Opioid prescription reductions and suicides

 Addictive drugs are repugnant, but painkillers are essential pharmaceuticals.  In an effort to reduce addiction, guidelines have been formulated that reduce prescription, and these sometimes backfire when applied to patients with unbearable pain.

The NY Times has the story:

What the Opioid Crisis Took From People in Pain  By Maia Szalavitz

"Though even some doctors are confused on this issue, addiction and physical dependence are not the same thing. Addiction, according to the National Institute on Drug Abuse, is compulsive drug seeking and use that occurs despite negative consequences. But pain patients like Mr. Slone are not considered addicted when medication improves their quality of life and the risks of side effects like withdrawal are outweighed by the relief medication offers.

"For people with chronic pain, research is only beginning to show how widespread the damage from opioid prescription cuts is. One study examined the medical records of nearly 15,000 Medicaid patients in Oregon who were taking long-term, high doses of opioids. Those whose medications were stopped were three and a half to four and a half times as likely to die by suicide compared to those whose doses were stable or increased. Another study, which included the medical records of over 100,000 people, found that drastically reducing a patient’s opioid dosage increased the risk of overdose by 28 percent and increased the risk of mental health crisis requiring hospitalization by 78 percent.

"Many opioid prescribing cuts were made under the auspices of guidelines published by the Centers for Disease Control and Prevention in 2016 to fight the overdose crisis. These guidelines recommend avoiding opioid prescriptions if at all possible and, when prescribing them for chronic pain, generally keeping the dosage below 90 morphine milligram equivalents, or M.M.E., per day 

...

"The C.D.C. is now updating those recommendations, admitting that the result has too often been unsafe changes in care.

...

"By 2019, the authors of the original guidelines warned in The New England Journal of Medicine that they were being misused, saying, “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.” That year, the Food and Drug Administration cautioned that it had “received reports of serious harm,” including suicides, associated with patients who suddenly had their medication discontinued or abruptly reduced.

"But by then, states had passed legislation giving some of the recommendations the force of law. The National Committee for Quality Assurance, which provides standards for insurers, government agencies and medical organizations, made keeping doses within the guidelines into a metric — incentivizing doctors to taper or stop seeing high-dose patients. Insurers, pharmacy chains and government agencies also use the guidelines to inform restrictions, and law enforcement uses them when prosecuting physicians for running “pill mills.”

"If these policies had reduced the death toll, some might argue that they are warranted. But they have not. Measured by the number of prescriptions written per capita, medical opioid use rates in 2020 were down to levels last seen in 1993, before OxyContin marketing helped spark the crisis. However, overdose deaths are still increasing dramatically, driven by illegally manufactured synthetic opioids and many who formerly got pharmaceuticals from doctors and now resort to dealers."

Stanford-Lancet Commission on the North American Opioid Crisis

 The recently released report of the Stanford-Lancet Commission on the North American Opioid Crisis made recommendations in 7 domains:

Domain 1: The North American opioid crisis as a case study in multi-system regulatory failure

Domain 2: Opioids' dual nature as a benefit and a risk to health

Domain 3: Building integrated, well-supported, enduring systems for the care of substance use disorders

Domain 4: Maximizing the benefit and minimizing the adverse effects of criminal justice system involvement with people who are addicted to opioids

Domain 5: Creating healthy environments that can yield long-term declines in the incidence of addiction 

Domain 6: Stimulating innovation in the response to addiction

Domain 7: Preventing opioid crises beyond North America

 

Forbidden Transactions and Black Markets

 Here's a paper that was just published early online. (Only now do I see that I left out the middle initial I always use, but I'm one of the coauthors...)  

The idea of the paper is to understand when a repugnant transaction can be effectively banned, versus when a ban will lack sufficient social support to succeed. We present a simple to state (but tricky to analyze) model of conditions in which banning a market is likely to lead to a difficult to extinguish black market.

