CHAPTER 2

Literature Review and Industry Scan

Method

The goal of this literature review is to synthesize existing literature and knowledge on the prevalence of drug use in transit environments and discuss agency responses to this crisis in the United States. Relevant academic literature was found initially through Google Scholar, with common general search terms including “public transport,” “transit agencies,” “transit,” and “drug use,” “drugs,” “narcan,” and “substance use.” A snowballing approach was taken to identify related research, and the review was conducted until the team believed no new research was being identified. Additional agency information was found by searching agency board reports when applicable or from agency websites.

The article searches were limited to a specific time frame, prioritizing those published after 2013, aligning with the increased prevalence of synthetic opioids like fentanyl (Sutter, Curtis, and Frost 2019). The primary analysis focused on articles from the United States, with additional insights drawn from Canadian sources.

Findings from the Literature

The first section of the literature review provides background knowledge on the underlying causes and issues associated with drug use on transit. The onset of the COVID-19 pandemic in 2020 significantly reduced transit ridership in many cities across the United States. Because unhoused individuals often turn to drug use as a way to cope with their situations (Sutter, Curtis, and Frost 2019; Skinner and Rankin 2016, Stepanova et al. 2024), this has resulted in individuals—in particular, those without access to stable shelter—using transit facilities as places to seek refuge (Skinner and Rankin 2016, Loukaitou-Sideris et al. 2021) and consume drugs. This, coupled with an overall post-pandemic rise in drug use across the United States due to COVID-related stressors and restrictions (NIMH 2024) has resulted in an ongoing spike in visible drug consumption and overdoses in transit facilities.

The second section of the literature review analyzes transit agencies’ past and current responses to drug use and related issues and outlines how responses have evolved over time. Responses were categorized into four main themes: Legislative and Enforcement-Led Measures; Station Design and Operations; Outreach and Harm Reduction; and Integrated Strategies.

Underlying Causes and Challenges of Drug Use in Transit Environments

The United States’ drug overdose crisis represents one of the most severe public health challenges of the 21st century, with devastating impacts on individuals, families, and communities.

Overdose deaths involving synthetic opioids (primarily illicitly manufactured fentanyl) represented 73,838 of the 107,941 drug overdose deaths reported in 2022 (Loukaitou-Sideris et al. 2020). The prevalence of illicitly manufactured fentanyl and other potent, synthetic opioids—which may be added to other drugs and unknowingly consumed—has been a major driver of overdose deaths in the United States (NIDA 2024), straining healthcare systems and prompting urgent responses from governments, healthcare providers, and communities.

The root causes of the opioid crisis are complex and subject to ongoing debate but include several factors. These factors include an overreliance on opioids for pain management, insufficient regulation of prescription practices, and the influence of pharmaceutical companies that minimized the addiction potential of opioids, along with the interconnection between poor health and structural factors, including poverty, lack of opportunity, and inadequate working and living conditions (Dasgupta, Beletsky, and Ciccarone 2018).

The COVID-19 pandemic was associated with an unprecedented rise in the number of people experiencing substance use disorder—a treatable mental health condition that affects the brain and behavior, resulting in an inability to control the use of substances such as drugs, alcohol, or medications (NIMH 2024). This surge was partly driven by pandemic-related stresses, including isolation due to the closure of community centers, loneliness, and economic instability (Melamed et al. 2022). Additionally, the pandemic caused significant disruptions to in-person mental health and addiction treatment as these services shifted to a telehealth delivery model. Although telehealth, which provides healthcare via video or phone, was intended to increase accessibility to its services, unhoused persons who use drugs often face challenges such as lack of internet access, poor digital literacy, and a lack of safe, private spaces for telehealth sessions, which negatively affect treatment outcomes (Stepanova et al. 2024, Melamed et al. 2022).

The COVID-19 pandemic affected transit agencies almost immediately as stay-at-home orders were put in place to reduce the spread of the virus. Ridership has been slow to rebound to pre-pandemic numbers in many cities, in part due to long-term changes in commuting patterns, including work-from-home flexibility. Simultaneously, transit agencies have struggled in recent years with safety and security concerns of riders, increases in the number of unhoused individuals sheltering in their systems, and the use of drugs on transit property. There is growing academic interest in understanding why individuals choose to use drugs in transit environments and how the use of public spaces affects the risks associated with drug use, however, these topics are outside the scope of this project.

