Harm reduction, overdose prevention, and the future of treating America’s overdose epidemic

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DAN RICHARDS: From the Watson Institute for International and Public Affairs at Brown University, this is Trending Globally. I'm Dan Richards. In February of this year, Providence became the first city in America to approve the opening of a state-sanctioned overdose prevention center. Sometimes known as safe injection sites, these are facilities where people can bring illegal drugs and consume them under the supervision of trained volunteers and healthcare workers. Set to open later this year, it will mark one of the boldest experiments in the country of an approach to addressing the drug overdose crisis, known as harm reduction, which focuses less on forcing people to stop using drugs and instead on making sure they use them more safely.

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It might sound counterintuitive that such a facility could help stem our country's drug overdose epidemic, which claimed over 112,000 lives in Twenty Twenty-Three. But as our guests on this episode explain, these types of facilities, along with many other harm reduction interventions, work.

BRANDON MARSHALL: Harm reduction is like a hug. It brings people in. And we know and the evidence shows that helps connect them to healthcare services. And in many cases, it's a pathway into addiction treatment.

COLLEEN DALY NDOYE: People are 30% more likely to access treatment when they use these facilities. We are an organization that really believes in the continuum of harm reduction recovery. They're not in opposition to each other. They're working towards the same goals.

DAN RICHARDS: The first voice you heard was Brandon Marshall. The second was Colleen Daly Ndoye. Colleen is the executive director of Project Weber/RENEW, the organization overseeing Rhode Island's first overdose prevention center. Brandon Marshall is Chair of Epidemiology at Brown, an expert on the overdose crisis, and a member of Rhode Island's opioid settlement advisory committee.

On this episode, you'll hear from them about Rhode Island's groundbreaking plan for an overdose prevention center, how it will work, why it matters, and what it says about the future of addressing America's drug overdose crisis. This is the first of two episodes, you'll hear this month about the overdose crisis in America. Later on in the month, we'll be sharing an episode from Humans in Public Health, a podcast from Brown School of Public Health, about how law enforcement officials are adjusting their approach to handling the opioid and drug overdose crisis. But to start, I spoke with Colleen Daly Ndoye, the Director of Project Weber/RENEW. Here is our conversation.

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Colleen Daly Ndoye, thank you so much for coming on to Trend Globally.

COLLEEN DALY NDOYE: Thank you for having me.

DAN RICHARDS: I wonder if we could start a little bit with your organization that is really involved instrumentally in this new project in Rhode Island. What is project Weber/RENEW?

COLLEEN DALY NDOYE: Project Weber/RENEW is a peer-based organization. We're harm reduction and recovery services organization. We have two drop-in centers and a mobile-- stationary mobile site. We provide a range of services, case management, street outreach, public health services essentially for folks who are at risk for HIV and overdose.

DAN RICHARDS: Your organization bases a lot of its work around concepts of harm reduction. Could you just define harm reduction for listeners who maybe aren't that familiar with it?

COLLEEN DALY NDOYE: Sure. So, for example, we talk about harm reduction as seatbelts. Driving in a car is not 100% safe. But a seat belt will make it safer. And so harm reduction encompasses the tools to stay safe or safer while using drugs, but also encompasses a philosophy. So it's really about giving people dignity and autonomy and safety in their lives and really sort of providing those services to support people in their own goals.

DAN RICHARDS: And just to be clear, and we'll get back to this a little later in the conversation, but these types of harm reduction services also help encourage people into recovery programs. This is not something that's in opposition to recovery and actually stopping using drugs.

COLLEEN DALY NDOYE: No, absolutely not. I mean, the majority of the folks that work for us are folks in long-term recovery. Their lives have been changed by recovery. And they're always living examples of the power of recovery. And we transport more than 200 people a year to recovery. We-- in the last year, we paid for more than 500 individuals to access recovery housing. So folks coming out of treatment, they need a place to go. And so we will fund that recovery housing for them.

So we are an organization that really believes in the continuum harm reduction recovery. They're not in opposition to each other. They're working towards the same goals.

DAN RICHARDS: And so what are some examples of harm reduction in the world of drug addiction, treatment, and overdose-- this current overdose crisis?

