Federal government contests safe injection facility in Philadelphia, where the overdose rate is four times the homicide rate

When will they ever learn? The Washington Post updates us on Federal efforts to prevent exploration of ways to cut down on drug overdose deaths.

Philadelphia plans to open supervised opioid injection facility despite federal lawsuit

"Though the plan for what is known as a safe injection site has garnered local support, the city now finds itself in the middle of a major legal fight with the federal government.

"The Justice Department sued the nonprofit Safehouse in February, arguing that opening the facility in Philadelphia — the first supervised consumption facility in the United States — would violate federal law. Likening the idea to a crack house, federal officials say allowing the use of illicit drugs with impunity enables and exacerbates the in­trac­table opioid problem; the U.S. attorney for the Eastern District of Pennsylvania argued that opening Safehouse would violate the Controlled Substances Act, which makes it illegal to open or run a place where illegal drugs are knowingly used.
...
"The overdose rate in Philadelphia is four times the homicide rate; were the statistics reversed “there’d be absolute citizen outcry, they’d have National Guard in the streets,” said former Pennsylvania governor Ed Rendell, who is on the Safehouse board and said the organization plans to move forward even with federal opposition."
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see earlier posts

Thursday, February 7, 2019

Philly and Feds at odds over reducing opioid overdoses

Sunday, September 2, 2018

The DOJ argues against harm reduction measures for drug addicts

Working alone: sex work in Britain

In Britain, prostitutes often feel compelled to work alone because working together puts them at risk of arrest for brothel-keeping.  But working alone is dangerous.  The Guardian has the story:

Decriminalise sex work to protect us from crime, prostitutes say
English collective says laws forcing women to work alone expose them to violence

"Prostitution should be decriminalised in the UK to make it safer for vulnerable women, a sex worker organisation has said.

The English Collective of Prostitutes is calling for the removal of laws relating to consensual adult sexual behaviour, arguing that the legislation forces sex workers to operate alone, leaving them vulnerable to crime and reluctant to report violence to the police because they fear arrest.

...

"The announcement comes ahead of International Sex Workers’ Rights Day, an annual event on 3 March. The government is about to publish research it commissioned on sex workers in coming months.

"In 2016, the home affairs select committee recommended decriminalising prostitution. The interim report on prostitution said the Home Office should immediately change the legislation so that soliciting was no longer an offence, and change brothel-keeping laws to allow sex workers to share premises without losing the ability to prosecute those who used brothels to control or exploit sex workers."

Philly and Feds at odds over reducing opioid overdoses

Here's the story from NPR:

U.S. Prosecutors Sue To Stop Nation's First Supervised Injection Site For Opioids

"After months of threats, federal prosecutors in Philadelphia launched a legal challenge on Wednesday against the nonprofit Safehouse, which is hoping to open what could be the nation's first site where people with opioid addiction can use drugs under medical supervision.

"The civil lawsuit, which is jointly being pursued by Pennsylvania-based prosecutors and the Department of Justice in Washington, is the first time the federal government has intervened in the hotly debated issue of supervised injection sites. The lawsuit could become an important legal test case as about a dozen cities across the country consider similar proposals.
...
"The provision of the law in question is widely known as the crack house statute. It makes it illegal to maintain a space for the purpose of making, storing, distributing or using an illegal drug. Safehouse would not make or provide opioids to users. But it would allow people to bring in their own drugs, to use while being monitored by medical staff."

Repugnant markets and black markets -- interview

Here's a short interview on repugnant markets, in Stanford's engineering magazine:

Repugnant markets spur thinking about how to engineer complex systems
"​When some people want to engage in economic activity that others seek to ban, society faces tough choices in designing the right market incentives — or disincentives."
By ​Edmund L. Andrews

"when is it effective to outlaw an activity, and when does that simply foster a black market? At what point does it make more sense to focus on harm reduction than prevention?

"Roth expanded on these ideas in a recent interview..."

Another link is here.

Harm reduction: quality assurance for illegal drugs in Australia

The WaPo has the story, from Australia

Music festivals are offering to test the safety of people’s drugs and police are increasingly liking the idea

"MELBOURNE, Australia — When young visitors from around the world headed to Australia’s Groovin the Moo music festival in Canberra last summer, public health policy researchers were watching carefully. In a rare decision, local officials there had allowed the installation of a pill testing facility, allowing festival goers to have illegal substances examined for unusual and potentially even more dangerous additives, without having to fear arrest.