The harmful effects of substance use disorder, coupled with the challenges faced by individuals experiencing homelessness, provide an explanation for the rising prevalence of drug use in transit environments. It is commonly believed that substance use disorder causes homelessness, however empirical evidence indicates the opposite. Individuals who are unhoused often turn to substances like methamphetamine, heroin, fentanyl, xylazine, and crack cocaine as a means to cope with the daily struggles associated with a lack of stable housing (Sutter, Curtis, and Frost 2019; Skinner and Rankin 2016; SEPTA 2021b). Risk factors that push people experiencing homelessness to engage in drug use include loss of income, social isolation, and an increased lack of self-worth (Skinner and Rankin 2016). One study estimated that approximately 50% of persons experiencing homelessness have a substance use disorder (alcohol or drugs), and at least 30% suffer from serious mental illness, with many suffering from both conditions (LeBrun-Harris et al. 2013).

Overcoming substance use disorder without access to adequate and stable shelter is extremely difficult, and results in a cycle of homelessness and drug use, further increasing the likelihood of becoming chronically homeless and spending more time in transit environments that offer an accessible place to shelter (Skinner and Rankin 2016, Loukaitou-Sideris et al. 2021). While

definitive data surrounding the number of people experiencing homelessness in American cities is scarce—particularly in transit environments—the available data shows an upward trend in the number of people using transit as shelter since the mid-2000s. In New York City, the percentage of people using transit as a means of shelter steadily increased from 19% of the estimated homeless population (approximately 3,500 to 4,500) in 2005, to 61% in 2019 (Loukaitou-Sideris et al. 2021). It is hypothesized that this number increased further during the COVID-19 pandemic because of many cities removing transit fares and a steep reduction in public transit ridership. To gain insight into how transit agencies are addressing homelessness, please see TCRP Research Report 242: Homelessness: A Guide for Public Transportation (Zapata et al. 2023).

Transit agencies across the United States are either actively facing and responding to the challenges of drug use on their systems or are looking for guidance on best practices to respond to this challenge, all while experiencing severe funding deficits. Drug use on transit affects the perception of safety and security among riders, non-riders, and transit employees and contributes to significant biohazard waste when used syringes and other drug paraphernalia are improperly discarded. Drug use in transit is also associated with other maintenance, operational and safety issues, including unhygienic practices (e.g., public urination), use of spaces like elevators and ancillary spaces for drug use, accidental track falls, vandalism of transit property, criminal activity, and conflicts between persons using drugs and other riders. The following section offers information on how public transit agencies are addressing these issues.

Agency Responses to the Problem

This section provides an overview of how transit agencies have responded to drug use in transit environments. Responses are categorized under the following themes:

1. Enforcement-led and Legislative Measures;
2. Station Design and Operations; and
3. Outreach and Harm Reduction.

Enforcement-led and Legislative Measures

Enforcement.

Transit agencies typically establish their own codes of conduct that outline guidelines and expectations for customers using the system. The enforcement of these rules is generally carried out by local law enforcement—sometimes with a transit detail—or through police forces maintained by the transit agencies themselves. A 2020 survey of 115 U.S. transit agencies revealed that contracts with police departments were the most common type of partnership with external organizations, accounting for 69% of the agencies surveyed (Loukaitou-Sideris et al. 2020).

Many transit agencies’ codes of conduct explicitly state that smoking (or vaping) is strictly prohibited on any transit property. With respect to other drugs, a recent example from LA Metro used an advertising campaign to make it clear that any form of drug use (e.g., smoking or injection) is prohibited on their system (Figure 1). The pilot program launched in 2023 emphasized Metro’s zero tolerance policy toward illegal drug use (LA Metro 2023a). The advertisement also provided clear messaging urging transit riders to contact Metro Security or report instances of open drug use through various communication tools such as a Transit Watch app.

Legislation Specific to Substance Use on Transit.