Two prominent examples are narcotic drugs (big black market) and hired killers (not so much, at least in the U.S.).  So we could have called the paper Heroin and Hitmen. (Hitmen were little more than a metaphor in this paper, but I expect to say a bit more about the actual market for hitmen in tomorrow's post.)

 Chenlin Gu, Alvin Roth, Qingyun Wu (2022) Forbidden Transactions and Black Markets. Mathematics of Operations Research  Published online in Articles in Advance 28 Jan 2022  . https://doi.org/10.1287/moor.2021.1236  (It's an open access article, so you can read the full paper: here's the pdf.)

 Abstract: "Repugnant transactions are sometimes banned, but legal bans sometimes give rise to active black markets that are difficult if not impossible to extinguish. We explore a model in which the probability of extinguishing a black market depends on the extent to which its transactions are regarded as repugnant, as measured by the proportion of the population that disapproves of them, and the intensity of that repugnance, as measured by willingness to punish. Sufficiently repugnant markets can be extinguished with even mild punishments, while others are insufficiently repugnant for this, and become exponentially more difficult to extinguish the larger they become, and the longer they survive."

Here are the first two paragraphs of the introduction:

"Why are drug dealers plentiful but hitmen scarce? That is, why is it relatively easy for a newcomer to the market to buy illegal drugs but hard to hire a killer? Both of those transactions come with harsh criminal penalties, vigorously enforced: in the United States, almost half of federal prisoners have drug convictions,1 and murder for hire2 is treated as a federal crime for both the buyer and the hitman.3

More generally, many transactions are repugnant, in the specific sense that they meet two criteria: some people want to engage in them, and others think that they should not be allowed to do so (Roth [48]). But only some repugnances become enacted into laws that criminalize those transactions, and only some of those banned markets give rise to active, illegal black markets. Only some of those black markets are so active yet so difficult to suppress that the laws banning them are eventually changed so as to allow the transactions that cannot be suppressed to be regulated. Laws that exact harsh punishments but are ineffective at curbing the transactions that they punish may come to be seen as causing harm themselves. Some well-known examples include Prohibition era laws against selling alcohol in the United States or laws in much of the world that once banned homosexual sex (and, in some places, still do)."

Chemistry is replacing agriculture in the supply of black market drugs

 The war on drugs is getting more complicated, as chemistry replaces agriculture as a primary source.  This calls for changes in both law enforcement and harm reduction.

Here's a balanced view from the WSJ:

The Once and Future Drug War. During the 50 years the U.S. has battled the narcotics trade, illegal drugs have become more available and potent. But that’s no reason to give up. Governments must adapt and find answers beyond law enforcement  By James Marson, Julie Wernau  and David Luhnow 

"America’s longest war isn’t the 20-year fight in Afghanistan. That struggle is dwarfed by the War on Drugs, started by President Richard Nixon more than 50 years ago and still raging.

"The drug war—which has relied on both law enforcement and the military, at a cost of untold lives and hundreds of billions of dollars—has fared little better than the Afghan campaign. Since Nixon’s declaration of war in 1971, drug use has soared in the U.S. and globally, the range and potency of available drugs has expanded and the power of criminal narcotics gangs has exploded.

...

"The global spread of synthetic drugs like methamphetamine, fentanyl and synthetic opioids is complicating interdiction—the core of America’s strategy for 50 years.

...

"Fentanyl has now killed far more Americans than all U.S. conflicts since World War II combined. In the past decade, it has claimed more than a half million lives, a toll that is growing swiftly. The nation was reporting fewer than 50,000 fatal overdoses as recently as 2014. 

...

"The Biden administration is the first to name “harm reduction” a priority. The White House Office on National Drug Control Policy, which was often run in the past by former generals and law-enforcement officials, is now led, for the first time, by a physician, Dr. Rahul Gupta.

...

"Europe is also pursuing harm reduction. The U.K., the Netherlands, Austria and others have offered drug testing, often at music events, to reduce the risk of overdosing or poisoning. Switzerland, the U.K., Germany and the Netherlands prescribe heroin to dependent users to cut fatal overdoses and needle sharing.

