Okay, good afternoon, everybody. It's five o'clock, and we're going to start the webinar. Welcome to today's AOAAM webinar on the state of harm reduction in the U.S. Progress, Barriers, and What's Next by Dr. Brandon Marshall. My name is Julie Kimmick, and I'll be your moderator for this session. This is the fifth of a six-hour webinar series on hot topics in the treatment of opioid use disorder and stimulant use disorders. Dr. Marshall is a professor of epidemiology at Brown University School of Public Health. He's also founding director of the People, Place, and Health Collective at Brown University. Dr. Marshall's research focuses on substance use epidemiology with a specific emphasis on harm reduction and overdose prevention. He is passionate about conducting research that improves the health and well-being of people who use drugs. So I'd like to welcome Dr. Marshall today. Thank you so much, Dr. Kimmick, for that introduction. It's really just a delight to be here and present all of you today. I'm going to share my slides in just a moment here, so give me one moment. Okay. Great. How's that? Can you see everything okay? Yes. Perfect. All right. So thank you again, everyone, for coming today. My name is Brandon Marshall. I'm going to be speaking to you today about harm reduction. I've got a couple of disclosures before we get into today's objectives. These are the funding statement for the overall speaker series, so I'll let you read those at your convenience. And in terms of my disclosures, I am employed by Brown University and have received grants from Arnold Ventures, the Cigna Foundation, which supports our research, as well as funding from the National Institutes of Health. I am also a paid expert witness in the state of Rhode Island's lawsuits against opioid manufacturers and distributors, which are now settled. And our moderator today, Dr. Kimmick, has no disclosures. So what I'm going to do today is talk to you about the state of harm reduction in the United States and highlight a few key interventions and underlying principles for harm reduction practice. And then at the end of the talk, I'll discuss barriers to their implementation in the United States. For the third objective, I'd like to save that for the Q&A session, which will be happening at this time next week. I am not a clinician. I'm an epidemiologist. And so I'm interested next week in hearing from you on how you see or might experience challenges as you might adopt the principles of harm reduction in your own clinical practice. So I encourage you to attend the Q&A next week, where we'll dive in more. If you do have any questions today, feel free to use the Q&A, and I'm happy to answer those as we go through the material and might save longer answers to your questions for next week's session. So I want to ground us in where we are today in terms of the overdose crisis. This is a nice figure from a paper published in Addiction in 2021 that shows very nicely this terrible reality that we have been on a 40-year exponential trajectory in the number of drug overdose deaths in this country. So this is not actually a new phenomenon. This is something that we have been experiencing and dealing with for multiple decades. And I took the liberty of adding data from 2020 and 2021 to this figure, which ended in 2019. And you can see that unfortunately, during the COVID-19 pandemic, the number of overdose deaths has been what you might refer to as super exponential. We are unfortunately exceeding this 40-year trajectory. And so we urgently need new tools and strategies to try to curb and bend the exponential trajectory that we have been on. And that's where I think harm reduction plays a role, in addition to a number of other prevention, treatment, and recovery strategies. I do want to highlight as well that we see really dramatic racial, ethnic disparities in drug overdose deaths in the United States. This is a recent figure from a paper that was published in the American Journal of Psychiatry this year, showing that drug overdose rates are increasing the fastest among non-Hispanic Black Americans, which is shown by the blue line. Blue line. In fact, more recent data from 2020 shows that drug overdose rates among Black Americans overtook those of White Americans for the first time in 2020 since the early 1990s. So what we see here are the result of shifting trends in overdose as they reflect the profound ways in which race shapes access to drugs, treatment, and justice in America. So this underlies everything that we do and has to be central, I think, to our harm reduction response. We also see pretty dramatic geographic and age-specific differences in drug overdose mortality in this country. This is a schematic from a figure that we published in 2020 that shows age-specific drug overdose rates, stratified by whether a state was east or west of the Mississippi, shown in orange and blue, respectively. And what you can see in both regions is a bimodal distribution in terms of drug overdose mortality rates peaking in the early 30s and then in the mid-50s in later life, but that the increase in more recent years was driven primarily in states east of the Mississippi in that younger age group, and that's due to the introduction of fentanyl in the unregulated drug supply. And we're going to talk later about tools and programs that aim to reduce the risk and the rate of fentanyl overdose in this and other age groups. So what is harm reduction? Well, this is a definition for you from the National Harm Reduction Coalition. Harm reduction is a set of practical strategies and ideas aimed at reducing the negative consequences associated with drug use. I'm going to talk more about the principles that undergird harm reduction in a moment, but now I want to give you the opportunity to hear directly from people who are most affected by the overdose crisis, family members, service providers, clinicians, and friends of people who have lost loved ones to overdose, about what harm reduction means to them, because I think that gives you a deeper understanding of what this movement and what these interventions actually aim to achieve in practice. So this is about a five minute video. Bear with me. I think it's powerful, and