Firefighters and police arrived at the Douglas Avenue address at 10:20 a.m. on January 4 and pronounced her dead shortly thereafter. But the exact time, or day, of Rhode Island’s first opioid-related fatality in 2020 is unknown. The woman’s friends and housemates hadn’t heard from her in a few days and, that morning, one of them forced themselves into her room to find her in bed, a needle under her leg and a crack pipe under her stomach. Then the housemate called 911.

The police report would later describe that morning in words officers would repeat again and again in reports of other overdoses across Rhode Island’s capital city in what would become a record-breaking year in the state’s opioid epidemic: fighting addiction, found alone, dead on arrival.

An autopsy would later reveal a combination of cocaine, fentanyl and other opioids in that first victim’s system. She became one of at least 77 people in Providence dead from overdose last year.

One street over on Branch Avenue, a body was discovered last June, decomposed in a storm drain. The medical examiner found fentanyl and methamphetamine in the person’s body. Three days later, someone overdosed and died a block away, again on Douglas Avenue. Then, in November, another person fatally overdosed at the same address.

A dozen doors up, a man, known for his gruff voice, boyish humor and love of chicken wings would die, alone in his second-floor apartment last July. The pizza place that does business out of the ground floor stuck his photograph by the cash register in his memory, next to the tip jar and a bottle of hand sanitizer.

“You’ve come to the right place,” said Sam Raja, owner of Sam’s Tobacco & Convenience Store when we tell him we are writing about fatal overdoses. “I became very religious, because I’ve seen so much death.”

Raja regularly sees ambulances come to revive or pick up bodies on Douglas Avenue, he said. Sometimes he finds out that customers who have come in to buy a snack or a soda have become victims of a national health crisis that claimed 384 lives last year in Rhode Island alone.

Seeking to better understand this epidemic, a team of Brown University journalism students obtained data from the Providence Police Department (PPD) revealing the location of every fatal overdose in Rhode Island’s capital city during 2018, 2019 and 2020. What emerges is a picture of an epidemic that gained momentum during the pandemic and touches all corners of the city, though hotspots point to locations where the crisis is most acute and where interventions may be most effective.

The police categorize a death as an overdose when the state medical examiner confirms overdose as the cause of death and the police are able to tie that death to an incident in their records. For 2020, there were 77 confirmed fatal overdoses, at least 66 of which involved an opioid, according to toxicology reports.

The Rhode Island Department of Health (RIDOH) says its count tells an even grimmer story: Last year, RIDOH documented at least 27 additional fatal overdoses in Providence that the PPD did not include in its count — situations in which police were not called to the scene of an overdose or did not suspect an overdose when they arrived at the scene. The PPD does not have these toxicology reports or detailed information about the circumstances surrounding these deaths.

Over the span of three years, at least 179 people died of an overdose in Providence, according to police reports. Analysis of these records showed that the cluster of deaths around Raja’s Wanskuck corner store is not unique. Providence is dotted by hotspots where people die on the same street, or even in the same building, days or weeks apart from the same kinds of drugs.

The deaths were clustered in Silver Lake, Hartford, Olneyville and the West End. Here, the epidemic’s devastation is next door, at the bus stop, the local fast food joint. All around. And the bodies just keep coming.

Listen to an interview with Hal Triedman, a reporter and technologist who worked on the Rhode Island Opioid Data Journalism Project.

Fatal Hotspots Dot The City

Persistently high numbers of deaths have been fueled by a medley of forces leaving Providence residents vulnerable, including housing insecurity, unmet basic health needs and a lack of a coordinated effort to respond to the overdose crisis, experts say. And the proliferation of illicitly-manufactured fentanyl has made a cheap drug supply even more dangerous.

During this three-year window, victims died from a lethal mix of drugs — most often containing fentanyl, a synthetic opioid 80-100 times stronger than morphine. Most fatalities involve someone using alone, with no one around to administer naloxone or call 911.

The zip code home to the most fatal overdoses in 2018 and 2019 was 02909. Last year this area was topped by the 02908 zip code, with at least 22 confirmed fatal overdoses. Though zip codes slice communities into arbitrary pockets, they provide a framework for thinking about place-based interventions in response to an epidemic that disproportionately impacts particular Providence communities, experts say.

Most of the neighborhoods with the highest number of fatalities per capita were areas with the lowest median income, largest average household size and high numbers of people living in group quarters, according to Census data.