As a response to increasing instances of drug use on transit systems, state governments have introduced legislation that reinforces enforcement measures used by transit agencies to address drug use. For example, in 2020 Oregon became the first state to decriminalize possession of small amounts of illicit drugs. However, ongoing concerns about the high prevalence of drug use on the Portland TriMet system affecting the safety of customers and ridership growth has resulted in TriMet supporting the passage

of Senate Bill 1553-1 in the Oregon State Senate (Altstadt 2023, TriMet n.d.). Senate Bill 1553-1, proposed by the Oregon Transit Association in 2023, would explicitly criminalize drug use in transit environments as a misdemeanor, punishable by a fine of $6,250, or imprisonment of up to 1 year (Oregon State Senate 2024). The bill passed and will be enacted in 2025. Senate Bill 1553-1 repeals Ballot Measure 110, a referendum passed by Oregon voters during the 2020 United States Elections which decriminalized possession of all illegal drugs, including fentanyl, methamphetamine, crack cocaine, and heroin (Oregon Health Authority 2021). TriMet hopes that this legislation will enable transit properties to become drug-free zones and give more powers to law enforcement to remove those engaging in drug use within transit property (York 2024).

Minnesota has introduced legislation that would classify smoking illicit drugs, carrying items related to the smoking of illicit drugs, and other disorderly behaviors (including defecation and urination) in transit environments as misdemeanors (Minnesota State Legislature 2024). However, this proposed legislation specifies that arrests can only be made if a warning has already been made or if the individual continues their disruptive behavior after being asked to stop. The legislation would also ensure that transit agencies across the state enact their own codes of conduct, with the condition that these codes must be posted in highly visible areas across the transit network.

State governments have also begun legislating measures that can be applied by transit agencies as integrated measures in responding to open drug use. In 2023, the State of Washington passed Senate Bill 5536, which criminalizes drug use in public spaces with a punishment of 6 months in jail or a fine not exceeding $1,000 (Washington State Senate 2023). The legislation also prohibits the sale of drug paraphernalia but does not prohibit public health agencies from distributing these supplies as part of harm reduction strategies. The legislation encourages law enforcement to offer alternatives to judicial punishment, including jail alternative programs and recovery assistance programs.

Station Design and Operations

This section reviews how agencies have used crime prevention design principles and enhanced station cleaning in response to drug use.

Crime Prevention Through Environmental Design.

Many agencies are beginning to use Crime Prevention Through Environmental Design (CPTED) principles to deter drug use within the transit environment. CPTED encompasses a set of design principles aimed at enhancing both actual and perceived safety, while reducing social disorder (including drug use) in public spaces (International CPTED Association 2024). CPTED reflects the concept that urban design can be

used to minimize opportunities for crime. Notable examples of transit agencies implementing CPTED strategies to reduce unwanted drug use and social disorder at their stations or stops include Denver’s Regional Transportation District (RTD) and LA Metro.

RTD has implemented several design changes based on CPTED principles to enhance safety, boost security, and reduce drug use, particularly at Denver Union Station, which has been a significant location for drug use, crime, and social disorder. Measures include improved lighting, installing directional railing that reconfigures passenger circulation patterns, installing improved security cameras, reclassifying stairs as emergency exit only, placing barriers to block access to certain areas, installing signs that discourage loitering, and increasing police surveillance (RTD Staff 2023, RTD Staff 2022).

LA Metro has begun a pilot project using CPTED principles at Westlake/MacArthur Park Station to increase perceptions of safety while deterring drug use. LA Metro has stated that Westlake/MacArthur Park Station has become a hotspot for drug overdoses and calls to the police and that the status quo is “not acceptable” (LA Metro 2023b). The pilot project measures include adding CCTV cameras, increasing enforcement against open drug use, enhanced lighting, having a custodial crew positioned at the station, closing secondary entrances in order to direct all passengers through one entrance, and instituting public realm improvements surrounding the station to deter illicit activity. These measures are in conjunction with LA Metro’s zero tolerance policy toward drug use, which will be expanded on later in this report.

