“Politics Versus Policy”: Qualitative Insights on Stigma and Overdose Prevention Center Policymaking in the United States

Abstract

Background:

Federal, state, and municipal governments in the United States have been reluctant to authorize overdose prevention centers (OPCs), which are evidence-based approaches for preventing overdose deaths and blood-borne pathogen transmission.

Methods:

From July 2022 to February 2023, we explored how stigma manifests in OPC policymaking by conducting in-depth interviews with 17 advocates, legislators, service providers, and researchers involved with OPC advocacy and policymaking in Rhode Island, California, Pennsylvania, and New York.

Results:

We found that although jurisdictions differed in their OPC policymaking experiences, stigma manifested throughout the process, from planning to authorization. Participants described OPCs as a tool for destigmatizing overdose and substance use, yet confronted institutionalized stigma and discriminatory attitudes toward people who use drugs (PWUD) and harm reduction from multiple sources (eg, politicians, media, and members of the public). Opposition toward OPCs and harm reduction approaches more broadly intersected with public discourse on crime, homelessness, and public disorder. Employed stigma-mitigation strategies included humanizing PWUD, publicizing the benefits of OPCs to the wider community, and strategically engaging media.

Conclusion:

These findings illustrate the importance of understanding stigma at different stages of the policymaking process to better facilitate authorization and eventual implementation of OPCs in the United States.

Introduction

In 2020, approximately 92 000 unintentional drug overdose deaths occurred in the United States (US), attributed to increases in overprescription and diversion of prescription opioids, and inflows of illicit opioids like heroin and fentanyl into the nation’s drug supply.^1–3 In addition, an estimated 6% of people who inject drugs (PWID) are living with HIV.⁴ While US syringe services programs (SSPs) have been successful in mitigating HIV transmission among PWID, local HIV outbreaks linked to injection drug use are driven by disruptions to SSP access.^5,6 Together, these trends reaffirm the importance of new approaches to mitigate drug-related harms.

One approach is the implementation of overdose prevention centers (OPCs) in communities affected by HIV and overdose.⁷ Also known as safe consumption sites and supervised injection facilities, OPCs reduce opioid-related deaths and transmission of blood-borne pathogens by supervising the use of preobtained drugs and providing sterile equipment.⁸ Outside the US, OPCs have been effectively implemented, showing positive health outcomes.^9–11 For example, in 2003, Canada established the first OPC in North America, and documented a 35% decline in community overdose deaths.¹⁰

Multiple barriers to implementing OPCs in the US exist, including funding constraints, public support, and punitive drug policies.^3,12 Stigma associated with OPCs and those who could benefit from OPC services may hamper implementation efforts.^13–16,20 Studies have shown that stigma and discriminatory attitudes toward people who use drugs (PWUD) attenuates political support for harm reduction services and decreases substance use treatment utilization.^17–19

Stigma is a process by which particular social identities are labeled, stereotyped, and devalued.^16,21,22 While existing in various forms, this study focuses on public, enacted, perceived, and structural stigma.¹⁶ Public stigma consists of negative attitudes espoused by citizens, including social perceptions that substance use is a moral failure or PWUD are dangerous. Enacted stigma is the direct manifestation of stigma toward PWUD, including socially isolating PWUD. Perceived stigma refers to internalization of these actions and beliefs. Last, structural stigma involves institutionally enforced policies and restrictions, limiting opportunities for those stigmatized.¹⁹ Stigma can also be cross-cutting and multidimensional, as exemplified by “NIMBYism” (Not In My Back Yard), which involves neighborhood-level opposition toward implementation of interventions like OPCs, despite conceptual support or approval.²³ These forms of stigma could pose barriers to harm reduction services^15,20; however, how these stigmas manifest in OPC authorization/implementation, and strategies to mitigate them, warrant further investigation.

