Will overdose deaths force an end to the US ‘war on drugs’?

Rosalind Pichardo didn’t just get her nickname “Mama Sunshine” because of her cheery disposition. For several hundred drug users in Kensington, a rundown neighbourhood in Philadelphia, she has been their lifeline: bringing each of them back from the edge of death after they overdosed.

“I revived a guy who OD’ed on the street this morning on my way to work,” says Pichardo, speaking matter of factly outside her workplace — Prevention Point — one of the largest needle exchange sites in the US. “Unfortunately, overdoses happen everyday in this neighbourhood.”

It is not just Philadelphia. On average more than 270 people — the equivalent of 10 or 12 high school classes — overdosed and died in the US every day in the year to April 2021. This added up to a new record toll of more than 100,000 lives in a country caught in the grip of an addiction crisis. Almost two-thirds of those deaths were caused by fentanyl, a synthetic opioid which can be 50 times as potent as heroin and has recently displaced other legally prescribed painkillers as the biggest driver of fatal overdoses.

Health experts say that some of those who died probably didn’t even know they were consuming fentanyl, which has become a common contaminant in a range of street drugs from counterfeit pills to cocaine. Many overdose victims are recovering addicts who relapsed during the pandemic, they add.

The mounting death toll has alarmed US policymakers, who had hoped that a crackdown on doctor and pharmacy “shopping” by prescription painkiller users and multibillion dollar settlements with pharmaceutical companies would ease an opioid crisis that has claimed more than 500,000 lives over the past decade.

Rosalind Pichardo sees the devastating effects of the fentanyl crisis every day in her work at Prevention Point © Ryan Collerd/FT

Instead, the crisis has worsened. And is accelerating a shift by some state and federal authorities to address the problem as a public health issue rather than a criminal justice one: to accept illegal drug use takes place, aim to minimise its effects via harm reduction policies and save lives.

Such a move away from the five-decade-old “war on drugs” is politically risky for the Democrats in particular, as Republicans step up attacks on the Biden administration alleging it is soft on crime ahead of midterm elections in November. But health experts say that continuing to prioritise enforcement over treatment will translate into tens of thousands more deaths.

The most contentious issue is the use of supervised injection sites, with many conservative politicians and some community leaders opposed to schemes which they argue encourage drug use.

In November, New York City opened the nation’s first supervised injection sites to be officially approved by city authorities, ignoring a federal law which prohibits their operation for the use, sale or storing of drugs. The Biden administration now faces a critical decision: change the law and further embrace harm reduction efforts or do nothing and embolden opponents who want to close such sites.

Dr Rahul Gupta, director of the White House Office of National Drug Control Policy, has said he wants to evaluate the science and data behind supervised injection sites, hinting that a change in policy is under consideration. “We want to learn and we want to make sure that every possible door we can open up to help people and connect them to treatment is available to us,” he told CNN in December.

“If you’re looking to save lives and you’ve reached a historic unprecedented level of deaths, then you cannot avoid looking at any and every option in order to save those lives,” he added.

For Joy Brunson-Nsubuga, a clinical addiction specialist who has helped introduce treatments such as methadone to clinics around the country, the need is clear. “People are not getting the care that they need because of the [stigmas around addiction],” she says. “[That is] leading to us losing individuals in our community that we could have saved.”

Political minefield for Biden

Since 1971 the “war on drugs” has cost the US an estimated $1tn — spent largely on locking up offenders — without solving America’s illegal drug problem. In contrast, advocates of supervised injection sites say they have prevented more than 17,000 overdoses in Canada since 2017. They argue that such schemes pay for themselves, with every $1 spent on the sites generating $2.33 in healthcare savings, according to a study published in the Journal of Drug Issues.

Since 2015, some US city and state authorities have been distributing Narcan nasal sprays, which can help resuscitate those who have overdosed, and fentanyl test strips, which enable drug users to test if a drug is contaminated.

A Prevention Point staff member displays a 4mg dose of Narcan that comes in their opioid overdose kit
A Prevention Point staff member displays a 4mg dose of Narcan, part of the group’s opioid overdose kit © Ryan Collerd/FT

Although safe injection sites are a key feature of overdose prevention in Canada, Europe and Australia, they have proved divisive in the US. In 2019 the Trump administration blocked the opening of what would have been the first such facility in Philadelphia. Days before Christmas protesters picketed outside one of the newly opened sites in Harlem where Republican lawmakers have introduced legislation to Congress to defund the projects, which were backed by the outgoing New York City mayor, Bill de Blasio, a Democrat.

