One Year Inside a Radical New Approach to America’s Overdose Crisis
Feb. 22, 2023
I. ‘Let’s not crowd her right out the gate.’
It was late summer, and the sun was high over East Harlem. Terrell Jones stepped out of a large black van that advertised help with detox and free hepatitis C testing and scanned the homeless encampment beneath the elevated train tracks across the intersection from where he stood. He was looking for a specific inhabitant, a white woman in her late 20s or early 30s whom he and his colleagues had heard about for weeks but had yet to meet. Like many of the women Mr. Jones encountered in his work, this one was unhoused, was attached to a possibly abusive man and was using hard drugs (crack, in this case). Unlike the others, though, she was also about five months pregnant.
While Mr. Jones checked the periphery, the van’s other passengers — Inspired Jones, Jesus Minier, Carlos Ramirez and Roberto Roman — disembarked and began working. They make up one of three community outreach teams employed by OnPoint, a New York City nonprofit that provides services for people who use drugs. Like their counterparts in the Bronx and Washington Heights, they spend the bulk of their workdays looping through a patch of the city, collecting used syringes and handing out supplies: not only clean needles and fresh crack pipes but also toothbrushes and tampons, Pop-Tarts and juice boxes, wound care kits and warm socks. They’re well known on certain corners, and on this particular morning, small crowds had been waiting for them at almost every stop, including this one.
Mobile outreach is only one part of what OnPoint does. Among other amenities, the organization’s East 126th Street location includes a free laundry and shower, an acupuncture and massage center and the nation’s first publicly sanctioned supervised consumption room, where people can bring illicit drugs and use them under the watchful eye of trained medical staff members. Technically speaking, such rooms are illegal in the United States. Under a law known as the crack house statute, anyone who maintains space for the purposes of facilitating illicit drug use can face hefty fines and long prison sentences. Underground operations have flourished for years in cities across the country. But even in liberal enclaves like Massachusetts and California, officials have balked at aboveground pilot programs.
New York City became the first to reach this milestone in 2018, when the mayor at the time, Bill de Blasio, announced that he would not take any enforcement action against supervised consumption programs, and four of the city’s five district attorneys quickly followed suit.
Since its official opening on Nov. 30, 2021, OnPoint has met with both praise and protest. Shopkeepers and school principals routinely thank Mr. Jones and his colleagues for their daily rounds of needle collection. But local civic groups have been furious about yet another substance abuse program in a neighborhood dense with them and have argued that, however well intentioned, the organization’s approach will only make a bad problem worse. People who are addicted to drugs need tough love and harsh consequences, they insist, not coddling. Community outreach’s mission was therefore twofold: Convince skeptics that programs like these can be a net positive for the community and persuade those with substance use disorders to accept the lifeline that OnPoint was offering.
It was this second mandate that most inspired Mr. Jones, and as the expecting woman came into view, he articulated the group’s strategy. “Let’s not crowd her right out the gate,” he said. “We don’t want to scare her off.”
The group quickly decided that Mr. Ramirez, who was more baby faced than Mr. Jones, would approach the woman and invite her to the van for breakfast and free supplies. Once she was there, Mr. Jones would chat her up. Maybe he could persuade her to visit the center — to see a doctor or even just to use the showers and laundry. If not, he would at least tell her about OnPoint’s programs and give her its contact information.
A few minutes later, she and another woman were picking through bags of donated clothes at the back of the van. They pulled out a pair of slippers and joked about their feet. “Mine are disgusting,” the friend said with a laugh, removing her sandal to reveal gangrenous-looking toenails, caked blood and dirt. Next they found two pairs of the same florid pants. “We should totally do a matching day,” the pregnant woman squealed.
Seeing they were relaxed, Mr. Jones leaned in. He asked when the baby was due and whether she knew yet if it would be a boy or girl. “I think, like, January,” she told him. “And I am praying for a boy.” She told him about her other children, who lived with their grandmother on Long Island. He explained what OnPoint was and what it had to offer.
“It’s going to get real cold out here come December, young lady,” he said gently. “You do not want to have that baby on these streets.” Mr. Jones knew firsthand how mean the streets of East Harlem could be. He grew up in the neighborhood, at the tail end of the crack epidemic, and had spent rough years there, selling and using hard drugs. He had also spent the past two decades trying to rescue others from similar hardship. The key, he said, was building trust. Almost all the people he and his colleagues encountered were, at one point or another, treated terribly by the very institutions charged with helping them. They were leery as a result, and progress took patience.
Mr. Roman and Mr. Minier continued doling out supplies to folks of every kind — young and old, housed and unhoused, Black, white and Latino. Some of them had festering wounds on their arms and legs. (Skin abscesses are common among injection drug users.) Others were clean-cut and using Citi Bikes. Many were well versed enough in the van’s offerings to make specific requests (Pop-Tarts please, not cereal), and almost all of them said “thank you” or “God bless” as they accepted their rations. Only a few asked about detox or other services, and one scruffy 20-something thanked Mr. Minier for saving his life. “I reversed his overdose, like, two weeks ago,” Mr. Minier explained, beaming. “It was the first one I did on the street like that.”
An hour had passed by the time the line dissipated. Mr. Jones was still talking to the pregnant woman, and Mr. Roman nudged him to wrap it up. They had other corners to stop at, and the Bronx team was waiting on them to hand off a shared gas card. “So you should really come visit us soon, young lady,” Mr. Jones said to his new friend. “Oh, yeah,” she replied. “I really need to do laundry. You’ll probably see me there next week.” He knew better than to trust such assurances. “But OK,” he thought. “It’s at least a start.”