We, therefore, sought to explore the sources, types, and genesis of stigmas manifesting throughout the OPC establishment process, from the perspective of professionals working on OPC planning, authorization, and/or implementation in 4 jurisdictions with distinct OPC authorization trajectories.

Methods

Setting

Only a few US jurisdictions have made measurable progress toward implementing OPCs. Four US jurisdictions were selected for this study (see Table 1) based on contrasting positions along the phases of OPC authorization and implementation at state and municipal levels.³⁸ Safehouse received approval from the City of Philadelphia but has yet to be implemented due to ongoing federal legislation.^24,25 Rhode Island (RI) became the first US state to pass state-level OPC legislation and plans to open an OPC in 2024.⁷ OPC legislation in California passed the House and Senate in 2022 but was vetoed by the Governor²⁶; however, 1 OPC operated in 2022 with authorization from the city of San Fransisco.²⁷ On November 30, 2021, OnPoint New York City (NYC) launched 2 municipally-sanctioned OPC services, with early evidence suggesting the reversal of hundreds of overdoses.²⁸ OnPoint is currently the only sanctioned US OPC in operation, though numerous unsanctioned spaces exist.²⁹

Table 1.

Summary of OPC Policy in Jurisdictions Sampled for In-Depth Interviews.

Location	Level of authorization	Year of authorization	Attempt details
Philadelphia, Pennsylvania	City	2019	The city approved Safehouse to open an OPC in 2019, but the US District Attorney filed a civil lawsuit against it. In 2020, the court found that the proposed activities did not violate federal law. However, in January 2021, the court ruled against OPC implementation. The case is still pending in federal court.
Rhode Island	State	2021	In July 2021, the state became the first in the United States to successfully pass and enact state-level OPC legislation. The city of Providence has approved plans for an OPC to open in 2024.
New York City, New York	City	2021	The city authorized OnPoint to open 2 OPCs which was completed in November 2021. OnPoint is currently the only municipally-sanctioned OPC in operation in the United States.
California	State	2022	OPC legislation passed the state's House and Senate in 2022; however, the Governor vetoed the bill in August 2022. There was 1 OPC in the city of San Francisco that began offering overdose prevention services in 2022 with local authorization.

Abbreviation: OPC, overdose prevention center; SUD, substance use disorder

Procedures

We conducted in-depth, semi-structured interviews with individuals involved with OPC authorization and/or implementation efforts in these jurisdictions. From July 2022 to February 2023, we leveraged existing academic and community contacts to purposively invite up to 6 respondents in each jurisdiction to participate in the study, using snowball sampling to supplement interviews. Eligible individuals were employed as: lobbyists/advocates, program managers, legislators, academic researchers, attorneys/lawyers, social workers, and public health professionals.

Interviews were conducted in-person, where possible, or via videoconferencing or telephone with a qualitative interviewer (JGR, JT, JNP) who participated in a standardized interviewer training in preparation. After providing verbal informed consent, participants responded to a 5-minute survey eliciting demographics, professional, and lived substance use experiences before interviewing. A semi-structured guide was initially developed for facilitating interviews to capture history of their involvement in OPC/authorization/implementation efforts, key partners and natures of their interactions, local perceptions of OPCs, strategies used to build support and address opposition, and major lessons learned. Interview guides were revisited after each interview, and tailored for participants from distinct jurisdictions to account for contextual differences.

Interviews lasted 40 to 60 minutes and were audio-recorded and transcribed. On completion, participants were offered a $25 VISA card. The study protocol was reviewed and approved by the Lifespan Institutional Review Board.

Analysis

The first author (KK) coded the data manually, with supervision from the senior author (JNP), and another investigator (JGR) reviewed and validated the applied codes. First, transcripts were read twice, line-by-line, and summarized. We used thematic analysis to synthesize interviews, using inductive coding based on the written interview summaries to generate an initial codebook, which was refined through ongoing discussion among investigators.^30,31 This codebook was piloted on 1 transcript, and then we collapsed it into 3 domains: sources of stigma (ie, landlords, neighbors, law enforcement, funders, politicians), type of stigma (ie, public, enacted, perceived, structural), and timing of stigma manifestation (ie, pre/post authorization, pre/post implementation). All strategies used to address stigma were also documented. Once a final codebook emerged, all transcripts were coded by the first author. The presence or absence of codes within each interview was used to ascertain thematic salience. Emerging themes were further refined through ongoing team discussion.