In 2018, 2019 and 2020, there were overdoses at addresses along Broad Street. Crossroads, Providence’s largest shelter for people experiencing homelessness, at 160 Broad Street, saw one fatal overdose in 2018. Two people fatally overdosed at the shelter in 2020, with two more suspected to have died from overdoses there last year, according to police records. In total, there were eight confirmed fatal overdoses on Broad Street in three years.

One 49-year-old man was found dead, lying face down on his bed in an apartment inside the shelter on April 6, 2020. Other residents at the shelter had not seen him in two days and contacted staff to conduct a wellness check, according to police reports. The man was known to have a long history of drug and alcohol abuse. The autopsy later revealed a mix of fentanyl and other opioids in his system at the time of death.

Less than three weeks later, another male resident died alone in his apartment at Crossroads.

In her five years working at Crossroads, front desk manager Teresa Luzzatto has lost track of the number of overdoses she has responded to.

Since the start of the pandemic, she estimates that staffers have reversed more than 25 overdoses in the building using naloxone.

“It can be tough,” Luzzatto said. “But it’s always very gratifying when the reversal is successful, because then there’s not a mother or father who's going to get their phone call.” This work is personal for Luzzatto; she knows what it’s like to receive that call. Her son died of an overdose in 2015 in Lowell, Massachusetts. He was 32.

All Crossroads staff are naloxone-trained, and a couple times a year, Luzzatto hosts trainings for Crossroads residents as well — the sessions are optional, but the shelter offers $15 gift cards funded by grants from the Department of Health to incentivize participation. And she supplies residents known to struggle with substance use disorder with fentanyl test strips.

Lieutenant Patrick Burke of the Providence Fire Department has lost count of the overdoses he has responded to in his 14 years of service, too. “They kind of just blend together to be honest,” he said.

Working in the West End, Olneyville, and Federal Hill, he has responded to people slumped over in their cars, others found collapsed by family members on their bedroom floor, and countless people passed out on the side of the road, in parking lots, behind dumpsters.

Calls often come in from bystanders on the street. Sometimes they’ll know with certainty that the person overdosed on fentanyl. Or they’ll say, “we didn’t see him do the drugs, but we do know he uses drugs,” Burke said.

Other times, the fire department receives calls for a “person down”. Burke recalls receiving a report of an older man slumped unconscious over the wheel of his car. Only after smashing in the window of the locked car did he realize the man had overdosed.

Calls also come in from relatives who don’t realize their family member is using drugs. “They think it’s some sort of natural occurrence, diabetes or something,” Burke said.

The Demographics Of An Epidemic

In an attempt to learn more about who was dying, how and where, the three Brown student reporters working on this story reviewed every Providence police report from 2018 involving a fatal drug overdose.

Their analysis found that more than three quarters of those who died were classified as white by Providence police, 43 of 55. The department’s reports do not note whether someone is Hispanic or Latino, classifying them instead as white.

Just three police reports mention that Narcan, a brand name of opioid-overdose-reversal medication naloxone, was administered at the scene. It’s possible that there were more cases in which Narcan was used and not reported, but most victims appeared to be long dead by the time police arrived, some for hours, others for days. The vast majority died at their residence.

Around 11:30 a.m. on March 22, 2018, police found one man sitting upright in a chair and facing the television in his living room, remote still in hand. He had overdosed on a combination of alcohol, fentanyl and cocaine at 44 years old. His cousin had decided to check in on him on that day at his home on Gladstone Street because no one had heard from him for several days. He was separated from his wife at the time. Family members told the police that he suffered from high blood pressure, diabetes, heart issues and drank heavily.

Another victim was found face down on the landing outside his Osborn Street apartment, keys dangling from the door left ajar. According to the police report, he had been complaining of chest pain and was known to use narcotics. Police found a small plastic bag of a brown powdery substance in his bedroom. On October 18, 2018, at 42 years old, he had overdosed on fentanyl.

That same night, a 24-year-old man and his roommate went to a concert together. The next day, the victim’s roommate found him dead in his room. The two shared an apartment on Doyle Avenue, just beyond the Moses Brown School and Brown University campus on the city’s East Side. The victim had a history with drugs, mostly narcotic pills, according to the roommate. He had overdosed on fentanyl.

Those not at home died alone in cars, behind dumpsters, in public restrooms, or while staying the night and getting high at a friend’s.