"For a long time, authorities at festivals in Australia and elsewhere almost entirely focused on preventing people from taking drugs in the first place. That approach has done little to drive down the number of drug-related deaths, however, and a mounting body of research suggests that pill testing facilities might be a more promising strategy.
...
"While the idea has recently gained more support, drug tests aren’t new and have also been tried out in some parts of the United States. Installing such facilities at music festivals has de-facto been the norm in some European countries, including the Netherlands and Austria, for more than a decade. But amid more detailed research and increases in drug-related hospital admissions, supporters of drug tests are now also gaining momentum in Australia and New Zealand, where authorities have so far only allowed limited trials.
...
"Critics argue that the approach could encourage young people to take more drugs and that it sends the wrong message. On-site tests have also been singled out for being inaccurate, given the sometimes limited availability of equipment.

But supporters of the tests maintain that their approach is far more effective than focusing on arrests. Pill testing “has been shown to change the black market” for the better and may even decrease overall drug consumption, as “negative results would deter a majority of people from consuming drugs and spur them to warn their friends,” according to a summary of arguments in favor of tests by Australia’s parliamentary library. Research by the Global Drug Survey came to a similar conclusion last year."

The DOJ may not get the last word on supervised injection sites

The WP has the story:
Cities defiant after Justice Department’s threat on ‘supervised injection sites

"Cities seeking to open sites where illegal drug users are monitored to prevent overdoses responded defiantly Tuesday to a Justice Department threat to take “swift and aggressive action” against that approach to the nationwide opioid epidemic.

"Plans for those “supervised injection sites” — under consideration in San Francisco, Philadelphia, New York City, Seattle and elsewhere — collided with a stern Justice Department warning issued last week, threatening to create a standoff between federal and local authorities like the confrontation over “sanctuary cities.”

As they have before, some liberal-leaning cities trying to cope with conditions on their streets find themselves at odds with more-restrictive Trump-era policy and enforcement.
...
More than 72,000 people died of drug overdoses in 2017, led by more than 49,000 deaths from opioids, according to preliminary statistics released last month by the Centers for Disease Control and Prevention."
************
Earlier related post:

Sunday, September 2, 2018

The DOJ argues against harm reduction measures for drug addicts

The perils of (too) sharply reducing opioid prescriptions

The ongoing opioid epidemic in the U.S. (and elsewhere) has at least some of its origins in the over-prescription of opioid painkillers. So there is a lot of interest in how, and how much, to cut back on prescribing these drugs.  The two articles below raise some flags about cutting back too sharply, and warn of the long road ahead in any event (partly because people in chronic pain and people who have become addicted to prescription painkillers sometimes enter the market for illegal narcotics when they lose their prescriptions).

Sally Satel directs my attention to this article in Politico:

How the opioid crackdown is backfiring
Hundreds of chronic pain patients responding to a POLITICO survey describe being refused opioid prescriptions they had relied on for years with sometimes devastating consequences.

"Many of POLITICO’s respondents described being tapered off narcotics too quickly, or worse, turned away by doctors and left to navigate on their own. Some said they coped by using medical marijuana or CBD oil, an extract from marijuana or hemp plants; others turned to illicit street drugs despite the fear of buying fentanyl-laced heroin linked to soaring overdose death numbers. A few, like Fowlkes, contemplated suicide."
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And here is an article by some of my Stanford colleagues that explores a model to make some predictions. It is forthcoming in The American Journal of Public Health (AJPH) (and published online first):

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic
Allison L. Pitt, MS, Keith Humphreys, PhD, and Margaret L. Brandeau, PhD

"Objectives.To estimate health outcomes of policies to mitigate the opioid epidemic.

Methods.We used dynamic compartmental modeling of US adults, in various pain,opioid use, and opioid addiction health states, to project addiction-related deaths, lifeyears, and quality-adjusted life years from 2016 to 2025 for 11 policy responses tothe opioid epidemic.

Results.Over 5 years, increasing naloxone availability, promoting needle exchange,expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years.

Conclusions.Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation. (Am J Public Health.Published online ahead of print August 23,2018: e1–e7. doi:10.2105/AJPH.2018.304590)"
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Note the contrast between these views and those of the Department of Justice as expressed by Deputy Attorney General Rod Rosenstein in yesterday's post.

The DOJ argues against harm reduction measures for drug addicts

In an opinion piece in the NY Times, Rod Rosenstein,  the deputy attorney general of the United States, comes out against harm reduction measures for drug addiction, such as those being considered in several U.S. cities and States.  He argues that increased prosecution is the way to go, and threatens to go after cities that institute "safe injection sites."