Results

We approached 33 potential participants and completed 17 interviews; participant demographics and occupations are presented in Table 2.

Table 2.

Characteristics of Interviewed OPC Participants in 4 US Jurisdictions (n = 17).

Characteristics	n	%
Jurisdiction
Philadelphia	3	18
California	4	24
Rhode Island	6	35
New York City	4	24
Interview modality
Virtual	11	65
Face-to-face (in-person)	6	35
Sex
Female	10	59
Male	7	41
Age in years (mean, range)	52	33–70
Ethnicity
Non-Hispanic Black	1	6
Non-Hispanic White	16	94
Hispanic/Latinx	1	6
Main occupation
Service Provider	6	36
Lobbyist/Advocate/Organizer	3	23
Lawyer	3	18
Legislator/Health Department	3	18
Academic Researcher	2	12
Family members or relatives experienced SUD	9	53
Friends or close acquaintances experienced SUD	13	77
In recovery from substance use disorder	3	18

Abbreviation: OPC, overdose prevention center; SUD, substance use disorder.

Stigma manifested in multiple ways across phases of OPC establishment, with similarities identified across jurisdictions. Participants described deep-rooted discriminatory attitudes toward PWUD and OPCs as impeding their efforts.

Stigma Toward PWUD and the Interventions Supporting Them

Perceived and enacted stigma toward PWUD and partnering organizations—at multiple levels from multiple actors—appeared to influence OPC policymaking and political support. Participants shared examples of stigmatizing and discriminatory attitudes encountered from communities throughout their work, which manifested from stereotypes:

“Oh, I don’t want those people.” Again, I heard that [from the community]. “Those people,” like they were some kind of insect or bug. “I don’t want those people coming to my neighborhood.” [But] they’re just like us. They just happen to have a problem.

This stigma was also reported toward people living in the same neighborhood. Reflecting on opposition toward OPCs opening in Philadelphia, one participant described the substantial stigma surrounding drug use, with some individuals preferring PWUD to use privately, rather than in the safety of an OPC:

People don’t want their neighbors to know. There is tremendous stigma. You’re a bad family if your loved one uses drugs, so we’d rather your loved one use drugs in the basement and die than be outside being seen going into a supervised consumption site.

Even after successful passage of OPC legislation in RI, participants reported stigma toward PWUD persisted among some constituents. An RI participant reflecting on obstacles during the legislation period described how some members of the public perceived PWUD and OPC services:

When it passed, and it hit the news the next day, the general public . . . out in the suburbs, who aren’t directly impacted by this issue, were like, “What on earth is going on here? No junkies with my taxpayer money.”

The focus on abstinence and structure of some treatment programs was emphasized as further stigmatizing PWUD:

When we’re talking as a community about meeting people where they’re at, I find that we don’t currently mean it. We will meet people when they’re in recovery. We’ll go to their funeral services or just ignore the problem when a person’s at their highest risk of . . . overdose . . . They’re currently shunned from our treatment systems where there’s an expectation of abstinence. When people can’t quite get there on their provider’s terms, they’re stigmatized. They’re abused. They have to submit their bodily fluids for evaluation, which is just asinine.

The criminalization of drug use was perceived to contribute to public stigma surrounding substance use disorders. In California, punitive policies against PWUD and unhoused individuals were explained as politically favorable:

Obviously, [addressing] the overdose [problem] . . . was the main solution we were actually interested in, but from a public perception piece, the problem has been homelessness, and people out and about and tenting, and using drugs out and about [in public spaces].