Fentanyl: A Rising Risk

Dr. Josiah Rich, professor of medicine and epidemiology at Brown University’s Warren Alpert Medical School, says that many of those who have fatally overdosed in Rhode Island had not previously been diagnosed with opioid use disorder, a problematic pattern of opioid use that often results in people taking larger and larger amounts of the drugs.

This could point to two problems, Rich says.

The current systems in place throughout the state to prevent overdoses and initiate treatment might be missing people with addiction. “But it also suggests that there may be people out there that actually don't have opioid use disorder, that are overdosing because of recreational use.” Oftentimes this happens with cocaine users, whose supplies are somehow tainted by fentanyl. Those victims might have not been aware that an opiate was present in what they were using.

“It doesn't take very much fentanyl to kill them,” he says. “And they just die.”

In 2018 and 2019, 38 people died in Providence from some combination of drugs that included both fentanyl and cocaine. And in 2020 alone, fentanyl and cocaine were both present in the autopsies of 29 confirmed fatal overdose victims who died in Providence.

Over the last three years, according to data from the Providence Police Department, the percentage of overdose deaths involving fentanyl has increased from 73% of overdose deaths in 2018 to 81% of confirmed overdose deaths in 2020.

In addition to finding fentanyl in cocaine, it's also found in counterfeit benzodiazepines and methamphetamine on the street, Rich says.

While the presence of fentanyl in the drug supply has been a concern for public health officials and advocates for the past few years, Rich said the pandemic has obscured the picture.

Although it has been good to see arrests for drug charges drop since the pandemic began, it has revealed a “public health vulnerability in our data source,” Rich said. Without drug arrests to bring in evidence that gets tested at the state lab, it's difficult to tell exactly what type of drugs are prevalent at this moment.

“We have no idea what the heck is out there,” he said in an interview last fall.

Saving Lives With Naloxone

Naloxone has become an essential tool in the effort to hold back the tidal wave of suffering by preventing overdose deaths that happen around other people.

But the pandemic shattered recent progress and complicated response measures. Rhode Island’s 384 overdose deaths in 2020 signal a 25 percent increase from the previous record in 2016. And it appears that there could be even more deaths from drug overdoses this year than last. Department of Health data shows there were more people who died of overdoses in January and February 2021 than in the first two months of 2020. The number of fatal overdoses in March and April were the same in 2021 as in 2020, a total of 31 and 34 for each month, respectively. Autopsy reports are still incomplete for months since then.

“The opposite of addiction is community,” said Ashley Perry, who works with peer-based, harm reduction non-profit Project Weber/RENEW. But the practice of social distancing during the pandemic has made fostering community more difficult and runs against one of the central tenets of safety when using drugs: Never use alone.

Last year, the City of Providence contracted with the Rhode Island Public Health Institute (RIPHI) to conduct a needs assessment in Downtown Providence, or the 02903 zip code, to better understand the neighborhood’s high number of overdose-related Emergency Medical Service (EMS) runs, despite having the fewest residents of any zip code in the city.

From 2016 to 2019, 85 percent of opioid overdose-related EMS runs in the 02903 zip code were to public settings, according to a RIPHI report. Kennedy Plaza and Burnside Park had the highest density of overdose-related calls across these years, followed by the Providence Place Mall and the vicinity of I-95.

Community leaders in the 02907 Health Equity Zone initiated a Community Overdose Engagement (CODE) project last year in the area encompassing Elmwood, the West End and Upper South Providence. The two-year CODE grant, funded by RIDOH, is being used to assess community needs relating to substance use and treatment, and to develop a plan of action.

Both groups presented their findings and recommendations in a meeting last November attended by public health experts, advocates for substance use treatment and Providence Mayor Jorge Elorza, as well as other stakeholders.

“This is one of those problems that is so big that it feels almost intractable,” said Dr. Amy Nunn, executive director of RIPHI, at the meeting. “But it turns out that once you talk to all these people and have a look at the data, the answers become pretty sharp.”

Nunn and her team interviewed local business owners, medical providers, housing advocates, local officials, frontline responders and people with lived experience of drug misuse.

Survey responses from 100 community members using drugs conducted during the needs assessment revealed persisting unmet needs for services in the Downtown area.

Many of those interviewed expressed concern for meeting basic needs such as housing, while others complained of finding needles in public places and pointed to a need for syringe disposal boxes. The unmet need for distributing Narcan came up frequently. “If I had gotten this Narcan last year, my friend would still be alive,” recounted one individual, according to a RIPHI report. His friend had overdosed in a Providence Place Mall bathroom and was blue by the time EMS responders arrived.