Fight Drug Abuse, Don’t Subsidize It
Americans struggling with addiction need treatment and reduced access to deadly drugs. They do not need a taxpayer-sponsored haven to shoot up.

By Rod J. Rosenstein

"Last year, San Francisco assembled a task force to establish an injection site, and last week the California State Senate passed a bill that would allow San Francisco to operate such sites and grant legal immunity to the drug users who visit them. In May, the mayor of New York City announced a plan to open four injection sites. A Seattle task force approved a similar plan, and city officials have pitched outfitting a van as a mobile injection site. Numerous states, including Colorado, Massachusetts, Vermont and Maine, have explored similar options to help their residents use hard-core drugs.

"One obvious problem with injection sites is that they are illegal. It is a federal felony to maintain any location for the purpose of facilitating illicit drug use. Violations are punishable by up to 20 years in prison, hefty fines and forfeiture of the property used in the criminal activity. The law also authorizes the federal government to obtain civil injunctions against violators. Because federal law clearly prohibits injection sites, cities and counties should expect the Department of Justice to meet the opening of any injection site with swift and aggressive action.
...
"To end the drug crisis, we should educate everyone about the dangers of opioid drugs, help drug users get treatment and aggressively prosecute criminals who supply the deadly poison. Under the leadership of President Trump and Attorney General Jeff Sessions, the Department of Justice is delivering results. Many federal, state and local agencies are working with us to combat opioid addiction. Cities and counties should join us and fight drug abuse, not subsidize it."
********

Here are my other posts on harm reduction.

New calls for decriminalizing drug use in Canada

Here's the story in the Washington Post:

Toronto medical official calls for decriminalizing drugs as opioid overdoses skyrocket in Canada

"With opioid-related overdoses and deaths reaching record levels in Canada, the top medical official in Toronto is calling for the decriminalization of all drugs as part of a strategy to treat illicit drug use as a public health and social issue, not a criminal one.

"In a report released Monday, Eileen de Villa, Toronto’s chief medical officer, urged the city’s board of health to pressure the federal government to eliminate legal penalties for the possession of drugs and to scale up “prevention, harm reduction and treatment services.”

"The report also recommended assembling a task force “to explore options for the legal regulation of all drugs in Canada,” which she hopes would destroy an illegal drug market contaminated with fentanyl — a synthetic opioid 100 times more potent than morphine — and other drugs like it.

“When we criminalize people who take drugs, we inadvertently contribute to the overdose emergency,” de Villa said. “It pushes people into unsafe drug use practices and creates barriers for people to seek help.”
********

Here's the Toronto report:
A Public Health Approach to Drug Policy
Date: June 28, 2018
To: Board of Health
From: Medical Officer of Health

*********
See also the Global Commission on Drug Policy's 2016 report:
ADVANCING DRUG POLICY REFORM: A NEW APPROACH TO DECRIMINALIZATION

Safe injection sites in New York City? Learning from Canada...

The NY Times has two recent stories, one perhaps a reaction to the other.  First this:
De Blasio Moves to Bring Safe Injection Sites to New York City

"Mayor Bill de Blasio is championing a plan that would make New York City a pioneer in creating supervised injection sites for illegal drug users, part of a novel but contentious strategy to combat the epidemic of fatal overdoses caused by the use of heroin and other opioids.

"Safe injection sites have been considered successful in cities in Canadaand Europe, but do not yet exist in the United States. Leaders in San Francisco, Philadelphia and Seattle have declared their intention to create supervised sites, although none have yet done so because of daunting obstacles. Among them: The sites would seem to violate federal law.

"The endorsement of the strategy by New York, the largest city in the country, which last year saw 1,441 overdose deaths, may give the movement behind it impetus.

"For the sites to open, New York City must still clear some significant hurdles. At minimum, the plan calls for the support of several district attorneys, and, more critically, the State Department of Health, which answers to Gov. Andrew M. Cuomo. The city sent a letter on Thursday to the state, asserting its intention to open four injection centers.

 ...
"The most serious obstacle to the safe injection sites may be the federal government. A section of federal law known as the crack house statute makes it illegal to own, rent or operate a location for the purpose of unlawfully using a controlled substance.

The enforcement of the statute in the case of safe injection sites, however, would be up to the discretion of federal authorities. While it is unclear how the Trump Justice Department will respond to the city’s proposal, the attorney general, Jeff Sessions, has taken a hard line on drug policy.

