With ‘fentanyl everywhere’ and Black deaths soaring, Massachusetts advocates test ways to save lives
Junior, a lumbering former high school football star, stood propped against a chain-link fence. He and his buddy chatted together, loading a crack pipe. He took a deep drag, leaning back to welcome a familiar surge of energy and clarity.
Instead, he collapsed.
“I was falling out right over here,” Junior said, gesturing toward the fence that separates Perkins Park in Brockton, Massachusetts, from a church. “It’s serious stuff.”
“It” was fentanyl, the powerful opioid that can stop breathing in seconds.
Junior’s friend raced to the church. The pastor stocks a metal mailbox with naloxone, a drug that can reverse an opioid overdose. Revived, Junior started breathing again.
Junior called himself lucky. He grew up not far from this park and knew many other Black crack and cocaine users in Brockton who were duped by drugs and didn’t make it.
“It’s taken out many of my friends,” he said, “many of my friends.”
By his count, Junior has overdosed three times during the pandemic smoking what he thought was crack. WBUR is only using first names for people who use illegal drugs or whose history of drug use makes them vulnerable for job or housing discrimination.
The trend affirms new realities: The overdose crisis has ensnared many more people, and it is no longer limited to opioids. The presence of fentanyl in stimulants like cocaine and crack, as well as fake pills of all kinds, is expanding the overdose crisis.
As researchers and public health officials raise alarm, the losses are mounting in Brockton, a city with one of the highest percentages of Black residents in Massachusetts. Overdose deaths have risen 40% for Black people in Brockton since 2017, according to state data.
Junior’s near-death encounters with fentanyl are among the blue dots that cover Perkins Park, near the center of this city map from the law enforcement coalition Plymouth County Outreach. These dots mark the location of non-fatal overdoses — 444 — last year. State data show 84 people died.
Now, researchers have turned a spotlight on overdoses in Brockton. The city is one of 67 communities from four states participating in a $350 million federal project. The HEALing Communities study set an ambitious goal: to reduce opioid deaths by 40% in three years.
In Brockton, the study launched as the first COVID-19 cases emerged in Massachusetts, and the state shut down. The HEAL Coalition, a group of local leaders who decided what actions to take to curb deaths there, had to adapt in real time to the pandemic, a more dire landscape of overdoses and the vastly different needs of stimulant users caught in the crisis.
The study comes at a critical moment. Overdose deaths rose 9% in Massachusetts in 2021. Nationwide, they topped 100,000 for the first time. State and local governments are scheduled to receive their first payments from opioid settlements that total about $26 billion this summer.
Brockton could become a model for what does, or doesn’t, work to save lives.
COVID interferes with crack and cocaine
As overdose deaths dramatically increased during COVID, several studies show the biggest jump was among Black drug users. Disruptions in the supply chain of illegal drugs may have played a role.
Gary was trying to buy cocaine as the lockdown hit. It was hard to find in Brockton. Fentanyl was not.
“During COVID when the streets were running out of cocaine,” Gary said, “there was so, so much fentanyl everywhere.”
A report from the United Nations Office on Drugs and Crime confirmed much of Gary’s experience. It said gas shortages interfered with cocaine production. Supply chain problems also slowed fentanyl shipments, but not as much.
“The timing was terrible, because it was an even stronger, more lethal version of fentanyl,” said Traci Green, director of the Opioid Policy Research Collaborative at Brandeis University.
People who sniff cocaine or smoke crack typically have little, if any, tolerance for fentanyl, said Green. Her surveys show they rarely carry naloxone, brand name Narcan, because they aren’t expecting their drugs to be tainted. They don’t take other precautions many opioid users have adopted, like starting with a small, test dose and never using alone. And in Massachusetts, Black people are more likely to die with a mix of coke and opioids in their blood than white people who use drugs.
There’s a lot of debate about how people who use crack and cocaine end up ingesting fentanyl. Drug users in Brockton say dealers sold what they had during COVID, even if they had to pass off fentanyl as coke.
Gary said his dealer didn’t do that, but he did urge people to try fentanyl.