I hope you enjoy the perspectives that these individuals share with us today. You ready? Personally, for me, harm reduction is important because I watched my brother use drugs for years and ultimately overdose and die. Harm reduction is important to me because it means keeping my family safe. I believe that it also includes therapeutic rather than punitive drug policies. I have a lot of family drug use and it was constant fights, bitterness, anger. I was lucky enough to make it when I had some times of struggle. In my world, I believe to change someone else's life is to change their narrative. And with harm reduction, I've learned not to have all that anger, to be more compassionate, to not judge anybody and be so critical. Harm reduction gave me a sense of family, sense of belonging, you know, a place where I was accepted just as I was, just as I am. As a physician, I believe in harm reduction because I'm sick and tired of my patients having to die. I lost my daughter to the disease of addiction. May all beings be free and may my work contribute to that freedom. It's important for you to find your own healing, to find your own path. It's about civil rights. It's about public health. Helping people regardless of the choices they make in life. We don't judge people. I believe that the people themselves are the experts on their own lives. My harm reduction truth is that I was a skeptic and even as a person who injected drugs. I believe that harm reduction is a movement that is never going to stop, that advocates for human rights, that advocates for humanity, that advocates for being a whole human being and respect. Harm reduction works because it was created for and by people who use drugs. It's not a radical idea. None of these concepts that people are complaining about and think are radical are radical. They're life-saving common sense things. I believe that harm reduction is the absolute opposite of tough love. Harm reduction asks us to look at people as full human beings and recognize their full humanity and that is challenging because we live within systems and structures that every day require us to do the contrary, to stigmatize and to dehumanize people. When I was looking to build a relationship with my father, there were so many people who told me to forget about it, to wait, and for me I lost the opportunity. My boy Kenny, he was only 25 years old, died of an overdose. He was a peer educator just like me. The truth about harm reduction is that the bigger our movement grows, we run the risk of losing the essence of harm reduction. My truth about harm reduction is that it is the answer to most of life's problems. The hard part about having that skill and knowing that that's true is actually doing it. I believe that people really do want to be healthy and well. I believe the war on drugs is a war on people. Harm reduction has helped me reunite with my family and most importantly with myself. Harm reduction is part of my life. Harm reduction saved me. I believe harm reduction is just another way of saying that I care about you. In my mind, harm reduction is the real thing and that is love and that's what I try to do each time I step on the street to deal in love and safety. I feel like our community has been so stigmatized and pushed down and pushed out and pushed away that people forget that we are, we're not even just like them, we are them. You know, we are people. We are your neighbor, we are your son, we are your friend from college. Harm reduction is rehumanizing. Harm reduction is love. Harm reduction is kindness. Harm reduction is helping. Harm reduction isn't about me, it's not just about you, it's about us. So, thank you all for listening to that video with me. I'm going to talk a lot about theories and show you a lot of data today and studies and research because that's what I do as an epidemiologist studying harm reduction, but I encourage all of us to keep those voices in the back of our heads as we're learning about this field and discussing how we apply harm reduction to our own work. So, I want to go through a couple of principles of harm reduction before we talk about the state of harm reduction in the United States and progress that we're seeing. There are several principles. I'm only going to highlight three. I encourage you to visit Harm Reduction International that talks more about the principles that really lie at the heart of this discipline. The first relates to the definition that I shared earlier, but I like this principle because it also highlights that harm reduction are policies, programs, and practices that attempt to minimize the health, social, and legal impacts not just associated with drug use, but also drug policies and drug laws. So, it helps us think more broadly about how to improve health and well-being in our society. It's also grounded in justice and human rights, as you heard in the video, and it focuses on incremental positive change. Working with people without requiring that they cease drug use is a precondition of that support, and so that's very central to what we're going to be talking about today. And finally, harm reduction principles apply to both what we consider to be illicit and licit drugs. We actually have many harm reduction-focused policies when we think about alcohol and tobacco and increasingly cannabis, and so that's another thing I encourage you to consider as we talk about applying harm reduction principles to substances that are unregulated or illegal. So, I want to talk now about what is the state of harm reduction in the United States, and unfortunately, the state is not good. I want to talk a little bit about syringe service programs, which have been around for decades. They've been studied for decades. This is an infographic published by the CDC, a federal agency which strongly endorses syringe service programs, highlighting this fact, and states very clearly that they save lives, they reduce HIV and infectious disease transmission, their use is associated with injection drug use cessation and entry into treatment for people who use them, and they do not increase crime and actually result in fewer discarded syringes in the neighborhoods in which they are located. So, this is, you know, coming