II. ‘There’s still deep hatred in this country for people who use drugs.’
The American approach to addiction and overdose needs, desperately, to change. The nation’s half-century war on drugs has failed: We are being pummeled by the third wave of a multigenerational opioid crisis that was triggered by our legal drug industry and our faulty regulatory apparatus. We spend roughly five times as much incarcerating people with substance use disorders as it would cost us to treat them, and the return on that expenditure has been meager at best. Drug use is soaring, and drug overdoses are killing more than 100,000 people a year — more than at any other point in modern history. Life expectancy is declining in the United States for the first time in generations largely as a result. The economy is losing a trillion or so dollars — equal to about 5 percent of its G.D.P. — every year in productivity, health care costs and criminal justice expenditures, among other things.
There is a path out of this quagmire. As studies and reports going back decades have plainly stated, it’s time for politicians and health officials to treat substance abuse like the public health crisis that it is: Repeal or amend outdated laws that push too many people into jails and prisons and not enough into recovery. Invest in treatment so that those who want and need help can get it. And replace abstinence-based policies with ones grounded in reality. “Instead of trying to eradicate drug use, we should focus on minimizing its worst effects,” said Dr. Daliah Heller, the vice president of drug use initiatives at the nonprofit Vital Strategies.
That includes providing people with clean needles so that they don’t contract or spread H.I.V. or hepatitis C; giving them overdose reversal medications like naloxone and promoting supervised consumption so that if they overdose, they don’t die; and helping the most vulnerable get access to housing and basic medical and mental health care so that they can live stably even when they are not abstinent. The concept is known as harm reduction, and its chief goal is to save as many lives as possible. The key to doing that, its practitioners say, is to meet people where they are and to help them without judgment or condescension.
The idea is hardly new. It gained fresh prominence during the AIDS epidemic, when syringe exchanges were created to prevent H.I.V. from spreading among injection drug users, and has since become part of many countries’ responses to the addiction and overdose crisis. But it’s been a tough sell in the United States, where public health is weak in general, personal responsibility is considered paramount and substance abuse has been viewed and addressed for generations through the prism of all-out war. Even people who understand that addiction is a chronic medical condition still tend to stigmatize those who suffer from it. And in communities that have been devastated by decades of epidemic drug use, patience for softer approaches to the crisis is proving thin at best.
“There’s still deep hatred in this country for people who use drugs,” said Keith Humphreys, an addiction expert at Stanford University and a former senior adviser to President Barack Obama on drug policy. “But there’s also legitimate frustration and anger at the havoc that people with substance use disorders can wreak. And policymakers have to be very careful about pushing too far beyond what a majority of people are ready to accept.”
As a result, equivocation abounds: Even as injection drug use soars, syringe exchanges like the one OnPoint runs are struggling — and in some communities shuttering — in part because of backward policies. (Congress has lifted a ban on the use of federal funding to support syringe exchanges but still prohibits the purchase of needles with that money.) Naloxone is in much wider use four years after the Food and Drug Administration approved the first generic version, but it remains difficult to come by in far too many communities that need it.
And despite allocating $30 million to evidence-based harm reduction initiatives — a welcome first for the federal government — the Biden administration has yet to publicly support supervised consumption programs like the one operated by OnPoint. “They have options,” said Leo Beletsky, a professor of law and health sciences at Northeastern University. “They could come out and say that safe consumption sites are not subject to the crack house statute or that they won’t enforce that statute against these sites. But they haven’t done either of those things, and so everyone is basically stuck in limbo.” Several states have expressed interest in using opioid settlement funds to create safe consumption pilot programs, he said. But without a clearer sense of the federal government’s position, few have been willing to try.
New York City’s safe consumption program began underground in the late 2000s when one syringe exchange known as the Washington Heights Corner Project began modifying its bathrooms so that people who shot heroin there could be monitored for signs of overdose. By 2016, enough groups were following suit that the State Department of Health published guidelines for the safe operation of such bathroom programs. And in 2017, the Washington Heights project began expanding its operation — to 13 bathrooms spread across two buildings and a mobile unit from just a few stalls in one location — and promoting it to people who use drugs. Technically speaking, the program was still unsanctioned. But its facilitators were sharing data with health officials.
In 2018 the city’s Department of Health and Mental Hygiene published a report suggesting that a citywide supervised consumption program could save some 130 lives every year and millions of dollars in health care costs alone.
The de Blasio announcement that followed, indicating support for at least four pilot projects across the city, did not come with any money or guarantees about what federal officials might do. But it did clear a path for the city’s Department of Health to work with nonprofits that wanted to bring supervised consumption aboveground.
It was still a tricky proposition. Even with the mayor’s blessing, those who tried it would be risking state or federal prosecution: Landlords could have their property confiscated, donors could lose their money, staff members could go to jail. Without city funding, such programs would be at the perpetual mercy of private donors. And as the very first of their kind, they would face enormous scrutiny and pressure. OnPoint (an entity created by merging two existing harm reduction programs) was the only organization willing and able to assume those burdens. And even it agreed to do so only after the Biden administration began.