“We don’t believe a president who has routinely voiced concern about the national opioid epidemic will use finite federal law enforcement resources to prevent New York City from saving lives,” Eric F. Phillips, the mayor’s press secretary, said in a written statement.

Advocates for the sites point out that needle exchanges were considered illegal when they began, and they are now commonplace; in 2015, for example, when Mike Pence was governor of Indiana, he put aside his moral opposition to needle exchanges and allowed a program to stem the flood of H.I.V. cases."

************

And, today, this:

Opioid Crisis Compels New York to Look North for Answers
Supervised injection sites for heroin users have prevented overdose deaths in Canada. But is New York City ready for the scenes that come with them?

"As Mayor Bill de Blasio has come out in support of supervised injection centers in New York, his stance has been shaped by Canada’s lead.

The country has been a pioneer; its first supervised injection facility, where heroin can be used under supervision, opened in Vancouver in 2003. A decade of political and legal wrangling followed, culminating with the Canadian Supreme Court ruling in favor of the approach in 2011."

Harm reduction (for opioids) in Canada

Here's a story from the Washington Post:
At the heart of Canada’s fentanyl crisis, extreme efforts that U.S. cities may follow

"the Overdose Prevention Society, took over a vacant building next door, giving users a clean indoor place to inject drugs. There are 29 similar sites in British Columbia, the epicenter of Canada’s drug crisis, and more across the country.

“To save lives, you need a table, chairs and some volunteers,” said Sarah Blyth, the manager here.
...
"As fentanyl rampages across North America, several U.S. cities have announced that they will open the first supervised drug-consumption sites like those in Canada. Their plans illustrate the gulf between the two nations: While Justin Trudeau’s government is doubling down on its “harm reduction” approach, any U.S. organization that tries to follow suit would be violating federal law and risking a confrontation with the Justice Department.
************
See also this academic paper
Addressing the Nation’s Opioid Epidemic: Lessons from an Unsanctioned Supervised Injection Site in the U.S.
Alex H. Kral and Peter J. Davidson
American Journal of Preventive Medicine, 53, 6, 2017, 919 - 922

and this January 2017 news story
Awash in overdoses, Seattle creates safe sites for addicts to inject illegal drugs

Legal marijuana and crime reduction

The Guardian channels an academic paper from the EJ:

Here's the Guardian story:
Legal marijuana cuts violence says US study, as medical-use laws see crime fall
Murder and violent crime found to have decreased most in states bordering Mexico as drug cartels lose business to regulation

And here's the paper:

Is Legal Pot Crippling Mexican Drug Trafficking Organizations? The Effect of Medical Marijuana Laws on US Crime  

Evelina Gavrilova

Takuma Kamada

Floris Zoutman 

Forthcoming in Economic Journal 

Abstract: We examine the effects of medical marijuana laws (MMLs) on crime. We exploit theintroduction of MMLs as quasi-experimental variation. Using data from the UniformCrime Reports, we show that the introduction of MMLs lead to a decrease of 12.5 percentin violent crime, such as homicides, aggravated assaults and robberies in states that borderMexico. We also show that the reduction in violent crimes is strongest for counties closeto the border (less than 350km), while there is no significant impact of MMLs on crimefor counties located further inland. Analysis from the Supplementary Homicide Reportsdata reveals that the decrease in homicides can largely be attributed to a drop in drug-lawrelated homicides. We find evidence for spillover effects. When an inland state passesa MML, this results in a decrease in crime in the nearest border state. Our results areconsistent with the theory that the introduction of MMLs reduces activity by Mexicandrug trafficking organizations and their affiliated gangs in the border region. MMLs exposedrug trafficking organizations (DTOs) to legitimate competition, and substantially reducetheir profits in one of their most lucrative drug markets. This leads to a decrease in drug-related crime in the Mexican border area. Our results indicate that decriminalization ofthe production and distribution of drugs may lead to a reduction in violence in marketswhere organized drug criminals meet licit competition.

