Harm Reduction, Healthcare, and the Opioid Overdose Crisis in Chicago

Alex Rains is an MS1 at the University of Chicago Pritzker School of Medicine. She can be reached at alex.rains@uchospitals.edu

Overdose deaths have been a serious public health concern in the United States for many years, and the COVID-19 pandemic has only highlighted the severity of this crisis. By disrupting access to substance use treatment and increasing psychological, emotional, and socioeconomic stressors, the pandemic exacerbated the risks that drug users face. From May 2019 to May 2020, over 81,000 people in the U.S. died from a drug overdose, an increase of over 10,000 people compared to the previous year. Many of these deaths were driven by synthetic opioids such as fentanyl, which have become the most common drugs involved in U.S. overdose deaths in recent years.1

These figures make it clear that deaths by drug overdose and the opioid overdose crisis have reached a boiling point. What will it take for us, as a country, to reimagine the way we care for the thousands of individuals at risk of fatal overdoses yearly? The current, largely punitive, system has proven ineffective, so how do we reform it to keep those 81,000 people safe?

As we deal with the tragic consequences of the pandemic, we are also presented with the opportunity to build new systems of care—ones that are community-oriented, centered around harm reduction principles, and rooted in evidence. To build a better system, we must first understand current information on drug overdoses and the opioid overdose crisis, including who is impacted and what measures are proven effective in reducing harm. And what better starting point for this process of analysis than Chicago, where our voices carry the most weight and have the opportunity to affect the most change?

Data on opioid deaths in Chicago largely mirror nationwide trends: as of August 2020, likely due in part to the pandemic, opioid-related emergency medical responses increased by 21% and deaths by 9% compared to 2019. A striking 90% of these deaths were driven by fentanyl and heroin. Additionally, 34% of deaths involved cocaine usage, which suggests that individuals may be ingesting mixed products of cocaine and opiates, either knowingly or unknowingly.2

City-wide analysis of these trends only reveals a portion of the full picture because it lacks the geospatial and demographic factors which influence drug use and its impact on Chicago’s diverse residents. Health disparities between racial and ethnic groups permeate rates of opioid-related overdose deaths, with Black individuals dying at the highest rates, followed by White, Latinx, and Asian individuals. Deaths by opioid overdose vary not only by race and ethnicity, but also by geography. Out of 77 total community areas in the city, three—Austin, Humboldt Park, and Lawndale—accounted for over 20% of overdose deaths according to the city health department’s 2018 Opioid Report.3 Two of these three areas, Austin and Lawndale, are comprised primarily of Black and African-American Chicagoans, and in Humboldt Park Black residents still make up a substantial 33% of the population.4 This demographic breakdown has important implications for the typical routes of drug administration and provides important context needed to establish effective harm reduction measures.

Given the differential impacts of the opioid overdose crisis on demographic groups and in community areas, harm reduction measures should be tailored to fit the needs of those at the highest risk of overdose. In Chicago, this means understanding the risks facing Black and African-American residents at danger of overdose. For example, we must consider the preferred route of administration by population in order to build more effective measures. Black Chicagoans are less likely to inject opioids than white and Latinx Chicagoans, and most likely to smoke and snort.5 Ingesting drugs via these routes comes with a specific set of risks that differ from other forms of injection. These preferred routes of administration precipitate a need for two important harm reduction tactics: safe administration supplies and increased infrastructure in community areas where Black and African-American individuals who use drugs might be at risk of fatal overdose.

Smoking and snorting drugs with unsafe or shared supplies can lead to increased transmission of Hepatitis C and HIV as well as substantial damage to the respiratory system, dangers which are especially salient in the context of the COVID-19 pandemic.6 However, harm reduction measures often focus exclusively on the risks associated with drug injection. While the Chicago Recovery Alliance and other groups in the Chicago area do provide drug users with safer snorting and smoking supplies5, access to clean syringes for those who inject drugs is far more widespread. In the same way that syringe exchange programs exist for people who inject drugs, clean supplies should be made widely available to those who smoke and snort to do so safely. Given the racial disparities in rates of overdose deaths and other health consequences of drug use, such as blood borne illness transmission, Black and African-American residents (as well as other drug users who preferentially use these routes of administration) should be provided with the safest mechanisms possible for smoking and snorting drugs. The call for further safe supply programs does not serve to diminish the positive impact and necessity of syringe exchange programs, but to emphasize the need to expand drug administration supplies to better meet the needs of the community. Increasing the availability of safer smoking and snorting supplies is one critical means of addressing this need.

Another approach that should exist in concert with improving access to safe supplies is ensuring that these supplies, along with other harm reduction services, exist throughout the city. We need to focus especially in areas with large Black and African-American communities such as the three high-risk community areas referenced above. The failure to establish equity in harm reduction not only limits access to safe drug administration supplies, but to a world of other harm reduction services as well. Syringe exchange commonly provide a wide range of additional harm reduction services including access to Naloxone (an opioid antagonist used to reverse overdose), fentanyl testing, referrals to treatment and healthcare services, and safer sex supplies. And for individuals who snort or smoke rather than inject drugs these sites may not be inviting enough for them to establish a relationship with community members and providers. This poses a barrier to obtaining harm reduction services for drug use as well as a much broader scope of services, which could drastically improve an individual’s quality of life. If we want to promote the health and wellbeing of our most marginalized communities we have an obligation to build this infrastructure where it does not currently exist, or does not exist beyond the scope of mobile delivery services such as those offered by the Chicago Recovery Alliance.

For too long, medical institutions have embodied much of the publicly held stigma around people who use drugs, leading to mistrust and frustration among community members.6 If we want to empower vulnerable populations and overcome preventable overdose deaths, we are obligated to stand behind harm reduction measures. But support for harm reduction in the abstract is not enough: while these services have long existed outside the scope of the medical community, it is imperative that we continue expanding these services in Chicago, especially where they may be disproportionately serving certain communities while overlooking others. As future policy makers, we must leverage the social power and privilege we have to engage in this activism and encourage the institutions we are a part to do the same. Harm reduction is practical and rooted in compassionate care and social justice. It is part of a better future that we have the power to bring about for Chicago, together.

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1. Overdose Deaths Accelerating During COVID-19. Centers for Disease Control and Prevention. https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html. Published December 18, 2020.
2. Chicago Opioid Update. Chicago Health Alert Network. December 2020. https://www.chicagohan.org/documents/14171/234367/Monthly+Opioid+Update+Dec_31_2020_.pdf/f2a061fc-28fa-ba63-fe54-025a6402dacc?t=1609454730688.
3. June 2020 Release. Community Data Snapshot. June 2020. https://www.cmap.illinois.gov/documents/10180/126764/Humboldt+Park.pdf.
4. 4. Past Training. Chicago Recovery Alliance. https://anypositivechange.org/past-training/.
5. Safer snorting. Canada’s source for HIV and hepatitis C information. https://www.catie.ca/en/practical-guides/hepc-in-depth/prevention-harm-reduction/safer-snorting. Published 2011.
6. Muncan B, Walters SM, Ezell J, Ompad DC. “They look at us like junkies”: influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City. Harm Reduct J. 2020;17(1):53. Published 2020 Jul 31. doi:10.1186/s12954-020-00399-8