“The safe consumption sites had to be built basically from scratch,” Kailin See, OnPoint’s senior director of programs, told me recently. “We had to scour the city for willing landlords, develop all the operating procedures and recruit and train staff from the community.” By the time the organization officially opened its doors — in East Harlem and Washington Heights — the pandemic had fully crested over New York City. Fentanyl was rampant in the drug supply, and overdose deaths were approaching an all-time high.
III. ‘Look at all you beautiful people.’
The new center had been open for just shy of two months when George Cosme first visited in late February 2022 to inject heroin with a friend. It normally takes several minutes for an excess of opioids to trigger the kind of respiratory crisis that can kill a person, but Mr. Cosme’s overdose was almost instantaneous. His face turned bright purple just moments after the heroin entered his bloodstream. His body went almost rigid with clenching. He lost consciousness and then, in a matter of seconds, stopped breathing.
Rayce Samuelson, the overdose prevention specialist on duty, sprang into action just as quickly. He injected 0.4 milligram of naloxone into Mr. Cosme’s thigh muscle, then tilted his chair back onto the floor, laid him flat and inserted a thin tube into his airway. The tube was connected to an oxygen tank and artificial manual breathing unit (or Ambu bag), and as the rest of the room descended into an anxious silence, Mr. Samuelson used it to breathe for Mr. Cosme, slow and steady, in and out.
Mr. Samuelson worked briefly in New York City’s unsanctioned program, in which he would send people into one of four bathrooms to inject and then knock on the door every three minutes to make sure they were OK. Responding to those overdoses was far more difficult. He often found people on the floor with their heads between the toilet and the wall and would have to immediately blast heavy doses of naloxone up their nostrils, which was an effective but very crude way to reverse an overdose.
Having everyone in a clean, well-lit room, where he could see them breathing — or not — felt heavenly by comparison. He found that in most cases he could prevent or reverse an overdose with a simple oxygen mask and that even when naloxone was called for, a microdose was more than enough. Less naloxone, injected right into the muscle, made for much smoother reversals, which in turn made people far more likely to return to the center.
He also found that in an open room he could sell participants on a litany of safer use techniques. He pushed vitamin C instead of lemon juice or Kool-Aid for cutting powders and saline instead of water for cooking them. (Saline is easier on human blood cells and thus easier on the body.) He also promoted booty bumping (injecting drugs up the anus through a syringe without a needle at the tip): It reduces the risk of overdose, helps people preserve their veins and, by some accounts, makes the high last longer. He had not yet had those kinds of conversations with Mr. Cosme, but he was still hoping to get the chance.
Someone had called a code blue over the walkie-talkies, and several OnPoint staff members were now in the room. It was policy to have extra hands on deck in moments like these, in case an overdose was the result of a bad batch that multiple people were using. But so far, just Mr. Cosme was down. As Mr. Samuelson worked the Ambu bag — slow and steady, in and out — Ms. See knelt on the floor, took Mr. Cosme’s ankles in her hands and began bending his legs in a running motion. She, too, had reversed hundreds of overdoses, if not thousands, and she knew tricks that could nudge a slumbering central nervous system into action.
The woman who had taken Mr. Cosme to OnPoint was crying in one corner, and Sam Rivera, the organization’s executive director, was praying softly in another. Mr. Samuelson stopped pumping oxygen for a moment, rubbed Mr. Cosme’s sternum and tried to elicit a response. When nothing happened, he resumed pumping. When some 20 minutes had ticked by, the room broke into a chorus of pleas. “Come on, George,” Mr. Samuelson and the others intoned. “Wake up, George! Stay with us, George! Come back to us, George!”
Finally, after what felt to Mr. Samuelson like an eternity, Mr. Cosme’s eyes blinked open. “Look at all you beautiful people,” he said. The room went rowdy with applause.
Mr. Cosme did not recognize the faces around him or remember how he had ended up on the floor. He knew only that he had passed briefly into a quiescence beyond sleep and that his daughters — two delightful little girls who were killed by their mother’s boyfriend several years back — had been waiting there for him. In truth, he had not wanted to return from that place. But for reasons he could not yet divine, here he was: back on Earth and looking up at some very relieved strangers. They seemed kind. Mr. Samuelson was helping him to sit up. Ms. See was offering him food and asking him, gently, to stay with them a little longer.
IV. ‘I pay more taxes than you.’
The tide of needle litter came in heavy at the start of every month, when benefit checks arrived and people were briefly flush. They took their used syringes to the van to exchange, sometimes by the bucket or bagful, and Mr. Jones and his colleagues collected so many from beneath parked cars, along littered sidewalks and near schoolyards, where they took extra care, that their hands sometimes ached from the effort. There were far fewer by month’s end, but when the first of the month came again, a fresh swell always followed. That tide would turn even more decisively after winter came and folks headed down into the subways or ducked into whatever shelter they could find. But it was late October now, and the days were still mostly warm.
As Mr. Jones and his team made their way through Marcus Garvey Park, collecting needles and distributing supplies in the homeless encampments, a man and woman approached and started an argument with them. “They told us they were tired of what we were doing to their neighborhood and that they would try everything in their power to stop us,” Mr. Jones told me the next day. “They wanted us to stop right then and there.” He and Mr. Minier tried to explain. They were collecting the needle litter, he said, and doing their best to connect people to services so that they would not have to live in the park. But it was no use. The woman accused them of helping the drug dealers and enabling drug use and insisted that because of them, the park was a mess of trash and used syringes.
“These people” leave their stuff all over the place, Mr. Jones remembered her saying. The argument escalated from there, and eventually the man blurted out something that offended him more.