from the CDC and is based on more than three decades of scientific evidence. There is also a federal funding for syringe service programs, but the way in which this is done is rather arcane. So, recent appropriations language from Congress allows states and other jurisdictions to spend money on syringe service programs except for the actual purchase of syringes themselves, but first those jurisdictions must show a demonstration of need, that is, that their jurisdiction is at significant risk of hepatitis and HIV outbreaks due to injection drug use, and this has to occur in consultation with the CDC. What you are seeing here are the states which have sought and have received that determination of need and therefore can use federal funding to support their syringe service programs. So, you can see here that all but a few states have received this statement of need for these services, and yet there are, I think, 11 states in which syringe service programs remain entirely illegal. These are shown in red on the figure in front of you. There are many other states, including some that have been most highly affected by the opioid and overdose crisis, such as Pennsylvania and West Virginia, in which syringe service programs are only permitted at a county or local level, not statewide, and so you can see very clearly we have a long ways to go to ensuring, you know, decent syringe service program coverage across the nation, even with support from federal agencies, and that support includes funding. The situation is actually more dire at a county level. This is one figure I pulled from AMFAR, apologies for the low resolution, that shows you the availability of syringe service programs at a county level, really showing the tremendous gaps we have in providing access to SSPs across the United States. Some states, like New Mexico, have long-standing and established syringe service programs located in throughout much of the state. Others, it really is in only a handful, and so even when it comes to SSPs, we have a long ways to go. That being said, I want to talk now about where we are making progress, and what's next in this field, and to do that I want to talk about three interventions, focusing on the third this evening. The first is naloxone. I'm sure many of you are familiar with naloxone, otherwise known as Narcan. It's an opioid overdose antidote. I'm then going to talk about fentanyl test strips, which are kind of like a COVID-19 rapid test that allow people to identify fentanyl and other fentanyl analogs in unregulated drugs, and then I'm going to talk about overdose prevention centers, what we're referring to here in Rhode Island, where I'm from, as harm reduction centers. These are facilities, be they fixed site or mobile, that allow people to use pre-obtained substances under clinical supervision, and I'm going to spend most of the time in the second half of this talk talking to you about OPCs. So to talk very briefly about naloxone, I think this is somewhere where we, this is an area where we have seen a lot of progress. The federal government, the Surgeon General, strongly endorse naloxone broadly as an effective overdose prevention strategy. The Surgeon General encourages everyone to be trained and to carry naloxone in the event that they witness or are a bystander to an opioid overdose. These are data from my home state of Rhode Island showing the tremendous scale-up of naloxone distribution in our state. We're on track to distribute more than 40,000 kits of naloxone this year, which is significant in a state of only a million people. We recently settled lawsuits against opioid manufacturers and distributors, and one of those lawsuits against Teva in particular has resulted in a sustainable amount to the magnitude of 50,000 naloxone kits to be made available in the state every year for the next 18 years. So that's great. That has provided a sustainable source of naloxone for our residents. Similar settlements have also been achieved in Texas, Florida, and perhaps a few other states. So I think this is where we're seeing a lot of success in terms of expanding access to naloxone, both through community organizations and pharmacies as well. I'm going to talk now about fentanyl test strips and other drug checking technologies, and I'm happy to spend more time on this during the Q&A session next week because it's an area where folks attending today might know a little bit less about. So our team here at Brown University, among others, has studied the feasibility and utility of fentanyl test strips to prevent fentanyl overdose. So just to go through a little bit again about how this technology works, this is an immunoassay, sort of like a COVID-19 rapid test as I mentioned, that allow people to identify very, very small amounts of fentanyl and many fentanyl analogs in a sample of an illicit drug dissolved in water. These are now being distributed in many states. As I'll mention in a moment, they are legal here in the state of Rhode Island. The result that you can see is shown in the figure. It's kind of the opposite of a COVID-19 test. A positive is one line, a negative is two lines. We conducted a pilot study in 2017-2018 with 100 people who use drugs and reported that the vast majority of people we enrolled in the study found these strips very easy to use. We gave them for participants to use whenever they feel they may be at risk for overdose. We trained them how to use them and then encouraged them to use them at home or elsewhere that they are using drugs. We also found that the use of these strips led to positive behavior change. People reported using more slowly, more likely to use with other people around who could intervene in the event of an overdose. We found in particular that positive results leads to decreased overdose risk. Many of participants in this study reported in the event of a positive result having naloxone, ensuring that naloxone was around to reverse that overdose or discarding the fentanyl contaminated substance altogether was something we weren't expecting but was reported by some study participants. We're now conducting a full randomized clinical trial to determine whether the use of fentanyl test strips in the context of a broader overdose