It was almost easy to miss the man “staggering” out of the Felipe’s Taqueria bathroom through the congested lines and bustle of hungry patrons, recalls Debra L. Cambridge, an employee there in charge of events. Luckily, the owner followed him outside and called 911 when, not 10 paces into the parking lot, the man collapsed to the ground from an opioid overdose.
When the responders arrived on the scene, they administered Narcan, a brand of the drug naloxone used to reverse suspected opioid overdoses. According to Cambridge, the man woke up within a couple minutes and was transported to the nearest hospital to be evaluated.
This was the summer of 2019, and Cambridge remembers how the people living on the street outside of Felipe’s would come in to use the bathroom. It typically didn’t pose an issue, but the events that transpired that particular night raised one serious concern: the “opioid epidemic” had found its way into their restaurant.
“We really didn’t have control of people just coming in and using the bathroom, and that’s where it happened,” Cambridge says. “So we decided to get more into training people, even the staff,” to administer naloxone, as well as acquiring Narcan to have on -hand.
Three weeks later, as Cambridge was leaving the restaurant for the night, she was called back in because “somebody fell.” Having worked as a nurse practitioner for over 25 years prior to working at Felipe’s, Cambridge is the go-to person for the restaurant’s health-related incidents. As she walked toward the man, people fed her the information they knew.
“It was kind of crowded in the front space, and he was on the ground, and you could tell,” Cambridge recalls. “He was a young guy, he had a backpack, he was kind of disheveled. And a young guy, unconscious—” she trails off. It was obvious, to Cambridge, that he was overdosing.
Another man was performing CPR until Cambridge ushered him away. Having undergone Narcan training along with the rest of the staff this time around, Cambridge ran and got their on-hand Narcan, came back, and administered the “very easy” autojet mechanism she likens to regular nasal sprays. As with the incident three weeks before, the man woke up within a couple minutes, in time to be whisked away by an ambulance.
Yet those recent cases at Felipe’s were not isolated incidents in Harvard Square, let alone the surrounding city. In 2020 alone, there were 2,035 confirmed fatal overdoses in Massachusetts and 93,331 nation-wide. Many believe having Narcan readily available as the bare minimum to combat rising overdose cases.
Narcan is a form of “harm reduction,” a set of practices that seek to reduce negative consequences resulting from drug use by providing a consistent, legal supply of drugs and spaces to use them. Currently, harm reduction measures are sparsely distributed through Middlesex County, and the philosophy behind harm reduction is divisive, with opponents arguing it encourages opioid consumption. Syringe exchanges are few and hard to find, supervised consumption sites are federally illegal, and nascent Narcan training and distribution efforts face severe opposition.
The city of Cambridge’s own harm reduction efforts have been interwoven with Harvard’s infrastructure, from student-run homeless shelters and University Health Services around the city to the allusory harm embedded in the Sackler Building’s namesake.
“It might not be the local jurisdiction of Harvard,” says Swathi R. Srinivasan ’21, a former leader of the Harvard College Overdose Prevention & Education Students group, but she does not think that means the University can just look away. She is among many Harvard affiliates who believe the University should use its physical presence and legislative prowess to support harm reduction efforts and meet the needs of drug users in Cambridge.
Jason B. Silverstein, a lecturer at Harvard Medical School, started researching the opioid epidemic in the late 2000s “as a way to try to make sense of the deaths of two people I cared a lot about,” he says. Two of his close friends suffered an overdose within six months of one another; one passed away in her own home and had not called any emergency services.
“I became really angry about the misconceptions around substance use,” he says. “Very angry about the inaction of governments and public health officials not doing something about this problem that has left so many people suffering.”
Silverstein explains that many people who overdose don’t seek help because of the stigma surrounding drug use. This stigma, in part, stems from the criminalization of drug possession and sales as felonies. He goes on, “It’s a medical problem that has been treated as a legal problem.”
But the opioid overdose crisis is, of course, in part a legal problem — as well as a medical, urban planning, and public health problem. That multidimensional epidemic has only been exacerbated by the Covid-19 pandemic, and responding to it will require the concentrated efforts of every segment of society: from doctors and public health organizations to community advocates and local governments to architects and restaurants.