“I pay more taxes than you,” he said, according to Mr. Jones.
“Hold up, homie,” Mr. Jones replied, trying not to lose his cool. “What makes you so sure of that? Is it because I’m Black and you’re white?” Mr. Roman advised his colleagues not to engage further. The way he saw it, the two were deliberately trying to provoke an altercation so that they would have more ammunition for their cause.
Mr. Jones backed off, but he was frustrated. It was at the community’s behest that they were in Marcus Garvey to begin with. The 25th Precinct reached out to OnPoint in July after a string of fatal overdoses in the park, and he and the rest of the team had been going every morning since then. They had even scrambled to open OnPoint at 6 a.m. so that the park’s early morning users would have a place to go. This was no small feat. OnPoint’s Harlem facility was open only Mondays through Fridays from 9 a.m. to 8 p.m. Additional funds had to be secured and budgets and priorities shifted to add three hours to every workday.
Mr. Jones and his team were in regular touch with the Police Department about violent encounters in the park. And after reversing a few especially troubling overdoses — in which people smoking crack seized up and fell over as if they had ingested heroin — they had partnered with the Department of Health to collect and test drug samples. The group was also making progress with some of the park’s long-term residents, more and more of whom were turning up at OnPoint’s headquarters to use the safe consumption room or for other services. (Mr. Jones had managed to get one man who was suffering from cirrhosis and cancer into a medical respite.)
They were trying, in other words, to alleviate exactly the kinds of problems that the angry man and woman were complaining about.
But not everybody saw it that way.
“We were on track to have another Harlem renaissance,” Xavier Santiago, the chairman of Community Board 11 told me this winter. “And a string of missteps and unforced errors have sent us backward by 15 or 20 years.”
OnPoint was just one of those missteps, he said. Gov. Kathy Hochul had recently signed a suite of harm-reduction laws, including one decriminalizing the possession and sale of hypodermic needles. But being forced to host the nation’s first and only supervised consumption program felt to Mr. Santiago like insult on top of grave injury. The city’s highest overdose rates were on Staten Island and in the Bronx. East Harlem was already heavily overburdened with substance-abuse-related facilities, including the largest methadone clinic in the city. And the majority of people using those facilities were coming from outside the community.
The community board had called for a moratorium on new programs, but Mr. Santiago said that that call was ignored and that he and others were deliberately misled by city health officials. “We asked explicitly very early on whether they were considering East Harlem for safe consumption,” he said. “And they told us that they were not.” Now the neighborhood was awash in needles and people who injected brazenly in broad daylight. “I’m walking up 110th Street with my son, and we see a man passed out on the stoop with a needle sticking out of his arm,” he said. “And I have to explain, in language that a 5-year-old can understand, why that is.”
He knew that the issues were complicated and that they did not begin or end with OnPoint. He had spent half his life in the neighborhood and had watched people he loved succumb to injection drug use when he was just a boy. But he still wondered how anyone could, in good conscience, open a safe consumption site across from a preschool or argue with a straight face that handing out needles and crack pipes instead of consequences was helping things.
Those arguments frustrated Mr. Jones and his colleagues. It was true that the Bronx had the city’s highest overdose rate, but OnPoint had not been able to find willing landlords in that borough, and no existing Bronx organization was prepared to assume the risks and burdens of operating a supervised consumption program.
It was also true that people with substance use disorders routinely descended on East Harlem from other parts of the city. But that had more to do with the Department of Homeless Services and the nature of methadone treatment than it did with OnPoint. Residents of the homeless shelters on nearby Wards Island were required to leave their dorm rooms during the day, and the free shuttle they relied on made just two stops, one of them in East Harlem. Methadone patients were also forced to visit the neighborhood daily: Under federal law, methadone must be administered one supervised dose at a time, and there are not nearly enough clinics qualified to provide that treatment in other parts of the city or the state.
Where people with substance use disorders congregated, drug dealers followed, almost as a rule. But eliminating methadone or harm reduction programs would only shift those dealings, not end them. The true solution — to the problem of public drug consumption or syringe litter or drug dealing — was to reduce the demand for drugs. And the key to doing that was to help the people who were struggling.
Mr. Jones knew the contours of that struggle well. He had lost basketball scholarships and good jobs in the roughest patches of his life. He had also spent years in prison and on more than one occasion broken his mother’s heart. He was not just the sum of those difficulties. He had also served in the National Guard and has spent two decades helping to build New York’s harm reduction movement. But he still remembered, vividly, what it was like to be spit on by his neighbors.
“Imagine having that be the only interaction you have with another human all day,” he told me. “I was like an alien, like I had two heads coming out of my neck. And I wanted, more than anything, to fix it. But when you’re that lost, you don’t always know where to start.”
The argument with the Marcus Garvey man and woman had upset him, but later that week, he was heartened to see his pregnant friend lingering near the outreach van at East 115th Street. Her belly was round and full now, and she looked even more tired and raggedy than she did in September. The two talked again, this time away from the rest of the group. When they were finished, she went over to the van, where he gave her a new blanket, sweatpants and warm socks. “These socks are the best,” she said. “I had a pair just like them, but I had to use them as toilet paper the other day because I ran out.” She was laughing. Her facade had not cracked yet, but Mr. Jones was hopeful that it would before the baby came.