prevention intervention reduces rates of fatal and non-fatal overdose. That study is currently ongoing. We're almost at our target of 500 participants and we'll be able to report on that study in a year or two. Hopefully I can come back to you in 2024 and let you know what we find in that study. Needless to say, some of this pilot work and work conducted in North Carolina and other states actually led to a bill that was passed by our senate several years ago and was signed into law by the governor in 2018, I believe, that fully legalized the possession of fentanyl test strips and their distribution. That has led to them being distributed on Overdose Awareness Day and by many harm reduction organizations working throughout our state. Here's a fentanyl test strip kit that shows you both the strips and then the instructions which are available in a small flyer and a photo here of people distributing them at overdose prevention events in our public parks. And similar things are happening in other states. At the same time, many states are struggling, many organizations are struggling to distribute these strips because their legality in some states remains unclear or illegal. They may be considered drug paraphernalia under some state laws. So we'll come back at the end of this presentation to talk more about some of the barriers to implementing harm reduction interventions and laws and policies at a state and federal level are certainly one important barrier that we need to consider if we're attempting to expand access to harm reduction technologies in our country. I want to turn now to overdose prevention centers, partly because this is an area where I've done a lot of work and spent a lot of my time, and we've also recently seen some of the first sanctioned overdose prevention centers opened in New York City just this past year. So this is very timely. You may have heard about it in the media and will likely continue to see a lot of attention focused on overdose prevention centers over the coming years. So I want to talk to you a little bit today about what these facilities are, some of their evidence that supports their effectiveness, and where we go next with overdose prevention centers in the United States. So what are OPCs? Well, these, as I mentioned, are community-based clinics where people who use drugs can consume pre-obtained controlled substances under the supervision of trained staff. This is something that I want to just underline for you. People obtain substances elsewhere and use them on site. Controlled substances like heroin, cocaine, or methamphetamine are not administered by staff who work in these facilities. The second thing I want to highlight is that OPCs are much more than the actual supervision of substance use itself. That plays a critical role in the reversal and prevention of overdoses, but they serve as an important pathway and connection for people to a whole host of other health care and support services. The vast majority of OPCs that are operating around the world provide access to medical care like wound care, direct referrals to treatment programs, sometimes OPCs are directly collated with treatment programs, other times they provide warm handoffs to treatment facilities, and a whole host of other social support services like housing and job training programs. This is not a new intervention. There are more than 200 OPCs operating in more than 14 countries. The first opened in Switzerland in the 1980s, so fortunately we have decades of scientific research that helps us understand their impact on both people who use them and the communities in which they're located. The terminology is confusing in this space. Historically they were known as supervised injection facilities or safe injection facilities. I like the term supervised consumption facility to highlight the fact that other modes of consumption can occur in some facilities, inhalation and smoking in particular. As I mentioned in Rhode Island, the law that we've passed uses the term harm reduction center, but for the purposes of today these are all synonymous. So I want to take you inside the first sanctioned supervised consumption facility that was opened in Vancouver, Canada in 2003, and where I was fortunate enough to do my PhD in epidemiology. I was served on the scientific team that evaluated this facility some years ago. This is a photo inside the consumption room. There are 12 booths here. This is a very large and busy facility. About 500 to 700 people use this service every single day. Clients register to use the service and then enter into this environment. They use their pre-obtained substances at one of the booths that you can see in the background of the photo. The mirrors allow for several things. They allow people to help find veins and wash themselves while they are administering their own substances. They also allow nurses who are stationed at a counter, you can see that in the foreground, to passively observe people as they use. This allows them to intervene in the event of an overdose. They might administer oxygen or naloxone among other interventions. There have been millions of injections in this facility alone, thousands and thousands of overdose reversals, and there has never been an overdose death in this facility, nor at any of the more than 200 OPCs operating around the world. That's a critical point, right? This shows you that overdose death is preventable. We have the tools in place to effectively reverse and prevent all overdoses. At the very foreground of the photo, there's a snapshot of the kit that's provided to people when they enter. It includes sterile syringe and other sterile drug use paraphernalia that is designed to reduce the risk of HIV and hepatitis C transmission. I want to highlight now and talk about the first two sanctioned overdose prevention centers that have opened fairly recently in New York City. There are two sites that are operated by one organization known as On Point. One facility is in East Harlem, and its sister location is in Washington Heights. These facilities, as you can see, are pretty similar. There are consumption booths and a station where overdose prevention specialists sit and intervene in the event of an overdose. The