Harvard is no exception. To Srinivisan, “It is our civic responsibility to know that this issue is so close to our front door and to know what resources that we have that could be useful to people around us.”
The ‘Overdose’ Epidemic
While it is common to speak of an “opioid crisis” that has afflicted the country since the 1990s, it’s now “a bit of a misnomer,” says Stephen P. Murray, a lieutenant for Northern Berkshire EMS who has responded to well over 100 overdoses in his career. “Technically, we’re in an overdose crisis.”
Murray asserts that this distinction is imperative for truly understanding the landscape of the crisis at present. According to him, we had an “opioid problem” until around 2011 due to the widespread, poorly-managed overprescription of opioid painkillers. Patient privacy laws and a lack of pharmaceutical communication across state lines meant that patients could amass exorbitant amounts of opioid medications for themselves and for sale to others.
“The solution to the opiate problem was to ban widespread prescribing of prescription opiates,” Murray says. Relatively successful efforts to crack down on prescription opioid exploitation in the early 2010s left a vacuum in the drug market that was inevitably filled by blackmarket illicit opioids such as heroin, which is 10 times more potent than morphine, and fentanyl, which is 80 to 100 times more potent than morphine. An opioid problem became an overdose crisis that is now an overdose epidemic.
Murray uses coffee consumption to explain how dangerous an unreliable dose of a drug could be: When you drink a cup of coffee, you can trust the FDA-regulated supply chain. There is an expected dose of caffeine and a reliable result: to feel more alert and get rid of your headache. “Now if you were to drink a cup of coffee from an unsafe supply, say that that coffee had 100 times the amount of caffeine that you were expecting,” Murray continues. “You would have palpitations, you could have a stroke, you could have a heart attack. I mean, there are so many things that can go wrong from having 2,000 milligrams of caffeine, right?”
This is what’s happening to the opioid drug supply. When people are “using,” they could buy two bags from the same dealer that have vastly different concentrations and, without knowing, take a dose of opioids that their body has not developed a tolerance to yet. Each time, they run the risk of overdosing. “It’s such a tainted supply that it’s like a crapshoot,” Murray says.
In Massachusetts, like in the rest of the nation, 2013 marked when overdose fatalities started trending upward as an unregulated supply of opioids, most notably fentanyl, became widely accessible through the blackmarkets. Fentanyl comes with a unique set of challenges because it is cheap to produce and regularly laces other drugs, including other opioids.
Sabrina Voegelin, a licensed social worker, says that when she joined the Cambridge Police Department in 2013, there “wasn’t as much of an outreach response or treatment referrals in place” for overdoses, and instead there was “more of a focus on enforcement.”
She is referring to the enforcement of laws that criminalize unregulated opioid consumption, a practice indicative of one of the most long-standing approaches to combating public health crises related to drug use: “zero tolerance” policies. Zero tolerance attitudes are undergirded by the idea that drug use is inherently risky, and even immoral. Enforcement of such policies takes the form of stopping and arresting drug users or suspected drug users and confiscating their property — which often results in racist and anti-poor policing.
The “enforcement” approach to the overdose crisis has been used both in Cambridge and throughout Massachusetts over the past decade. One notable example, from neighboring Boston, was “Operation Clean Sweep” in August 2019. Precipitated by an altercation between a police officer and a man in Roxbury, the Boston Police Department launched the sweep and forcibly removed drug users, many of them unhoused, from the streets of the South End.
“That was 48 hours of arrests and throwing away people’s belongings and moving people along,” says Rachel N. Bolton, the program and outreach coordinator at the Material Aid and Advocacy Program in Cambridge. The BPD confiscated personal property, destroyed people’s wheelchairs, and made dozens of arrests, according to the American Civil Liberties Union.
In her role, Bolton has helped support people being targeted by the police by offering “food, water, warmth, weather-related support, or anything that someone identifies they need.” During Operation Clean Sweep, her job became harder.
“Sweeps inherently displaced people from where they have set up community and safety nets for each other and are able to respond to overdoses and take care of each other’s wounds,” she says. After the sweep, she found it difficult to find people to whom she can provide sterile supplies or medication, which has led to worse health outcomes.