Opioids and harm reduction: drug checking and Safe Injection Facilities

From Mason Marks writing on the Bill of Health blog at Harvard Law School:

The Opioid Crisis Requires Evidence-Based Solutions, Part III: How the President’s Commission on Combating Drug Addiction Dismissed Harm Reduction Strategies

" it is noteworthy that the Commission ignored harm reduction strategies such as drug checking, which could reduce deaths due to consumption of contaminated opioids. Many countries including Austria, Belgium, Switzerland, Portugal, Spain, Switzerland, and the Netherlands offer free and confidential drug checking (also known as pill testing) to drug users. Drug checking could reduce consumption of adulterated drugs and provides opportunities to support and counsel users who may otherwise receive no contact with medical or public health professionals. Drug checking is also a valuable source of information about drug use such as pricing, availability, effects, and composition of street drugs. This information can be used to further our understanding of drug use and its effects.

Some experts argue that drug dealers will be less likely to add dangerous adulterants to their products if they know that consumers have a mechanism to test their contents. The identification of drug contents can alert authorities to the presence of synthetic opioids, which can lead to public warnings and announcements that may further drive dealers to withdraw deadly additives from the market. The practice can also improve law enforcement efforts to reduce the illegal importation and sale of synthetic opioids. Dr. Carl Hart, Chair of the Department of Psychology at Columbia University, supports the use of free and anonymous drug checking in the United States. In a Scientific American article, heargues that the opioid crisis is a distinctly American problem. According to Hart, “Throughout Europe and other regions where opioids are readily available, people are not dying at comparable rates as those in the U.S., largely because addiction is not treated as a crime but as a public health problem.” Drug checking is one example of how European countries approach drug abuse from a public health angle rather than a punitive law enforcement perspective.

Critics of drug checking argue that it could normalize drug use or “send the wrong message” to potential users. For instance, the practice could create the appearance of safety when in fact the drugs being consumed are dangerous. ...

"Supervised injection facilities (SIFs), arguably a more controversial option than drug checking, were also ignored by the President’s Opioid Commission. SIFs provide a place for people to inject drugs under professional supervision to minimize the risk of HIV and hepatitis C infection, drug overdose, and death. They are primarily used in Switzerland, Canada, and Australia. However, the City of Denver is taking steps to become the first U.S. city to offer SIFs. In November, a plan for a pilot program won unanimous approval from a bipartisan ten-member legislative committee. However, the City’s General Assembly must approve the plan in January 2018 for it to move forward. Seattle and San Francisco are considering similar proposals. The State of Vermont is also considering using SIFs. On November 29, 2017, a commission of health and law enforcement professionals, led by State’s Attorney General Sarah George, recommended that Vermont make SIFs a part of its opioid strategy. However, the Vermont Commissioner of Public Safety and the Vermont Association of Police Chiefs disagree. The Commissioner stated, “Facilitating the ongoing use of heroin through SIFs sends the wrong message, at the wrong time, to the wrong people.”

...

"A 2014 review published in the journal Drug and Alcohol Dependence, examined the outcome of 75 studies and concluded that SIFs are an effective harm-reduction strategy not associated with increased drug use or crime. In early 2017, the Massachusetts Medical Society published its analysis of SIFs. It found that peer-reviewed research published in leading academic journals, such as JAMA and the New England Journal of Medicine, supports the conclusion that SIFs produce positive outcomes such as reduced mortality and increased access to drug treatment.

...

"Admittedly, there could be an “ick factor” associated with SIFs, and overly zealous drug control advocates could find them repugnant. However, when thousands of lives are at stake, emotional reactions to SIFs must be weighed against the scientific evidence. If the evidence suggests that SIFs are effective, then lawmakers must be courageous and allow their decisions to be guided by science rather than emotions such as disgust."

Wild (and abandoned) horses are starving, because we love them too much

Chris Stewart, a horse-loving Republican congressman from Utah, writes in the NY Times:

The Hard Truth About the West’s Wild Horse Problem

"The federal government’s Wild Horse and Burro Program is broken, leaving thousands of animals to starve. The Bureau of Land Management says that the nearly 27 million acres it manages for wild horses and burros can sustain only about 27,000 animals. This year, the bureau estimates that there were more than 72,000 wild horses on the land, almost 50,000 too many and all fighting to survive.
...
"This isn’t just a horse management disaster, it’s a financial disaster too. In addition to the 72,000 horses it oversees on the range, the B.L.M. keeps about 45,000 horses that it has removed from the wild in corrals, off-range pastures and in sanctuaries. Over their lifetime, these horses will cost taxpayers roughly $1 billion overall, according to the B.L.M. That’s $1 billion we could otherwise spend on defense, education, job training or any other worthy cause.
...
"the bulk of the blame lies with shortsighted decision-making by misinformed but well-meaning members of Congress.