COLLEEN DALY NDOYE: So there's a huge range of services. There's fentanyl test strips where folks can test the drugs that they're taking to determine whether there is fentanyl present. And then they can choose either to not use that drug or they can choose to use it in a safer manner, make sure that there's people around them, make sure that they're using more slowly.

Then there's naloxone, obviously, which is Narcan, which is one of the most well-known harm reduction tools. And we distribute more than 10,000 doses every year. Syringes, providing syringes to folks, not only obviously reduces the spread of infectious diseases, but it also engages people. So it brings people into the services. And then once folks are ready or if they are ready for treatment, they know where to go. They can come in and access treatment right away with us.

DAN RICHARDS: So Rhode Island is the first state in the country to officially sanction the opening of an overdose prevention center. There are other prevention centers. There are two in New York city, though they haven't been sort of officially allowed by the state. There are also others operating less publicly. But I wonder, why do you think Rhode Island was the first state to really formally approve this type of harm reduction facility?

COLLEEN DALY NDOYE: So I think Rhode Island is a perfect storm in some ways.

The impact of the crisis has been particularly stark in our state. And then also, I think we've got a lot of community activists and a lot of community groundswell around the issue of overdose. And then we've got wonderful legislative leaders who really took this on as their issue and something that they really pushed.

And I think we see that a lot of senators and reps are actually facing this crisis in their own families, and many have lost a loved ones. And the majority of Americans have either, a person in their family or somebody that they know who has died of an overdose. So it is now touching everyone. And so I think that there was a perfect storm of a small state, lots of folks were very focused on this issue, and then a lot of infrastructure within the legislature that really allowed this to move forward.

DAN RICHARDS: So would you walk me through a little bit, what happens in this center? What would it be like the experience for someone taking advantage of the services? They walk in, what happens next kind of?

COLLEEN DALY NDOYE: So what we like to tell people is that all of the services that will be taking place in the overdose prevention center are services that we currently have, with one exception, which is the safe consumption. So when folks walk in, they can get access to food, they can get access to clothing, they can get access to-- in this new facility, there will be showers and a laundry.

Folks can get access to case management. Folks can get access to medical care. The one additional service that they can get access to if they choose is safe consumption. So essentially, being monitored while using substances and then somebody being able to intervene if the person does overdose.

DAN RICHARDS: Is someone allowed to use any substance? Or is it a particularly defined thing?

COLLEEN DALY NDOYE: Yes, there are two ways that people can use their substances. So folks can use to safer smoking rooms, which is really important as a racial equity issue. So we see that people of color are more likely to be smoking drugs. People who are white are more likely to be injecting drugs. So if we only allow people to inject drugs, really it becomes a racial equity issue where we're excluding unintentionally, of course, but we're excluding folks, a majority folks of color.

So we'll have both routes of administration. So we'll have folks who will be able to inject drugs and people who will be able to smoke. And then obviously, there will be folks who are peers who will be able to intervene, talk to people, provide services, and really make those connections that people need.

DAN RICHARDS: What would you say to listeners who might think, wow, this sounds like something that makes taking drugs easier? Is that not a problem for ultimately sort of curbing this crisis?

COLLEEN DALY NDOYE: Well, we tell people that the overdose prevention centers, the only thing that they enable is for people to stay alive. So we have folks right now, hundreds, even thousands of them that we serve, who are utilizing our services. And then going outside. So it's in a McDonald's bathroom or in a behind a dumpster or in abandoned houses. And they're using there. And they're obviously leaving syringes and things like that. And public parks, places where people can step on them or can pick them up.

And so we say that folks are already using drugs. And they have been using drugs for the past millennia. And so we recognize that this is a public health intervention into a public health crisis. In our country, obviously, we have to have a lot of tools in our toolbox, and an overdose prevention center is one really important tool.

DAN RICHARDS: Another criticism that has been sort of leveled against these types of places is that they might spur crime or just unsavory behavior around them, that they might be bad for the neighborhoods they're located in. Have you gotten any sort of meaningful pushback along those lines or along any other lines?