site that you see here is a more medically oriented facility in East Harlem. There are medical facilities directly above this consumption room, which is on the ground floor. There are nurses and doctors available who work at Montefiore Healthcare who are available and can actually provide treatments such as buprenorphine on site. Again, I want to highlight a pathway and a connection for people into evidence-based addiction treatment. The overdose prevention specialists who work in the facility have intervened since the sites opened last November on more than 280 overdoses. They have effectively reversed all of them. They have only had to call EMS five times, and that's usually due to some very complicated overdose syndrome or some other health incidents like a seizure, for example. As in every other OPC, they have not experienced a death. More than 1,100 New Yorkers have registered to use one of these two sites, and have visited the clinics more than 17,000 times in just more than eight months of operation, showing the demand and the need for these types of services in New York City. So moving now to Rhode Island, we are the first state in the nation to fully legalize overdose prevention centers at a state level. This bill was strongly supported by our House and Senate, and was passed and signed into law by our governor, Dan McKee, in July of last year. As part of the state law, the Department of Health was required to develop and promulgate regulations that would oversee the licensing and operation of these facilities. Our Department of Health does not, will not, operate or fund these facilities, but they will license them just like any other medical facility. As part of the regulations, any site that opens a new As part of the regulations, any site that opens in Rhode Island will need to provide basic needs provision, referrals to housing, have strong connections to treatment programs and legal assistance. The law also, the regulations, sorry, also require services for both injection and inhalation and smoking of substances, given that non-injection substance use, crack and crystal methamphetamine are increasing in our state and are attributed to an increasing number of overdoses. The figure in the lower part of the slide shows you a mock site that opened in the City of Providence last year. This was able to show members of the public and our media what these types of facilities would look like. No site has yet opened. The regulations were finalized in March, so an organization could apply for a license now. The state recently finalized its opioid settlement allocations for fiscal year 2023, and as part of that $20 million settlement, we'll fund harm reduction centers at a level of $2.25 million in this fiscal year. So this is the first time a state will financially support the development and operation of these centers, and the state is just in the process right now of putting out RFPs to support their operations. So I'm anticipating that these centers will start to receive funding and open over the coming months. So I want to talk now about research that's been conducted to evaluate the impact of supervised consumption sites, or I should say overdose prevention centers, on both individuals who use these facilities and the communities in which they're located. I told you earlier that there has never been an overdose death in any overdose prevention center anywhere in the world, but one question that I was interested in studying and that we were able to answer was whether overdose prevention centers reduce community overdose rates. And so that's something that we studied and published in the Lancet in 2011, and I want to walk you through the study design and some of the results from this work that we published more than a decade ago. So in terms of the methods now, just fairly briefly, this was a population-based study. We analyzed all deaths deemed by our provincial coroner to be caused by an illicit drug overdose in the city of Vancouver between January 2001 and December 2005. The in-site, the facility, opened in September 2003. So this allowed us to look at overdose rates both before and after the facility opened. This was a spatial epidemiologic study. We were able to estimate the location at which the overdose death occurred at a very high level of resolution using six-digit postal codes. In Canada, these are in urban areas about a half of one face of a city block. We knew from utilization data that the vast majority of people who used in-site, about 75%, resided within 550 yards of the facility. This facility on purpose was located in a highly impoverished neighborhood with a high level of homelessness and injection drug use, and in which the vast majority of clients resided. So we hypothesized that if there was a reduction in overdose death rates, it would be apparent within this geographic region. We then, as a quasi-control, looked at the change in overdose rates in the rest of the city of Vancouver. All overdose, all city blocks that were outside of this perimeter. And then, pretty simple, we just looked at the difference in overdose mortality before and after the facility opened in both of these geographic areas. These are the quantitative data. I'll then show you the maps in a moment. This shows you the number and rate of overdose deaths and the change within the 500-meter radius of the facility itself, and in the rest of the city of Vancouver over these two time periods. What we saw was a 35% reduction in community overdose mortality rates before and after the facility opened within this radius in which it's operating, compared to only a 9% reduction in the city of Vancouver overall in the same time period, which was non-significant. We conducted a number of other analyses, which I'm not going to go into this evening just due to the time, but I did want to show you a block-by-block analysis which we did conduct. This is a map showing the downtown eastside neighborhood in Vancouver where the facility was located. Its location is shown by the red dot, and overdose mortality rates are shown by the colors. The darker the color, the higher the overdose mortality rate. And what you can see is a reduction in overdose mortality in every single city block