V. ‘A cocktail waitress who serves mental health.’
OnPoint’s headquarters consists of a four-story brick building near the intersection of East 126th Street and Park Avenue. Its nearest neighbors include a bodega, a locked Department of Transportation garage, a public housing complex and, directly across the street, a preschool. From a distance, the area can look chaotic. Dealers and program participants regularly clog the sidewalk out front, and drama from the street periodically spills into the building. But Anthony Santiago, the manager of the front room, is a master of de-escalation, and any chaos inside is well controlled as a result.
On the day of Mr. Cosme’s overdose, OnPoint was bustling. Health officials interested in starting their own supervised consumption programs had come from all over the country for a tour. A dozen or so people were waiting to use the supervised consumption room, and a couple dozen more were watching TV, waiting for the showers or laundry to free up or simply napping.
It was amid that stir, as he fought to regain his bearings, that Mr. Cosme first met Samantha Corso, the mental health counselor he would later credit with changing his life.
Ms. Corso joined OnPoint after working for several years in abstinence-based outpatient clinics, in which people were often expelled when they relapsed. It didn’t make sense to her that people had to be sober to get help, when they clearly needed help to get sober.
“I just felt like we were missing a lot of people,” she told me recently as we sat in a sparse office two flights up from OnPoint’s intake room. The work she was doing now did not look anything like what she learned in graduate school. There, symptoms, diagnosis and treatment followed logically, one from the other. Here, people struggled with homelessness, substance use disorders and mental health issues at the same time, and it was not always clear which had caused which. “The assumption outside is that they’ve ended up here due to their addictions,” Hilton Webb, a social worker and close colleague of Ms. Corso’s said. “But it’s often the opposite. People end up on the street because they lose their jobs or their rent goes up. Their mental health deteriorates, and they start taking drugs to cope.”
The streets are a terrifying and deeply uncomfortable place to live. Ms. Corso found that poor personal hygiene was often strategic — a woman who smelled disgusting was far less likely to be raped — and that sleep deprivation and sleep psychosis were at least as common as serious mental illness. She and Mr. Webb knew people who used heroin to sleep or meth to stay awake when they were too afraid to close their eyes.
She also found that a snack, a cigarette, a drink of water and a nap could solve 90 percent of a client’s immediate distress and that providing those things was the fastest way to build rapport. She liked to joke that her experience as a cocktail waitress was at least as useful as any coursework or prior counseling jobs she had done. “It’s not like people are summoned to our office for sit-down therapy,” she said. “It’s more like I walk the intake room striking up conversations and trying to upsell people on services. I am basically a cocktail waitress who serves mental health.”
It was tricky work, she said. Most people she sees have survived severe traumas — rape, molestation, physical abuse — that they had never discussed with another human or even grappled with themselves. For many of them, conversations in her office or around OnPoint are their first meaningful human interactions after something horrific.
When she first met Mr. Cosme, he was cycling between friends’ couches and the street and using heroin and crack regularly. He had served eight years in prison for a felony burglary conviction, had been on parole for two years and was still unemployed. He was affable. But he shut down quickly when talk turned serious. He did not really want anyone to care about him, he said. And he did not want to care about anyone.
He had not thought much about why that was. His life had been rough, by almost any metric. He saw his first killing, in a barrio in San Juan, P.R., when he was 4 years old; he still remembered touching the brains that had spilled across the sidewalk and being yelled at by some adult to get inside. He remembered other things, too, some of them done to him, that he preferred not to discuss. He’d fallen into drugs early and suffered the usual consequences and then some. In 2010, just a few days after he’d gotten out of prison (two years that time, for attempted robbery), his daughters and their mother were stabbed to death.
Still, he did not consider himself a depressed person. And if he eschewed human connection, he was not entirely without ambition. He’d love to have a job — maybe to be a cook again if he could — and his own place one day, if possible. But he spent most of his waking hours in pursuit of something else, a feeling that he could not quite describe. Maybe the closest word to it was “peace.”
Drugs sometimes got him there. Talking about sad things did not, but Mr. Cosme liked Ms. Corso instantly, and in the weeks that followed his overdose, he found himself telling her all sorts of things he had never told anyone. He did not think of it as therapy, whatever that was. They were just talking. She had offered to help get him on buprenorphine, a medication that eases opioid cravings, so he could stop taking heroin, and he was considering it. She was also talking to him about jobs he might want to do one day and places he could live.
It could take a month or more to get someone like Mr. Cosme into a supportive housing or inpatient program. “The amount of paperwork we have to submit and the level of proof we have to provide for every single need is prohibitive,” Ms. Corso said. “It can be a full-time job just getting one person placed, and we are never dealing with just one person.” Paperwork was not the only barrier. People who were ready to enter treatment were often turned away because they stopped using a few days earlier and were therefore deemed not to be in crisis. Mr. Webb had shepherded one actively suicidal man to the hospital, only to be told — almost casually — to take him to detox instead.
The policies and rationalizations undergirding such decisions were infuriating and nonsensical. But the real problem, as everyone knew, was a shortage of available programs. Project Renewal Support and Connection Center, a short-term care facility on East 116 Street, was the team’s favorite option, by far: beautiful facilities, amazing staff. But it had only around 16 beds (13 for men, three for women), and it could keep people only for five or so days.
Ms. Corso and Mr. Cosme talked for many hours in the weeks and months that followed his overdose. He was bright and spirited, warm and occasionally hilarious. She often wondered what his life might look like if not for the traumas he had endured or what it might become with just a little more support. But at the end of the day, when she went home, he returned to the streets.
