someone was actively using or not, we met people where they were. We provided what we called low-thresholdin other words, just come on in. Well talk about the other stuff later. Lets keep you alive so we can talk about the other stuff.
In the Hudson Valley, only a handful of organizations offer harm reduction services. One is the Samadhi Center in midtown Kingston. Ulster County resident Mary Goldsmith goes to Samadhi for its holistic wellness programs like meditation. I became homeless when the pandemic hit, and turned to Samadhi, and not gonna lie I was apprehensive about it, she says. Am I going to be hanging around people that are using? I wasnt using, so I was a little skeptical if it was going to be a safe place for me or not. Instead, she says, she found a warm and welcoming community that challenged her to rethink her own biases.
The Stigma Barrier
What makes opioids so deadly is not only the biochemistry of the substance, but the stigma attached to the individual using it. Turner traces contemporary stereotypes to Reagan-era propaganda. If you would try to imagine the face of the crack epidemic, it was usually someone of color, he says. The stigma was very cruel, they used words like crackhead, crack whore, crack baby. The image was someone out of control. And the response to that was a criminal justice response: the war on drugs. People get killed in war. For decades, substance use has been seen as a criminal act, and by extension, an indicator for morality. Despite current knowledge about the reality of addiction as an illness that requires medical treatment, the stigma persists, and people who inject drugs are often seen as disposable.
Harm reduction, and particularly supervised injection, is often controversial because detractors claim it enables or encourages substance use. That sort of thinking comes from this old treatment mindset that you need to let people hit bottom, which is an absolutely blindingly stupid thing to say at this point in history, says John Barry, executive director of the Southern Tier AIDS Program (STAP). Because bottom for a lot of peoplegiven how poisoned the drug supply is with fentanylis death.
Lets keep you alive so we can talk about the other stuff.Joe Turner, co-chair of the New York State Harm Reduction Association
Popular narratives surrounding recovery sound a lot like the 12 steps of Alcoholics or Narcotics Anonymousan individual admits they have a problem, stops using through the strength of their willpower, and then lives a life of stringent sobriety. That may work for some people, but its a norm that leaves many others on the margins, and instills ideas about recovery that often take on a moral valence.
The reality is often much more complicated, and the process of recovery can be physically and emotionally brutal. In a survey of community members who used STAPs syringe exchange program, 79 percent had already been through treatment at least once before, according to Barry. But many people see relapse as a moral failing, rather than evidence of shortcomings with a treatment program or structural barriers to recovery like homelessness, lack of transportation, or poverty.
We hear people use the language of clean, staying clean, or having clean urine, says Dr. Chinazo Cunningham, the recently appointed commissioner of New York States Office of Alcohol Services and Supports (OASAS). The language of cleanliness that pervades substance use treatment implies that relapse is akin to contamination or impurity, which can be deeply stigmatizing. Addiction is a health condition, its a chronic condition, she continues. We dont talk about other health conditions in this way. Like other chronic conditions, addiction can be effectively managed, and relapse is normal. But with addiction, a relapse is often grounds for removal from recovery and housing programs.
Systems of Humiliation
Treatment is a broad term that can refer to a variety of modalities. One of the most effective forms of substance use treatment is the medications methadone and buprenorphine, which alleviate cravings and the severe symptoms that accompany withdrawal. However, the barriers to access medication-assisted treatment (MAT) are substantial; the US Department of Health and Human Services states that less than 1 percent of people who need treatment for a substance use disorder receive it. The Hudson Valleys dearth of resources is an ongoing issue: at the start of the COVID-19 pandemic, Westchester Medical Center Health Network gutted the only inpatient detox beds in Ulster County. Opioid treatment programs offering methadone remain concentrated in New York City, and throughout the rest of the state they are few and far between. Joe Turner describes the resulting obstacles as systems of humiliation for patients.
When Mary Goldsmith signed up for a traditional recovery program, I didnt know I was signing myself up to be shamed, she recalls. Thats exactly what I received from the woman who was helping me. I dont think she had any problems with addiction her entire life, but she had a degree in substance counseling. Despite her desire to begin recovery, Marys program created an atmosphere of distrust by submitting her to random drug testing and reporting her to her probation officer.
