Workers at Safehouse, a nonprofit hoping to begin serving people who use drugs in Philadelphia, know all too well the struggle in getting people on board with overdose prevention sites (OPS). After announcing last year that the city had cleared a path to open an overdose prevention site in the South Philadelphia area, backlash brewed. The site would be a place where injection-drug users could drop in to use heroin or other substances under medical supervision and potentially be administered Narcan (naloxone), an overdose reversal drug, if necessary. However, local residents rose up in a massive, furious protest, claiming that they had been blindsided—and Safehouse, overwhelmed, canceled its plans.
Since then, of course, COVID-19 has devastated the nation, with one of its repercussions being a dramatic increase in drug-overdose deaths, as the Centers for Disease Control and Prevention (CDC) just reported. That’s likely due to higher rates of isolation and depression among drug users, plus the fact that needle-exchange and other drug-user service providers have had to sharply cut back their face-to-face services in the past year due to coronavirus risk.
In fact, the CDC just factored overdoses in alongside COVID as the reasons why life expectancy rates in the U.S. have plunged sharply in the past year, particularly among Black and Latinx Americans. While the average American life expectancy fell one year for the entire population, due to multiple factors affecting Black and Latinx Americans, some demographics faced much harsher statistics. Black men’s average life expectancy fell three years, while Latinx men’s fell 2.4 years.
Such news would seem to strengthen the argument for overdose prevention sites. But in fact, in January, a federal appeals court ruled that such a site in Philly would run afoul of a 1986 law known as the “crack-house statute”—and expose its operators to potential prosecution.
“Safehouse’s benevolent motive makes no difference,” wrote a judge in the 2-1 decision, which was made by a three-judge panel, not the whole court. “Congress has made it a crime to open a property to others to use drugs. And that is what Safehouse will do.”
The ruling was a devastating setback for the OPS movement. Only two years ago, it appeared possible that several U.S. cities—including San Francisco, Philly, Seattle, and New York—would open sites, even in the face of a Trump-era Department of Justice (DOJ) declaration that such sites would face prosecution.
In fact, despite the DOJ stance, it was a lower federal court that upheld the legality of Safehouse—before the appeals court reversed it.
Are overdose prevention sites thus off the table for the immediate future? Not necessarily, says Jennifer Flynn-Walker, who works on harm-reduction initiatives as senior director of mobilizing and advocacy at the Center for Popular Democracy.
“Biden needs to reverse existing policies,” she says. “He could issue an executive order allowing for consumption of ... controlled substances in sites like Safehouse.” Flynn-Walker pointed out that the president has several avenues open to him if he wanted to help curb the ongoing injection-drug-use epidemic. He could have a different interpretation of the Controlled Substances Act of 1970, which essentially classifies levels of legality and federal regulation of different drugs. He could ask federal agencies to issue emergency guidance, given the scope of the overdose public-health crisis. And he could guarantee that his attorney general and Justice Department don’t prosecute or interfere with states and localities issuing public health waivers that decriminalize use of or sheltering of certain drugs. That could bring legal harm-reduction services, like these sites, to those in need.
She continues: “Biden has the power to do all these things. And we have an overdose crisis raging out of control. Even after we all get the COVID vaccine and COVID is out of the news, the overdose crisis will come crashing down on him—100,000 to 200,000 overdose deaths a year. So these are actions he could take now to prevent that from happening.”
Safehouse vice president Ronda Goldfein found herself in the public eye last year when the backlash on the Safehouse OPS erupted. “Those are all options,” she says, adding that “we need a signal from the new administration or DOJ” that they are open to such ideas.
Those, she says, could include legal pilot projects in the U.S. further proving that overdose prevention sites are safe, effective, and not more disruptive to neighborhoods than current levels of open-street drug use—perhaps even less so. (A 2014 review of 75 studies from other countries, where these sites are legal, generally confirmed this.)
Goldfein says that such conversations between advocates and the new administration cannot really begin in earnest until after top job-confirmation hearings, which have been delayed due to the Trump administration’s unwillingness to partake in the usual transition of power.