“It makes things pretty tedious,” Bolton says, explaining that setting up appointments with people has been increasingly difficult. “People may not be able to leave their spot because they’re afraid that police are going to come in and sweep their belongings, take belongings from them, or just otherwise harass and target people.”
Such enforcement of zero tolerance policies does not prevent opioid use or overdoses; it cannot respond to overdoses as they happen or treat people in their aftermath. Instead, enforcement approaches tend to disrupt support networks and displace communities, which only encourages isolated opioid consumption. Two years after Operation Clean Sweep, the number of opioid-related overdoses and fatalities in Boston has not decreased.
‘Not Just a Matter of Willpower’
“What if you had a common community agreement that, ‘We understand drug use happens and this is a way you can do it safely?” asks Joe Wright, a physician and addiction specialist at Boston Health Care for the Homeless Program.
The “way” he is referring to involves harm reduction, an alternative approach to zero tolerance and enforcement practices.
Voegelin says that since she started at CPD in 2013, Cambridge’s response to the overdose crisis has veered away from criminalization and toward treatment and harm reduction. Specifically, she explains that this shift meant “not punishing the individual for having substance abuse or mental health problems” and instead looking for ways to “work with individuals where they’re at.”
Emergency medical services, the fire department, and the police department generally all respond to overdose incidents. In Cambridge, all three services are authorized to carry and deliver Narcan to ensure the patient stays alive.
Then, Voegelin explains, a case management team talks to the patient about recovery services at the hospital and does home or community visits, working with individuals at risk and their families to devise a treatment plan. In her experience, individuals struggling with substance abuse can require a wide range of follow-up services, from medication-assisted treatments to abstinence to rehabilitation.
Jeremy Warnick, the CPD spokesperson, says that the department only relies on enforcement when it comes to larger-scale trafficking and distribution operations, especially given the most recent September 2021 national alert for a steep increase in fake prescription pills with fentanyl.
Case management, Voegelin emphasizes, involves long-term relationships. Even if someone isn’t interested in talking to her at the hospital, Voegelin follows up after 24 to 48 hours with resources like Section 35 — a policy which allows people to place their family members in involuntary treatment for substance abuse.
Many longtime harm reduction advocates like Silverstein and Bolton still believe these municipal efforts based on 911 calls, meeting patients at hospitals, or championing Section 35 are far from sufficient. Many drug users will not call 911, visit hospitals, or follow through with involuntary treatment — which some say is, by virtue of being involuntary, not a far cry from policing.
“Ending the involuntary commitment of people who use substances, which is Section 35 in Massachusetts, is a really important thing for people’s health and wellness and ability to live,” Bolton says. “Criminalization exacerbates the number of fatal overdoses.” She believes the core tenet of harm reduction is the need to recognize “people’s autonomy and drug use as a right.”
Instead, Bolton calls for practices like syringe exchanges and expanding homeless shelters. “Harm reduction is recognizing that people use drugs for a variety of reasons,” she says. “It’s a continuum: so some people use for pleasure, some people have a physical dependency on some substance, and will have withdrawals if they stop using it.”
In 2020, there were 181 overdose-related deaths in Middlesex County, of which the majority were concentrated in Cambridge. When asked why Cambridge is an epicenter of drug use and overdose, Voegelin says, “Cambridge has a lot of resources.” She mentions services for unhoused individuals, homeless shelters, and a syringe exchange, as well as bus and T stations that increase access to the area. “I think [these services] do draw people who are struggling and might need assistance,” she says.
But this relationship is not causal; that is, providing resources does not cause overdoses but rather brings together drug users who might otherwise be using elsewhere, only with less people and resources nearby. And the resources available to people consuming opioids around Harvard Square and in Cambridge are not perfect, evidenced by the high overdose fatality numbers: the Massachusetts’ state government website lists one syringe exchange in Cambridge, supervised consumption sites are illegal, and the unhoused population far outstrips shelters’ capacities.
Interventions like Narcan availability are a “starting place,” according to Wright. It is our way of acknowledging that “people might be using anywhere, because there’s no commonly agreed place where people can use, because we’ve shaped the city in a way that just says, ‘Drug use is not acceptable,’ and that if you have to use, you have to hide.”