COLLEEN DALY NDOYE: There's always folks who are going to repeat talking points that are really not borne out by evidence. So, I mean, if you look at the evidence from the sites around the world, you see that crime doesn't increase around these sites. You see that they save money, of course, when you think about the impact of the reduced EMS runs, you think about reduced emergency room visits. All of these kind of things save enormous amounts of money. People are 30% more likely to access treatment when they use these facilities. So there's all this evidence.

And so there are people who want to use taglines or sort of catch phrases, like this is enabling folks to use drugs. But really, when we say people are 30% more likely to access treatment, who utilize these services, that's the opposite of that, really.

DAN RICHARDS: Another really interesting aspect of this organization and this center you're planning to open soon is that many of the volunteers, as you've described, are people who have used your services before. And I wonder how that affects the organization and affects your thinking about this overdose crisis.

COLLEEN DALY NDOYE: Certainly, we have a number of people that work for us. Now who are former clients. Many of them are overdose survivors themselves. So we think about or I certainly think about the value that they have brought to my life personally, to the lives of our clients, the lives of our fellow, staff members, and how it would be such a tragedy if nobody had been around to reverse their overdose. And then we think about the number of clients that we who have passed away because they were alone. It's a preventable death.

And that's what we keep telling people is that it is a preventable death. And if you want people to access recovery, which everyone says is that should be the ultimate goal, they have to be alive. And so I just think of the number of people that I know personally who are no longer here and how much we miss them and how much we wish that there had been some way to prevent those deaths.

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DAN RICHARDS: Well, Colleen Daly Ndoye, thank you so much for coming on to Trending Globally. And we look forward to hearing more about this project as it moves forward.

COLLEEN DALY NDOYE: Thank you so much for having me.

DAN RICHARDS: As Colleen explained, part of the reason this project has been able to move forward is that because today, decades into this crisis, almost everyone has been affected by it in one way or another. And while that may help change public perceptions of things like overdose prevention centers, it's also a sign of how deeply entrenched this epidemic is.

BRANDON MARSHALL: This is almost like as complex as the obesity epidemic in the US. It's something that is with us and will be with us, unfortunately, for generations.

DAN RICHARDS: Brandon Marshall is an epidemiologist at Brown and has been a vocal proponent of this overdose prevention center. I spoke with Brandon about how this project fits into the broader effort to curb this overdose crisis and about the big picture trends defining this epidemic in America. We started by unpacking the dramatic rise in overdose deaths during the pandemic and the plateau in fatalities that we've seen in the last few years since then. Here's Brandon.

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BRANDON MARSHALL: There was a really impactful study that was published in Twenty Eighteen that looked at the longer view of the overdose crisis, that extracted mortality records and looked at rates way back since the Nineteen Seventies. And that study showed actually an exponential increase in overdose deaths for the better part of three, almost four, decades. So what I took from that study is to be very cautious about reading into short-term changes or plateaus. We saw a decrease in Twenty Eighteen, for example, that was quickly overtaken by those increases you mentioned during COVID. And I do worry that over the long term, we'll continue to be on this exponential trajectory unless we don't do something fundamentally different to understand and address the roots of this crisis.

DAN RICHARDS: When we talk about what needs to be done to fundamentally address the roots of the crisis, what do you think of as those sort of fundamental approaches?

BRANDON MARSHALL: Yeah, a few things, really. So COVID taught us, I think, how fragile in particular American society truly is. Our housing stability, our employment opportunities are all so tenuous. And those impacted people who use drugs disproportionately hard. And so I think we need to look to a lot of those drivers, what we call the social determinants of health, how they got worse during COVID.

DAN RICHARDS: Could you expand on that a little bit? When you say social determinants of health, what do you mean exactly?

BRANDON MARSHALL: Yeah. So those are the underlying drivers of a lot of health outcomes. For us folks that study overdose prevention, we think a lot about housing. We know that housing instability or homelessness is a major driver of overdose risk. Another one would be criminal justice involvement. This particularly affects Black and Brown people in Rhode Island and across the nation. And we know that criminal justice involvement, and particularly the period of release from a jail or prison, is a particularly pronounced period of high rates of overdose. So that's a major underlying or social determinant in this area, criminal justice involvement, housing instability, and then things like economic opportunities as well.