"Portugal has gone further. It decriminalized all drugs in 2001 amid a surge in heroin use and drug-dependent prisoners. Anyone caught with less than a 10-day supply of any drug is sent to a local commission that includes a doctor, lawyer and social worker for treatment. Overdose deaths have fallen from about 360 a year to 63 in 2019.

...

"Growing social and legal tolerance of drugs dismays people like Mike Vigil, who had a 31-year career in the DEA, including chief of international operations. He acknowledges that interdiction and law enforcement have not solved the problem. But he says that the U.S. has failed to develop a comprehensive strategy, including investing in down-and-out communities where drug use flourishes and trying to reduce future demand through massive, sustained education programs.

...

“We aren’t going to be able to arrest our way out of this,” says Mr. Vigil. His frustration is widely shared. “The U.S. has never taken the demand side of things seriously,” says former Mexican President Felipe Calderón."

Decriminalizing personal drug use

 The WSJ has the story

Some Cities Turn to Decriminalizing Drugs as Overdoses Climb. Toronto follows Vancouver and the state of Oregon in seeking to make it legal to carry small amounts of heroin, fentanyl and other drugs for personal use.  By Vipal Monga

"Canada’s largest city is the latest jurisdiction aiming to decriminalize drug possession as it faces a surging overdose epidemic.

"Toronto’s board of health this month said it would seek permission from Canada’s federal government to allow drug users to carry small amounts of drugs for personal use, including heroin, fentanyl and cocaine, without fear of prosecution. The exemption wouldn’t cover drug trafficking, which would remain a criminal offense.

"City officials hope that decriminalization will make it easier for people to get help. They say it could also make it easier for drug users to get jobs and stable housing because they won’t have criminal records.

...

"The new policies and proposals come as officials say they are seeking ways of handling an overdose epidemic that has swept across North America. Drug users are dying in record numbers as an increasingly toxic drug supply overwhelms the black market.

“The current approaches to drug policy and regulation are not working,” said Dr. Eileen de Villa, medical officer for Toronto, during a presentation to the city’s board of health on Dec. 6."

Supervised drug injection sites open in NYC

 The NY Times has the story:

Nation’s First Supervised Drug-Injection Sites Open in New York. During the first official day in operation at the two Manhattan facilities, trained staff reversed two overdoses, officials said.  By Jeffery C. Mays and Andy Newman

"New York, the country’s most populous city, became the first U.S. city to open officially authorized injection sites — facilities that opponents view as magnets for drug abuse but proponents praise as providing a less punitive and more effective approach to addressing addiction.

"Other cities including Philadelphia, San Francisco, Boston and Seattle have taken steps toward supervised injection but have yet to open sites amid debate over the legal and moral implications of sanctioning illegal drug use.

...

"Mayor Bill de Blasio began championing safe injection sites in 2018, citing their use and success in European and Canadian cities. The decision to officially allow the sites to open comes during the mayor’s last few weeks in office and as he considers a run for governor. He said in a statement that the decision will show other cities that “after decades of failure, a smarter approach is possible.”

"The mayor also sent a letter to the providers promising “not to take enforcement action” against their operations. Four of the city’s five district attorneys — excluding only the Staten Island district attorney, Michael McMahon — support supervised drug sites."

Can it be made safe for drug users to call for help when a friend overdoses?

There are lots of ways that drug laws contribute to the design of the black market for drugs, and the behavior of its participants. Here's a recent post from the blog Bill of Health:

New Data Highlights Complexity of Good Samaritan Overdose Law Landscape, By David Momjian

 "To combat the rising death toll from drug overdoses, 47 state legislatures and the District of Columbia have passed Good Samaritan laws (GSLs) to protect bystanders from criminal prosecution if they call for medical assistance during a drug overdose. Bystanders to a drug overdose are often worried that by calling for help, they could be arrested for drug possession or evicted by the police, who often arrive first at the scene of a 911 call, even if it is a medical emergency.