Robust public health interventions necessitate just as much effort from non-health sector actors. For instance, Wright explains how currently, a concern for civic order and real estate does not always align with a concern for health. “The people who are primarily focused on what it is like to walk through Harvard Square are not necessarily focused on how we reduce mortality,” he says.
In other words, visible harm reduction efforts like supervised consumption sites, syringe disposals, and Narcan dispensaries cannot become a reality unless every public actor and civic participant believes they have a stake in them. If the police were to arrest people near syringe exchanges or coming in and out of safe consumption sites, those places would not be safe or effective. If cities do not evict people from their homes as happened during Operation Clean Sweep and do not build more affordable housing, then implementing more programs for the unhoused will not solve the roots of homelessness.
As a physician, Wright’s goal is two-fold: to reduce the adverse effects of a substance on the patient’s body, as well as to prevent an overdose if they use again, since abstaining from opioids will decrease their tolerance to them and, as a result, increase their risk for overdosing when they use again. These treatments generally involve both medication and behavioral changes. Wright is careful to note that behavioral changes are “not just a matter of willpower,” but a matter of ensuring a patient’s social support network can see them through recovery.
This social support network is not only shaped by an individual’s characteristics — like their family income, education, and resilience — but also by the city spaces they can occupy and how much power they can hold in these spaces. For example, a drug user’s housing, employment, and family situation might not allow them to commit to weeks or months of medication or therapy — medical interventions are never solely about medicine. And even if they receive all these medical interventions, they may have to live with a permanent disability.
Populations hard hit by these economic and urban factors include, but are not limited to, racial minorities, construction workers, and unhoused individuals. In Massachusetts, unintentional overdose deaths among Black men increased by 69 percent in 2020, the highest of any ethnic group, and construction workers are six times more likely to die of an opioid overdose than people in other professions because they are prescribed opioids for the physical pain their work involves.
Even after months of good faith attempts at treatment, people experiencing homelessness might return to large shelters or return to the streets, where, Wright says, their trauma system can be activated and their symptoms made worse. He questions, “How long can [they] do that? How can [they] get through that pain to a more hopeful place?”
Never Use Alone
When the Covid-19 pandemic began in 2020, not all people had the same choices and options for distancing and isolating.
Bolton recalls how, before lockdown and social distancing procedures were enacted, the “community members experiencing homelessness or living in poverty” she served were initially living in group gatherings or congregate-setting shelters for safety. As the pandemic raged on, homeless shelters closed for undetermined periods of time, and many of the services initially available to unhoused individuals decreased their open hours or shuttered completely. People were forced outside, Bolton says, and left to “use” alone.
People weren’t able to access treatment for an opioid use disorder or withdrawal, or group therapy. Limited access to syringe exchange sites also meant less available Narcan, especially with emergency medical services overloaded with Covid-19 cases.
In Murray’s eyes, “there were a lot of things that were happening kind of all at once, which worsened us to the worst year that we’ve ever had” with the overdose crisis.
“We know that using alone is probably the number one risk factor for fatal overdose,” Murray says. “Non-fatal overdoses are generally non-fatal for one reason, and that’s because there was somebody else there who was able to recognize that there was an overdose and either respond themselves with Narcan, or get help from an outside group.” In other words, the difference between a fatal and non-fatal overdose boils down to connections.
Bolton recalls that a hotline called Never Use Alone has been helping facilitate these connections since 2019. “I know it had an increase in usage during the pandemic,” she says.
Murray, as the director of the New England chapter of Never Use Alone, explains that the service connects people who are using primarily opioids alone with an operator who can get EMS to them if they were to become unresponsive. The service is for the most part anonymous — asking only for the location in which the person is using, down to the room, and the substance and the quantity they believe they are using to help dispatchers locate and help the caller if necessary.
“It’s been really successful. We’ve had more than 4,500 calls. There’s been 28 overdoses on the hotline with 100 percent save rate,” Murray says.