“He told me, ‘Whenever I don’t have coke, I do a little bit of this, and I’m OK ‘til somebody show up with some coke,’ ” Gary recalled. “We would tell him like, ‘somebody overdosed on that,’ and he would say, ‘that’s because they didn’t come to me.’ ”
Gary, who’s now in recovery, didn’t buy the story or the fentanyl. But, he said people he used coke with in Brockton did. And their experiment happened as pandemic stimulus checks started to arrive.
“They got the checks,” Gary said. “They were, like, buying a lot of drugs. And a week after, they were dead.”
Brockton’s HEAL Coalition didn’t know deaths among Black people would spike when they began meeting in March of 2020. Over Zoom, the group spent months choosing from a menu of study-approved drug overdose “interventions.”
Brockton’s 34-step “action plan” includes training people who use drugs to distribute naloxone, adding addiction treatment providers and a recovery coach to a local medical office and hospital, new telehealth options, rides to treatment for newly released inmates, and a mobile clinic with an outreach team.
Dave is one of the regular patients that team visited last year in a wooded patch of Brockton. Dave isn’t sure how many times he overdosed early in the pandemic when he rarely left the tent he called home.
“There were many more people with more time on their hands,” said Dave, who numbs childhood trauma with drugs. “If I have time and money, I will get high.”
COVID-imposed isolation contributed to more drug use and overdoses for people of all races. But Dave said there were other devastations that affected Black people especially hard: the killings of George Floyd, Breonna Taylor, Ahmaud Arbery and others.
“Things have always been f—ed up, like that guy, Floyd, that they choked to death,” Dave said. “I wake up with the knowledge that that could happen every single day.”
Francesca Villanueva, a nurse practitioner visiting patients in Dave’s tent encampment, nodded vigorously as she listened.
“People of color who struggle with addiction, they feel like they’re not valued,” she said. “All of the killings and all this stuff, that’s part of the obstacle, because how are you going to help me when you don’t subconsciously value my life because I’m Black?”
Some outreach workers suspect there are at least twice as many overdoses in Brockton than the dotted law enforcement map shows because many Black and brown people who use drugs rarely call 911.
Dave said Brockton city workers confirmed the feeling that his life doesn’t matter late last year when the city, at the request of the property owner, bulldozed his camp. Dave and others were given notice and offered space in a shelter or help finding treatment. Researchers are documenting ways these evictions are linked to physical and mental health harms. Dave now sleeps in Perkins Park.
Dave, Gary and Junior are all at high risk for a fatal opioid overdose. In addition to being homeless and Black, they’ve been in and out of jail for drug-related thefts. In Massachusetts, the overdose death rate for people with a history of incarceration is 120 times higher than for adults as a whole.
But stimulant drug users like these three men were initially outside the scope of the HEALing Communities study. The focus was on helping people addicted to opioids.
“The phenomenon of fentanyl-laced stimulants was not a major player when we began,” said Dr. Jeffrey Samet, a Boston Medical Center primary care physician who leads the study in Massachusetts.
But when overdose deaths among Black peoplejumped 75% in the first year of the study, Brockton’s HEAL Coalition responded with lots more attention to stimulant drug users. It funded public affairs shows for the Cape Verdean and Haitian Creole communities, outreach to predominantly Black churches, and more trainings for Black and Latino counselors.
Samet says that for people who use crack and cocaine “harm reduction is the treatment” HEAL offers. There’s not much choice. People addicted to stimulants can try abstinence, but there is no established medical treatment.
That focus, on tools and strategies that can help them stay alive, starts with distributing lots and lots of naloxone.
Naloxone for all
Junior wasn’t carrying naloxone the day we met, but “I have it all around me,” he said, referring to the church mailbox between Perkins Park and the shelter. Naloxone is tacked to bulletin boards near the shelter’s dorm rooms. And outreach workers walk the streets and through the woods, passing out bags of harm reduction supplies with the overdose-reversing nasal spray.
Making sure every Black and brown person knows about naloxone — whether they use drugs or not — has become a mantra of sorts for Brockton’s HEAL Coalition. They rebranded it as a broad overdose prevention tool. Workers fanned out to warn residents that fentanyl is in crack, cocaine and pretty much every street drug sold as a powder, pill or crystal — not just opioids.
The HEAL Coalition has struggled to persuade people who don’t use drugs that they need to carry naloxone and be prepared to use it on a loved one or a stranger.