Some CPTED strategies can be viewed as “hostile architecture.” Hostile architecture (e.g., installing arm dividers at benches at bus stops to prevent people from using them as beds) is often implemented in tandem with other enforcement strategies to deter vulnerable groups from using transit stops, stations, or vehicles as a form of shelter or for substance use (drugs or alcohol) (Loukaitou-Sideris et al. 2021; Ding, Loukaitou-Sideris, and Wasserman 2022). A 2020 survey on strategies of transit agencies to address homelessness found that approximately one-half of the 115 U.S. agencies analyzed used hostile architecture (Loukaitou-Sideris et al. 2020). Although many agencies reported success, the metrics used to define this success are unclear, and it is not clear how effective hostile architecture is in preventing drug use on transit property. Hostile architecture has faced criticism for promoting exclusionary measures that fail to address the root causes of social disorder by instead focusing on displacing vulnerable populations and deterring behaviors like sheltering and substance use.

Enhanced Cleaning Protocols.

Transit agencies have also enhanced cleaning and control measures in response to drug use on transit systems so as to reduce health risks for both riders and employees. These measures include upgrading air filtration in vehicles, forming dedicated custodial teams to handle major cleanups (e.g., clearing encampments), and increasing the frequency of cleaning for both vehicles and stations.

In 2023, transit agencies in the Pacific Northwest requested University of Washington’s (UW) School of Public Health to conduct a study to assess what levels of secondhand exposure to drugs (e.g., fentanyl, methamphetamine) operators may encounter on transit vehicles such as buses and trains (Baker, Beaudreau, and Zuidema 2023). Given the high priority for both occupational and community health, transit agencies asked UW researchers to undertake an exposure assessment and recommend protective measures to reduce exposure to secondhand drug residues. Researchers used standard occupational hygiene sampling methods to measure the presence of fentanyl and methamphetamine in the air and on surfaces in 11 buses and 19 train cars. Among the 78 air samples, 20 (25%) showed detectable levels of fentanyl, while 100% had detectable levels of methamphetamine. Of the 102 surface samples, 47 (46%) contained fentanyl, and 100 (98%) showed methamphetamine. The detection of fentanyl or methamphetamine in these samples does not necessarily indicate a health risk to operators or the public.

The presence of methamphetamine and fentanyl on transit vehicles is unlikely to pose an acute, short-term health risk to the riding public, who generally spend less time on transit compared to operators. At the levels found in the study, there is no evidence of acute health effects from passive exposure to these substances, whether through contact with contaminated surfaces or inhaling secondhand smoke. However, the potential for long-term physical or mental health effects from low-level, daily exposure should be considered for transit operators, who typically spend 40 or more hours each week on buses or trains. The study underscores the importance of implementing protective measures to reduce exposure for operators and passengers.

Outreach and Harm Reduction Responses

In recent years, transit agencies have launched outreach programs to improve the well-being of members of vulnerable populations as well as individuals using drugs on transit. These programs aim to connect people with mental health, substance use disorder treatment, and housing or shelter services and harm reduction efforts. Harm reduction is a public health approach that focuses on reducing the adverse effects of drug use (e.g., disease transmission and overdose) by providing non-judgmental, needs-based care for people who use drugs, rather than solely promoting abstinence (Centers for Disease Control and Prevention 2022). This approach recognizes that drug use is a part of some people’s lives and works to minimize negative impacts while emphasizing dignity and compassion for those using drugs. Harm reduction efforts may include providing sterile syringes, distributing naloxone, offering fentanyl test kits, and offering referrals and information related to supportive care and other services.

For transit agencies using outreach services, having addiction support and substance use clinics near transit can enhance access for people who use drugs. A case study from Hartford, CT, found that treatment facilities within 1 mile of a new bus rapid transit (BRT) line helped providers serve more clients with substance use disorders at a lower cost due to economies of scale (Cohen et al. 2024). The study also recommended aligning transit schedules with treatment facility hours, increasing bus service, offering transit subsidies, and encouraging clinics to operate near transit centers to enhance accessibility.

The following sections explore various approaches to delivering outreach services within transit environments.

Hub of Services Model.