Never Use Alone is a virtual form of supervised consumption sites, meant to keep people safe while they are using. Ideally, a physical site would resemble a health care facility with trained staff. Such sites, similar to syringe exchanges, also ensure that if someone is injecting a drug intravenously that they have a clean syringe to prevent the transmission of blood-born diseases like Hepatitis C and HIV.
At these physical locations, people can get something to eat, injection wounds are taken care of, and workers offer connections to housing services, among myriad other wrap-around services. These locations have been employed internationally for decades to combat opioid overdose deaths, yet in the United States, it remains federally illegal to open one. As a result, all the safe injection sites currently operating in America are “underground,” their whereabouts primarily spread by word of mouth within the drug-using community and by local advocates, according to Murray and Bolton.
Never Use Alone, as a virtual supervised consumption site, has skirted the legal obstacles, occupying a grey area where “nobody’s told us what we’re doing is illegal,” Murray says.
Advocates for supervised consumption sites have put together a bill that would authorize a 10-year pilot program for opening sites in Massachusetts, which is currently working its way through the state legislature.
At a virtual public hearing on Sept. 27, dozens of community members shared testimonies both in favor of and raising concerns about supervised consumption sites over the course of eight hours. Opponents of the bill tended to believe required treatment, and not harm reduction, would prevent harm. Those in the favor questioned why some drugs like opioids are criminalized while those like coffee are not.
Proponents of safe consumption sites and harm reduction more broadly believe fatalities will occur unless we make changes. A man died from overdose in Central Square’s Portland Loo, a stand-alone bathroom, in March 2019, and another died from overdose in front of Blue Bottle Cafe in July 2019. A few months later, Cambridge installed first aid kits with naloxone in 28 city buildings.
The choice is not between drug use or no drug use; it’s between supervised or unsupervised use. As Silverstein puts it, “So long as we don’t have supervised consumption sites, we will have unsupervised consumption.”
’Our Civic Responsibility’
Fahedur Fahed ’22 is ready to respond to unsupervised use anytime because he carries Narcan everywhere he goes. Fahed has spent the last eight years volunteering at the Harvard Square Homeless Shelter, creating lasting relationships with people experiencing homelessness.
“There’s a porta-potty right across the street from the Amazon locker hub,” he says, describing one of his trips to an area of Central Square with a large unhoused population. “I saw someone who looked like they were experiencing an opioid overdose.” After identifying telltale signs like pinpoint pupils and respiratory arrest, Fahed administered Narcan, allowing the man to recover and go to a hospital afterwards.
Though HSHS itself does not allow shelter guests to have substances on them, volunteers on the street outreach team need to be trained to respond to overdoses when they travel through Central and Harvard Square.
“We also carry Narcan in all of our backpacks because we know opioid addiction is a really, really common concern among people experiencing homelessness,” he says.
In fact, from 2010 to 2015 the risk of death from an opioid overdose for an unhoused person was 30 times greater than for the rest of the population.
“I think that anyone can be trained to use Narcan within three minutes,” Silverstein says. “Narcan is incredibly easy to administer. Narcan should be anywhere where people congregate.”
Yet nation-wide, there is resistance to training people to administer Narcan and making it readily available in public spaces, and Harvard’s campus is no exception. Allan M. Brandt, a professor of History of Science who taught a course on the history of the opioid epidemic, believes that this resistance largely stems from the stigma associated with opioids and people who use opioids.
“What’s the difference between teaching people CPR and teaching them appropriate use of naloxone?” Brandt asks. He argues that although cardiac arrest occurs more frequently among older people, college campuses and programs do not hesitate to teach (and sometimes even mandate teaching) CPR to save a life. However, they often don’t lend the same level of concern to people who use opioids.
A group of students who took Brandt’s class in 2018 founded an organization called HCOPES. Their goal was to put what they learned in the classroom into action by going door to door in the Ssquare to offer Narcan training to businesses and writing policy to push for widespread harm reduction measures amongst other initiatives.
Within Harvard, the students advocate for Narcan to be added to AED boxes around campus. When asked whether this Narcan is for the local community or Harvard students, Srinivasan replies, “I don’t think they are mutually exclusive.” She thinks there is likely a nonzero number of overdoses among college students, but hopes their work expands beyond the boundaries of campus. Like Silverstein, she advocates for Narcan at MBTA stops, libraries, and street corners.
