What should officers and departments do to answer the opioid crisis?
In the late 1990s, when I was in my early 20s, I patrolled Flatbush as part of a special NYPD unit. We were the neighborhood’s Scrubbing Bubbles: We broke up dice games, cited the men who got drunk on street corners and harassed women, went after terrible drivers, chased stolen cars and responded to serious crimes in progress. We also hunted for guns and drugs. My partner was a cop we’d nicknamed Bull for his resemblance to the bailiff on “Night Court.”
One early winter evening in 1998, Bull and I were cruising the side streets off Flatbush Avenue. A flash of movement caught our eye. Two people had ducked into an abandoned lot through a hole cut in its fence. We got out of our squad car, sidled up to the lot, and darted through the hole. We startled a man and a woman with their backs to us. The man let something drop. It was a burnt glass pipe, stuffed at one end with a piece of metal screen and a rock of crack cocaine. It was a crack pipe.
The couple was in their 40s. They were terrified and desperate. Their eyes darted back and forth as their bodies trembled. This was the tail end of the crack epidemic, and they were deep in the throes of a long-term addiction. Bull and I looked at each other. A few weeks before, he had yanked a loaded shotgun out of the hands of an old man threatening to kill a deaf mute banging on his front door while I covered him. We may have saved a life. In contrast, arresting the man in front of us for the pipe would be one of the most useless acts of our police careers.
Nearly 25 years later, after rising through the ranks at the NYPD and serving as the chief of police of Burlington, Vermont, I’m an assistant professor of medicine and public health at Brown University. I research the nation’s response to the worst drug overdose epidemic in world history, one that now claims more than 100,000 lives in the United States every 12 months. I went into this line of research because my time as a chief brought into sharp relief just how fractured our approach to addiction was. Policing strategies toward drugs reflect the values of our larger society, which are hopelessly adrift from bases in evidence. I decided to spend my time attempting to anchor policing to the science it needed to save lives, both in terms of what it does and doesn’t do.
Some basic truths have emerged. Naloxone is extremely effective at reversing the respiratory depression that makes an opioid overdose fatal, anyone can safely administer it with the barest of training, and there are no negative effects when it is given in error. But unlike the police, not everyone is plugged into a system of emergency response that can get them to the scene of an overdose in minutes, when minutes count. This makes the police poised to save countless lives, especially in rural areas where other types of help are often too far away. In New York City, where EMS is part of the fire department and is comparatively well resourced, the need for police on the front lines of overdose response is less acute, and they are less likely to be the first to arrive, but officers remain poised potentially to save lives.
Policing strategies toward drugs reflect the values of our larger society, which are hopelessly adrift from bases in evidence.
Research bears this potential out. One study found that police arrived first to overdoses 74% of the time in Tempe, Arizona, and 95% of the victims police treated survived. Another found that of 9,133 police naloxone administrations reported to New York State from 2015 to 2020, officers had arrived first at the scene 86% of the time, and the patients they treated had an 87% survival rate. Anyone can administer naloxone, and anyone who may need it should have access to it, but ensuring the police can administer it is a basic responsibility of government. If we expect police to race to the scene of accidents and pull people out of burning wrecks if they get there first — even though fire rescue is clearly the responsibility of firefighters — then their overriding duty to save lives extends to overdose, too, especially when it is the leading cause of accidental death in the nation.
Yet with the looming threat of drug-induced homicide charges for people who share drugs, or users who sell them to each other, many people are afraid to report an overdose if the police might come. Even with a disparate patchwork of Good Samaritan laws that shield people who call 911 from arrest, there is a lingering fear of routine arrests for minor charges. As a result, people who call 911 often simply say something is wrong, rather than saying a life is in danger from overdose, in the hopes a vague call won’t trigger a police response. Pending research by my colleagues and I found that in one large U.S. city, when a Black person was the overdose victim, the risk of this type of vague report doubled. This should hardly come as a surprise, but we cannot allow it to persist. There should be no hesitation in calling for help and arming responders with accurate information about the problem when a person is dying and seconds matter.
Some things our research discovered were counterintuitive. For example, when police seize opioids in a neighborhood, it exposes the people addicted to them nearby to about double the risk of overdose in the following weeks. People who use drugs exist in a fragile equilibrium, and when they lose their supply, their tolerance goes up, withdrawal sets in, and their risk aversion goes down. When they seek a replacement supply of uncertain potency — one that’s not necessarily stronger, but simply harder to correctly dose — they face a greater risk of death because of the almost nonexistent margin of error for fentanyl. The police I tell this to usually react with denial, but when you explain the mechanism, the experienced ones often say it makes total sense.