Some 12,000 naloxone sprays, paid for by the state, were distributed to 10 Brockton-based nonprofits in one year.
“We’ve had a lot of people who had no idea what naloxone was,” said HEAL Coalition manager Valerie Bassett. “Hopefully more people will have access now to overdose prevention.”
For stimulant drug users, Brockton also has ramped up distribution of two other harm reduction tools: fentanyl test strips and single-use glass vials that serve as crack pipes.
Two clusters of fatal overdoses a year ago linked to fentanyl-laced crack and cocaine highlighted the need to test all street drugs. The pipes help outreach workers find people who use crack and introduce them to naloxone. There’s evidence it works.
When a center that stocks clean needles and naloxone started carrying pipes last June, “the number of people coming to us exploded, and 67% of them are Black or Latinx,” said Jesse Pack, director of HIV Services for BAMSI, a major human services nonprofit in the city.
The HEALing Communities study doesn’t fund the pipes or the fentanyl test strips. The federal government does not allow funding for pipes. BAMSI uses a grant from the RIZE Foundation to pay for the pipes and is getting some assistance with test strips from the Massachusetts Department of Public Health.
Some former crack users in Brockton argue that handing out pipes makes it more likely people will smoke. Research doesn’t support that point of view. It does support another harm reduction program: supervised consumption sites. These are clinics that monitor drug use to prevent an overdose.
“Brockton needs one. It needs one bad,” said Michelle, standing in Perkins Park, where she often stays. “Right here, this is the center.”
Such clinics are not sanctioned by federal law and not allowed in the HEALing Communities study.
Michelle said she overdosed on fentanyl last year while smoking what she thought was crack. Someone revived her. Now Michelle says her purpose in life is to keep an eye out for other drug users in the park who might need rescuing. She learned CPR and always carries naloxone.
Michelle has heard the argument that supervised consumption clinics encourage use.
“No,” said Michelle. “They’re going to do it anyway, so why not help and save more lives?”
‘Pray it away or ignore it completely’
In late 2021, Gary was living out of his car, trying to manage his recovery. He said he had to leave home in Brockton because his family, who is from Cape Verde, won’t acknowledge his struggle with depression and addiction.
“It’s like taboo, we don’t talk about it,” Gary said. “They just pretend it’s not there.”
Gary found someone to talk to at the Brockton Neighborhood Health Center. His counselor, Christina Cazeau, is Haitian and said she often hears similar distress from other Black patients whose family members do not understand addiction is a disease.
“[They’re told] either try to pray it away or ignore it completely,” Cazeau said, “but never talking about how to help. I hear that a lot.”
So, the HEAL Coalition tried to leverage the power of church leaders.
“The pastors, who have influence over their flock, can introduce services in the city and with that we’ll be able to prevent more deaths,” said Pastor Roberto Silveira, who leads the Universal Missionary Church next to Perkins Park.
The HEAL Coalition asked Silveira to meet with other church leaders and help correct some misperceptions. He tells pastors, for example, that there’s no conflict between praying for help and seeking medical treatment for addiction.
“Science comes from God,” he said, “so God is providing all this service to the community.”
Silveira acknowledged many church members will only discuss addiction with a pastor or priest because they are ashamed. Cazeau said that shame is more prevalent for Black patients and their families than for her white clients who, in many cases, have been talking about addiction for longer.
“A lot of times, white families see addiction more as a disease that needs to be treated than Black families do,” she said. “Black families, they see it as, ‘you just have it too good’ or ‘you can never get it right.’ ”
Opioid use disorder is a well-established medical condition at this point, says Cazeau, but many providers don’t have the same treatment playbook for patients addicted to stimulants and don’t always take their addiction seriously.
“A white patient using opiates is more likely to get help than a Black patient using crack,” she said, adding that racism in health care may play a role.
Brockton’s HEAL Coalition also tried to correct misinformation and bias about addiction through increased community education. It helped produce radio and TV shows in Cape Verdean and Haitian Creole, hosted by local leaders.
The shows discussed calling 911. Some parents don’t out of fear their loved one will go to jail instead of a hospital after an overdose. A guest on one show explained how to do rescue breathing and use naloxone. Another episode described treatment options and defined some common terms: detox, medication-assisted treatment and sober housing.