Srinivasan says that implementation on campus has been difficult, especially because of pushback from HUHS administration. Initially, HUHS was concerned about how Narcan training and monitoring would work, as well as how effective implementation is given that Narcan was never actually administered even when it was available at other college campuses, as reported in a 2018 NPR article, such as the University of Texas at Austin.
Srinivasan appreciates this concern about data on implementation, but argues that “just because people are not using Narcan doesn’t mean there’s not an opioid crisis.” She says that the boxes would be a source of comfort and encourage more community members to learn to use Narcan. Plus, the drug has no side effects, a relatively long shelf life of three years, and the Massachusetts Good Samaritan Law ensures that bystanders will not face repercussions for administering it. “We’re preventing preventable death,” she says.
Srinivisan says that in addition to practical concerns about Narcan distribution, members of HUHS administration also made arguments against Narcan on the basis of moral hazards — the idea that if we support people in harm reduction with clean syringes or Narcan, that will encourage them in some way to use more.
“The largest obstacle [HCOPES faced] was our stereotyping of people who use drugs, that they’re not like us,” Brandt says. “One of the things we heard quite frequently was there really isn’t an opioid problem at Harvard. But Harvard is in a dense urban area, and we have responsibilities to the wider community here. An argument that we don’t need Narcan on our campus reflects a certain kind of marginalization of people who have real needs.”
Eventually, HUHS denied the proposal, citing that Harvard University Police Department officers already carry Narcan, that maintaining up to date medication would be difficult, and that data on Narcan is not conclusive yet. In 2019, then-HUHS spokesperson Michael Perry wrote to The Crimson, “HUHS will continue to consider the possibility of Narcan in our AED boxes when we have more data.”
University spokesperson Jason A. Newton declined to comment for this story. Two years later, HCOPES is still advocating to have Narcan in AED boxes.
Srinivasan and Jim Stewart, a Harvard Divinity School graduate who runs a homeless shelter at First Church in Cambridge, would like to see Harvard provide institutional support to the community efforts focusing on tackling the overdose crisis. They argue that Harvard can equip every building it owns with Narcan, place syringe disposal containers around public spaces, help empty them, and bring it’s prestige to support legislation for supervised consumption sites. Silverstein, for one, would like the University to purchase fentanyl test strips in bulk, since it could acquire them at a wholesale rate.
“When you’re as big a property owner as the University, you have a responsibility to be part of public health responses to challenges like the overdose crisis,” Stewart says. Knowing how much goes into running a shelter, he sees lots of room for the University to provide more support to the students doing this work.
Stewart cites how the shelter had to shut down in March 2020, when students were sent home from campus, because it was so student-dependent.
Fahed explains that Harvard did not sanction in-person activities during the fall of 2020, so the HSHS street outreach team ran through the University Lutheran Church instead of Harvard. The church provided its sanctuary space for the HSHS team to store their equipment and the volunteer base expanded from undergraduates to members of the general Cambridge community. These volunteers were able to drive further into Kendall MIT, Central Square, South Station, Davis Square and other areas around Cambridge. In the absence of the University’s support, the shelter relied on the community to sustain itself.
Ultimately, the opioid overdose epidemic manifests on a “continuum that includes Harvard students along with people living on the streets in Harvard Square,” Wright says. And similarly, resolving this epidemic requires a continuum of responses: eEconomic and urban planning policies to combat homelessness, less punitive legislation regulating drug consumption, infrastructure for safer use such as supervised consumption sites, acute responses like Narcan training and accessibility, post-overdose case management, and more. All of these responses depend not only on one another, but also on that continuum of actors — from drug users to doctors to staff at Felipe’s to students to University administrators — to succeed.
Reflecting on his nearly 20 years of medical experience, Wright says, “I can think of no moment as immediately powerful and gratifying as just happening to be the person who was carrying Narcan for somebody who was dying on the sidewalk.”
— Staff writer Akila V. Muthukumar can be reached at firstname.lastname@example.org. Follow her on Twitter @akila29m.
— Staff writer Kevin Lin can be reached at email@example.com. Follow him on Twitter @kevinlin0903.