The ‘seatbelt’ approach to the opioid crisis

In the 1960s, the U.S. government began requiring that cars include seatbelts. It was an acknowledgment that driving poses risks, and that people do it anyway. Today, deaths per miles traveled are about one-fifth of what they were in 1965. Imagine if America approached its overdose crisis the same way.

Overdose caused 888 needless deaths in Baltimore last year, more than homicides or car accidents. And it’s not just here: In 2018, 72,000 people in the U.S. died of drug overdoses. As the body count rises year after year, the official response has been lethargic at best, and at worst, openly hostile to strategies that have proven remarkably successful.


This has left the U.S. with no definitive, federally directed approach to what is arguably its most urgent public health problem. Instead, efforts to tackle the overdose crisis have been scattershot: Some 60 different bills related to the crisis were introduced in Congress last year, each applying its own approach. Meanwhile, when President Donald Trump weighs in on the issue, he frames it as a supply issue to be solved with more enforcement or throws out ill-advised ideas like seeking the death penalty for drug dealers — the same old prohibition-based approach that has never worked.

The federal government’s inability to positively impact the crisis is all that more tragic when you consider the array of proven strategies that have had a transformative impact in other countries. Take Portugal, once known as the heroin capital of Europe. In 2001, it decriminalized drugs and replaced arrests with addiction treatment and social services. Overdose deaths in that country fell by 85 percent.


The decriminalization solution has been adopted by some U.S. cities, too, notably Seattle, which has stopped jailing people caught with small amounts of drugs, even “hard” ones. A 2017 study found that people who use drugs there were more likely to have a job and a home, and less likely to be rearrested.

The main obstacle to implementing such clearly successful strategies is simple: Americans tend to see drug use through the prism of criminality rather than public health. Embracing harm reduction efforts requires seeing drug use as a part of life — even if we would rather it did not exist. This can be hard for us to wrap our minds around.

Indeed, some might be surprised to hear that in Vancouver there is a place where people can bring their drugs to safely inject them using clean syringes under the supervision of a trained health care worker. This supervised injection facility, called Insite, is North America’s first. Since 2003, it has overseen over 3.6 million injections without a single death. Overdoses in nearby neighborhoods have declined. OSI-Baltimore has been urging city leaders to explore the possibility of opening SIFs, also called safe consumption spaces, in Baltimore for several years. Earlier this year, State’s Attorney Marilyn Mosby signed onto a legal brief supporting the establishment of SIFs.

Likewise, drug checking, in which one can test the content of drugs before they’re taken, helps. OSI-Baltimore has been advocating for free distribution of fentanyl test strips to check for the poisonous substance, and they are now available statewide. There are mobile machines that NGOs can use to test tiny samples of drugs to identify things in them that are particularly dangerous. These ideas seem crazy until you start to view drug use the way you view driving — as an activity with a degree of risk attached that we nonetheless accept as something that goes on every day.

And distribution of the medication Naloxone, which reverses opioid overdose, to family, friends and other people who use drugs, is recommended by the World Health Organization. It has saved lives around the world, including here in Baltimore.

These tactics may sound radical, but they work. Specious claims that they encourage more drug use have been disproven by academic research. In Portugal, in fact, injection drug use actually declined after decriminalization. What’s more, health officials across the globe agree that such methods are effective at combating overdose deaths.

Our current approach assumes that overdose deaths can be eliminated with tough talk and crackdowns, and that harm reduction services don’t work or even exacerbate the problem. But none of the evidence bears this out. Denying harm reduction services to people who use drugs is no different than denying seatbelts to people who drive. In both cases, you’re withholding the very thing that just might save their lives.

Scott Nolen ( is director of the Addiction and Health Equity Program at Open Society Institute-Baltimore.