January 11, 2022

California State Assembly Committee on Health
California State Capitol
1315 10th St, Sacramento, CA 95814

Dear Assembly Member Wood:

I am writing on behalf of R Street Institute (R Street) in support of Senate Bill 57, which would allow some localities to operate overdose prevention programs (OPP). These innovative programs will help combat California’s growing drug overdose crisis. We believe that harm reduction strategies, such as OPPs, provide a vital lifeline to communities by reducing the number of drug overdoses and public intoxication; keeping law enforcement and citizens safer; saving taxpayers money; and facilitating treatment for those suffering from substance use disorders. SB 57 is of special interest to us as a right-of-center public policy research organization that promotes free markets and limited, effective government.

Public-health officials have made a lot of progress in understanding substance use and abuse, as well as how addiction can best be treated and managed. However, no cessation or prevention program is 100 percent successful, and many people are often left behind. While society continues the search for more just and effective ways to reduce supply and demand for illicit substances, harm reduction helps people who use addictive substances live long enough to access treatment, providing them with the knowledge and tools needed to protect their health and lives. Existing harm reduction initiatives such as expanded access to overdose reversal drugs and syringe services play an important role, reducing disease transmission and overdose death, but they are insufficient in the current situation.

A Growing Overdose Crisis

More than 100,000 people died of drug overdoses during the 12-month period ending in April 2021. [1] During this time, California experienced one of the largest increases, with overdose-death numbers climbing more than 50 percent annually in recent years. [2] A novel approach is desperately needed to combat this crisis as the current one, which emphasizes incarceration, has proven ineffective. Rather than targeting high-level traffickers, enforcement-driven efforts too often focus on street-level, substance-dependent buyers and sellers, an approach that does little to curb supply, but that strains local jails and pretrial services. [3] Furthermore, incarceration and fear of law enforcement increase the risk of overdose by pressuring people to consume drugs too quickly, reducing the likelihood of seeking emergency medical care and disrupting access to treatment and harm reduction services. [4] These consequences disproportionately affect people of color and individuals living in poverty or experiencing homelessness. [5]

While evidence-based treatment options exist for substance use disorder, they can be hard to come by. In a given year in the United States, only about one fifth of adults deemed in need of specialized substance use disorder treatment are able to access it. [6] Individuals who are uninsured or privately insured access needed treatment at the lowest rates, often citing cost and underinsurance as substantial barriers to care. [7]

Overdose Prevention Programs Save Lives and Improve Health

Overdose prevention programs—also known as safe consumption sites or supervised consumption facilities—represent a promising, evidence-based tool to reduce overdose risk and more efficiently mitigate associated fallout. The National Harm Reduction Coalition defines overdose prevention programs (OPP) as “designated sites where people can use pre-obtained drugs under the safety and support of trained personnel.” Since their inception more than three decades ago, OPPs have been implemented in more than 60 cities in 11 countries. [8] During this time, OPPs have been extensively studied, and research indicates that the programs consistently meet their objectives. One survey of 39 sites operating in Europe found no reported overdose deaths. [9] Data from a Sydney, Australia OPP suggest that in addition to reducing overdose mortality, the facility cut the need for emergency response to overdose by 67 percent. [10] Other studies have found reductions in skin infections, hospital stays and incidence of HIV and hepatitis C. [11] In addition, OPPs reduce the potential for negative interactions between clients and police by reducing stigma and providing access to personnel trained to work with substance use and mental health disorders.

Overdose Prevention Programs Benefit Communities

In addition to directly improving the well-being of clients served, OPPs benefit communities more broadly. By reducing the need for emergency responses and other medical care, the facilities have been shown to save taxpayers money. A model of a San Francisco OPP predicted that a single 13-booth facility would generate $2.33 in savings for every dollar spent, for an annual net savings of $3.5 million. [12] Similarly, a model of a hypothetical OPP in Baltimore projected $7.8 million in savings for a cost of 1.8 million. [13]

In addition, contrary to popular assumptions and some of the concerns raised in objections to this proposed bill, OPPs can lead to a reduction in public drug consumption and many of its consequences. Research shows that the presence of an OPP does not lead to an increase in drug-related crime in the surrounding area. After a site was introduced in Vancouver, British Columbia, car break-ins and vehicle thefts in the neighborhood actually declined. [14] Indeed, harm reduction programs can even improve police-client interactions by reducing stigma and allowing individuals to be more forthcoming about paraphernalia possession, thereby reducing officers’ risk of needlestick injuries. [15]

