Journal of Urban Health

, Volume 96, Issue 3, pp 353–366 | Cite as

Willingness to Use Safe Consumption Spaces among Opioid Users at High Risk of Fentanyl Overdose in Baltimore, Providence, and Boston

  • Ju Nyeong ParkEmail author
  • Susan G. Sherman
  • Saba Rouhani
  • Kenneth B. Morales
  • Michelle McKenzie
  • Sean T. Allen
  • Brandon D. L. Marshall
  • Traci C. Green


Safe consumption spaces (SCS) are evidence-based interventions that reduce drug-related morbidity and mortality operating in many countries. However, SCS are yet to be widely implemented in the USA despite the escalating overdose epidemic. The aim of this multi-city study was to identify the factors associated with willingness to use a SCS among people who use drugs (PWUD) in Baltimore, Providence, and Boston, stratified by injection drug use status. Our secondary aim was to characterize the anticipated barriers to accessing SCS if they were to be implemented in these cities. PWUD were invited to complete a cross-sectional survey in 2017. The analysis was restricted to 326 opioid users (i.e., heroin, fentanyl, and non-medical opioid pill use). The majority (77%) of participants expressed willingness to use a SCS (Baltimore, 78%; Providence, 68%; Boston. 84%). Most respondents were male (59%), older than 35 years (76%), non-white (64%), relied on public/semi-public settings to inject (60%), had a history of overdose (64%), and recently suspected fentanyl contamination of their drugs (73%). A quarter (26%) preferred drugs containing fentanyl. Among injectors, female gender, racial minority status, suspicion of drugs containing fentanyl, and drug use in public/semi-public settings were associated with higher willingness to use a SCS; prior arrest was associated with lower willingness. Among non-injectors, racial minority status, preference for fentanyl, and drug use in public/semi-public settings were associated with higher willingness, whereas recent overdose held a negative association. The most commonly anticipated barriers to accessing a SCS in the future were concerns around arrest (38%), privacy (34%), confidentiality/trust/safety (25%), and cost/time/transportation (16%). These data provide evidence of high SCS acceptability among high-risk PWUD in the USA, including those who prefer street fentanyl. As SCS are implemented in the USA, targeted engagement efforts may be required to reach individuals exposed to the criminal justice system.


Supervised injection Substance use Addiction Overdose prevention 



This work was supported by the Bloomberg American Health Initiative. T.C. Green is also supported by the COBRE on Opioids and Overdose funded by the National Institutes of Health (P20GM125507). S.T. Allen is also supported by the National Institutes of Health (K01DA046234). The funders had no role in study design, data collection or in analysis and interpretation of the results, and this paper does not necessarily reflect the views or opinions of the funding agencies. Dr. Sherman is an expert witness for plaintiffs in opioid litigation. We are grateful to the FORECAST study team, collaborators, and study participants. We also thank Rajani Gudlavalleti and Natanya Robinowitz for providing a locally appropriate definition of a safe consumption space.

Author Contributions

S.G. Sherman and T.C. Green conceived and supervised the parent study. J.N. Park and M. McKenzie managed the study implementation. J.N. Park and S. Rouhani completed the analyses with input from K. Morales, T.C. Green, B.D.L. Marshall and S.G. Sherman. J. N. Park led the writing with support from S. Rouhani and K.B. Morales. S.T. Allen provided analysis support for generating the sampling frame. B.D.L. Marshall contributed to survey development. All authors provided critical revisions and approved the final manuscript.

Compliance with Ethical Standards

The study was approved by the Johns Hopkins School of Public Health (#00000287) and the Rhode Island Hospital Institutional Review Boards (#1062206).