Stigma against opioid use disorders in healthcare settings is widely documented and can lead to suboptimal care or punitive neglect. According to one study, patients may delay or avoid care to escape another dehumanizing experience, potentially resulting in untreated bloodborne illnesses or wound-related infections. People who inject drugs are also more likely to omit details of their medical history, and are less likely to receive relevant care. Whats more, when individuals internalize this shame, they are less likely to seek or continue treatment. People who inject drugs are disproportionately likely to struggle to find stable housing or employment or access education. Taken together, all of these risk factors can have devastating health consequences.
The OnPoint NYC sites represent a sea change in federal drug policy. Previously, the only other time an overdose prevention center attempted to publicly open was Philadelphias Safehouse in 2019; it was promptly sued by Trumps Department of Justice for violating the Controlled Substances Act. The Biden administration has indicated a more supportive stance for harm reduction, and tepid support regarding the overdose prevention centers. While it has drawn criticism for not weighing in on supervised injection specifically, the Biden administration named harm reduction as a year-one priority for drug policy and authorized $30 million of funding for harm reduction programs through the American Rescue Plan.
Likewise, Governor Kathy Hochul has not explicitly condoned the overdose prevention centers, but has expressed an interest in researching their impact. In her first few months in office, she has signed bills decriminalizing syringe possession, requiring jails and prisons to provide MAT, and prohibiting Medicaid from requiring prior authorization for MAT. The governors proposed executive budget, released last week, offers a 56 percent increase in funding for the Office of Addiction Services and Supports and a new Division of Harm Reduction within OASAS. But the bill that would formally legalize overdose prevention centers in New York State has sat in the health committees of both legislative bodies for over three years.
The Local Outlook
For those witnessing the daily death toll on the front lines, life-saving services cant wait. Horace (his name has been changed to protect his identity) directs a substance use services organization in upstate New York. A lot of the folks that come to our location are homeless or unstably housed, he says. We have a bathroom that has a shower. We have laundry facilities. During the pandemic, most other public restrooms in the area closed. Horaces organization did not want to put a camera in one of the only private bathrooms available to vulnerable community members. Having said that, were pragmatic folks. Were not naive about who we serve and what their needs are. Those needs sometimes include a safe place to inject. In the fall of 2021, two FBI agents entered the building through a back entrance and interrogated one of Horaces employees about clients injecting drugs in the bathroom.
Horaces program is in an unassuming two-story house, but the bathroom may not look like it belongs in a residence. It has a stainless steel counter and a sharps container for safe syringe disposal. The door has a timer that goes off every few minutes so that staff can check on occupants, and strike locks should they need to open the door from the outside to intervene. These are all safety measures to make sure that nobody dies in our building, he says. That actually happened in one of our sister agencies. Are we telling people to come on in and inject? No, were not. But people are using the bathroom for various things.
While supervised injection remains legally ambiguous, local law enforcement will be a critical piece of the puzzle. Should other organizations or towns in New York decide to open their own overdose prevention centers, a sheriffs decision to arrest or a district attorneys decision to prosecute could determine the programs success.
In Ulster County, harm reduction has already found favor among top law enforcement officials. Sheriff Juan Figueroa has been growing the countys High Risk Mitigation Team since his inauguration in 2019. Why do we let a revolving door at the county jail continue when we can do something to stop that? he asks. Why let people die of overdoses when theres something that you can do to stop that? The intention of the High Risk Mitigation Team is to divert people away from the criminal justice system and towards treatment. Overdose calls, rather than resulting in arrest, receive a response from a social worker, peer specialist, and a plainclothes officer trained in crisis intervention. According to the Sheriffs Office, between January and October 2021 the team provided 226 referrals, 24 percent of which led to the individual beginning MAT.
But when it comes to supervised injection sites, Ulster Countys top law enforcement officer is more hesitant. I would have to do more research on it, Figueroa says. I dont know enough on that to say I agree with it or not. I do have an open mind. He does acknowledge the need for novel solutions, pointing to the recent changes regarding substance use treatment in jails. I think its our obligation to try new things that might be able to help society.