Furthermore, because OPPs predominantly serve marginalized people–many of whom lack private spaces in which to consume drugs–they lead to less public consumption and extreme public intoxication, while reducing the likelihood that needles and syringes will end up in parks or playgrounds. [16]

Overdose Prevention Programs Facilitate Treatment

Though abstinence is not the primary goal of harm reduction efforts, it is, very often, a welcome outcome. OPPs have been associated with increased initiation of treatment for substance use disorders. [17] This is consistent with a substantial body of evidence showing that harm reduction programs effectively connect those they serve with a wide range of resources, including treatment and detox programs. [18] Harm reduction is a step in the right direction, but California needs a multi-pronged approach. There is no question that treatment and prevention programs are important tools in our efforts to stop substance use disorders and their consequences, including the current overdose crisis. However, on their own, these approaches leave too many people behind. With overdose deaths spiking around the country, the situation demands an approach that is both practical and rooted in evidence. OPPs fit this bill.

R Street believes that government should not interfere with people’s ability to protect their health, and that public health initiatives should benefit the communities in which they are located. [19] In addition to saving the lives and improving the health of populations they directly serve, harm reduction programs such as OPPs reduce public disorder and ensure efficient use of shared resources. It is critical that the Legislature pass Senate Bill 57 to protect the health and welfare of Californians.

Respectfully submitted,

Stacey McKenna, PhD
Senior Fellow
Integrated Harm Reduction
R Street Institute
[email protected]

[1] National Center for Health Statistics, “Drug Overdose Deaths in the U.S. Top 100,000 Annually,” Centers for Disease Control and Prevention, Nov. 17, 2021. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm.

[2] Enrique Rivero, “Overdose deaths up 42% in 2020; largest increases among Black and Latino communities,” UCLA Newsroom: Health+Behavior, May 26, 2021.  https://newsroom.ucla.edu/releases/overdose-deaths-increased-42-percent; Roni Caryn Rabin, “Overdose Deaths Reached Record HIgh as the Pandemic Spread,” The New York Times, Nov. 17, 2021. https://www.nytimes.com/2021/11/17/health/drug-overdoses-fentanyl-deaths.html.

[3] Kristin M. Tennyson et al., Fentanyl and Fentanyl Analogues: Federal Trends and Trafficking Patterns, United States Sentencing Commission, January 2021, p. 28. https://www.ussc.gov/sites/default/files/pdf/research-and-publications/research-publications/2021/20210125_Fentanyl-Report.pdf; Bryce Pardo and Peter Reuter, “Enforcement strategies for fentanyl and other synthetic opioids,” The Opioid Crisis in America: Domestic and International Dimensions, Brookings Institution, (2020). https://www.brookings.edu/wp-content/uploads/2020/06/5_Pardo-Reuter_final.pdf; Marc Levin and Michael Haugen, Overflowing Jails: Addressing High Rates of Rural Pretrial Incarceration, Center for Effective Justice, May 2018, p. 3.  http://rightoncrime.com/wp-content/uploads/2018/05/2018-04-RR-Rural-Pretrial-Incarceration-CEJ-Levin-Haugen.pdf.

[4] Lauren Brinkley-Rubinstein et al., “Risk of fentanyl-involved overdose among those with past year incarceration: Findings from a recent outbreak in 2014 and 2015,” Drug and Alcohol Dependence 185 (April 1, 2018), pp. 189-191. https://www.sciencedirect.com/science/article/abs/pii/S0376871618300644; Bernadette Pauly et al., “Impact of overdose prevention sites during a public health emergency in Victoria, Canada,” PLoS ONE, 15:5 (2020), pp. 7-8. https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0229208&type=printable; Caleb J. Banta-Green et al., “Police officers’ and paramedics’ experiences with overdose and their knowledge and opinions of Washington State’s drug overdose-naloxone-Good Samaritan law,” Journal of Urban Health, 90:6 (December 2013), p. 1103. https://europepmc.org/backend/ptpmcrender.fcgi?accid=PMC3853169&blobtype=pdf; Harm Reduction International, “Harm reduction and prisons: Global State of Harm Reduction 2018 briefing,” 2018. https://www.hri.global/files/2019/03/29/prisons-harm-reduction-2018.pdf.

