The solution to Baltimore’s overdose crisis—safe consumption sites

Testing heroin for fentanyl / Photo by Baynard Woods

Last week, the Abell Foundation released a report encouraging Baltimore to establish overdose prevention sites—regulated locations staffed with medical personnel where people can use drugs. This report, “The Whole is Greater than the Sum of its Parts” comes at a moment when attitudes towards overdose prevention sites (or as they are sometimes called, “safe consumption sites” or “safe injection facilities”), a solution that has been internationally embraced for years, is finally changing in the United States.

“While providing a crucial service, overdose prevention sites also serve larger public health goals, such as increasing the dissemination of sterile drug use materials and changing norms and customs around drug use,” the report reads. “For many people, overdose prevention sites are a mere entry point into the system in which they get other services; for others, overdose prevention sites remain the only engagement they ever have with medical professionals.”

The report is written by Natanya Robinowitz, executive director of Charm City Care Connection, a nonprofit focused on getting marginalized communities proper healthcare. Robinowitz was a Fulbright Scholar in Barcelona, Spain for two years and her report focuses on how Barcelona addressed its overdose crisis in the ’90s. Baltimore, which has seen a 500% increase in overdoses since 2011, could learn a great deal from Barcelona, which became “a model of a holistic, robust public health system for people who use drugs.” 

As for what a safe consumption sites looks like and how one operates, the report provides this detailed description of one Barcelona site, CAS Baluard:

CAS Baluard feels like a medical clinic: Surfaces are sterile, with little decoration, and all staff wear short-sleeve white coats or red vests for street outreach. The program’s offerings are divided between two floors, which participants can access from the same entrance. The lower floor hosts all harm-reduction services: the safer injection and smoking rooms; a doctor’s office; the syringe exchange; and a hangout area with tables and chairs, a small kitchen, showers, and computers for participant use. The upper floor hosts the treatment services, including individual and group therapy and methadone dispensing. Outside, a variety of staff conduct street outreach, engaging with local businesses and people who use drugs, as well as mediating between the community, people who use drugs, and CAS Baluard.”

This is not even the first time the Abell Foundation has encouraged the creation of safe consumption sites. In 2017, Abell published “Safe Drug Consumption Spaces: Implications for Baltimore City,” which explored the effectiveness of one safe consumption site in Vancouver which included, the report’s author, Johns Hopkins University Bloomberg School professor Susan Sherman explained, six million dollars in savings by saving users’ lives on top of reducing overdoses, addiction, crime, and HIV infections. 

That 2017 report also argued that Baltimore’s city charter allows the Health Department to establish such a center and that the city could also declare a local state of emergency to open safe consumption sites, so maybe Baltimore should just get on with it already, right? 

In both 2016 and 2017, Baltimore County Delegate Dan Morhaim introduced a bill that would have made it legal to establish safe consumption sites in Maryland though both years, the bill died in the House. In 2017, Maryland’s Republican governor Larry Hogan called safe consumption sites an “insane” concept. There are currently around 100 safe consumption sites operating around the world and research shows they are highly effective.

Local support for safe consumption keeps growing though. In July of this year, Baltimore State’s Attorney Marilyn Mosby signed onto an amicus brief with many others around the country supporting Safehouse, a nonprofit attempting to establish a safe consumption site in Philadelphia. The Department of Justice has argued it is not legal to establish such a space.

In October, U.S. District Judge Gerald McHugh ruled in United States v. Safehouse that Safehouse was not in violation of what is called “the crackhouse statute”—an outdated, ridiculous law established by Joe Biden in the ’80s that has been used to criminally prosecute anyone using a property “for the purpose of manufacturing, distributing or using any controlled substance.” The DOJ tried to argue that Safehouse fell under this statute but Judge McHugh disagreed because, he said, “the ultimate goal of Safehouse’s proposed operation is to reduce drug use, not facilitate it.”

There is still plenty of pushback against Safehouse and the DOJ surely has more legal arguments locked and loaded, but the judge’s ruling is a win for harm reduction advocates. We may see the first safe consumption site in the United States quite soon.

In Baltimore, there was a discussion in September titled “Everybody Deserves a Safe Space: A Panel Discussion on Overdose Prevention Sites,” which included Mosby and City Council president (and mayoral candidate) Brandon Scott, who has also spoken out in support of safe consumption sites. Rajani Gudlavalleti of the Baltimore Harm Reduction Coalition, an organization that has been among the most aggressive and progressive when it comes to dealing with change to drug policy and how drug users are treated, stressed how effective safe consumption sites are when she spoke that day.

“There have been dozens and dozens of testimonies, oral and written testimonies to support legally authorizing these spaces and zero, zero testimonies—oral and written—in opposition,” Gudlavalleti said.

She held up her fist, made it into the shape of a zero for emphasis.

“Zero—just like the zero deaths that have occurred in overdose prevention sites across the world,” Gudlavalleti said to applause from the packed room. “So I don’t know why we haven’t passed this yet.”

Gudlavalleti also encouraged a “racial justice lens” towards changes to drug policy.

“Baltimore City has been targeted by the racist war on drugs for decades and an overdose prevention site would not be the end-all, be-all to saving lives or even reparations, right? But it is a way to connect to treatment and access and resources and love and care and compassion,” she said. “Even if somebody is not ready for treatment, they do deserve to be treated like a human being and we have not been treating people like human beings for far too long in this city.”

For those who have been arguing for drug reform, Abell’s “The Whole is Greater than the Sum of its Parts” is heartening. And for those who want to better understand drugs, it is a fairly plainspoken guide. For example, drugs users’ behavior is broken down into five “stages of change”: precontemplation (using drugs without wanting to stop), contemplation (using drugs and considering negative consequences), preparation (preparing to stop using), action (actively stopping using drugs), and maintenance (avoiding drug use and establishing new behaviors to continue not using). When too often the language surrounding drug use is simplistic and stigmatizing (describing all opioid users as “addicts,” for example), that breakdown offers up a more nuanced approach. 

And in no uncertain terms, the report explains that you cannot help drug users and also arrest them: “The government cannot treat drug use as a public health issue as long as it is being treated as a criminal justice issue.”

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