Unlike the public bathrooms, dark alleys and vacant rowhomes where addicts furtively conduct their business, the facility’s atmosphere would be welcoming and clean. Users could avail themselves of new needles and alcohol swabs — with trained staff discreetly nearby in case of overdose — then linger in a “chill” room as they come down from their high.
At a time of rampant overdose deaths, when opioids claim four lives a day in Maryland alone, the provocative idea of allowing addicts to use illegal drugs in a supervised setting is gaining greater traction here.
“Clearly, the way we’ve been dealing with addiction in Baltimore hasn’t been working," said City Council President Brandon Scott.
Scott, a Democrat who is running for mayor, is among a growing chorus of government officials, health professionals and advocates who say the time has come to try something that has proved life-saving in other cities around the world to help control the deadly opioid crisis.
No U.S. cities currently have such a facility, sometimes called safe consumption spaces or overdose prevention sites. But after a federal judge ruled last fall that a plan to open a site in Philadelphia does not violate drug laws, there is new momentum for multiple efforts across the country.
In Baltimore, Scott proposed and the City Council approved hosting an informational hearing on overdose prevention sites. Additionally, he said, he is working on an ordinance that would allow such sites to open in the city, while Maryland legislators are drafting bills to authorize them statewide.
Still, much opposition remains, from Republican Gov. Larry Hogan, who considers the prospect of consumption facilities “absolutely insane," to the U.S. Department of Justice, which considers it a felony to “maintain any place” for using controlled substances. And some in the treatment field remain wary, saying that while the sites can save lives, they also enable addicts to continue dangerous habits, increasing their tolerance and desire for ever more drugs.
“Any facility for drug use leads to more drug use. The brain adapts to drug use, it gets used to a higher level, and there’s no stopping it."— Bob Gehman, CEO of Helping Up Mission, a residential recovery center in Baltimore
“There’s nothing safe about it,” said Bob Gehman, CEO of Helping Up Mission, a residential recovery center in Baltimore. “Any facility for drug use leads to more drug use. The brain adapts to drug use, it gets used to a higher level, and there’s no stopping it."
But proponents say supervised drug usage is only one part of what the facilities offer. They also can provide detox, referrals to treatment programs and assistance with housing, medical and other needs.
The sites are part of a trend that seeks to address drug use less as a crime and more as a disease. Known collectively as harm reduction, the approach focuses on preventing overdoses and keeping users alive so eventually they can seek treatment.
With its long-running struggles with heroin and other drugs, Baltimore has often been an early adopter of harm reduction strategies, from providing clean needles to help prevent the spread of HIV and hepatitis, to making the overdose antidote naloxone widely available, to opening a stabilization center where users can sober up and connect to treatment and other services.
For some, consumption sites are a natural next step, and they’ve drawn high-powered support locally. The Abell Foundation has published several studies, and the Open Society Institute Baltimore has brought in representatives from facilities around the world to meet with officials and community groups. There are more than 120 safe sites in countries such as Canada, Australia, France, the Netherlands and Spain.
Research has consistently shown the benefits of the sites, said Susan Sherman, professor of health, behavior and society at the Johns Hopkins Bloomberg School of Public Health.
Sherman was the lead author of an Abell report several years ago that detailed how the sites helped reduce overdose deaths and the spread of disease and encouraged clients to enter treatment or quit using. Additionally, surrounding areas saw less crime and public use of drugs, she said.
“Sometimes people find it hard to swallow, but these sites do not increase drug use or high-risk behavior,” she said. “They aren’t ‘honey pots’; they don’t bring people to neighborhoods. They are put in neighborhoods with high concentrations of drug use.”
Sherman said the sites also make economic sense by reducing infectious diseases, emergency calls and hospitalizations. A 2017 study found each $1.8 million invested in sites would save the health care system $7.8 million, she said.
It’s still tough for some people “to wrap their heads around” the idea of allowing people to use illegal drugs, she said. But once the sites open, “people have been pleased with how they’ve impacted their communities.”
That happened in Vancouver, home to North America’s first supervised use site, said Russell Maynard, who previously oversaw the facility. While nearby businesses opposed Insite, which opened in 2003, they eventually saw its benefits to an area long plagued by rampant drug use and dealing, he said.
“They saw a drop in people sleeping in their doorways and drug paraphernalia all around,” said Maynard, now a senior manager at PHS Community Services Society, a nonprofit that co-manages Insite.
Insite’s clients weren’t “using because the site is there," he said. "These people were already using, behind the bushes or leaning against a car.”
Maynard was part of a group that the OSI brought to Baltimore recently to meet with city and state officials and speak at a community forum in Dundalk.
While the U.S. has lagged behind other parts of the world in accepting sites, Maynard said he believes the persistently high toll of the opioid epidemic will convince more jurisdictions to at least try them on a pilot basis.
“Honestly, the question is not if but when, because there are no other tools in the arsenal to effectively manage the overdose crisis.”— Russell Maynard, a senior manager at PHS Community Services Society, a nonprofit that co-manages the Canadian supervised-use site Insite.
“Honestly, the question is not if but when, because there are no other tools in the arsenal to effectively manage the overdose crisis,” he said.