DAN RICHARDS: So social determinants of health covers a lot-- economic opportunities, housing, as you said. What are the other types of things that have contributed to this rise in overdose deaths over the last few years?

BRANDON MARSHALL: We also have to look to the supply of drugs in this country. It continues to get more and more toxic and deadly. We saw the introduction of fentanyl in Twenty Thirteen, which resulted in an increase in overdose deaths in Rhode Island and across the New England and mid-Atlantic states that has grown across the country. Fentanyl is a highly potent opioid that's 50 to 100 times stronger than morphine. And so that drove increases over the last 10 years.

Now we're seeing other products being introduced into the supply as well, like psilocin and benzodiazepines that continue to make that drug supply more toxic and unpredictable for people. And so that at a very proximal or immediate level, I think, has is driving overdose rates as well.

DAN RICHARDS: And this gets to a point that you actually helped clarify for me before we met today, making clear that this is not a crisis solely connected to opioids. I think a lot of people maybe think of it as an opioid epidemic, but there's a broader crisis.

BRANDON MARSHALL: That's right. Some people characterize it as the fourth wave of the overdose crisis, where we're seeing deaths due to stimulants like cocaine and methamphetamine, often alongside fentanyl as well. But at the end of the day, we really have to think more broadly about all of the substances people use, the ways in which they use them. And again, that unpredictability and toxicity of the drug supply affecting people, regardless of whether they intend to use opioids, stimulants like cocaine or methamphetamine, or other products as well. So it has become a much broader problem over the last decade, as we've seen that shift from primarily prescription opioids, like you mentioned, to a whole variety of unregulated drugs that have significant overdose risk.

DAN RICHARDS: So listeners just heard from Colleen Daly Ndoye, the executive director of Project Weber/RENEW, the organization leading the rollout of Rhode Island's soon-to-be first overdose prevention center, one of the first in the country. What role will this center play in helping to address this crisis?

BRANDON MARSHALL: Yeah. So overdose prevention centers are spaces where people can consume pre-obtained controlled substances under supervision. So people come into the center, they might register and then use drugs under the supervision of trained professionals. Those might be nurses or trained peers who intervene in the event of an overdose.

So at the most fundamental level, the goal is to reverse overdoses, prevent overdoses, and save lives. We know they do that very effectively. There's never been an overdose death anywhere in the world in an overdose prevention center, despite them existing for more than two decades.

DAN RICHARDS: That's a wild statistic.

BRANDON MARSHALL: Yeah. You know, it shows you that overdoses are-- overdose death is preventable. With the right resources and tools immediately in place, we can always intervene effectively to save that person's life. So it's a very powerful thing to do. So that's one of the primary goals. But there's a lot of other services that are usually provided in such centers that provide direct pathways into health care services, treatment, recovery supports. So they're really that one stop shop for people to help access the services they need.

Research has shown that the more frequently someone uses an overdose prevention center, the more likely they are to enter into addiction treatment. So again, it's not like harm reduction is an opposition to treatment services. This is an example where they're actually working together to achieve that goal.

DAN RICHARDS: What is the legality of a type of place like an overdose prevention center where people knowingly have drugs that are illegal? Is that a state by state process to change the laws? Or how is it legal, I guess, someone might ask.

BRANDON MARSHALL: Yeah. So with overdose prevention centers specifically, we were the first state to pass a law that explicitly authorizes their operation. So they are legal under state law in Rhode island. And they're being opened publicly under that law. At a federal level, this matter is unsettled, I would say. There has been a court case in Pennsylvania, which went to the Third Circuit of Appeals. And the organization that was hoping to open an overdose prevention center in Pennsylvania recently lost that case.

That doesn't have direct bearing on what we're doing here because we're in a different circuit. But nonetheless, you're seeing some of these lawsuits play out in different ways across the nation. And we don't also have a very clear stance from the federal government on overdose prevention centers. So they continue to pursue this lawsuit in Pennsylvania that was a holdover from the Trump administration.