VI. ‘This was somebody’s brother right here.’
It was late fall — freezing out and not yet 6 a.m. — and Mr. Jones and Mr. Roman had not been at East 116th and Lexington for more than two minutes when someone ran over screaming. A man was unconscious, appeared to have overdosed and needed help immediately. They found him quickly a few feet from where they had parked. He was upright, leaning against an ice machine in front of a bodega, but stiff, bluish and ice-cold. Mr. Jones called 911 while Mr. Roman shot four milligrams of naloxone up his nostrils then laid him flat on the ground and started him on an Ambu bag: in and out, slow and steady, breathe breathe breathe. It had been raining. The man was soaking wet and reeked of urine.
In the few minutes it took emergency services to respond, a small crowd had gathered, half of them cheering Mr. Roman on, the other half shouting obscenities. “Why you even wasting your time on that junkie?” one man yelled. “Stop helping these people and let them get what they deserve,” another said. Mr. Roman kept working the Ambu bag, but his hands were shaking now, and he was crying. “Yo,” Mr. Jones replied, full-throated. “This was somebody’s brother right here. Somebody’s son. Have some decency.” He said a quick, quiet prayer for the man’s soul and then did what he could to comfort his colleague.
It was not the only body the team would find that week.
The next day, a rumor that someone had died in a basement trap house near 129th Street began circulating through OnPoint’s intake room. The first person to say it did not have an address or any details, but before long, a woman came in who did. “I think my friend is dead,” she said, trembling. Mr. Jones, Mr. Santiago and Inspired Jones, the other team member, followed her to the building, where they called 911 and, after talking to dispatch, descended into the basement. Mr. Santiago brought the oxygen tank, but opening the door was enough to make clear that the time for overdose reversal had passed. “The smell flipped my stomach,” Ms. Jones said later. “I think I blacked out for a few minutes.” The woman, known as Lilian, was a regular at OnPoint and had been dead for a couple of days.
Mr. Jones knew Lilian well. He had first met her in Marcus Garvey Park, had coaxed her into the OnPoint community and had nudged her for several weeks to try detox. “You way too pretty for these streets, young lady,” he would tell her. “They going to eat you up if we don’t do something.” She had told him the week before that she was finally about ready to try it. “Next week,” she said. He was planning to hold her to it. She had died over the weekend, while OnPoint was closed.
In response to the deaths, OnPoint’s outreach director, Jason Beltre, gathered all of his teams (including from the Bronx and Washington Heights), divided them into groups of four and five and sent them out to blanket East Harlem. “There’s probably some bad batches out there,” he said. “So let’s double down on everything right now.” They gathered used needles and gave naloxone and fentanyl test strips to anyone who would take them. They hung reversal kits and OnPoint fliers on fences. They also tried to collect drug samples from the dealers and users they encountered, for the city Health Department to test. Some were more than willing — one man gladly gave up a bag after watching three friends nearly die from the same batch — but others were skittish, and at least one group was overtly hostile, following the workers for several blocks in an effort to intimidate them.
While outreach was responding to that crisis, a new one erupted in OnPoint’s offices. News had broken that Ms. Hochul was rejecting the Opioid Settlement Advisory Board’s recommendation to put at least some of the coming settlement money toward supervised consumption programs. The decision was not entirely surprising. Her excuse was the same as her counterparts’ in California, Massachusetts and elsewhere: The state could not invest in a project that the federal government might easily deem illegal.
But it created a real problem for OnPoint. The organization could not use any of the money it was receiving from the state or the city to fund its two safe consumption rooms. Its managers had been relying on private funds to cover those costs, but that private money was running out. They had been hoping that settlement funds, combined with some changes in state policy, would close the gap. Ms. Hochul’s decision meant they would have to do another round of fund-raising. If that effort failed, the supervised consumption room would have to close, and all the people who had come to rely on it would return to injecting on the street or in places like the basement where Lilian’s body was found.
In the weeks that followed Lilian’s death, Mr. Jones and several others made a series of trips to Albany, sometimes piling into one of the OnPoint vans and often heading out at the crack of dawn. They met with the Opioid Settlement Fund advisory board and demonstrated outside Ms. Hochul’s office. They also walked the halls of the State Capitol, proselytizing about the import of their work and underscoring the precariousness of the moment: They had intervened in nearly 700 overdoses, saved some $19 million in emergency medical response costs and become a hub for hundreds of people with no other community to speak of. But the situation was still dire, and they needed support not only to continue but to expand.
The governor was being criticized by both sides of the harm reduction debate just then. Opponents blamed her harm reduction policies for the uptick in public drug use. Proponents saw her decision against supervised consumption as an act of political cowardice. Yes, the legal landscape was tricky. But Rhode Island had just authorized a two-year supervised consumption pilot project. And officials from across the country were reaching out to OnPoint for all manner of guidance — a sign that many others were hoping to do the same. With the advisory board behind her and two facilities already up and running in New York City, they argued, Ms. Hochul should be leading this charge.
VII. ‘Whose houses are they breaking into?’
Not all the news was bad. As fall yielded to winter, Mr. Cosme was alive and abstaining from heroin. He was off parole, too, no longer state property for the first time in years. To his great pride, he had reversed an overdose himself, out on the streets, one early evening in late fall. He was still meeting with Ms. Corso regularly, and if he had not found his way into stable housing or gainful employment, he had developed at least some insight into the forces that motivated him. “I don’t want to care about anyone because I don’t want to lose anyone,” he told me in early December. “And I don’t want anyone to care about me because maybe I don’t think I deserve that.” He was still using some drugs; he had never really known a life without them, he said. But for the first time in forever, he felt his future was speckled with hope.