  1. 1.
    Scholl L, Seth P, Kariisa M, Wilson N, Baldwin G. Drug and opioid-involved overdose deaths - United States, 2013-2017. MMWR Morb Mortal Wkly Rep. 2018;67(5152):1419–27.CrossRefPubMedPubMedCentralGoogle Scholar
  2. 2.
    Drug Enforcement Administration. National Drug Threat Assessment. Washington D.C.: U.S. Department of Justice; 2017.Google Scholar
  3. 3.
    Sherman SG, Hunter K, Rouhani S. Safe drug consumption spaces: a strategy for Baltimore City. Baltimore, Maryland: Abell Foundation; 2017.Google Scholar
  4. 4.
    Potier C, Laprevote V, Dubois-Arber F, Cottencin O, Rolland B. Supervised injection services: what has been demonstrated? A systematic literature review. Drug Alcohol Depend. 2014;145:48–68.CrossRefPubMedGoogle Scholar
  5. 5.
    Barry CL, Sherman SG, McGinty EE. Language matters in combatting the opioid epidemic: safe consumption sites versus overdose prevention sites. Am J Public Health. 2018;108(9):1157–9.CrossRefPubMedGoogle Scholar
  6. 6.
    Marshall BD, Milloy MJ, Wood E, Montaner JS, Kerr T. Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study. Lancet. 2011;377(9775):1429–37.CrossRefPubMedGoogle Scholar
  7. 7.
    DeBeck K, Kerr T, Bird L, Zhang R, Marsh D, Tyndall M, et al. Injection drug use cessation and use of North America’s first medically supervised safer injecting facility. Drug Alcohol Depend. 2011;113(2–3):172–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Vipler S, Hayashi K, Milloy MJ, Wood E, Nosova E, Kerr T, et al. Use of withdrawal management services among people who use illicit drugs in Vancouver, Canada. Subst Abuse Treat Prev Policy. 2018;13(1):27.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    Irwin A, Jozaghi E, Bluthenthal RN, Kral AH. A cost-benefit analysis of a potential supervised injection facility in San Francisco, California, USA. J Drug Issues. 0(0):0022042616679829.Google Scholar
  10. 10.
    Irwin A, Jozaghi E, Weir BW, Allen ST, Lindsay A, Sherman SG. Mitigating the heroin crisis in Baltimore, MD, USA: a cost-benefit analysis of a hypothetical supervised injection facility. Harm Reduct J. 2017;14(1):29.CrossRefPubMedPubMedCentralGoogle Scholar
  11. 11.
    Mars SG, Ondocsin J, Ciccarone D. Toots, tastes and tester shots: user accounts of drug sampling methods for gauging heroin potency. Harm Reduct J. 2018;15(1):26.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Kral AH, Wenger L, Carpenter L, Wood E, Kerr T, Bourgois P. Acceptability of a safer injection facility among injection drug users in San Francisco. Drug Alcohol Depend. 2010;110(1–2):160–3.CrossRefPubMedPubMedCentralGoogle Scholar
  13. 13.
    Bouvier BA, Elston B, Hadland SE, Green TC, Marshall BD. Willingness to use a supervised injection facility among young adults who use prescription opioids non-medically: a cross-sectional study. Harm Reduct J. 2017;14(1):13.CrossRefPubMedPubMedCentralGoogle Scholar
  14. 14.
    Leon C, Cardoso L, Mackin S, Bock B, Gaeta JM. The willingness of people who inject drugs in Boston to use a supervised injection facility. Subst Abus. 2018;39(1):95–101.CrossRefPubMedGoogle Scholar
  15. 15.
    Glick JL, Christensen T, Park JN, McKenzie M, Green TC, Sherman SG. Stakeholder perspectives on implementing fentanyl drug checking - results from a multi-site study. Accepted in Drug and Alcohol Dependence. Drug and Alcohol Dependence. In press. 194:527–532.Google Scholar
  16. 16.
    Sherman SG, Morales K, Park JN, McKenzie M, Marshall BDL, Green TC. Feasibility of implementing community-based drug checking services for people who use drugs in three United States cities: Baltimore, Boston and Providence. Int J Drug Policy. 2019;68:46–53.CrossRefPubMedGoogle Scholar