that surrounds this facility after it opened, a pattern which was not observed in the rest of the city of Vancouver overall. So I want to talk now about a second of the third question I'm going to propose for you this evening, which is whether supervised consumption service helps people enter into treatment, right? Does it actually provide a pathway for people to enter into evidence-based care and treatment? Several studies have looked at this, so I'm going to talk about two. This was one of the first that was published in the New England Journal by my PhD supervisor actually in 2006. This was a linkage study. The authors were able to essentially link insight utilization data with, at the time, the registry of detoxification admissions in the city of Vancouver over 2003 to 2005. They looked at detox because this was the primary modality of addiction treatment available in Canada at that time. Buprenorphine, for example, wasn't even approved by Health Canada as a treatment for OUD until 2007. So this is something I like to highlight, that the results you're going to see in this and the next study were all done before we had some additional approved therapies for OUD. So I'm very interested to see the replication of these kinds of studies as sanctioned OPCs open in places like New York City and Rhode Island because I'm hypothesizing that we may see even higher uptake as we have more options to offer people. Nonetheless, this was an important study. It showed that within the 15 months of operation, over 20% of people in the sample had entered into some kind of detoxification program and people who use the site at least weekly were 72% more likely to enter into a detox program over this time period. Particularly important was whether people spoke with an addictions counselor or peer counselor post-consumption. So that's what I want to highlight, the mechanism underlying this process. In the vast majority of sites, there is a post-consumption room where I always say a lot of the magic happens, where there are counselors, providers, clinicians working to help connect people to treatment and care. And that's where we really see the impact from some of these studies. This is a longer-term study that was conducted and published in 2011 that looked at 600 people who were using Insight in Vancouver and followed them for about two and a half, or sorry, two years. What these authors found was that over that time period, over 40% of people had enrolled into some form of treatment. They looked at multiple modalities, methadone, inpatient residential, and so on and so forth. And the model, I won't go into detail, is a survival analysis. They looked at factors associated with an increased uptake of addiction treatment. And what they found was that regular attendance at the supervised injection facility, and again, contact with counselors working on-site, were some of the strongest predictors of uptake of treatment during this follow-up period, in addition to having a history of treatment at baseline. This is another excellent study, which I just wanted to highlight. We just came out in the International Journal of Epidemiology. This is a French cohort study of people using overdose prevention centers. What I love about this study from an epidemiologic standpoint is that they have a nice control group of people who were not using an OPC, but who were engaged in other harm reduction services, namely SSP. So a nice strong control group, which is honestly missing from some of the other studies. What they found over 12 months of follow-up is that people who used the OPC, compared to people who used other harm reduction services, had a 67 percent decreased rate of overdose, had a 79 percent decreased rate of abscesses, and had a 59 percent decreased rate of ED visits over this time period. You know, showing again that OPC utilization is affecting not only overdoses, but other health endpoints of interest. So I want to finish now by talking about the community impact before we wrap up today, and then I'm happy to take some questions and continue that discussion next week. So this is an important question. This is one I get asked a lot by policymakers who are interested in these harm reduction interventions. Do they have an impact on public disorder and crime in the neighborhoods in which they're located? This is one of the first studies that came out that addressed this question. This is a really nice design. We're going to replicate this in Rhode Island as harm reduction centers open, hopefully in the state. Here, what researchers did was had research assistants systematically canvas the neighborhood in which the OPC was located in the six weeks before it opened, and the 12 weeks afterwards, and counted, as they observed and walked throughout the neighborhood, measures of drug-related public disorder, both the number of people injecting in public, the amount of publicly discarded syringes, and the amount of injection-related litter. And what you can see here is that as daily use of the facility increased, all three measures of drug-related disorder decreased, and this effect remained even after accounting for other confounding factors like weather or police presence in the neighborhood. This is a very recent study that was published in Drug and Alcohol Dependence last year that looked at the effect of opening a supervised consumption service on crime. This is from the United States. This is an unsanctioned facility that is located somewhere in the nation. This is a quasi-experimental time series design. You can see here the standardized counts of police incident reports for a series of types of crimes, both in the neighborhood in which the SCS is located, that's shown in green, and two control neighborhoods. One that's neighboring the facility, I think that's the red one, and then a neighborhood that's most similar sociodemographically to the neighborhood in which the SCS is located. And you can show again that actually, you can see that crime and arrests went down after the facility opened. That was also observed in one of the control regions, and pretty stable rates in the other control regions. So, certainly showing no negative impact of opening these centers on neighborhood crime. So, I