"Congress had once supported laws that allowed for proper management of these animals. Horses in excess of what the land could sustain were to be captured, put up for adoption, sold without restriction — including to slaughterhouses, which the B.L.M. does not do as a matter of policy — and as a last resort, humanely euthanized. The program wasn’t perfect, but the B.L.M. was able to keep the herds’ numbers in check while ensuring that the ranges were viable and healthy year after year.

"But since 2010, Congress has used annual appropriations acts to significantly restrict the ability of the B.L.M. to sell or euthanize horses. "
************

This is clearly not the situation intended by those who put in place the laws and regulations that prevent wild horse populations from being managed.  Maybe it's time to eat horsemeat, for the sake of the horses?  Not likely soon in the U.S.: see my previous posts on that...

Supervised injection facilities for opioids

From Statnews:
As a doctor, I was opposed to supervised injection facilities. Now I’m ready to give them a try  By Henry L. Dorkin (the president of the Massachusetts Medical Society).

"Over the last few years, I have watched with a blend of amazement and grave concern as an odd phenomenon has unfolded against the backdrop of our nation’s opioid crisis: Despite the clear need to battle this ongoing epidemic with all of the tools at our disposal, one evidence-proven option — supervised injection facilities — is being overlooked, and even disparaged.
...
"A supervised injection facility is a safe, clean space where individuals can inject drugs they already possess under the supervision of trained medical staff. The facilities also offer sterile injection equipment. The advantage is that medical expertise is immediately present in case an emergency occurs. At the same time, these on-site clinicians can facilitate pathways to treatment and rehabilitation from the chronic disease of opioid abuse disorder.
...
"As a physician and president of the Massachusetts Medical Society, I was initially inclined to oppose the concept of supervised injection facilities. How, I thought, could a health care professional, someone grounded in ethics and an oath to “do no harm,” stand by and watch as individuals inject street drugs into their veins?
...
"The concept of supervised injection facilities fits well with the overarching and proven public health philosophy of harm reduction: meeting patients where they are in their disease to eliminate existing barriers to rehabilitation.

With lives being lost each day from all segments of our society, dealing in theoretical solutions can be counterproductive. Fortunately, supervised injection facilities operating in other parts of the world have yielded substantial and evidence-backed reductions of death, disease, and expenditures.

"To better understand the utility of these facilities, the Massachusetts Medical Society created a task force to examine the evidence for and against supervised injection facilities. This group produced a report that reviewed all available data regarding the use of supervised injection facilities around the world.

"The report clearly showed that these facilities save lives. For example, after the Insite facility opened in Vancouver, British Columbia — the first supervised injection facility in North America — researchers reported a 35 percent decrease in the number of lethal overdoses in that area.

...

"Shortly after our medical society overwhelmingly voted to adopt a policy in support of a pilot supervised injection facility program in Massachusetts, the American Medical Association adopted a similar policy.

...

"As we continue to look for ways to increase access to recovery programs for those with opioid use disorder, we must remember that in order to get people into recovery, they must first stay alive."

Temporary brothels in Britain

The Guardian has the story:

How ‘pop-up’ brothels transformed Britain’s suburban sex industry
MPs are investigating a surge in flats being used short-term for prostitution – but the women who work in them say they often have no safer option

"Last month, MPs launched an inquiry into the apparent rise of so-called “pop-up” or temporary brothels. The phenomenon, where sex workers use Airbnb, hotels, or short-term holiday lets as a work base, has caused concern among politicians and the police. But what is the reality for women working in brothels in Britain today, and what is driving them to work in temporary set-ups?

“People think we’re either in five-star hotels or we’re on flea-bitten mattresses with a line of men outside the door,” says Amy, a single mother who works in the north London brothel. “Both of those things are real, both of those things happen, but the vast majority of us are just somewhere in the middle. Demystifying it is really important.”

...

"After a year, she found her current place with two others. With CCTV and a panic alarm, she says the more permanent setup means she has better security measures: “I honestly can’t imagine working any other way now and it astounds me that what we’re doing is technically illegal.”

Still, she does not want to paint a rose-tinted picture of her new situation. “When [sex workers] are talking to the press, there’s a lot of pressure for us to be like, ‘Oh I love my job, everything’s great’ when it’s not great. It’s like any other job – you have good days and bad days. It’s just like being in any kind of office job, or a call centre, just with more nudity, and dildos everywhere,” she jokes.