Mr. Samuelson, who had reversed Mr. Cosme’s overdose, was proud of him and of the other lives he and his colleagues had saved and of the community they were building. But he was also haunted by Lilian’s death. “She was a really, really lovely individual,” he told me, choking up, a few days after her death. “Hard to work with sometimes, but she always showed up with her makeup on fleek.” He had seen her nearly every day for many months, and it troubled him to know that at the very moment she lay dying, he and his colleagues were out celebrating OnPoint’s first anniversary. “It was a Saturday, and we were drinking and partying, and she was out there, with no place to go.” OnPoint had been trying to secure the money and permissions needed to stay open nights and weekends but so far had come up short.
In the meantime, they were still working to win the neighborhood over. They had begun a regular vaccination drive at the preschool across the street, given the school’s administrators a tour of OnPoint and met with parents to discuss concerns. “They’ve really worked hard to be good neighbors,” Gretchen Buchenholz, the school’s longtime executive director, told me. “And to be clear, a lot of the problems that get laid at their feet are things we’ve been dealing with since long before they even existed.”
But parents were still largely ambivalent about these new neighbors. They were not uniformly opposed to the mission of harm reduction. But they worried for their children. “We have never had this many dealers or users on this corner before,” Francesca Barreiro, whose 3-year-old attends the school, told me. “We find needles on the street and poop on the school doorsteps, and some of us don’t feel comfortable allowing our children on educational walks anymore because of the environment.”
Things had improved a bit recently, she said, after parents complained and a meeting was held. OnPoint staff members were now patrolling the school during student drop-off and pickup. But she worried that such fixes would not prove sustainable, and she felt strongly that a safe consumption program shouldn’t have been situated across from a school in the first place. “What happens when they are short-staffed and my 3-year-old finds a needle that they miss? Or someone who is high or has serious mental health issues wanders over to the school?”
Similar frustrations were echoing well beyond OnPoint’s corner of East Harlem. For example, Bistro Casa Azul was a good 20-minute walk from there, but at a recent Community Board 11 meeting the restaurant’s general manager, Lou Martins, drew a direct link between the public drug use and crime he was seeing and the advent of supervised consumption.
Mr. Martins said he could no longer count the number of people he’d found cooking, injecting or passing out from drugs on the streets and stoops around his restaurant or the number of needles he’d been forced to collect. He said there were at least a dozen robberies or attempted robberies reported around his block in the past two weeks alone. “Where do they go when they leave high or before they come and they need to go get dope so they can go shoot it up in a safe injection site?” he asked. “Where are they robbing? Whose houses are they breaking into?”
It was late November, and the Manhattan district attorney, Alvin Bragg, had joined the group to answer questions and address what concerns he could. The list of frustrations was long and the roots of those frustrations entwined: The vertical patrols responsible for policing public housing stairwells were notoriously understaffed. The police did not respond quickly enough to calls. And in a neighborhood riddled with petty crime, there were not nearly enough cameras to deter or help catch offenders. But for the meeting’s attendees, public drug consumption — and by extension, OnPoint — still ranked high among those grievances.
Xavier Santiago, the board’s chairman, asked whether the D.A. would consider prosecuting drug dealers operating around OnPoint under the Trespass Affidavit Program, which enables police officers to arrest people who don’t live in a given building if they are found loitering near it. “Some of the residents in that area have complained about the dealing that’s now happening in their buildings,” he said. The residents were often old and the dealers young and armed. “We want to heal people, but the dealers take advantage of that.”
The Trespass Affidavit Program, also known as Operation Clean Halls, was shuttered in 2020 after a rash of lawsuits and at least one constitutional challenge. When it came to trespassing, Mr. Bragg said, unless there was violence, there was not much the D.A.’s office could do. Still, he seemed broadly sympathetic. He did not live far from East Harlem, he said. And he agreed fully that the area was overconcentrated with substance abuse programs.
Mr. Martins and others hoped those remarks signaled support for broader changes, including a rollback of Ms. Hochul’s harm-reduction edicts. They wanted safer, cleaner streets, free of dealers and users and all the trouble they brought. And Mr. Martins could not see how giving people needles and letting them shoot up in public would get them there. “I think that there’s the really beautiful spirit in trying to give everybody help,” he said. “But at some point the residents and the community members and the taxpayers of East Harlem have to gain some kind of precedent over and above the violators and criminals and drug addicts that are blighting our community.”
VIII. ‘The science doesn’t really matter.’
In its first year of operation, OnPoint welcomed more than 2,000 people into its program — at least half of whom became regular participants. It’s too early to say whether the program’s efforts will translate into better long-term outcomes for them. Opioid addiction, in particular, can take years to recover from, even in the best of circumstances, and the people who go to OnPoint seeking help tend not to be in the best of circumstances.
But there are reasons for optimism. Dozens of studies, from the 200 or so safe consumption programs around the world (many of them decades old), suggest that such programs can not only reduce overdose deaths but also increase participation in substance abuse treatment. And scores more, from the United States and elsewhere, indicate that needle exchanges can do the same. Compared with drug users who do not use such programs, people who use them are far less likely to spread H.I.V. and hepatitis C. By some estimates, they are also more than five times as likely to enter treatment.