As described by an NYC participant, drug use stigma intersected with forms of marginalization, including homelessness, poverty, and untreated mental health:

It wasn’t explicitly about drug users. It was about people who were marginalized and poor and experienced trauma and generally treated incredibly poorly in the system and who cost the system a lot of money because they were never really adequately taken care of, either through supportive housing or adequate resources and support. They really weren’t seen even as legitimate clients.

Neighborhood and Municipal NIMBYism Rooted in Stigma and Misperceptions Amplified by Media

Multiple participants expressed that NIMBYism in locations being considered for implementation was omnipresent, as some neighbors believed introducing OPCs would, in turn, attract PWUD and increase crime, despite evidence to the contrary, as this Philadelphia participant explained:

The neighbors seem to think that the syringe exchange brought the people [who use drugs]. The drugs actually brought the people. It’s this ongoing fight, and so some neighbors are like, “If you weren’t here, then all the drugs would go away,” which is kind of a myopic, ridiculous understanding of drug use.

In addition, enacted stigma from communities was reported, with multiple participants sharing that neighborhood organizations harassed those involved. A participant from California involved in OPC research explained:

You’d have neighborhood associations that were pissed and up in arms about homelessness and drug use. They were anti-needle exchange because they saw the needle exchange as being the problem. They would harass the Department of Public Health.

Broadcast media and talk radio were perceived as playing critical roles in fueling OPC stigma in California during the OPC planning process, with OPCs misrepresented in some news discourse as “publicly funded crack houses,” reinforcing stigma toward OPCs and PWUD.

The headlines are pretty outrageous. I think the media is largely driving it . . . Look at the data surrounding property crime, which people can more readily connect to drug use because people think they’re stealing to support their addiction . . . Property crime is not going up as substantially as the media would have you believe.

However, stigma was not the only barrier encountered. For example, an RI participant explained business interests interfered with location selection despite overdoses being common in commercial areas:

I think that they’re picking a place that’s politically feasible . . . It would make the most sense to put them [OPCs] there [overdose hotspots]. [But] there was a lot of political opposition to putting it in the places that were most impacted.

Influence of Stigma on OPC Policymaking and Political Decision-Making

Stigma influenced OPC policymaking in multiple ways. Participants in California and Pennsylvania described a lack of vocal political support for OPC legislation. Public stigma surrounding OPCs were perceived to drive political decision-making related to OPCs.

[Policymakers] won’t say it publicly because they don’t want the pushback from [the] community saying, “You’re soft on crime.” They will tell us all day long in private, “We’re all for this. It’s all good. Go for it, but sorry, we’re not gonna tell that to the media or anyone else.”

Participants from California universally described situations where they believed fear of public stigma toward OPCs and supporting legislators worked against approval of legislation that passed in both the House and Senate:

[Governor] Newsom vetoed it [OPC legislation] because he’s got larger political ambitions, and he didn’t want this to be able to be used against him.

Another California participant explained that while misleading headlines in media drove backlash OPC advocates received, social media platforms amplified stigmatizing voices, which sometimes manifested in political action:

Someone wrote a Twitter rant, and it got picked up everywhere because she positioned herself as a progressive who really cares about these issues, but she’s so frustrated . . . It’s a real backlash against “liberal policies” that I think is fueled by the media, but then is also just picked up on people’s own social platforms. It spreads really quickly, and then it translates to political action . . . Senate Bill 57 was vetoed. Those are real consequences of that narrative.

Similarly, one Philadelphia participant, while reflecting on political opposition to OPC legislation, explained the lack of support from legislators was a reaction to perceived public stigma toward PWUD, ultimately driving policymaking:

In lots of ways, our legislators’ resistance to this is what people really feel about people who use drugs. I think that it drives policy. That feeling drives bad policymaking. It always does, and I think the country’s full of bad policies because we don’t think clearly when it comes to this discussion.