A new dataset built by the Center for Public Health Law Research at Temple University’s Beasley School of Law and funded by Vital Strategies, covers the evolution of GSLs in the United States from January 1, 2007, to June 1, 2021."

Drug overdose deaths between April 2020 and 2021 reach 100,000

 The Washington Post has the story:

100,000 Americans died of drug overdoses in 12 months during the pandemic  By Dan Keating and Lenny Bernstein

"The U.S. drug epidemic reached another terrible milestone Wednesday when the government announced that more than 100,000 people had died of overdoses between April 2020 and April 2021. It is the first time that drug-related deaths have reached six figures in any 12-month period.

...

"The new data shows there are now more overdose deaths from the illegal synthetic opioid fentanyl than there were overdose deaths from all drugs in 2016."

We should be thinking about harm reduction...

Luxembourg combats cannabis black markets by legalizing home cultivation

 Luxembourg is combatting cannabis black markets by ending the prohibition on home cultivation.

The Guardian has the story:

Luxembourg first in Europe to legalise growing and using cannabis. Relaxation is part of government rethink designed to keep users away from illegal market

"Adults in Luxembourg will be permitted to grow up to four cannabis plants in their homes or gardens under laws that will make it the first country in Europe to legalise production and consumption of the drug.

"The announcement on Friday by Luxembourg’s government was said to deliver fundamental changes in the country’s approach to recreational cannabis use and cultivation in light of the failure of prohibition to deter use.

...

"Justice minister Sam Tanson described the change to the law on domestic production and consumption as a first step.

...

“We want to start by allowing people to grow it at home. The idea is that a consumer is not in an illegal situation if he consumes cannabis and that we don’t support the whole illegal chain from production to transportation to selling where there is a lot of misery attached. We want to do everything we can to get more and more away from the illegal black market.”

Opioid prescription and curtailment are associated with increased rates of suicide among rural veterans:

 Chronic pain, followed by prescription of opioid pain medicines, is sometimes followed by opioid addiction.  A recent NBER working paper shows that policies to reduce prescriptions are associated with increased rates of suicide, particularly among rural military veterans.  Presumably some of these are related to addiction, and some are related to pain.

The Opioid Safety Initiative and Veteran Suicides by Joshua C. Tibbitts & Benjamin W. Cowan WORKING PAPER 29139, DOI 10.3386/w29139,  August 2021

"We investigate the relationship between opioid diverting policy and suicides among the veteran population. The opioid epidemic of the past two decades has had devastating health consequences among U.S. veterans and military personnel. In 2013, the Veterans Health Administration (VA) implemented the Opioid Safety Initiative (OSI) with the goal of discouraging prescription opioid dependence among VA patients. Between 2012 and 2017, prescription opioids dispensed by the VA fell 41% (VA, 2018). Because this involved the aggressive curtailing of opioid prescriptions for many VA patients, OSI may have had a detrimental effect on veterans’ mental health leading to suicide in extreme cases. In addition, because rural veterans have much higher rates of VA enrollment, more prescription opioid use and abuse, and lower rates of substance abuse and mental health treatment utilization, we expect any effect of OSI on veteran suicides to be concentrated in rural areas. We find that OSI raised the veteran suicide rate relative to the non-veteran (“civilian”) rate with rural veterans suffering the lion’s share of the increase. We estimate that OSI raised the rural veteran suicide rate by a little over one-third between 2013 and 2018."

U.S, drug overdose deaths at 93,000 in 2020

Fentanyl infused opioids are epidemic on the street. Here's the story from the Washington Post:

Drug overdose deaths soared to a record 93,000 last year By Lenny Bernstein  and Joel Achenbach

 The death toll jumped by more than 21,000, or nearly 30 percent, from 2019, according to provisional data released by the National Center for Health Statistics, eclipsing the record set that year.

...