Naloxone is extremely effective; ensuring the police can administer it is a basic responsibility of government.
None of this is in conflict with a moral imperative to punish the dealers who profit from vulnerability and suffering, nor does it take into account the possibility that large seizures foreclose new addictions. But that is not generally what the police have in mind these days when they take drugs off the street. If they are going to continue to do so, they must work with their public health partners to reduce the risk of overdose death that emanates from drug enforcement itself. That should mean distributing naloxone much more consistently to all who interact routinely with drug users, improving outreach in the aftermath of drug seizures and truly taking to heart the idea that, in some contexts, enforcement may not only be futile but harmful.
Other studies confirm that we have room to innovate and evolve without acute collateral consequences for public safety. One, released this November by me and my research partner Aaron Chalfin, found that when New York City converted two Manhattan syringe service programs to the nation’s first government-sanctioned safe injection sites, it didn’t increase crime or disorder in their neighborhoods compared to similar areas in the city. These are the facilities that allow people to consume illicit drugs under supervision while trained staff stand by to reverse potential overdoses.
The results were unsurprising: When a syringe service program that serves vulnerable clients in a neighborhood long beset with elevated rates of addiction becomes a safe-injection site, it won’t serve as a magnet for people bent on crime and disorder.
What was more notable in that study was that the NYPD largely stopped enforcing drug possession around these sites, to no discernible ill effect. The decrease in drug enforcement was unmistakable; it jumped off the statistical page when you compared it to the 17 other areas where New York had syringe service programs.
Looking back, I see that one of the things that led me to my work researching the opioid crisis was frustration with how fixable it all seemed to be. Our failures haven’t stemmed from science, but rather from our systems. Early on in my time as chief of police, I learned there are two medications, both of them opioid substitutes, that work extremely well at reducing overdose, staving off withdrawal, and restoring normal function in people: methadone and buprenorphine. Both are barely available in comparison to the widespread need for them amid the present crisis. Methadone is more potent and more tightly regulated, but buprenorphine is just as effective for many people, and has a ceiling on its opioid effects that greatly limits its dangers. When France greatly loosened its restrictions on the medication and widely prescribed it in the midst of a heroin epidemic in the 1990s, its fatal overdoses dropped 79%. When the city of Baltimore followed suit a few years later, ODs fell dramatically there, too.
In some contexts, enforcement may not only be futile but harmful.
Based on this data, I spent my time as chief in Burlington using an NYPD-style Compstat approach to ensure anyone who needed buprenorphine could get it without a waiting list in traditional clinics, the emergency department, the syringe service program and jails and prisons. Overdoses in our county fell 50%, while they rose 20% in the rest of Vermont. The progress persisted for two years, then was lost to the pandemic, but it showed what was possible.
As we in the Burlington police learned about the effectiveness of buprenorphine, we realized that arresting the people who possessed it without a prescription was deterring the use of a lifesaver. In fact, most of the people who used buprenorphine illicitly were attempting to manage their own addictions without easy access to formal treatment. In 2018, my prosecutor and I became the first officials in the country to decriminalize its unprescribed possession. The entire state of Vermont would follow suit, as did Rhode Island in 2021. But everyplace else in America, with the exception of Philadelphia and Washtenaw County, Michigan — where police and prosecutors have also made policy decisions to decriminalize it — buprenorphine remains illegal to possess without a prescription.
When I was commander of two precincts in the NYPD, the 6th and the 50th in Manhattan and the Bronx, young officers would come to me with requests to transfer to the Narcotics Bureau. It was undercover drug work, one of the fastest ways to get promoted to detective other than getting shot or being friends with the police commissioner. I would offer subtle discouragement, asking them if they really wanted to do something so Sisyphean. Taking down cartels has value and signals that there is a moral price to be paid for exploiting human weakness and desperation, but the value of rounding up people contending with addiction and taking down street-level dealers seemed elusive to me. Other than a temporary reprieve for neighbors understandably fed up with local drug dealing, I have yet to see it achieve something lasting and meaningful.
That night back in 1998, Bull and I escorted the couple out of the yard and let them go. I doubt they are alive today; there still isn’t an effective treatment for stimulant addiction. We got back in our car, drove a few blocks, and threw the crack pipe down a storm drain. The sewers of New York City are swollen with these pipes, and needles, and every other type of contraband. They are repositories of the detritus of police who struggle to make sense of what we expect of them when it comes to the human tragedy of addiction.