"Like many sex workers, trust and communication with the police is a huge issue for her and her workmates. “At the moment, I have absolutely no trust in the police whatsoever,” she says. “You can literally go from being the victim, to being the criminal in a matter of minutes.”

...

"How the law stands

• There are an estimated 72,800 sex workers operating in the UK.
• In a study of 6,000 men, 11% reported paying for sex. More than a half of these said they paid for sex outside the UK.
• The mortality rate for sex workwers is 12 times higher than average.
• Keeping or managing a brothel is illegal under the 1956 Sexual Offences Act.
• The sale and purchase of sexual services is legal in England and Wales, but certain related activities are not.
• In 2015 Northern Ireland made it illegal to pay for sex. The first prosecution was in October 2017."

Legal prostitution and crime in the Netherlands

Here's a new paper on the relationship of legal prostitution and crime.

Street Prostitution Zones and Crime 
Paul Bisschop, Stephen Kastoryano, and Bas van der Klaauw,
American Economic Journal: Economic Policy 2017, 9(4): 28–63

Abstract: "This paper studies the effects of legal street prostitution zones on registered and perceived crime. We exploit a unique setting in the Netherlands where these tippelzones were opened in nine cities under different regulation systems. Our difference-in-difference analysis of 25 Dutch cities between 1994-2011 shows that opening a tippelzone decreases registered sexual abuse and rape by about 30-40 percent in the first two years. For cities which enforced licensing in tippelzones, we also find reductions in drug-related crime and long-term effects on sexual assaults. Effects on perceived drug nuisance depend on the regulation system and the proximity of respondents to the tippelzone."
**********

See my earlier post, about a paper drawing similar conclusions from a different kind of natural experiment.

Wednesday, August 30, 2017

The accidental experiment with legal prostitution in Rhode Island

Decriminalization of narcotics in Portugal, an update

Kristof in the NYT on narcotics policy and outcomes in Portugal:
How to Win a War on Drugs: Portugal treats addiction as a disease, not a

"Decades ago, the United States and Portugal both struggled with illicit drugs and took decisive action — in diametrically opposite directions. The U.S. cracked down vigorously, spending billions of dollars incarcerating drug users. In contrast, Portugal undertook a monumental experiment: It decriminalized the use of all drugs in 2001, even heroin and cocaine, and unleashed a major public health campaign to tackle addiction. Ever since in Portugal, drug addiction has been treated more as a medical challenge than as a criminal justice issue.

"After more than 15 years, it’s clear which approach worked better. The United States drug policy failed spectacularly, with about as many Americans dying last year of overdoses — around 64,000 — as were killed in the Vietnam, Afghanistan and Iraq Wars combined.
...
"The number of Portuguese dying from overdoses plunged more than 85 percent before rising a bit in the aftermath of the European economic crisis of recent years. Even so, Portugal’s drug mortality rate is the lowest in Western Europe — one-tenth the rate of Britain or Denmark — and about one-fiftieth the latest number for the U.S."

The accidental experiment with legal prostitution in Rhode Island

A scholarly paper and an easy to read-or-listen-to NPR report recount the period in which indoor prostitution was legal in Rhode Island.

The paper (forthcoming in Review of Economic Studies):

Decriminalizing Indoor Prostitution:Implications for Sexual Violence and Public Health  by Scott Cunningham and Manisha Shah

Abstract:
Most governments in the world, including the United States, prohibit sex work.Given these types of laws rarely change and are fairly uniform across regions, our knowledge about the impact of decriminalizing sex work is largely conjectural.  We exploit the fact that a Rhode Island District Court judge unexpectedly decriminalized indoor sex work to provide causal estimates of the impact of decriminalization on the composition of the sex market, reported rape offenses, and sexually transmit-ted infections.  While decriminalization increases the size of the indoor sex market, reported rape offenses fall by 30 percent and female gonorrhea incidence declines by over 40 percent.
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And here's the NPR report and podcast:
Prostitution decriminalized: Rhode Island’s experiment

It's worth reading, with lots of interesting bits, and links.  Here is a section of the transcript that struck me:

"So, what did she and her colleague, Scott Cunningham at Baylor University, find?

The obvious: sex work exploded.

But then, the not so obvious: female gonorrhea rates statewide plummetedduring the overt decriminalization period.

"It goes down by around 40 percent," Shah said. "We spent a lot of time beating up the data and estimating these things in different ways, and we just can't get the results to go away, regardless of what we do, they're there.