“We have a lot of work to do,” said Marline Amedee, president of Haitian Community Partners Foundation in Brockton. “You’ll see the mother of someone using drugs fight to hide that because she doesn’t want her child tarnished with that problem.”
That fear or shame may fuel another problem that contributes to overdoses and deaths: fewer Black people who use drugs are in treatment. To fix that, the Brockton HEAL Coalition sent treatment to the streets.
Treatment out of a trailer
A heavy-duty gray pick-up pulls into a parking lot beside Brockton’s bowling alley and stops at the back, well away from other cars. The public health workers from Brockton Neighborhood Health Center pile out. They unhook a big white trailer and set up shop.
This mobile clinic travels to seven sites a week — near parks, wooded areas and soup kitchens, based on overdose mapping. Allyson Pinkhover, director of substance use services at the Brockton Neighborhood Health Center, says the trailer team tries to reach people most at risk for an overdose: people who use drugs and were recently released from jail and who don’t have stable housing.
“We’re just trying to run the gamut and hope we catch the right people,” Pinkhover says.
Catch them and warn them. Pinkhover’s staff uses a spectrometer to check drug samples people bring to the trailer. Lately, the results show lots of Xylazine, the animal tranquilizer that can complicate an overdose because it doesn’t respond to naloxone.
“The drug supply has never been as lethally toxic as it is right now,” Pinkhover says.
Anyone who stops by the trailer can get supplies to help them stay alive while using drugs. Trailer staffers have recorded more than 1,600 visits for fentanyl test strips, naloxone, clean needles and crack pipes. Many people living on the streets also need some basic health care.
A woman who says she may have strep throat steps into the trailer and opens her mouth wide. The nurse works in a question about addiction treatment. This woman isn’t interested, but 28 people have started using buprenorphine, a medication that can help people addicted to opioids manage cravings, since the trailer started making rounds in September. Buprenorphine is also sold as Suboxone or Subutex.
That number, 28, may seem low, but Pinkhover says the moments when people are ready for treatment are limited.
“Then you throw in all the uncertainty, ‘oh, I’ve been in and out of jail,’ or ‘I was in and out of the shelter,’ or ‘somebody took my meds,’ ” says Pinkhover. “Just the general chaos of having to manage your own medications can be tricky.”
Prescribing a medication to treat an opioid use disorder increases the chance a patient will continue treatment and avoid an overdose. A white man named Randy says he’s been on Suboxone for 10 years and plans to stay on it.
“Oh yes, my friend,” Randy says, with a gravelly laugh. “It keeps me regular. I’m proud. I’ve come a long way.”
But HEAL Coalition members are finding less interest among Black people who use drugs. At Brockton Neighborhood Health Center, for example, 73% of patients receiving treatment for a substance use disorder in the past year are white while 21% are Black.
Michelle, the woman who watches out for other drug users in the park, says buprenorphine can help, but it’s hard to stop using it too, so “why not keep going with the same drug we’re already doing?”
For patients addicted to crack or cocaine, the nurse in the trailer can refer patients to an experimental treatment option. It’s called contingency management. Patients get gift cards if they keep counseling appointments and pass drug-free urine tests.
Contingency management shows promising results, but it’s not approved for widespread use and not reimbursed by private health insurers. The Massachusetts Department of Public Health is running a few pilots, including at Brockton Neighborhood Health Center.
‘Real help, somebody to take their hand’
Brockton’s HEAL Coalition funded street outreach workers and case managers to help people find addiction treatment. But the need is still enormous.
“You know these people need real help, somebody to take their hand,” said Will Newton, musical director at the Universal Missionary Church next to Perkins Park.
Newton, who’s in recovery for drug use, looked across Perkins Park at a man dosing next to a statue, a woman asking passersby for money and a couple with a lit pipe, shielding it from the wind.
“I know it sounds like babying them, but if society really wanted to help some of these people out here, don’t just drive by and say, ‘oh, there’s a program you can go to down the street,’ ” he says. “When we’re caught up, we’re not going to make it there.”
Newton says Brockton needs more programs, like the Homeless Improvement Project, that focus on building compassionate relationships. HIP, based out of the church, is a HEAL Coalition partner.
