At no other point in history have we witnessed such devastating consequences of the opioid crisis. Americans are experiencing opioid overdoses at a rate that far surpasses any other country. Last year alone, more than 108,00 Americans died from drug overdoses, with this burden disproportionately falling upon the most marginalized and under-served communities in the country. In the face of these egregious disparities, this begs the question: Why does the United States stand out?
Mass incarceration may provide a clue.
Since Nixon declared the “war on drugs” in 1971, the US has spent roughly a trillion dollars on drug-related law enforcement in an effort to reduce drug use, the highest globally. But epidemiological studies show that this simply isn't working. Not only has this “tough on crime” approach failed to produce meaningful success in curbing the overall rates of drug use and overdoses, but in many cases, this has exacerbated this crisis by pushing people towards illicit markets where highly potent contaminants, such as fentanyl and xylazine, are often laced into opioids. Worse still, this approach diverts crucial funds away from evidence-based social and public health initiatives that work to address the underlying root cause of the opioid crisis: addiction.
The message is clear: It’s easier for some government officials to put people behind bars than it is to implement comprehensive treatment and rehabilitation programs to help them recover from their addictions.
I believe that if we want to turn the tide against the opioid crisis, this mentality needs to change. We should treat the opioid crisis as a public health crisis, rather than a criminal justice issue. We need to approach this with compassion and understanding, rather than perpetuating the “war on drugs” narrative that stigmatizes and further alienates people struggling with opioid use disorders. We must embrace the opportunities to form deep connections with these communities, bringing us closer to a shared humanity. Above all, we need courage to shatter the status quo.
A promising step forward is “harm reduction.” This refers to an umbrella of social and public health services that aim to minimize deaths and adverse health outcomes from drug addictions and overdose. Most importantly, I believe, is that workers at these facilities are trained to meet patients where they are, with compassion and dignity, offering a nurturing and supportive environment to streamline their recovery process.
Coming from Canada, I’ve been immensely proud of the progress that we’ve made to implement harm reduction programs in our most affected communities. In Vancouver, BC, we opened our first supervised safe injection site, Insite, just over two decades ago. These centers are safe and welcoming spaces where patients, who have been struggling for months and years to self-manage their opioid addictions, can bring in their own supply to use under the watchful eye of health professionals to prevent and treat overdoses so they are not fatal. Patients receive sterile needles, food, clothing, hygiene items, as well as public health education (including strategies to reduce needle sharing), which helps to reduce the transmission of blood-borne illnesses, such as hepatitis C and HIV. There is compelling research evidence backing up the effectiveness of these sites. According to a widely-cited study from The Lancet, the rate of fatal overdoses sharply declined by 35% within 500 meters of Insite after they opened. Another study predicted that Insite prevents nearly 84 HIV infections per year among intravenous drug users. Beyond circumventing the physical and psychological toll of living with HIV, this saves the Canadian healthcare system roughly $3 million per year in medical treatments, far more than what it costs to operate Insite.
Above all, these supervised safe injection sites are a conduit for the kindness and holistic support in our healthcare system that will be necessary to overcome the opioid crisis. People who use these services are treated as patients, not criminals. They receive the opportunity to share their story to receptive ears and open hearts. I fundamentally believe that this is a crucial step to chipping away at the bedrock of stigma that patients with opioid use disorders have been incessantly experiencing due to their addictions. This, in turn, may help patients regain trust in the healthcare system, serving as a meaningful re-entry point into primary care and social services so that they can receive enduring care and support.
The US is lagging many years behind Canada in terms of implementing harm reduction programs to address the opioid crisis, but I’m hopeful. A year and a half ago, OnPoint became America’s first sanctioned supervised safe injection site, with the support of former mayor of New York City, Bill de Blasio. As of March 2023, OnPoint NYC has served roughly 3,000 patients and intervened on over 800 potentially fatal overdoses across their two sites.
This is clearly a step in the right direction for the US. But it's important to recognize that there are still formidable structural barriers hindering the expansion of opioid harm reduction programs across the country. Notably, a federal law originating from the mid-1980's known as the "crack house statute" still makes it illegal to maintain and operate a facility for the purpose of using controlled substances such as opioids, including supervised safe injection sites. This statute was leveraged by critics in 2021 to reject Safehouse, a nonprofit-supervised safe injection site proposed in Philadelphia, and also places OnPoint in treacherous waters. Despite municipal endorsement, OnPoint is still considered to be illegal under state and federal legislature. Further, without access to federal grants and support, OnPoint is bleeding cash, relying on a sporadic constellation of private donations and foundation grants to fund their monthly expenses exceeding $100,000 in order to stay afloat.
I believe that it is now more important than ever to address the humanistic challenges at the root of the opioid crisis. We must strive for a legacy of compassion and empathy, not criminalization and persecution. This will only be possible with stronger cross-sectoral collaborations between the Biden administration, legislators, public health officials, nonprofit leaders, and local organizations to fund and implement evidence-based harm reduction initiatives. Now is our window of opportunity—will we have the courage and conviction to step through it?
David T. Zhu
Department of Social and Behavioral Sciences
Yale School of Public Health
New Haven, CT