But at the same time, the National Institutes of Health have funded us and our colleagues in New York University to do evaluations of the centers that are open in New York, and that will be opening here in Providence. And some leading federal officials, like the director of the White House Office of National Drug Control Policy, have made statements to suggest that they're open to at least considering this intervention and evaluating the evidence that comes from these evaluations.

So the situation is a bit unclear right now. At the end of the day, though, states need to address the public health crisis that is happening in these places. And so I hope to see other states take steps like we've done to fully legalize, not only overdose prevention centers, but other harm reduction programs that we know work.

DAN RICHARDS: You mentioned that the Biden administration is maybe signaling more of an openness to approving harm reduction-focused strategies than the previous administration, the Trump administration. How much do changes at the federal level really affect what can happen to treat this crisis in a place like Providence?

BRANDON MARSHALL: The federal stance on this is huge. It matters tremendously that harm reduction is now, for the first time, officially in the federal strategy to address drugs and overdose. So that sends a signal that harm reduction should be part of a comprehensive approach to address the overdose crisis. And funding matters, too.

So this was the first time that the federal government is investing in harm reduction, which previously had been funded very haphazardly through often philanthropic or private means. That being said, the amount of funding is minuscule. It was about $30 million annually now that is dedicated to harm reduction, which sounds like a lot. But the budget of the Drug Enforcement Agency is over 3 billion. So that still shows you really what we're funding. But at least in terms of the policy approach, we are seeing what I think is a very important shift at a federal level.

DAN RICHARDS: All right. Let's turn back to this soon-to-open overdose prevention center in Providence. One thing I found really fascinating was how this center is largely being funded by the settlement from a lawsuit against companies that profited off of selling and manufacturing opioids. And could you explain a little bit how that happened? And is this something Rhode Island specifically was suing these companies on? Or was it part of a bigger project?

BRANDON MARSHALL: So every state is involved in what we call these opioid settlements. They are legal settlements with manufacturers of opioids, distributors like McKesson, very large companies that were responsible for distributing these opioids, and then pharmacies like Walgreens, Walmart, for example. Rhode Island got a significant chunk of money, more than $100 million from these settlements to spend on addressing the overdose crisis over the next 18 years.

There is an advisory committee at a state level that makes recommendations around how this money should be spent to most effectively reduce overdose deaths and help people at risk for overdose. And overdose prevention centers were seen as one thing that should be part not all, but part of that spending package. We are, to my knowledge, the only state that has used these settlement dollars for this purpose. But in my view, it certainly an allowable use of these funds because it's directly trying to address the overdose crisis through a program that we have seen be effective in other countries.

DAN RICHARDS: You describe how this money will be spent over a long period of time, which I think brings to mind the sense, again, that this is a crisis that's going to unfortunately be with us probably still for some time. I wonder, you described how there have been different waves historically of this crisis. And how are you thinking about the next phase of all this? Is there a new wave on the horizon? Or are you seeing signs of hope that maybe we are finally starting to see this really trend down in the near future?

BRANDON MARSHALL: I am hopeful. I think these settlements are unprecedented money that is now available to help address the crisis, so that's one important piece. We've seen a shift in how to approach this issue at a federal level, which is important. Maybe I'm just a positive person, but I'm hopeful that we may start to see a fundamental shift in the trajectory.

The way I see it is that we have a crisis of overdose deaths right now. We have an unprecedented number of overdose deaths. We need to bring that down. So that's where crisis management comes in, implementing harm reduction programs, trying to really save people's lives. And then what I'm hopeful is that over the next 10 or 20 years, we'll start to see a reduction in deaths. We'll have more and more people living successfully and healthily in recovery. And some of the resources then can shift to providing services to help people stay in recovery and avoid recurrence of use.

So that's my hope is that we'll see that shift from needing to deal with an urgent crisis of deaths to supporting people more long term in achieving their own recovery goals.

DAN RICHARDS: Your description is an immediate crisis. And then over 10 to 20 years, the downward shift. That's a sobering thought. Just that that's the scale to be thinking on still with this crisis.