The Hub of Services model is designed to be implemented in municipalities that have high degrees of social disorder concentrated at major geographic hotspots, or if an agency seeks to redirect vulnerable groups sheltering across the system to a main location where they can receive support (Loukaitou-Sideris et al. 2021). The most prominent example of the Hub of Services Model is the Hub of Hope in the City of Philadelphia. The Hub of Hope is located at Suburban Station (see Figure 2)—a center-city underground SEPTA commuter rail station—that is run by the nonprofit Project HOME. The Hub of Hope offers critical services and supplies to those experiencing homelessness, including case management, clothing, footwear, laundry, shower facilities, primary medical care, dental care, community spaces, and transportation to nearby shelters. The Hub coordinates with nearby shelters, nonprofit agencies, law enforcement, and outreach programs to facilitate operations and support.

The Hub of Hope can be used by law enforcement and outreach workers to redirect individuals from other pockets of SEPTA to seek services and assistance. At the time of writing this report, it is a drop-in space, operating weekdays from 7:00 a.m. to 4:00 p.m.

Mobile Outreach Programs.

Several transit agencies have implemented mobile outreach programs across their systems. Although mobile outreach programs can vary significantly in terms of team composition, size, budget, and deployment strategies, these programs all typically

Source: David Cooper

involve staff moving throughout the transit system to meet unhoused riders and persons using drugs where they are and offer services or referrals to support services.

Outreach programs employ staff with different educational and professional backgrounds, including social workers, mental health professionals, nurses, and certified peer support specialists, some of whom have lived experience with being unhoused, mental illness, or drug use. In some cases, outreach workers collaborate with law enforcement or security for safety purposes (Skinner and Rankin 2016, Loukaitou-Sideris et al. 2021), working together across the transit system to identify or respond to situations involving the unhoused or persons who use drugs on transit. (This is commonly referred to as a co-responder model or a co-response team model and is discussed further below.) Outreach workers engage with vulnerable populations to assess needs, offer transportation services to shelters or drug use treatment, and document interactions for follow-up (Loukaitou-Sideris et al. 2021). Harm reduction is another key focus—for example, outreach workers often carry naloxone or Narcan to reverse overdoses. Several large transit agencies, including each of the five case example agencies (i.e., CTA, Denver RTD, LA Metro, SEPTA, and TriMet) have all developed outreach programs that are responsive to regional social challenges and will be discussed in more detail in Chapter 3.

Many outreach programs emerged during or after the COVID-19 pandemic, as attitudes shifted from traditional law enforcement approaches—like removing individuals from the system—toward more compassionate, support-based models for helping vulnerable populations (Loukaitou-Sideris et al. 2021, Hunter et al. 2018). Initially launched as pilot projects with a limited scope, many outreach programs became permanent features after proving successful in connecting individuals to resources and achieving high customer satisfaction, with several expanding their scope to address drug use and homelessness (Loukaitou-Sideris et al. 2021, SEPTA 2021b, TriMet 2023).

Transit agencies often partner with third-party organizations (e.g., nonprofits specializing in social services) or form intergovernmental agreements with municipalities to design and/or deliver outreach services (Loukaitou-Sideris et al. 2021, SEPTA 2021b). Collaborating with local agencies that employ social workers, mental health professionals, healthcare workers, and individuals with lived experience in mental health or drug use helps transit agencies address social challenges on their systems (Loukaitou-Sideris et al. 2021, SEPTA 2021b, SEPTA 2024). In Chapter 3, SEPTA’s SCOPE program will be used as an example of a comprehensive program that involves building a network of local partners to support vulnerable populations on transit and the development of contracts with outreach firms.

Increasingly, transit agencies are reserving law enforcement for last-resort situations when dealing with unhoused individuals and/or persons who use drugs. For instance, TriMet’s Safety Response Teams offer individuals using drugs a chance to stop their illicit behavior, involving law enforcement only if they fail to comply (TriMet n.d.).