Because the majority of overdoses that happen Downtown are in public settings and non-fatal, distinguishing the area from other zip codes experiencing high rates of overdose, the area requires a locally-tailored response. The scale of the crisis necessitates a collaborative, holistic approach, Nunn said.

Beyond addiction treatment services, Nunn said that housing and STD prevention alongside location-based outreach need to be a part of the solution to reduce drug-related deaths.

“Maps tell us where we need to go with scarce resources,” Nunn said in an interview. “Yet we haven’t redirected our resources to those neighborhoods or communities.”

Searching For Solutions

Though invaluable in helping to pinpoint effective response measures, the statistics do not tell the full story. They do not tell us about the people the numbers represent. The statistics say nothing of the lives lived and the dreams yet to be achieved. And they say nothing about the exhaustion of those who bear witness to the tragedy day in, day out.

Beyond reviewing hospital data and scouring police reports, this team of reporters spoke to over a dozen people in the community — epidemiologists and treatment providers, outreach workers and public health officials, people in recovery and those who have lost loved ones — to learn more about the victims of the opioid crisis and ongoing efforts to save lives.

Every Wednesday morning, several of these stakeholders hop on a 30-minute Zoom call run by Linda Mahoney, who heads the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals substance use programming, to assess how the state’s overdose situation is faring.

The state is mapped into zones — sometimes by zip code, town and city — and each has its own designated overdose threshold which, when exceeded, triggers an action plan. This could be something as simple as flooding an area with fentanyl test strips or naloxone kits. It could trigger more outreach workers being sent into a particular hotspot. In Providence alone, the most active overdose spot in the state, the threshold was 16 overdoses reported by hospitals per week. The statewide threshold is 45 overdoses. But these numbers could change in 2021 based on current trends and previous years’ data, according to BHDDH.

In addition to discussing the numbers, the meeting is a chance for those who are witnessing the epidemic first-hand to discuss kinks in their overdose prevention initiatives. During one week last November, that meant trying to figure out how to get outreach workers COVID-19 tests so that they could return to the streets to help those in need.

Mahoney hopes that someday the weekly overdose numbers in the city reach the single digits. “I don’t know how old I’ll be,” she added. “But one day.”

Still, she recognized that non-fatal overdose numbers are only one part of the picture, especially in a year as unique as 2020. Emergency room visits were down due to COVID-19 fears, which could skew the statistics, she said in an interview. People are also using in public less frequently, leading to fewer trips to the ER and possibly more deaths, Mahoney said.

As the number of opioid overdose deaths continues to spike, a growing chorus of voices are pressing for bolder action in the face of record high numbers: overdose prevention sites, also called safe injection sites. Here, people can use drugs under medical supervision.

In response to the overdose assessment, the Providence City Council passed a resolution late last year recognizing the importance of recommendations made by Nunn and her team, including “harm reduction sites to reduce fatal overdoses.” And just before the Fourth of July weekend, the General Assembly passed bills that will make Rhode Island the first state in the US to legalize safe injection sites. They are not currently legally operational in the United States, but have been employed with success in Canada.

The legislation here, signed by Governor Daniel McKee in early July, institutes a two-year pilot program to prevent drug overdoses through the creation of “harm reduction centers,” beginning next March, with individual city or town approval. The centers will provide health screening, disease prevention counseling and recovery assistance referrals and will be places where persons can safely consume pre-obtained controlled substances.

In the meantime, Nunn continues to advocate for data-driven harm reduction responses. First responders — medical staff, firefighters, police officers — continue to work, day in and day out, wondering when they’ll next come face-to-face with the opioid crisis’ latest victim. And Perry continues her regular outreach shifts, handing out naloxone and connecting people with the services they need.

Still she wonders: “I could be out Narcan-ing everybody for days and days and days, and yeah, I’ve saved a life. But how long can I save a life for?” She remembers the woman from October 2018, the glass in her knees, the children across the street. “Only until they overdose next time.”

This story was produced as part of a reporting project on the opioid crisis by a team of Brown University student journalists. Find more of the reporting here.

The reporting team would like to thank Sergeant Albert DeCristofano and Deputy Chief Thomas Verdi from the Providence Police Department and Daniel Clement, the crime and information systems specialist in the Providence Public Safety Commissioner’s office, for providing mapping, police reports and data for this story.