just want to finish here by noting, you know, what's next for overdose prevention centers, both in Canada and in the United States. I've spoken primarily about what are called fixed site models. That's what we see in New York City and what we see in Vancouver. There are other models around the world and opening in Vancouver. This is a figure of a mobile supervised consumption site in my hometown of about 175,000 people in British Columbia, two injection booths. And the idea here is that this is a service that could provide access to people living in more rural or suburban areas. The other figure is what's called an integrated harm reduction center, in which this is a facility integrated within a residential program for people living with HIV that's only open to people accessing other services. This is also done in other countries. There are integrated supervised consumption services in hospitals, for example, in France. So, I want to spend the last couple minutes talking about barriers, in the United States, and I'm hoping that this will lead into a robust Q&A today and next week. I see a number of barriers to harm reduction in the United States, and there are likely more that I'd love to hear from you about. The first, I think, is a history in this country of punitive racialized approaches to addressing drug-related problems. And that's just a fact. That's the way we've dealt with drug crises for much of the history of the United States. And harm reduction represents a shift in our thinking and in our approach overall to addressing addiction and other drug-related problems. And so, this is something I think that us working in the field need to acknowledge continually and actively address. The second is false narratives and poor public understanding of substance use disorders. And I'm sure many of you experience this in your own clinical work as well. One of the most harmful and deadly narratives that I see is this perception that people will only engage in treatment and services until they hit rock bottom. And so, harm reduction is problematic because you are enabling people rather than, quote-unquote, allowing them to hit rock bottom, and only then would they be willing to engage in treatment. We know from decades of research that this is not how the ideology of substance use disorders work. We know that there are windows of opportunities throughout the course of addiction that allow effective engagement and entry into treatment. We also know that the idea that we should allow people to hit rock bottom is deadly, particularly in the era of fentanyl contaminated in our drug supply. And so, these kind of ideas, I believe, have very deadly consequences and we need to work very hard to address them. The third is that I see a lot of myths out there with harm reduction broadly and supervised consumption services specifically about what they do and what they don't do. You know, the myth that these types of programs increase drug use crime or public disorders in the neighborhoods in which they're located. The myth is that they act as a honeypot for people who use drugs. And that's just not true. I hope I've showed you this through evidence and data that these kinds of services are very local. They provide services to people who live in these neighborhoods, who need these services, who are at risk for overdose. And we do not see this effect in the vast majority of studies that have evaluated these issues. And the final barrier, as I mentioned earlier, are legal. This is a reality in many states and certainly at a federal level. This is where I am starting to see some progress, particularly with the Biden administration. There was a supervised consumption site that was slated to open in Philadelphia during the Trump administration. That administration sued those operators, claiming that it violated what is colloquially known as the crack house statute under the Federal Controlled Substances Act. That went through several appeals. The current Justice Department is in the process of settling this case. This settlement has been delayed several times, but we're optimistic that some positive signal is forthcoming from the Justice Department on this issue, perhaps after the midterm elections. So I've taken you through a flyby of harm reduction, what it is, where we stand in this country, and where we're going. And so I look forward to the Q&A this week and next. I do want to finish by acknowledging our participants for their countless contributions and the willingness to share their stories and their experiences in our research. My wonderful staff, faculty, and students at Brown, and funding from Health Canada, from CHR, who funded the original evaluation of Insight, and funding we currently receive from National Institutes of General Medical Sciences, other institutes at NIH, Arnold Ventures, and the Cigna Foundation. And I want to thank my mentors and colleagues as well for their wonderful friendship, mentorship, and collaboration. And with that, I'm happy to take a few Q&As. I also encourage you to contact me. I'm available via email. Our team, the People, Place, and Health Collective also has a website and an active Twitter account, so you can follow us there. And this is the plug for the next webinar next week at the same time. Over to you, Dr. Kimmick. Yeah. Thank you so much. This is very interesting, very enlightening. And we do have a few questions in the Q&A box. I'll start with the first one. As for overdose prevention centres, curious what strategies have trended across states to move things forward from the political pushback and legal process? I think naloxone is a great example of where we've seen a lot of movement, both politically and practically. You know, there was a time, and you can see in the Rhode Island data, when very little naloxone was distributed, very few states had laws that allowed for broad access to naloxone through pharmacies, like standing orders, or through community-based organizations, for example. You know, and now we're at a place where this is an intervention that's strongly supported by the federal government. There are standing order laws in the vast majority of states, and we're really seeing naloxone get into the hands of people