Today is International Overdose Awareness Day, though unfortunately too many New Yorkers are intimately aware of the dangers. In 2021, almost 2,700 people officially died of overdoses in New York City, an increase of 565 over 2020, and the numbers do not seem to have really improved. This week, Gov. Hochul pledged $8 million in new harm reduction programs and $28 million for existing Health Department programs from the state’s substantial Opioid Settlement Fund, a result of legal settlements with companies that manufactured, marketed, and distributed opioids.
Societally, we’ve taken a significant step over the last few years, which is to move away from carceralism and punitive measures as a supposed solution to the problem of substance abuse and escalating overdoses. Even setting aside broader debates about justice, proportionality, and economic opportunity, that approach just doesn’t seem to work very well. If it did, the overdose problem would have dissipated along with the 90s War on Drugs; instead, we’re in a worse spot than we’ve ever been.
Still, even reaching the consensus of harm reduction as a path forward, there’s a whole spectrum of possible approaches, some more readily embraced than others. Conspicuously missing from the governor’s announcement was support for so-called overdose prevention centers (OPCs), sometimes also called safe or supervised injection sites. That came as another blow to initiatives that have had a 100 percent success rate at their base goal of preventing overdose deaths.
Not a single recorded death at OPCs
Now, I know that stat sounds fake, an exaggeration for rhetorical effect that cannot possibly hold up to scrutiny. Yet in researching the overdose prevention model, I was struck by the fact that there does not appear to be a single recorded death from overdose at any such center, sanctioned or unsanctioned, anywhere in the world, ever. A 2017 report by the British Columbia Ministry of Health looked at results for the over 90 OPCs operating worldwide — with the oldest legally sanctioned one having opened in Berne, Switzerland, in 1986 — and found not one reported death. None have been reported since.
As a journalist, this type of success rate sets off alarm bells in my head. How can there possibly be this clean of a record? It must be embellishment. But if you think about it a little more, there’s a simple explanation: opioid antagonists like naloxone are really good at reversing overdoses. Medications like naloxone, for example, bind to your body’s opioid receptors and prevent the opioids from acting on them, effectively rendering them inert to the point of stopping an ongoing overdose in its tracks.
The whole conceit of these centers is that people are using the drugs under direct supervision from staff ready to jump in with the medication the second it becomes clear someone is overdosing. It’s like pointing out that a fire has never gotten out of control provided it was started in a specialized facility manned by trained firefighters holding extinguishers. Put like that, it seems obvious that no one has been killed by an overdose in an OPC. Beyond that, observing usage and reversing overdoses when needed is just the first point of contact. OnPoint and the other OPCs around the world use this entrypoint to give drug users wraparound services like medication-assisted treatment and mental healthcare.
Centers are threatened with closure
We might expect an initiative with that kind of a track record to be the poster child for harm reduction; it is quite literally undefeated at mitigating death, the gravest harm of all. One would think it would have been enthusiastically embraced by political figures who are under significant pressure to do something about ballooning overdose deaths and who love touting the return on investment of specific policies. Yet not only is that not the case, the only two officially sanctioned such centers in the United States — both located in Upper Manhattan and run by the nonprofit OnPoint since 2021, with the blessing of the then-Mayor Bill de Blasio administration — have never gotten the okay from the state government and are now being threatened with closure by U.S. Attorney Damian Williams, the federal prosecutor for Manhattan.
Every step of the way has been uphill for OnPoint and its executive director, Sam Rivera. The nonprofit has long intended to run its centers 24/7 (people are obviously not just overdosing during regular business hours), but has been stymied by an inability to raise public funds and a reticence by private donors to contribute. Last December, Gov. Hochul’s commissioner for the Office of Addiction Services and Supports, Chinazo Cunningham, shocked the Opioid Settlement Fund advisory board — a body that had been created specifically to issue recommendations on how to spend potentially billions of dollars the state would receive as, and on which Cunningham herself sat — by sending a letter stating the government would not fund overdose prevention centers.
Then, Williams came in with the legal threat, raising the specter that federal agents could come in and shut down the whole operation. Even if this threat doesn’t fully materialize, or if the centers are closed and then reopen, it will probably irreparably infringe on their ability to operate given the likelihood that would-be clients will stay away out of fear of getting swept up by the feds. So why all the strife? It comes down to the so-called “crack house statute,” a part of a 1986 law (incidentally passed the same year as the first-ever OPC opened up in Europe) that makes maintaining a space for the use of controlled substances itself illegal, i.e. OPCs are definitionally illegal under federal law.
No state support
I’ve had the chance to speak to Rivera a few times, and he’s rightfully sanguine about the potential of his operation, which resulted from the combination of two prior harm reduction nonprofits, while being frustrated at what he views as pointless obstacles. He’ll often point out that marijuana, too, is a federally prohibited substance, but states including New York have set up their own legal frameworks and the federal government has largely let them do it without incident. Why then is this relatively narrow initiative, staffed by personnel dedicated to saving lives and with a perfect track record of doing so, getting the book thrown at it with no state support?
I think it comes down to a kind of squeamishness with the whole process of recovery; elected leaders are all for recovery, but they’d prefer if you could just flip a switch and have someone go from active dependence to recovery without intermediate steps, but that’s just not the way it works. Quitting cold turkey has largely been discredited as a real strategy, and in fact it can often be more dangerous than just continuing to use drugs regularly, as intense relapses can trigger overdoses.
People are going to keep using even if they want to stop, and the only way to make sure they don’t die will they keep using, especially as broader swaths of the drug supply get contaminated with potent fentanyl, is to reverse overdoses, which can best happen in a controlled setting with antagonists nearby and available. If we want fewer people to die, we should be calling for this model not to be shunned but given official approval and plenty of funding.
This is part of a series of articles exploring health inequities in New York that is funded by a grant from the Commonwealth Fund.