In overdose prevention centers, people are allowed to use illicit drugs obtained elsewhere, under the watchful eyes of staffers who will rescue them if they overdose. They also provide: a safe place to hang out, get a snack, and meet with peers in recovery; clean syringes and other supplies to prevent infections; and referrals to medical care, including addiction treatment. In Providence, there’s even a treatment center in the same building.

Whether this approach works to reduce overdose deaths is among the questions researchers will examine through a grant from the National Institutes of Health, which also encompasses two centers that opened in New York City in 2021. Studies conducted at more than 200 overdose prevention centers around the world have consistently shown that these facilities save lives, says Brandon Marshall, the principal investigator for the Providence study. Marshall is a professor of epidemiology at the Brown University School of Public Health. “We don’t know exactly how they work in the United States,” he says, because the healthcare system is different. And most of the research has been conducted in large cities like Sydney, Berlin, and Toronto, not smaller municipalities like Providence.

Marshall spoke with Harvard Public Health’s Felice J. Freyer. Their conversation has been edited and condensed.

HPH: What questions do you hope your research will answer?

Marshall: We’d like to understand the impact that overdose prevention centers have on the health of people who use these facilities. We’re enrolling 500 people in Rhode Island and 500 in New York City—people from the overdose prevention center directly and people who use syringe service programs but not OPCs. That will allow us to look at the differences in health outcomes over time between people who use overdose prevention programs and people who are using more traditional harm reduction services.

The second question [we’re asking] is the impact that overdose prevention centers have on the neighborhoods in which they’re located, such as whether the number of non-fatal overdoses changes.

Third, we’re going to be speaking with people who use these sites and the staff who work at them to understand facilitators and barriers to use of the facility.

And the final question: We want to understand how much overdose prevention centers cost to start up and operate in the United States, and what are some of the potential cost savings. We hypothesize that overdose prevention centers save money by preventing emergency department encounters for overdose and hospitalizations.

HPH: Other than being in a small city, is there anything else that’s unique about the Providence facility?

Marshall: There is. It’s directly beside our largest tertiary care center, Rhode Island Hospital. That provides a two-way pathway for folks. A lot of people get discharged from the emergency department after experiencing an overdose, with very little resources and connections to care. We would like to study the extent to which people could be discharged directly to the overdose prevention center. And we will also be studying whether people who use the overdose prevention center then access more advanced care in the hospital setting—say, for severe skin and soft tissue infections.

HPH: Discussions about opening overdose prevention centers have occurred in many other locations. What’s different about the places that have succeeded in building these centers?

Marshall: Some common themes are emphasizing their scientific benefits, developing diverse coalitions of stakeholders inside and outside the overdose prevention space, and then prioritizing transparency, building public trust. We’re a small state, and so almost everyone in Rhode Island has some connection to the overdose crisis. That gives it a sense of urgency.

It also takes courage and leadership. Politically, we’ve had strong advocates here in Rhode Island in both the executive branch and the legislative branch. In Providence, the city council unanimously approved the location. In a recent community survey of 125 residents and people who work in the area, we found that 75 percent support having an overdose prevention center in their neighborhood. People understand this as primarily a health care intervention.

HPH: Many people consider overdose prevention sites illegal under federal law. President Trump’s pick for Secretary of Health and Human Services, Robert F. Kennedy Jr., has said he would try “anything that works,” but also spoke of increasing the role of law enforcement. Are you worried that the Trump administration will try to shut it down?

Marshall: If they do proceed, it would likely involve a lawsuit between the federal government and the state. It would play out in the courts. The incoming administration has not clearly articulated a drug overdose policy. Kennedy has expressed openness to overdose prevention centers in the past, but at the same time, [he has made] concerning comments around rolling back the clock to a more punitive approach. We just have to wait and see where this goes in 2025.

HPH: Meanwhile, in Rhode Island and most states, the overdose death rate has started declining significantly. Will the need for overdose prevention centers also decline in the near future?