Its volunteers walk through Perkins Park offering meals. A woman who has become incontinent counts on HIP for diapers. A man who lost his only sack of clothes gets a few new shirts, some pants and socks. A woman who’s been offered demolition work if she can secure steel-toed boots cries as she’s handed a free pair.
Some longtime drug users in Brockton call HIP a lifeline.
Junior is crossing the trampled grass between Perkins Park and the church when he spots Pastor Roberto Silveira, who started HIP.
“Seven days a week, 365 days, he’s here,” says Junior, his large hand on the pastor’s shoulder. “That’s my brother right there. Without him, I wouldn’t be here.”
Junior moves on. Pastor Silveira takes a breath before speaking.
“My heart is a little bit melting,” he says. “Thank God for [Junior’s] life, gives me the strength to keep going.”
Before the HEAL study, Silveira says Brockton had lots of different agencies and organizations interacting with people who use drugs — but they weren’t sharing information or coordinating care for clients.
“Now we have a stairway to recovery,” Silveira says. “I see a lot of change.”
But as the study wraps up, Silveira and others worry whether the changes will last.
Fears about what happens now
It’s crunch time for Brockton and the seven other communities in Massachusetts that were part of the study’s first phase. On July 1, another eight Massachusetts cities and towns will begin their two-year portion of the study.
Brockton’s $1.6 million in funding will run out at the end of June, and the HEAL Coalition will dissolve. The mayor’s office has told coalition members it will continue regular meetings. Some worry about losing ground without the dedicated staff, analytics and funding the study provided.
It’s not clear, for example, what will happen to the mobile trailer clinic team.
“Everyone wants to say it’s a crisis,” said Pinkhover, whose trailer staff routinely reverse overdoses. “[And yet,] we’re providing these really critical services in the community and we’re just constantly looking for grant funding.”
Brockton Fire Chief Brian Nardelli sees the crisis continuing. He said 911 calls related to an overdose are up slightly so far this year as compared to 2021.
“Brockton is an old mill city that’s in transition. We’ve got a lot of great things going on downtown right now,” Nardelli said, “but there’s also still a population downtown that is struggling greatly.”
Brockton is in line to receive $500,569 this year from one group of opioid settlements. Payments of about half that amount are expected to continue through 2038. HEAL study leaders say they hope some of this money can be used to continue HEAL’s work. The Brockton mayor’s office did not respond to repeated requests for information about the city’s drug overdose response plans or about how it will spend opioid settlement funds.
The final numbers are not in yet, but study administrators say a 40% reduction in overdose deaths may be difficult. Researchers will be comparing Brockton to other cities and towns in the study to measure how well these interventions performed.
If Brockton doesn’t meet the goal, it wasn’t for a lack of trying.
“They did everything possible to meet and move forward with the goal of increasing access to the treatment we know works and will make an impact,” says Redonna Chandler, who directs the HEALing Communities study, at the National Institute on Drug Abuse.
Chandler says the study’s researchers have made a “tremendous” effort to get real-time reports about who is overdosing and on what, but they’re still often months behind. Chandler says the drug overdose epidemic needs the same emergency response and commitment to data collection that COVID galvanized.
“When you drive, you want to look and see where you are, not in the rearview mirror,” Chandler says. “I can’t look out the front window. I just see the rearview mirrors. All I see is destruction, I don’t see where I need to steer the car.”
Jesse Pack, the harm reduction advocate with BAMSI, agrees, but says it’s hard to get out in front of every twist in the overdose crisis.
“I don’t even know what that would look like,” Pack says, “but right now, we’re constantly reacting to this ongoing crisis, as opposed to being more proactive. Right now, we’re always chasing the fall out.”
Michelle and others in Perkins Park have a lot of ideas about what would help them emerge from that fall out: more housing, a rec center with counseling, and ways to be productive — like planting a community garden.
A lot of the people in the park are like flowers, said Frankie, a Black man who has been experiencing homelessness and spends a lot of time in the park.
“They just need a little bit of watering,” he said, pointing to Michelle. They both say the overdose crisis should matter to everyone.
“The reality is,” Frankie said, “none of us should be out here, white or Black, right?”
“The drug has no color,” Michelle said, “and right now it’s taking everybody and anybody out.”