Although outreach programs have become a key response to drug use within transit environments, there are limitations in how vulnerable populations can be effectively connected to and access support and resources. When it comes to securing short-term housing for individuals experiencing homelessness, bed availability and entry restrictions pose significant challenges to the effectiveness of outreach programs (Stepanova et al. 2024). For example, data collected during the early days of the COVID-19 pandemic from New York City’s MTA indicated that only 32% of unhoused individuals agreed to be transported to shelters after being asked to disembark at the conclusion of operating hours (Loukaitou-Sideris et al. 2021). One explanation behind the low uptake of shelters relates to difficulties accessing shelter spaces, especially shelters that have restrictive policies surrounding drug use and “staying clean” (Skinner and Rankin 2016), and restrictions related to storage of or ability to bring personal belongings. Although data on the prevalence of these practices is hard to obtain, a 2016 survey of shelters in the United States revealed that 24% refused admission to intoxicated individuals during extreme cold weather (Skinner and Rankin 2016). The authors also noted that a larger percentage of shelters might require sobriety during milder temperatures. They emphasized that “Shelter providers requiring strict sobriety ask the near impossible of [unhoused people who use drugs]: to suppress the mental disorder that creates the compulsion to [use drugs] and to withstand agonizing and dangerous withdrawal.” (Skinner and Rankin 2016).

Similarly, support and resources for persons using drugs is also limited, particularly when it comes to long-term services. In Philadelphia, transit police officers noted the large amount of short-term services available to unhoused persons who use drugs, including mobile recovery units and charities distributing food and clothing. However, the officers raised concerns that these services, while having good intent, do not go far enough in helping individuals get the help that they need and only serve as a temporary solution. Officers were more supportive of long-term treatment efforts, although they recognized the rarity of treatment initiation due to barriers in accessing treatment and challenges in initiating treatment by persons who use drugs (Wight and Ratcliffe 2024).

Another form of mobile outreach that transit agencies and/or municipalities use is a “co-response” team model, which involves developing partnerships between police forces and professional mental health practitioners so they can simultaneously respond to incidents involving mental health crises (Dee and Pyne 2022). The co-response team model, an example of a reform to the traditional policing approach, shifts the approach of policing from enforcement to helping provide vulnerable individuals with therapeutic responses, either by providing direct assistance or connecting them to necessary services or resources (Burkhardt and Akins 2022).

Ambassador Programs.

Some U.S. transit systems have piloted and expanded ambassador programs (e.g., San Francisco’s Bay Area Rapid Transit [BART] system, LA’s Metro, and TriMet

in Portland, OR). The primary stated goals of ambassador programs are to be a presence on the system, providing a sense of security and confidence to riders, while offering both customer service and outreach-type resources to riders. Ambassadors are typically uniformed but represent a larger shift to “find new approaches using unarmed personnel to respond to people in crisis, such as mental health emergencies, drug overdoses or the unhoused population” (Jordan 2021). The programs developed by LA Metro and TriMet are discussed further in the case example section of this report.

Naloxone Access Programs

Although naloxone is commonly carried and administered by police officers, paramedics and other emergency responders, outreach workers, and even the general public, transit agencies are now exploring ways to provide naloxone within their systems or equip staff and contractors with it. Naloxone is an opioid antagonist that rapidly reverses an opioid overdose by restoring normal breathing when breathing has slowed or stopped. Given that opioid overdoses are extremely time-sensitive, with only a 3-to-5-minute window before permanent brain damage occurs (Sutter, Curtis, and Frost 2019), ensuring naloxone access is a critical harm reduction priority.

Naloxone is a safe medication that causes no harm or effect to individuals without opioids in their system (Jordan 2021) and should be stored at room temperature (Estephan, Loner, and Acquisto 2020). Naloxone is available in two forms: injectable and a nasal spray. Narcan, the nasal spray version of naloxone, was first approved by the FDA as a prescription drug in 2015. However, as of winter 2023, Narcan is approved for over-the-counter use, meaning it can be purchased directly from places like drug stores, convenience stores, gas stations, and online (FDA 2023).