A forty percent drop is a big deal in the world of public health. Shah thinks one of the reasons for this positive outcome is that legalization empowered sex workers to say no to riskier sexual behavior. She also wonders if newer people were entering the market and didn't have as big of an STD risk.

Still, perhaps even more surprising than the decrease in gonorrhea was another public health development. Sexual violence, or rapes, dipped dramatically. And this wasn't just amongst sex workers. It was across the board, according to FBI crime reports and jurisdiction level data.

"Reported rape offenses decreased by about 30 percent," Shah said.

That's another big decrease. Shah says, if anything, you'd expect rape to go up as when prostitution is decriminalized, sex workers are more likely to report rapes. She compared this to neighboring states, too. The drop was only in Rhode Island. So she examined other crime data in Rhode Island, like burglaries and murders, to see if there had just been a drop in crime generally.

It didn't match. So what happened?

That, she says is harder to answer. She has a theory, though, in that while she knows for some men rape is about power, "I think the argument that we're making is that that might not be true for all men, and for some, these activities could be substitutes."

In other words, for some men, rape may be just about sex. And if there's a legal and accessible market for it, the number of rapes in a community may go down.

This has not been a popular theory or study. And for many, it challenges the notion that rape is about violence and power, and not sex.

"So I consider myself a feminist, but I think this finding angers a lot of feminists," Shah said. "It is a very controversial idea."

And then there's that other controversial area: could decriminalization fuel sex trafficking and sexual exploitation?

"I definitely worry about that," Shah said. "It's an area that I would love to, to be able to do more with."

Still Shah believes there's no solid evidence yet that decriminalizing prostitution does lead to an increase in trafficking women and forcing them into prostitution.

"There is not good empirical evidence for this either way, and part of that is because it's just very, very hard to collect good data on numbers of human trafficking."

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Scott Cunningham has been studying black markets for some time, and I'm a long time fan of his work. Here are some of my earlier posts covering it.

Harm reduction: decriminalizing drugs to reduce overdoses?

From the Toronto Star:
Should Toronto push to decriminalize all drugs? The city’s medical health officer ready to consider it
The city is convening a committee of health and drug policy experts to explore “a different approach that puts the health of the community first,” Dr. Eileen De Villa said.

"Toronto’s new Medical Officer of Health is calling for a public discussion on the merits of decriminalizing all drugs in the wake of the ongoing overdose epidemic.

“It’s clear that our current approach to drugs in this city and this country doesn’t seem to be having the desired impact,” Dr. Eileen De Villa told reporters Friday at a briefing on how the city is responding to drug users overdosing and, in some cases, dying.
...
"On Friday, following Thursday’s emergency meeting of city partners, De Villa reviewed with reporters the city’s overdose prevention strategies which include asking police to carry the fentanyl antidote and speeding up the opening of three safe injection sites.

De Villa said among the 10 key strategies in Toronto’s Overdose Action plan is a call for a public health approach to drug policy that puts the health of the community first, “rather than looking at this as an issue of criminal behavior and or an area for law enforcement.”

The city is convening a committee of health and drug policy experts to explore “a different approach that puts the health of the community first,” she said.

While acknowledging the city doesn’t have the power to change the Criminal Code, “Toronto has always been a leader … in policy and I don’t see why we wouldn’t continue to be a leader on this front,” said De Villa, who stepped into her high-profile position four months ago."
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Not everyone is interested in this kind of harm reduction. Here's a Washington Post story about a different point of view expressed by an Ohio sheriff (I think this is a point of view that also comes up in opposition to e.g. making clean needles available to drug addicts):

Why this Ohio sheriff refuses to let his deputies carry Narcan to reverse overdoses

"No one has come up with a solution to the opioid epidemic that has decimated Rust Belt states, but for people who overdose, Naloxone is about as effective an antidote as there is. The results of the opioid antagonist, which is sprayed up a person's nose and reverses the effect of opioid overdoses, have been likened to resurrecting someone from the dead.

"Paramedics and firefighters routinely carry the easy-to-administer medication in their vehicles. For police officers in the nation's hardest hit areas, like southwest Ohio, the Food and Drug Administration-approved nasal spray, known by the brand name Narcan, can be as common as handcuffs. Even some librarians have learned to use the drug to revive people who overdose in their stacks.

"But Richard K. Jones, the sheriff of Butler County, Ohio, raised eyebrows recently when he said that his deputies will never carry the medication.
...
"Jones said Narcan is the wrong approach for a war on opioids that “we're not winning,” and said he favored stronger prevention efforts to prevent people from first using the drug."