Marshall: I would love to see a world where we don’t need so many services because we have successfully addressed the overdose crisis. We are nowhere near that point. Even though overdose deaths are going down, they remain greatly above pre-pandemic levels. Overdose prevention centers still are very much needed.

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I worked at a community health center in the South Bronx for a year, often counseling patients who struggled with addiction. I talked them through treatment options, trying to connect them to the right resources. These already difficult conversations were even harder if children were involved.

Once, I worked with a young woman who had been dealing with severe opioid use disorder for a few years. She had tried multiple times to quit, including through an outpatient addiction medicine clinic, but none of it stuck. She was also a single mother to an eight-year-old boy. No one else in her family could take care of him.

When I suggested that she check into a residential drug treatment program, her eyes widened with anxiety.

“What’s gonna happen to my kid?” she asked.

The truth was, I didn’t know. I wanted her to get the help she needed, and I wanted to help her find a way to keep custody of her son. But I knew this would be very difficult.

“That’s my baby,” she said. “I’m not leaving him.”

This young woman’s situation was far from unusual. In 2017, more than 2 million children had at least one parent affected by opioid use disorder. The figure includes children whose parents died from an opioid overdose as well as children removed from their homes because of their parents’ opioid use. Experts expect that number to rise to 4.3 million children by 2030.

These children are at increased risk for developmental disorders, behavioral issues, poor parental attachment, abuse and neglect, and substance use disorders. Their challenges have ripple effects, from health care and special education spending to child welfare and criminal justice. Yet there is little research on the long-term effects of parental opioid use on children.

I’m part of a research team examining the health outcomes of children experiencing parents’ opioid use disorder. Our research shows that the number of children who are placed in foster care because their parents used opioids increased by 213 percent between 2014 and 2020. Those children in foster care experienced developmental, substance use, and mental health disorders at higher rates than children who remained with their parents. We need to better understand why these children in foster care have poorer health outcomes, and how we can identify and better meet the needs of their nuclear families.

We should also rethink how we treat opioid use disorder among parents. The child welfare system and substance abuse treatment centers have often worked independently. But if we want to break cycles of trauma, we need to increase access to family-friendly treatment for opioid use disorder. Opioid treatment programs should offer counseling on parenting skills and preventing youth substance use. Recent programs targeting parents that combine addiction treatment with parenting therapy have improved both parents’ recovery rates and parent-child attachment.

Treatment should also accommodate childcare. Family-based residential recovery programs that allow mothers and children to remain together during the mothers’ treatment produce more women completing the programs and fewer children removed from their homes by the child welfare system.

The success rate at the Los Angeles SHIELDS for Families’ Exodus program over five years—81 percent—was four times the national average. (The program no longer offers residential treatment.) At Minnesota’s Wayside House, 70 percent of participants’ children remained at home—and 94 percent were free from abuse and neglect—12 months after their parents completed the program, a vast improvement in child welfare outcomes. Earlier this year, New York City Mayor Eric Adams announced similar plans to open an $8 million substance use disorder clinic for pregnant people and new parents, aiming to treat affected families as a unit.

We also need to identify these children as early as possible. The American Academy of Pediatrics recommends that pediatricians learn how to screen for family member substance use and then partner with appropriate mental health, child welfare, and other professionals.

To move this forward, federal and state governments must increase funding for child welfare agencies, addiction treatment programs, youth development programs, and other organizations. The funding needed may seem high, but these efforts will help reduce unnecessary foster care placements, create long-lasting support networks for affected families, and improve these children’s health outcomes.

Finally, we must reduce the stigma around opioid use disorder, including when childcare is involved. We need to shift language from blame to support, to combat misinformation about addiction, and to work to build trust with affected families.

The young mother I counseled ended up joining the waitlist for a family-based residential treatment program where she could bring her son. In the meantime, her son was placed in foster care. Five months later, by the time I stopped working at the health center, she was still waiting.

Image: LightFieldStudios / iStock

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