For his part, Ulster County District Attorney Dave Clegg was one of 80 signatories to an amicus brief in the 2019 case brought against Philadelphias Safehouse, and he firmly supports overdose prevention centers. While Cleggs office has continued to prosecute what he describes as higher-level drug traffickers, he does not see incarceration as a viable solution for the overdose crisis. You dont want these people to die because theyre using the wrong needles or theyre taking the medication or drugs that are coming from the wrong place, he says. If there is a safehouse concept that can work and save lives, I think the entire community should support it.
Statewide, New York is seeing an unprecedented level of support for harm reduction and supervised injection among elected leaders and public health officials. The fact that Governor Hochul recently appointed leaders with harm reduction backgrounds to high levels in both OASAS and the Department of Health is a significant shift. There is a wealth of hard evidence pointing to the success of overdose prevention centers, and a moment of great potential as Manhattan and Ithaca forge ahead without explicit decriminalization. But the biggest hurdle for the rest of the state may have little to do with policy, and everything to do with people.
Philadelphias Safehouse gained legal standing to open after a federal judge decided in its favor in 2020. But instead, it delayed opening following pushback from residents and local elected officials. In New York, the Greater Harlem Coalition that opposed the overdose prevention centers may have found unwitting allies in New Yorks Republican House coalition, who introduced a bill that would withhold federal funding from any entity offering supervised injection. While the bill is unlikely to move forward, it signals a long road ahead.
Why let people die of overdoses when theres something that you can do to stop that?Ulster County Sheriff Juan Figueroa
An article published by the American Psychiatric Association found that large majorities of respondents blamed individuals with opioid use disorders for their addiction and believed they lacked self-discipline. A majority of respondents also expressed that they would not want someone with an opioid use disorder as a coworker or family member, and felt that employers should be allowed to deny employment on the basis of an opioid use disorder. These attitudes were also associated with greater support for punitive policies (e.g., arresting those who attempt to acquire prescription opioids from multiple providers), and less support for public health-oriented policies (e.g., Good Samaritan Laws or increasing government spending to improve substance use treatment).
Even basic harm reduction services have met resistance from local communities in the Hudson Valley. In October 2021, over a dozen midtown Kingston residents called into an Ulster County Legislature meeting to complain about the Samadhi Centers community members. But many of the behaviors lamented by the speakersfor example, individuals sleeping in lobbies or urinating in publicare just as much symptoms of Ulster Countys housing crisis. While law enforcement has softened its approach, relations with neighbors have grown embittered. Its really hard to convince people that people who use drugs are not bad, because we arrest people who use drugs, says Samadhi executive director David McNamara. So its definitely a confused message. As Samadhi looks towards relocating services to a non-residential area, other entities that may consider overdose prevention centers in the region will need to consider the unavoidable necessity and significant challenge of public opinion.
Into the Light
People who inject drugs have been criminalized and stigmatized to the point that they have been forced to use in the shadows, further from public view. And people who use in isolation are more likely to die in isolation. No one wants the opioid crisis to worsen, but not many people are willing to bear witness to the toll substance use has taken in their own communities. Overdose prevention centers may visibilize an activity that was previously criminalized and hidden away. They may appear inconvenient, or even ugly, but the potential benefits for community wellbeing and safety are profound.
When substance use services are available, they are often concentrated in metropolitan areas. Thats not a coincidence, says Moore of the Drug Policy Alliance. Decades of not-in-my-backyard politics have driven life-changing programs from rural communities in particular. Now theres been a bit of an awakening for people, she says. We are in a moment where we can reimagine what it looks like to have responsive services and supports and treatment all across the state.
Moore is hopeful that New York State is entering a new era in treating addiction: One where there is a commitment to prioritizing evidence-based solutions, and an appreciation of the devastation of the overdose crisis in the state. Its not enough to just have a couple overdose prevention centers openits wonderful, but also we need to extend the analysis around what actually are the policies and practices that are going to keep people safe and help communities thrive. Thats certainly not what weve been doing.
For Mary Goldsmith, the possibility of more overdose prevention centers is acutely personal. A few months ago, her brother, Thomas Fisher, died from an overdose. He was only 38. He was using alone with his girlfriend, she says. I wish there was a place like that around him so that he could go use in a safe environment, not being alone and being in the dark about it.
This article was also published in the March 2022 issue of Chronogram.