Supporters say such sites save lives, improve health outcomes and nudge addicts towards recovery. Critics counter that they provide an official seal of approval for illegal drug taking.

Despite its support for other harm reduction measures, the Biden administration is yet to overturn the federal government’s opposition to supervised injection sites. The US attorney’s office was scheduled to file a response this Wednesday to a fresh lawsuit mounted by the Philadelphia project which is calling for the Trump ban to be overturned. But both parties agreed a 60-day extension to the deadline, last week.

If the US attorney’s office decides to end the federal government’s opposition to supervised injection sites it would provide a green light to similar projects in several states, according to legal experts. But it could also open a new front for Republicans to attack a Democratic administration, which they already accuse of not cracking down hard enough on the Mexican drug cartels that control the fentanyl trade.

“There is a long history of the ‘war on drugs’ and famously President Reagan’s wife Nancy led a campaign ‘Just Say No’. This [supervised injection sites] is clearly the opposite of saying ‘no’, it is acquiescence,” says Howard Husock, senior fellow at the American Enterprise Institute, a right leaning Washington-based think-tank. “The social conservatives could make hay with this.”

‘The worst that I have seen’

Overstretched hospitals in Philadelphia and other US cities have been dealing with the fentanyl crisis on top of the coronavirus pandemic. Now, some health experts are urging state and federal authorities to do whatever it takes to solve the overdose crisis.

“It is the worst that I have seen. Almost every day in the work that I do I hear about someone who has lost a sibling, a friend or a loved one. It is just devastating,” says Jeanmarie Perrone, professor of emergency medicine at the University of Pennsylvania Hospital.

Infographic showing why fentanyl is so deadly. (1) Blood-brain barrier model showing that fentanyl can cross more easily than other opioids like heroin. (2) Fentanyl binds tightly to the mu-opioid receptor in such a way that it confers much stronger effects, compared to heroin or morphine. (3) Opioid receptors that fentanyl can bind to are all over the brain, including in pain centers like the amygdala but also in breathing centers in the brainstem. When fentanyl binds to those receptors, the brain cannot properly regulate breathing and, in an overdose, breathing can stop completely.

Perrone says heroin users, some of whom graduated on to the drug after becoming hooked on prescription painkillers, are now turning to fentanyl. And other illegal drugs are now being deliberately laced with fentanyl — which is cheap to make, easy to transport and highly addictive, making it more lucrative for the cartels — often with tragic consequences.

Overdose deaths hit a record 1,214 in Philadelphia in 2020, a 6 per cent increase on 2019. Fentanyl was involved in 81 per cent of them.

“It’s like drowning,” says Perrone, who has become used to treating overdose victims in the emergency department. “Fentanyl depresses the respiratory effort and people stop breathing. They go a few minutes without oxygen, the heart rate slows and they have a cardiac arrest.”

Most of the staff and volunteers at Prevention Point — which was used by 25,000 people last year and annually dispenses over 6.5m syringes — know people who have succumbed to fentanyl.

Prevention Point executive director Jose Benitéz, pictured standing in street outside his work, is hopeful that a cultural shift will lead to a change in policy on supervised injection sites
Prevention Point executive director Jose Benitéz is hopeful that a cultural shift will lead to a change in policy on supervised injection sites © Ryan Collerd/FT

The organisation’s executive director José Benitez, led the unsuccessful push to open the supervised injection site in 2019. “There is one data point that really stands out,” he says of the dispute over allowing such schemes, “no one has [ever] died of an overdose at a safe injection site.”

Fentanyl is ‘killing people all over the place’

Tonja Myles, an ordained minister in Baton Rouge, Louisiana, has spent almost 30 years working with people struggling with addiction. She echoes the view of many health experts, that persuading drug users to seek treatment is more important now than ever before because of the rise of fentanyl.

“People used to say, well [the opioid epidemic] is just a white, middle-class thing, but, no, it’s everybody, because nobody is safe. [Fentanyl’s] crossing all barriers,” she says. “[Fentanyl] doesn’t care if you’re black, white, rich or poor, from the kerbside to the country club, it’s killing people all over the place.”

East Baton Rouge Parish has one of the highest rates — at least 307 in 2021 — of fatal overdoses in the country. Molly was 37 when she overdosed in April 2020 on fentanyl-laced heroin. It was the second such tragedy to hit her family: in 2015, her father Randy found his eldest son, Mike, dead at home from a heroin overdose. Both siblings had struggled for years with opioid addiction, going in and out of treatment programmes.