In Maryland, 1,774 people died of drug or alcohol intoxication in the first nine months of 2019, the latest data available, with opioids responsible for nearly 90 percent of those fatalities. While the overall number of deaths dropped for the first time since 2010, by about 4 percent, the toll remains high because of the influx of fentanyl, the highly toxic opioid often mixed with heroin and responsible for more than 80 percent of fatal overdoses.
Opening sites in Maryland won’t fix everything, Maynard said, but it will give some addicts a chance at recovery that they might not otherwise get.
“These are not the answers to the drug crisis," he said. "These are immediate reactions to what’s happening.”
OSI Baltimore has been working on the issue for four years and has started seeing some shifts in thinking, said Scott Nolen, who directs the group’s addiction and health equity program.
“I’ve seen a change in tone in the conversation,” he said. “But we aren’t there yet."
He has explained in community meetings that “no one has ever died in one of them, period; that we have a problem of pushing people who use drugs into the darkness, literally dark alleys and abandoned buildings; that we’ve put people at higher risk of overdose deaths,” Nolen said. "People get that.”
Nolen said he thinks Baltimore and Anne Arundel counties should consider sites because of their high numbers of overdose deaths. Cecil and other rural counties could benefit because they have high per capita deaths and potentially fewer resources for those with addictions. “They would get the biggest return on investment,” he said.
The court decision in Philadelphia could help efforts, he said.
“This gives us a pathway and has energized us to see the sites move forward,” Nolen said. “It certainly gives us some legal cover.”
In Philadelphia, a mayoral task force in 2017 recommended implementing overdose prevention services to combat one of the nation’s worst opioid death rates. That prompted a private nonprofit group, Safehouse, to propose opening supervised use sites in the city, drawing opposition from some residents and city council members. Mayor Jim Kenney, however, said that as a privately funded operation, Safehouse didn’t need council approval.
In February 2019, the U.S. Department of Justice filed a civil lawsuit asking a federal court to declare that supervised consumption sites are illegal under what’s known as the “crack house statute” that makes it a felony to operate a place to make, distribute or use drugs.
Officials from across the nation, including Baltimore State’s Attorney Marilyn Mosby, filed amicus briefs in support of Safehouse. A federal judge ruled in October that Safehouse would not violate the law because the goal was to reduce overdose deaths.
The ruling is not considered final, nor binding in other cities. William M. McSwain, U.S. attorney for the Eastern District of Pennsylvania, said he would appeal.
Safehouse officials said in a statement on its website that the ruling was “a major step forward and lays the legal groundwork to enable us to proceed with this critical public health intervention.” They are working now with neighborhoods to identify proper locations.
Other cities including Boston, Denver, New York, San Francisco and Seattle are considering supervised sites.
In Maryland, state Del. Dan Morhaim, a Baltimore County physician who unsuccessfully introduced legislation in the past, retired last year. But Del. Shelly Hettleman, a fellow Democrat from the county, introduced a bill to allow the sites on Friday. Sen. Brian Feldman, a Montgomery County Democrat, also plans to introduce legislation as he has in the past.
“Something like this takes a while to break through,” Hettleman said. “We keep chipping away every year.”
She sees the sites as part of the shift in drug policy.
“I think we are evolving from a policy approach of, ‘Just say no,’ which didn’t work very well," she said. "We’re looking at it as a public health issue rather than a criminal justice issue. There’s just real evidence that it works. They are connecting people to services, they are preventing deaths.”
Scott likens the policy evolution to his own shifting views. Growing up in the 1990s when crack ravaged his Park Heights neighborhood along with other large swaths of the city, “you were taught people who have an addiction are less than human," he said.
“These folks are human like everyone else,” he said. “At the end of the day, the most basic responsibility of city government is to protect the lives of citizens.”
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Scott said there could be less resistance to a supervised site now that the opioid crisis is claiming the lives of whites, suburbanites and rural residents, unlike in the past when the stereotypical heroin victim was a black inner-city resident.
“The way people look at people addicted to drugs has changed now that it’s not just people in Park Heights, in Sandtown, in Broadway East.”— City Council President Brandon Scott
“We can’t ignore the elephant in the room,” he said. “The way people look at people addicted to drugs has changed now that it’s not just people in Park Heights, in Sandtown, in Broadway East.”
Still, there is resistance to the sites, or at least a wait-and-see attitude. Baltimore Mayor Bernard C. “Jack” Young has not taken a position, instead allowing the city’s health and law departments to continue what his spokesman Lester Davis called “exploratory work on this important matter.” Dr. Letitia Dzirasa, the city health commissioner, has expressed concern about the legality.
Proponents have taken to using the term “overdose prevention sites” to shift the focus off illegal drug usage and on to saving lives.
“It’s not just about the drug use,” said William Miller Jr., a coordinator of Bmore POWER, a group that advocates for harm reduction efforts. “These facilities, it’s about developing relationships.”
Miller, who survived his own past use of heroin and other drugs, said that by offering a place where addicts don’t feel judged or stigmatized, they eventually might become open to seeking treatment and other assistance.
“People think there’s only one path to recovery,” he said. “This is another pathway.”