  17. 17.
    Sherman SG, Park JN, Glick J, et al. FORECAST study summary report: Johns Hopkins Bloomberg School of Public Health: Baltimore; 2018.Google Scholar
  18. 18.
    Green TC, Park JN, Gilbert M, et al. A multi-site assessment of the limits of detection, sensitivity and specificity of three devices for public health-based drug checking of fentanyl in street-acquired samples. Under review.Google Scholar
  19. 19.
    SIFMA NOW. Available at: Accessed 11/01/2018.
  20. 20.
    Allen ST, Footer KHA, Galai N, Park JN, Silberzahn B, Sherman SG. Implementing targeted sampling: lessons learned from recruiting female sex workers in Baltimore, MD. J Urban Health. 2018.Google Scholar
  21. 21.
    Rhodes T, Singer M, Bourgois P, Friedman SR, Strathdee SA. The social structural production of HIV risk among injecting drug users. Soc Sci Med. 2005;61(5):1026–44.CrossRefPubMedGoogle Scholar
  22. 22.
    Dasgupta N, Beletsky L, Ciccarone D. Opioid crisis: no easy fix to its social and economic determinants. Am J Public Health. 2018;108(2):182–6.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Ciccarone D. Fentanyl in the US heroin supply: a rapidly changing risk environment. Int J Drug Policy. 2017;46:107–11.CrossRefPubMedPubMedCentralGoogle Scholar
  24. 24.
    Macmadu A, Carroll JJ, Hadland SE, Green TC, Marshall BD. Prevalence and correlates of fentanyl-contaminated heroin exposure among young adults who use prescription opioids non-medically. Addict Behav. 2017;68:35–8.CrossRefPubMedPubMedCentralGoogle Scholar
  25. 25.
    Park JN, Weir BW, Allen ST, Chaulk P, Sherman SG. Fentanyl-contaminated drugs and non-fatal overdose among people who inject drugs in Baltimore, MD. Harm Reduct J. 2018;15(1):34.CrossRefPubMedPubMedCentralGoogle Scholar
  26. 26.
    Hunter K, Park JN, Allen ST, Chaulk P, Frost T, Weir BW, et al. Safe and unsafe spaces: non-fatal overdose, arrest, and receptive syringe sharing among people who inject drugs in public and semi-public spaces in Baltimore City. Int J Drug Policy. 2018;57:25–31.CrossRefPubMedPubMedCentralGoogle Scholar
  27. 27.
    Kral AH, Davidson PJ. Addressing the nation’s opioid epidemic: lessons from an unsanctioned supervised injection site in the U.S. Am J Prev Med. 2017;53(6):919–22.CrossRefPubMedGoogle Scholar
  28. 28.
    Wood E, Kerr T, Small W, Li K, Marsh DC, Montaner JS, et al. Changes in public order after the opening of a medically supervised safer injecting facility for illicit injection drug users. CMAJ. 2004;171(7):731–4.CrossRefPubMedPubMedCentralGoogle Scholar
  29. 29.
    Stoltz JA, Wood E, Small W, Li K, Tyndall M, Montaner J, et al. Changes in injecting practices associated with the use of a medically supervised safer injection facility. J Public Health (Oxf). 2007;29(1):35–9.CrossRefGoogle Scholar
  30. 30.
    Mattson CL, O’Donnell J, Kariisa M, Seth P, Scholl L, Gladden RM. Opportunities to prevent overdose deaths involving prescription and illicit opioids, 11 states, July 2016-June 2017. MMWR Morb Mortal Wkly Rep. 2018;67(34):945–51.CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Krieger MS, Yedinak JL, Buxton JA, Lysyshyn M, Bernstein E, Rich JD, et al. High willingness to use rapid fentanyl test strips among young adults who use drugs. Harm Reduct J. 2018;15(1):7.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Sutter A, Curtis M, Frost T. Public drug use in eight U.S. cities: health risks and other factors associated with place of drug use. Int J Drug Policy. 2019;64:62–9.CrossRefPubMedGoogle Scholar