“If I mapped out his life, from the time he was 15 till the day he died, all he was doing was going in and out of rehab . . . and Molly was just kind of following his same path,” says Randy, a 70-year-old Baton Rouge construction worker, who asked not to use his real name. “I think a lot of places are money hungry, they get them in and out. You felt like they were supposed to be helping them but kicking them out ain’t helping them.”

Lollipop charts for each region of the US showing the deaths from illicit fentanyl overdoses per 100,000 people by race and by age group. Circle size and height both indicate the death rate per category. Black Americans and 25-44-year-old Americans are disproportionately dying from fentanyl overdoses, and the north-east has seen some of the highest overdose death rates in the county. The time period for the death data spans from July 2019 to December 2020, and data represents 39 states and DC.

Jon Daily, the head of the overdose prevention task force within the East Baton Rouge District Attorney’s Office, has been following fentanyl’s deadly rise since it first took hold in Louisiana in 2019.

“The crackdown in the early 2000s on the doctor shopping and pill dumping has been effective in that it’s decreased the overdoses from prescription pills,” says Daily, a former drug user. “But it’s only fuelled the trade in illicitly manufactured fentanyl, which is what’s killing everybody.”

The use of fentanyl is being driven by Mexican drug cartels, which are flooding the US with the drug. This year, the US Drug Enforcement Administration has seized approximately 1,500 pounds of fentanyl — an amount which, the agency says, is enough to kill every American.

Jaime Arredondo, a researcher with the Canadian Institute for Substance Use Research, refuses to use the term “war on drugs”. He believes Mexico is a victim of demand from the north, and that the problems caused by fentanyl require a public health strategy.

“It’s very reductionist to see it just as a security issue,” he adds, “instead we should also be looking at the health issues.”

Overdose deaths hit a record 1,214 in Philadelphia in 2020, up 6 per cent on 2019. Fentanyl was involved in 81 per cent of them © Spencer Platt/Getty

Policy shift or wishful thinking?

Translating that into political change has for years seemed unlikely. Yet, there is optimism among health experts that the Biden administration will overturn years of national government opposition to funding supervised injection sites. In April, it signalled a pivot in policy towards support for harm reduction schemes when it announced federal money could be used for the first time to buy fentanyl test strips. It has also made it easier to access medications — such as methadone and buprenorphine — to treat addiction and called on Congress to back an $11bn budget request to expand access to substance abuse programmes.

But the administration is not backing away from enforcement and plans to make permanent a Trump-era decision to ban fentanyl substances.

Adoption of harm reduction remains piecemeal across the US and still faces legal barriers. Possession of fentanyl test strips, for instance, remains illegal in as many as 30 states, where existing laws ban drug paraphernalia which includes controlled substances testing. Some state laws still restrict access to Narcan due to concerns that providing easy access to the overdose treatment could increase opioid use — an opinion that runs counter to a study by the Boston University School of medicine.

“Encouraging even more drug abuse has to be the stupidest idea that has ever been proposed to combat the addiction crisis,” says Lee Zeldin, a Republican congressman representing New York.

Republicans in New York state have called on Biden to direct the Department of Justice to close down the “illegal” injection sites. So far Biden, a co-author of several tough anti-drug measures while a senator, has not offered public support to safe injection sites.

In December, the National Institute on Drug Abuse, a federal government research institute, published a report on supervised injection sites which concluded that they “may represent a novel way of addressing some of the challenges presented by the overdose crisis”. The report also found that they could contribute to a reduction in deaths and improve public health.

“We have a horrible situation right now, with so many people dying. And we need to do everything that we can to minimise that,” says Nora Volkow, director of the NIDA.

She says there needs to be a shift away from the prevalent culture in the US of criminalising the user, which does not deter drug taking. More treatment options and widespread availability of Narcan and fentanyl test strips, she adds, would be important harm reduction measures. However, Volkow stops short of advocating safe injection sites, saying more research and further study of any pilot sites is needed.

Advocates disagree, saying that studies of similar sites opened in Switzerland and Australia more than two decades ago provide that research and that there is no time to waste in the US. But they are hopeful that reform is on the way.

“In the Biden administration you’ve seen a little more understanding and embracing of harm reduction approaches than we have ever had in the country,” says Prevention Point’s Benitez. “I think we are just now getting a cultural shift and it’s looking like policy changes are coming down the road.”

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