[5] Ricky Camplain et al., “Racial/Ethnic Differences in Drug- and Alcohol-Related Arrest Outcomes in a Southwest County From 2009 to 2018,” American Journal of Public Health, 110:1 (Jan. 22, 2020). https://ajph.aphapublications.org/doi/10.2105/AJPH.2019.305409; Alison Sutter et al., “Public drug use in eight U.S. cities: Health risks and other factors associated with place of drug use,” International Journal of Drug Policy, 64 (February 2019), pp. 62-69. https://www.sciencedirect.com/science/article/abs/pii/S0955395918302913.

[6] Substance Abuse and Mental Health Services Administration, Results from the 2018 National Survey on Drug Use and Health: Detailed Tables, U.S. Department of Health and Human Services, June 2020, p. 988. https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHDetailedTabs2018R2/NSDUHDetailedTabs2018.pdf.

[7] Kendal Orgera and Jennifer Tolbert, “Key Facts about Uninsured Adults with Opioid Use Disorder,” Kaiser Family Foundation, July 15, 2019.  https://www.kff.org/uninsured/issue-brief/key-facts-about-uninsured-adults-with-opioid-use-disorder.


National Harm Reduction Coalition, “Supervised Consumption Services,” Harm Reduction Issues.  https://harmreduction.org/issues/supervised-consumption-services.

[9] Jo Kimber et al., “Survey of drug consumption rooms: service delivery and perceived public health and amenity impact,” Drug and Alcohol Review, 24:1 (May 29, 2009), pp. 21-24. https://onlinelibrary.wiley.com/doi/abs/10.1080/09595230500125047.

[10]  Allison M. Salmon et al., “The impact of a supervised injecting facility on ambulance call-outs in Sydney, Australia,” Addiction, 105:4 (April 2010), pp. 676-83. https://pubmed.ncbi.nlm.nih.gov/20148794.

[11] Jennifer Ng et al., “Does evidence support supervised injection sites?” Canadian Family Physician, 63:11 (November 2017), p. 866.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685449; Pauly et al., (2020), p. 2.  https://journals.plos.org/plosone/article/file?id=10.1371/journal.pone.0229208&type=printable.

[12] Amos Irwin et al., “A Cost-Benefit Analysis of a Potential Supervised Injection Facility in San Francisco, California, USA,” Journal of Drug Issues, 47:2 (Dec. 13, 2016). https://journals.sagepub.com/doi/full/10.1177/0022042616679829.

[13] Amos Irwin et al., “Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility,” Harm Reduction Journal, 14:29 (May 12, 2017). https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-017-0153-2.

[14] Evan Wood et al., “Impact of a medically supervised safer injecting facility on drug dealing and other drug-related crime,” Substance Abuse Treatment, Prevention, and Policy, 1:13 (May 8, 2006). https://substanceabusepolicy.biomedcentral.com/track/pdf/10.1186/1747-597x-1-13.pdf.

[15] Pauly et al., (2020), p. 8. https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0229208#pone.0229208.ref013; Samuel L. Groseclose et al., “Impact of Increased Legal Access to Needles and Syringes on Practices of Injecting-Drug Users and Police Officers–Connecticut, 1992-1993,” Journal of Acquired Immune Deficiency Syndromes & Human Retrovirology, 10:1 (September 1995), pp. 82-89. https://journals.lww.com/jaids/abstract/1995/09000/impact_of_increased_legal_access_to_needles_and.12.aspx.

[16] Colleen L. Barry et al., “Language Matters in Combatting the Opioid Epidemic: Safe Consumption Sites Versus Overdose Prevention Sites,” American Journal of Public Health, 108:9 (September 2018), p. 1157. https://ajph.aphapublications.org/doi/epub/10.2105/AJPH.2018.304588.

[17] Kora DeBeck et al., “Injection drug use cessation and use of North America’s first medically supervised safer injecting facility,” Drug and Alcohol Dependence, 113:2-3 (Jan. 15, 2011), pp. 172-176. https://www.sciencedirect.com/science/article/abs/pii/S0376871610002693.

[18] S.A. Strathdee et al., “Needle-exchange attendance and health care utilization promote entry into detoxification,” Journal of Urban Health, 76:4 (December 1999), pp. 448-460. https://pubmed.ncbi.nlm.nih.gov/10609594.

[19] Mazen Saleh and Chelsea Boyd, “R Street Integrated Harm Reduction Principles and Priorities,” The R Street Institute, Dec. 14, 2021. https://www.rstreet.org/2021/12/14/r-street-integrated-harm-reduction-principles-and-priorities.