BRANDON MARSHALL: Yeah. It's not like an infectious disease where we can both rapidly see increases and rapidly see decreases. This is almost like as complex as the obesity epidemic in the US. It's something that is with us and will be with us, unfortunately, for generations. So that's the kind of view, we need to take. It's a whole of society approach that needs to come on board. But it's not going to be an overnight shift. It really is a multigenerational problem that we're dealing with.

DAN RICHARDS: What concerns you right now? Like, what sorts of things do you see on the horizon that you think could make it more difficult, again, to address? Because, again, this has seemed to come in so many different shapes and forms over the last few decades.

BRANDON MARSHALL: Yeah. So we see-- we have seen and we continue to see backlash against some of the progress we've been making in terms of harm reduction and taking a different approach to dealing with drug-related problems in our society. A good example is Oregon, right. They were the first state to decriminalize the possession of substances,

I think, in Twenty Twenty-One. And that law has recently been repealed because of what people see as rising drug-related problems in their communities in Portland and across the state-- homelessness, open drug use. And the issue in several studies have looked at this is that it's not so much the law that drove those things, but that it coincided with dramatically rising housing prices, the introduction of fentanyl into the drug supply in Oregon. So in some ways, it was just really bad timing in my view.

But nonetheless, unless you're really deep in some of the research on this, it's very easy to believe that the law had some of those unintended consequences. So I think as a research community, we need to be out front and be communicating what we're seeing in the data and explaining when what we see as maybe a correlation is not a true cause and effect.

DAN RICHARDS: Something you have been working on, in addition to all of your research, is a group called the People Place and Health Collective at the Brown School of Public Health. I wonder if you could describe a little bit what that organization is and what gaps you hope it will fill in the world of public health.

BRANDON MARSHALL: So we're a research team. We focus primarily, but not exclusively on overdose prevention, harm reduction. We also do and have research projects focusing on HIV and STIs and COVID. We work extensively at a state and local level. So that's what we're trying to do is like to bring that research, that rigorous research to Rhode islanders, to policymakers to try to increase impact. So we do that with our overdose prevention work. We're doing that with our HIV and STI prevention work as well.

So it's a lot of fun. We've been around for two years. We launched in February Twenty Twenty-One, coming out of or through the pandemic. We're fortunate to have a research space in South Providence, which is great.

DAN RICHARDS: And South Providence is not where Brown's main campus is. What's the value of having an office sort of not on in the heart of Brown's campus and in a part of Providence that has historically been underinvested in?

BRANDON MARSHALL: We saw the need for this really speaking with our research participants. Many, not all, but many, don't feel comfortable on Brown's campus. It's not always a very welcoming environment for people who are disenfranchised, marginalized, and have experienced tremendous stigma throughout their lives because perhaps of their drug use or because of their race, ethnicity, the language they speak, and so on. So, a, that's important for us to reflect on as an academic community about how we could do better and make our spaces more accessible to the community. And I would love to be part of that mission.

But then moving off campus to a community-facing research space really allows us to be more accessible over the short term. So it's a very welcoming space for research participants. We hold a lot of community meetings in this space. Volunteers or community partners can use the space for their meetings or interview rooms or focus groups. So it's just a way for us to open up and be more accessible to the research participants that we work with and also the community partners.

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DAN RICHARDS: That sounds like a wonderful office and a really fantastic project. Brandon Marshall, thank you so much for coming back on to Trending Globally.

BRANDON MARSHALL: Thanks so much for having me. It's been great.

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DAN RICHARDS: This episode was produced by me, Dan Richards and Zach Hirsch. It was engineered by Eric Emma. We'll put links in the show notes to Project Weber/RENEW, the organization that is in charge of opening Providence's overdose prevention center, as well as the People, Places, and Health Collective at Brown University's School of Public Health.

If you enjoyed the show, please leave us a rating and review on Apple Podcast, Spotify, or wherever you listen. And if you haven't subscribed to the show, please do that too. If you have any ideas for guests or topics, send us an email at trendingglobally@brown.edu Again, that's all one word, trendingglobally@brown.edu. We'll be back in two weeks with another episode of Trending Globally. Thanks.

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