Two notable examples of early-adopter agencies of this strategy include MBTA in Cambridge, MA, and CTA in Chicago. In Cambridge, between 2018 and 2020, 10% of all overdose calls made to first responders were concentrated at five of the six MBTA Stations in Cambridge (Kohli et al. 2023). In response, a pilot program was launched in 2023 to create a public access naloxone program by deploying Narcan kits in designated boxes at the five identified hotspot stations (i.e., Harvard, Kendall/MIT, Central Square, Porter, and Alewife) in partnership with MBTA and the Cambridge Department of Public Health. Two boxes, each containing two units of Narcan, are placed at every station—one on the inbound platform and one on the outbound platform. Stations with bathrooms have an additional third box. When a commuter encounters someone overdosing and opens a box, a silent alarm is triggered, automatically calling 911 and initiating an emergency medical services (EMS) response.

Despite the rationale behind this 1-year pilot project, various stakeholders—including representatives from the Cambridge Department of Public Health, paramedic staff, 911 dispatchers, homeless advocates, and naloxone experts from Harvard Medical School and the Harvard T.H. Chan School of Public Health—expressed concerns during the program’s conceptualization (Kohli et al. 2023). Concerns included the silent alarm system, which could imply potential involvement of law enforcement, and the risk of naloxone wastage or reduced motivation to call 911 if the drug became more widely available, although Kohli et al. considered these outcomes unlikely. Nevertheless, the project was regarded as a cost-effective strategy for reducing overdose deaths, with a total budget not expected to exceed $45,000.

CTA, in collaboration with the Chicago Department of Public Health (CDPH), recently launched a pilot program featuring a Public Health Vending Machine to improve access to naloxone (Chicago Department of Public Health 2023). These machines are free to use and aim to reach a wide population of people who use drugs, particularly those who have not engaged with other harm reduction services (e.g., outreach teams, addiction services, or shelters). In addition to naloxone, the vending machines offer other harm reduction supplies, including fentanyl test kits, hygiene and menstrual products, and clothing.

Although the vending machines are designed to reduce barriers to harm reduction supplies, questions remain, including the level of public awareness surrounding the program, public knowledge on how to safely administer naloxone, public awareness on how to access naloxone from the vending machines (which can be achieved by entering the code “1-2-3-4” into a vending machine), and the willingness of members of the public or transit agency staff to provide naloxone to an overdosing individual.

Chapter Conclusions

This literature review chapter outlines how transit agencies across the United States are grappling with the challenges posed by drug use and are implementing a range of strategies from enforcement to outreach and harm reduction. The prevalence of drug use in transit environments, exacerbated by the opioid crisis and the COVID-19 pandemic, highlights the need for integrated, multifaceted responses.

Transit agencies’ responses to drug use were categorized into three themes: enforcement and legislative measures, station design and operations, and outreach and harm reduction. Enforcement measures include the establishment of transit agency codes of conduct, prohibiting drug use on transit property, and involving law enforcement for enforcement.

In terms of station design and operations, many agencies are adopting Crime Prevention Through Environmental Design (CPTED) principles to deter drug use. Examples include Denver’s RTD and LA Metro, both of which have implemented measures like improved lighting and increased surveillance to reduce drug-related activities.

Outreach programs, such as mobile outreach teams and Naloxone distribution initiatives, are designed to provide support to individuals using drugs in transit environments. Several agencies, including the CTA and the MBTA, have piloted Naloxone access programs to reduce overdose deaths by providing public access to Naloxone kits.

The chapter also discusses the role of partnerships with external organizations and local governments in addressing drug use. Transit agencies are increasingly working with public health agencies, nonprofits, and law enforcement to provide comprehensive responses to the drug crisis. These efforts are evolving as agencies move from solely enforcement-based strategies toward more compassionate approaches, focusing on harm reduction and outreach to vulnerable populations.

Many agencies, particularly the largest U.S. agencies, are responding to and addressing drug use on their systems using several programs or actions. Broadly, these actions can be categorized into “enforcement” or “services and outreach,” as Loukaitou-Sideris et al. did in their 2020 report “Homelessness in Transit Environments Volume I: Findings from a Survey of Public Transit Operators.” Although drug use in transit and homelessness are distinct challenges faced by transit agencies, there is significant overlap in the actions taken to respond to both pressing issues.

The following chapter examines five case example agencies in the United States through the lens of outreach, enforcement, data collection, and operational procedures. These case examples demonstrate how agency responses to drug use on transit are multifaceted and involve complementary responses that involve both enforcement and outreach.