who need it, generally. You know, I think we can do better, we can do more. There are, you know, interventions attempting to go farther. We and the New York City Health Department, as an example, are installing harm reduction vending machines in some neighborhoods that have historically had poor access to harm reduction and treatment services. So these would be basically, you know, as it sounds, vending machines that allow people to anonymously access naloxone. So we see continued progress on this front, but I think that's a nice example of, you know, how we can see progress over a relatively short period when it comes to harm reduction efforts in the United States. Yeah, I was thinking about that while you were speaking, and I was looking at that graph, and I thought, well, is this going to be a model for how these other harm reduction interventions kind of explode over time, too, if it can go as quickly as it did with naloxone? I mean, naloxone has been around for non-medical or use outside the medical field since, what, 1996 or so? Yeah. And so there was a bit of a lag before it caught on within medicine as well. So how do you see, like, things like fentanyl test strips being taken up by medicine, too, and having either physicians or advanced practice providers recommending these things to patients? I think, so, you know, I'll be the first to admit that we do need more research around some of this drug checking technology and fentanyl test strips in particular to understand who is likely to benefit the most, and then to refine our interventions and the distribution of these tools most effectively. What we're learning from the trial and from other studies is that the fact is people who have severe opioid use disorder, who are using street opioids frequently, are, you know, being exposed to fentanyl so often, and in many cases, that's really the only thing that's available at this point in terms of unregulated opioids. So the utility of fentanyl test strips in that context, you know, is questionable. Where I think we're going to see this be effective is in populations of people who use drugs who don't want to be exposed to opioids at all, who have very low tolerance to opioids, where even a small amount of fentanyl can be deadly. And so, you know, that might be people who more casually use cocaine or methamphetamine, or specific populations, queer communities, for example, where we see stimulant use really dominate. And so I think that might help guide us, Dr. Kimmick, in terms of where we deploy these terms of interventions. I think from a treatment perspective, one thing that I'm hearing from some of my colleagues is that they might have patients who are stable on treatment for opioid use disorder, but who might be using some of these stimulants, you know, cocaine, crystal methamphetamine, infrequently. And fentanyl in that context can still be potentially problematic, particularly with methadone. And we do see those overdoses in the surveillance data. And so I think from a clinical standpoint, we need to think more about, could fentanyl test strips be used in that context as an adjunct to treatment for OUD? But that's an area where we do need more work and research as well. There's one question in here, and I think this kind of relates back to your experience when you were at Insight. And when somebody injected and they were using heroin or fentanyl, and they kind of nodded from using, what happened next? I mean, did they stay there or did they leave immediately after injecting? Or what if they do become a little bit drowsy after injecting, what usually happens? Yeah, that's a great question. So I was fortunate to visit the New York City site two weeks ago. And, you know, it's really amazing to see the overdose prevention specialists do their work. They are highly skilled at appropriately responding to overdoses, in my opinion. The vast majority of instances, they're actually able to, you know, bring people out of an OUD just by using oxygen, honestly, rather than naloxone. If they do use naloxone, they start with very small intramuscular doses, not the nasal formulation. So that's one piece, it's really the highly trained staff in these environments who are monitoring and who are using tools to make sure that we're not seeing overdoses happen. In the context, though, the post-consumption environment, most people will stay for a while. There's usually not typically rules around how long they can stay. If they're drowsy or nodding off, that's an environment where they can stay, where they might be able to talk to a peer counselor or connect with other services. One question I get, which is honestly challenging, is what to do about driving. The vast majority of supervised consumption sites are in highly urbanized environments where very few people are coming to the facility by vehicle. And so if and when we start to see these facilities in more suburban environments, I don't have an answer for you yet. I don't know what that will look like. I don't know the best policies in the context of people using such a facility and then driving. So that's an outstanding question. It's one that I want to talk to my Canadian colleagues about as they start to deploy these interventions in more suburban environments. Yeah. Okay, I think, you know, we're coming on the six o'clock hour. We do have some other questions that we're going to copy and bring into next week that are still in the Q&A. But I wanted to encourage everybody to attend our Q&A session next week. It's at five o'clock. And if you do have questions for Dr. Marshall that you'd like answered, please go to the AOAA education page and enter your questions under the discussion tab for next week's or for this week's lecture. And the link is posted in the chat box right now for you to use. So I'd like to thank you again, Dr. Marshall, for this excellent presentation, and we look forward to seeing you again next week. And thank you everybody for attending. Thank you so much. Take care, everybody. We'll see you next week. Bye-bye.

harm reduction

overdose prevention centers

drug use

overdose crisis

drug overdose deaths

racial disparities

geographic disparities

naloxone

fentanyl test strips

community-based clinics