By comparison, RI was successful in passing legislation authorizing OPC implementation at state level. RI participants consistently emphasized how, unlike other jurisdictions, local OPC legislation confronted minimal organized opposition.

We had no opposition to this from law enforcement, which is very uncommon. We had no opposition to this from any entity, as a matter of fact. During committee hearings, there were no adversaries, nobody submitting testimony in opposition to—it was really just smooth sailing.

RI participants attributed this to strong alignment between different advocates and support across the political spectrum, driven in part by the personal toll of overdose on legislators:

A lot of people have lost people . . . [or] know someone that lost somebody. We’re a very small place . . . I think that there is a conversation you’re able to have with people . . . that you’re maybe not able to have in a larger place . . . It presents a different environment than other places.

Having discussions with community members suffering similar losses created space for open dialogue. Participants also described strategic decisions and compromises made during the legislative process to address anticipated or enacted stigma. Specifically, RI participants explained how legislators favored the terms “harm reduction centers” or “overdose prevention centers” over “supervised consumption” to reduce references to stigmatized drug use behaviors and center service delivery.

Strategies Used to Mitigate Stigma in OPC Policymaking and Implementation

Interviews revealed that OPCs are multifaceted interventions with potential to mitigate stigma toward PWUD, aiming to “connect people to care” and “keep people alive” instead of emphasizing drug abstinence or mandated drug treatment. Implementers, like the NYC participant below, framed OPCs as spaces that respected PWUD, which could powerfully counter everyday stigma and discrimination:

OnPoint is a model of a health care center that doesn’t exclude drug users. Like, that’s just what it is . . . And every other space is designed to do the opposite.

NYC implementers invited detractors to their OPC to elicit new thoughts and feelings about the intervention:

It’s emotionally and psychologically challenging for people to be in that space [OPCs] with their beliefs about that space, especially if they’re negative . . . People fear what they don’t understand . . . We’re an organization of transparency. We let people in. We want people to see, ask questions, and have those conversations in real time, not necessarily to achieve full and complete political alignment, but at least to neutralize some of those more damaging thoughts and beliefs.

Other NYC participants concurred that directly engaging elected officials about their preconceptions was an effective strategy for reducing stigma and fear:

A lot of the epiphanies are people . . . realizing that their perceptions of who drug users are and who they represent in communities is inaccurate.

People [in public settings] behave and look differently when they are unsafe and targeted, and have violence inflicted upon them and are disinvested in . . . They look very differently when they’re in a space that’s built for them and to serve them, [especially] when they’re in community with other people . . . People have that “ah-ha” moment, “I show up very differently in a space where I belong verses a space where I don’t belong.”

Another participant, reflecting on experiences of Canadian OPC implementation, emphasized that by centering the voices and advocating for inclusion of all PWUD, US OPC movements could effectively mitigate OPC- and substance use-related stigmas:

We . . . raised up a number of people who had never done media before and got them quite comfortable . . . to tell the [implementation] story in different ways, and make people realize, “Those people are doing good things for their community.” It humanizes people who are at risk of overdose because people are speaking on their own behalf. It’s ultimately very stigma-defying.

In addition, NYC strategically offered free services to the communities who did not necessarily use drugs:

You can’t say, “Not in my backyard,” if the person saying not in my backyard also gets services from you. We have . . . free acupuncture, free acupressure, sound therapy, massage, Reiki—free to any community member . . . not just people who use drugs. We’ve continually tried to make ourselves useful to the community where we’re located.

RI adopted strategies to avoid disruptive consequences of stigma in OPC policymaking, as exemplified by their advocacy and media strategy. Prior to OPC legislation passing, advocates wanted legislation to “stay under the radar” to avoid proactive media engagements—only talking to media after legislation passed to mitigate public opposition and using data to counter emotionally charged opposition:

When it [OPC legislation] passed, we took a different media approach . . . We did some local media for damage control to just thoroughly explain it, but we did it in a way that was based in science and evidence.