Additionally, she says, there are judicial pathways. The likeliest next step, she says, is that Safehouse will request that the entire appeals court hear the case (an en banc hearing), not just a panel, “because the case is of national importance.” Working on a longer timeline, she says, Safehouse could appeal the case to the Supreme Court (which could be a risky venture, given the dramatically more conservative makeup of the post-Trump court).
...But the Push for Medication-Assisted Treatment Might Come First
Meanwhile, harm-reduction advocates are pushing a less controversial approach to opioid addiction and overdose prevention that might take priority over the OPS fight in the short term: promoting various ways of making it easier for drug users to access methadone and buprenorphine. Those are medications that prevent the horrible withdrawal symptoms of opioids (especially heroin) that keep users hungry for the next fix, and hence continually at risk of overdose. They are weak forms of opioids themselves but don’t produce the euphoric highs of heroin or even opioid pills like Oxycontin.
Their use is usually called medication-assisted treatment (MAT) for drug addiction, as opposed to the classic 12-step or group-therapy models that often push total abstinence from all drugs, legal or not.
Usually available only at clinics, the medications were made more widely accessible under the Trump administration due to the emergency circumstances of COVID. Now, advocates want to make that wider availability permanent, including raising limits on how many providers can prescribe the meds, and how much.
“Medication-assisted treatment is the most successful form of drug treatment, better than 12-step or harm-reduction groups,” says Flynn-Walker. (A growing body of research upholds the effectiveness of medication-assisted treatment.) “Putting people on meds and making them easy to stay on those meds enables them to go on with their lives,” she says, adding that prescribers and social workers have attested that no harm has come to drug users who were sent home from clinics with long-term supplies of the medications.
But Flynn-Walker and other advocates, including medical groups, were disappointed in late January when the Biden administration canceled an eleventh-hour plan by the previous administration to permanently loosen prescription requirements for such medications, in order to expand access. This was to be done mainly by eliminating a longstanding training requirement for providers, which many experts have called outdated and unnecessary.
The Biden administration said that it was committed to permanently expanding access to medication-assisted treatment; in the above-linked Washington Post story, anonymous administration sources said the reversal was because the Trump plan was riddled with legal and logistical flaws that had to be worked out first.
On a Feb. 11 Zoom call among advocates—including the prominent artist-turned-opioid-crisis-activist Nan Goldin—organized by Flynn-Walker’s CPD colleague Vinay Krishnan, expanding medication-assisted treatment was the main topic, rather than the fate of overdose prevention sites. Krishnan pointed out that only 20% of substance users had access to medication-assisted treatment, and that few counties in the U.S. had a prescribing provider.
On the Zoom, a health-policy staffer for Sen. Maggie Hassan (D-NH) said that Hassan had partnered with Sen. Lisa Murkowski (R-AK) to push a Senate bill that would permanently remove the prescribing restrictions, and that a twin bill existed in the House of Representatives. He said that countless rural areas around the country experiencing the overdose crisis would benefit from the change.
“It’s incredible to me that this is even a discussion about who should be kept alive and how,” said Goldin, adding that buprenorphine had “saved my life” amid her struggle with opioid pill addiction.
Asked on the Zoom by TheBody about efforts to keep pushing forward overdose prevention sites, Krishnan echoed Flynn-Walker in wanting to push for policy reversals from both the Biden administration and the DOJ. “And we’re also trying to move this [via Congress],” he said. “Those are ongoing talks.”
In Philadelphia, Goldfein says that the backlash Safehouse faced is due to persistent stigma around drug users and drug use—an inability to see both as part of a public health crisis rather than as a criminal problem and a moral failing.
“If we were trying to open a COVID vaccine center because a neighborhood desperately needed it, it would just open and be there,” she says. “If people could take the stigma out of drug use, then they’d see that all we were doing was trying to open an evidence-based health center for people dying at an alarming rate.” The site, in fact, was going to be tucked away in a suite in a health care plaza.
Hence, she says, Safehouse will continue to try to make overdose prevention sites a reality. In the future, they will focus on community buy-in, whether in South Philadelphia or in other areas.
In the meantime, she notes, Philadelphia health officials are likely to soon announce that 2020 set a new record for fatal overdoses in the city—a fact that had already been forecast late last year.