That data is imperfect, to be sure. But most addiction experts and public health officials believe there is enough solid evidence to justify giving programs like OnPoint a chance.
The odds of success for any such program would be vastly improved by additional support. It’s difficult to treat people for substance use disorders when they are living on the street or with untreated mental illnesses or when treatment is so scarce. And it’s unreasonable to expect any one program to address all the societal failures that have led to the current addiction and overdose crisis. But in the vortex between what people with substance use disorders need and what the rest of society is willing to give, hard truths about what success requires often get lost.
“Science doesn’t really matter,” Mr. Humphreys said. “It’s about culture and politics and all the things we vote for and all the things we fight over.” For society to move forward from its failed and waning drug war — and for harm reduction to succeed where that war failed — it’s those fights that will have to be resolved.
For now, the nation waffles, and the death toll rises.
IX. ‘Community is like the antidote to stigma.’
The sun had not yet risen, but the people standing near the intersection of 116th and Lexington were visible by the light spilling out of a bodega and a sign offering cash loans in electric red. Some folks bounced with stories and jokes, but most leaned quietly against the gates of closed shops. They surrounded the OnPoint van as soon as it parked. Winter had come. The cold was biting, and their needs were voracious. They wanted needles and cookers, warm clothes and breakfast. They wanted naloxone, too, but not fentanyl test strips because, in truth, they wanted fentanyl. Heroin without it was considered old man junk.
While Mr. Minier and Mr. Roman worked the van, Mr. Jones patrolled the surrounding streets for whatever needles he could find in the darkness. Lately he had been seized by the feeling that for all their efforts — in the prevention room and on the street and in Albany — they had managed only to place a Band-Aid over a bullet wound. Clean needles, naloxone and a safe place to use were no-brainers. Of course people should have those things. But what the people he saw every day really needed was housing, mental health care and help with job placement. They needed a pathway to stability and a touch of human decency.
What they needed, he often thought, was community.
It was community that had saved him. Nature had made Mr. Jones an introvert, and traumas stretching back to childhood had made him a loner. He was not quick to trust or to let people in. But when he showed up at a Hunts Point warehouse one night some 20 years back to volunteer with the New York Harm Reduction Educators, the people he met welcomed him and treated him with respect — and in so doing, created a space for trust to grow. He opened up slowly from there, like a clenched fist finally able to unfold into an open palm.
And as the years passed and he graduated from volunteer to program manager to advocate, those people cheered him on. When he stumbled, they held him up. When he suffered losses — when his daughter died of lupus and his mother died of Covid and his son died from a gunshot wound — they supported him. And more recently, when he almost died himself (first from pneumonia, then from atrial fibrillation), they showered him with love. “That is what a community does,” he told me later that morning. “Community is like the antidote to stigma.”
Mr. Jones had been heartened by the progress of recent years. The president had allocated funds to harm reduction. The governor had decriminalized syringes. And for now at least, safe consumption was a reality in New York City. But things were still rough, and it seemed clear to him that the war he and his colleagues had been watching unfold for the past year would continue to escalate for the foreseeable future.
That war was not between people who wanted harm reduction and people who did not. It was between basic human biology and the pills and powders circulating through the city on any given day.
In the overdose prevention room, Mr. Samuelson was watching that narrow window, in which he could reverse an overdose quickly with a simple oxygen mask, close and open in tandem with the amount of fentanyl in the drug supply: When the concentration increased, more people would overdose immediately, as Mr. Cosme did. When people developed tolerance to the higher doses, things would even out. And when the concentration increased again, the cycle would start anew.
On the street, Mr. Jones worried about the growing roster of adulterants, including an animal tranquilizer known as xylazine that was ravaging Philadelphia, and how they might impede his team’s ability to reverse overdoses quickly. Testers from the Department of Health had not yet identified xylazine in many East Harlem samples, but Mr. Jones had already seen a few suspicious overdoses in which naloxone had barely worked, and he figured it was only a matter of time.
It was at their second stop that morning, near the elevated train at 115th and Park, that Mr. Jones found his pregnant friend again, shivering under a thin, wet blanket. It had rained earlier. Her hands were trembling, and she looked about ready to go into labor. She was quiet and unsmiling this time but, when asked, acknowledged that she had not had a hot meal in weeks. Mr. Jones gave her warm socks and toiletries, then asked her what she liked to eat, for real.
“I’d love Popeyes,” she said. “And some water.”
By noon, he had returned with enough chicken to feed three people, plus drinks and sides. He took a chair out of the van for her to sit in, and they ate together and talked. She would not say much, except that she was physically uncomfortable. He spoke to her as gently as he did the first day they met, but he was adamant now. She needed a shower and clean clothes. She needed to get real rest and to see a doctor. She needed to get indoors, fast. OnPoint could help with all of that, he said. There was hot food there and medical professionals and some very nice case managers she could talk to.
She nodded and tried to make a joke, then stopped abruptly. “I know it’s not really funny,” she said. Before the conversation could continue, she caught sight of a man she said she needed to talk to and scurried off with a half-eaten chicken leg still in hand. Mr. Jones sighed heavily and put the chair back in the van. He was not sure she’d heard a word of what he had said.
But the next day, she arrived at OnPoint’s headquarters, where all the resources that Mr. Jones had told her about were waiting. And with the promise of new life heavy in her womb, she finally went inside.