However, when speaking with legislators and public health officials, RI advocates found that humanizing people with lived experience and emphasizing their shared goal of engaging marginalized individuals and preventing overdose deaths was more useful. Furthermore, participants from RI and CA also explained how sunset clauses in state-level OPC legislation appeased legislators who were more reticent to authorizing OPCs indefinitely.

Finally, participants discussed US history of harm reduction and the legacy of federal drug control policies. The fraught legal climate was a key driver of unsanctioned “underground” OPCs. While major harm reduction policies (eg, marijuana legalization, statewide SSP expansion) are implemented in the context of legislation undermining these policy gains, participants emphasized that resilience, perseverance, and optimism were needed and used to meet these challenges.

Discussion

These findings illustrate the presence of multiple and intersecting forms of stigma throughout the policymaking process, from planning to implementation, that can have profound social and structural consequences. Participants emphasized the presence of stigma toward PWUD, OPCs, and harm reduction and ways in which these stigmas interfaced with efforts to authorize and implement OPCs. Participants also described how opposition toward OPCs, including NIMBYism, intersected with broader concerns of crime, homelessness, and public disorder.

This study extends literature demonstrating the influence of stigma on harm reduction policymaking and service delivery, which affects the health of PWUD.^17,18,32 Stigmatization of PWUD and harm reduction organizations is an enduring social and structural barrier well documented in the SSP.¹⁸ Previous US research from 2017 suggested that most Americans do not support legalizing OPCs and SSPs.¹⁹ To comprehensively address overlapping stigmas, participants suggested fostering broad coalitions, strategically conducting community outreach and media activities, utilizing scientific evidence, and centering the voices of PWUD and service providers. Notably, OPC implementation has been a vehicle for mitigating the same stigma that hinders adoption of these interventions in the US.

The extant literature has described a range of evidenced-based, multilevel stigma-mitigating interventions for PWUD and harm reduction services. Effective strategies include motivational interviewing and values clarification/alignment within advocacy networks, communicating uplifting stories of PWUD that cultivate empathy, and contact-based training and education programs for clinical professionals.^33–35 Recently, employing person-centered language and messaging, and centering the expertise of people with lived experience, are recommended.^36,37 These stigma-mitigating interventions warrant further investigation in the context of US OPC authorization and implementation efforts.

Our findings are subject to limitations. First, utilizing purposive sampling for recruitment and restricting our eligibility criteria to OPC supporters in 4 states limited recruitment of those who may have divergent perceptions (eg, law enforcement, drug treatment associations) or individuals from other jurisdictions. Internalized stigma may have resulted in underreporting of recovery status. Racial/ethnic minorities were underrepresented in the workforce and among participants. Last, research questions interrogated in the present article were secondary to primary aims of the parent study, which may have constrained emergent inquiry.

Conclusions

We explored the ways overlapping stigmas manifested in planning, authorization, and early implementation of US OPCs. Stigma manifested frequently at various stages and interfered with progress, driven by discriminatory attitudes, policies, structures, and misinformation about PWUD and OPCs. Given these data, existing literature, and past experiences of US harm reduction programs,^16–19 research is needed on strategies to mitigate stigma in the context of OPC authorization and implementation. US implementers and researchers could explore the stigma-mitiga strategies outlined in this study as well as promising educational, counseling-based stigma-mitigation interventions.³⁴ Understanding and addressing overlapping stigmas from various actors is integral to increasing support and access to OPCs for PWUD, creating pathways for federal OPC legalization and, ultimately, preventing overdoses and transmission of blood-borne pathogens.

Highlights.

• Efforts to open Overdose Prevention Centers in the United States has been met with controversy.

• This paper explores the potential role of stigma in Overdose Prevention Center policymaking. Advocates, legislators, service providers, and researchers provided insights into the ways in which stigma impacted their work.

• Future implementation projects will benefit from stigma mitigation strategies to protect service users and staff.