  33. 33.
    Collins SE, Malone DK, Clifasefi SL, Ginzler JA, Garner MD, Burlingham B, et al. Project-based Housing First for chronically homeless individuals with alcohol problems: within-subjects analyses of 2-year alcohol trajectories. Am J Public Health. 2012;102(3):511–9.CrossRefPubMedPubMedCentralGoogle Scholar
  34. 34.
    Tsai J, Mares AS, Rosenheck RA. A multi-site comparison of supported housing for chronically homeless adults: “housing first” versus “residential treatment first”. Psychol Serv. 2010;7(4):219–32.CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    O’Donnell JK, Halpin J, Mattson CL, Goldberger BA, Gladden RM. Deaths involving fentanyl, fentanyl analogs, and U-47700 - 10 states, July-December 2016. MMWR Morb Mortal Wkly Rep. 2017;66(43):1197–202.CrossRefPubMedPubMedCentralGoogle Scholar
  36. 36.
    Burris S, Blankenship KM, Donoghoe M, et al. Addressing the “risk environment” for injection drug users: the mysterious case of the missing cop. Milbank Q. 2004;82(1):125–56.CrossRefPubMedPubMedCentralGoogle Scholar
  37. 37.
    Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, et al. Release from prison--a high risk of death for former inmates. N Engl J Med. 2007;356(2):157–65.CrossRefPubMedPubMedCentralGoogle Scholar
  38. 38.
    Beletsky L, Cochrane J, Sawyer AL, et al. Police encounters among needle exchange clients in Baltimore: drug law enforcement as a structural determinant of health. 20150808 DCOM- 20151030 (1541–0048 (Electronic)). 2015;105(9):1872–9.Google Scholar
  39. 39.
    Beletsky L, Grau LE, White E, Bowman S, Heimer R. The roles of law, client race and program visibility in shaping police interference with the operation of US syringe exchange programs. Addiction. 2011;106(2):357–65.CrossRefPubMedGoogle Scholar
  40. 40.
    Alexander M. The New Jim Crow: Mass Incarceration in the Age of Colorblindness. New York, NY: The New Press; 2012.Google Scholar
  41. 41.
    Cooper HL. War on drugs policing and police brutality. Subst Use Misuse. 2015;50(8–9):1188–94.CrossRefPubMedPubMedCentralGoogle Scholar
  42. 42.
    Cooper HL, Fullilove M. Editorial: excessive police violence as a public health issue. J Urban Health. 2016;93(Suppl 1):1–7.CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Csete J, Kamarulzaman A, Kazatchkine M, Altice F, Balicki M, Buxton J, et al. Public health and international drug policy. Lancet. 2016;387(10026):1427–80.CrossRefPubMedPubMedCentralGoogle Scholar
  44. 44.
    Kerr T, MacPherson D, Wood E. Establishing North America’s first safer injection facility: lessons from the Vancouver experience. In: Stevens A, editor. Crossing Frontiers: International Developments in the Treatment of Drug Dependence. Brighton: Pavilion Publishing; 2008.Google Scholar
  45. 45.
    Anoro M, Ilundain E, Santisteban O. Barcelona’s safer injection facility-EVA: a harm reduction program lacking official support. J Drug Issues. 2003;33(3):689–711.CrossRefGoogle Scholar

Copyright information

© The New York Academy of Medicine 2019

Authors and Affiliations

  1. 1.Department of Health, Behavior, and SocietyJohns Hopkins Bloomberg School of Public HealthBaltimoreUSA
  2. 2.Miriam Hospital and The Warren Alpert Medical School of Brown UniversityProvidenceUSA
  3. 3.Department of EpidemiologyBrown University School of Public HealthProvidenceUSA
  4. 4.Department of Emergency Medicine, Rhode Island HospitalThe Warren Alpert Medical School of Brown UniversityProvidenceUSA

Personalised recommendations