"The estimated number of overdose deaths reached 93,331 in 2020, according to the new data. Annual final numbers usually differ little from the provisional figures released Wednesday. More than 900,000 people have died of overdoses since the U.S. drug epidemic began about 1999, according to the Centers for Disease Control and Prevention. The National Center for Health Statistics is part of the CDC.

"Opioids, primarily illegal fentanyl, continued to drive the death toll, as they have for years. Overdose deaths involving opioids reached 69,710 in 2020, up from 50,963 in 2019, according to the data. Deaths from methamphetamine and cocaine also rose.Nora Volkow, head of the National Institute on Drug Abuse, said in an interview that fentanyl has so thoroughly infiltrated the illegal drug supply that 70 percent of cocaine overdose deaths and 50 percent of methamphetamine overdose deaths also involved fentanyl."

‘Harm Reduction’ Gains Federal Support.

 Another shot has been fired in the American war against drugs, this time in the battle between those who insist that drug abuse is everywhere and always a criminal problem, and those who think that even drug abusers might be entitled so some support in their personal fight against fatal overdosing.

The NY Times has the story.

Helping Drug Users Survive, Not Abstain: ‘Harm Reduction’ Gains Federal Support. By Abby Goodnough.

"Overdoses have surged during the pandemic. Now, for the first time, Congress has appropriated funds specifically for programs that distribute clean syringes and other supplies meant to protect users."

...

"Overdose deaths rose by nearly 30 percent over the 12-month period that ended in November, to more than 90,000, according to preliminary federal data released this month — suggesting 2020 blew past recent records for such deaths. The staggering increase during the pandemic has many contributing factors, including widespread job loss and eviction; diminished access to addiction treatment and medical care; and an illegal drug supply that became even more dangerous after the country essentially shut down.

...

"Now, with the nation reopening, the Biden administration is throwing support behind the contentious approach ... known as harm reduction. Instead of helping drug users achieve abstinence, the chief goal is to reduce their risk of dying or acquiring infectious diseases like H.I.V. by giving them sterile equipment, tools to check their drugs for fentanyl and other lethal substances, or even just a safe space to nap.

"Such programs have long come under attack for enabling drug use, but President Biden has made expanding harm-reduction efforts one of his drug policy priorities — the first president to do so. The American Rescue Act includes $30 million specifically for evidence-based harm reduction services, the first time Congress has appropriated funds specifically for that purpose. The funding, while modest, is a victory for the programs, both symbolically and practically, as they often run on shoestring budgets.

...

"Still, many elected officials and communities continue to resist equipping people with supplies for drug use, including the recent addition of test strips to check drugs for the presence of illicitly manufactured fentanyl, which shows up in most overdose deaths. Some also say that syringes from harm reduction programs end up littering neighborhoods or that the programs cause an increase in crime. Researchers dispute both claims.

"West Virginia just passed a law making it far more difficult for syringe service programs to operate, even though it is seeing a surge in H.I.V. cases driven by intravenous drug use. North Carolina’s legislature weighed a similar proposal this spring, and elected officials in Scott County, Ind., whose syringe exchange helped curb a major H.I.V. outbreak six years ago, voted this month to shut it down. Mike Jones, a commissioner there who voted to end the program, said at the time that he feared the syringes it distributed could be contributing to overdose deaths."

***********

Earlier post: 

Friday, May 14, 2021

Clean needle exchange faces renewed opposition in Indiana and elsewhere

Clean needle exchange faces renewed opposition in Indiana and elsewhere

Harm reduction measures in connection with intravenous drug abuse can remain repugnant even where they were successful.

Statnews has the story:

Years ago, a syringe exchange helped end a devastating HIV outbreak. Now it might be forced to close  By Lev Facher

"The Indiana county at the center of a devastating HIV crisis in 2015 may soon close the syringe exchange program widely credited with helping to end its outbreak.

"For public health advocates in Scott County, home to 24,000, the controversy is all too familiar. Six years ago, the county drew national attention for recording roughly 200 HIV cases in a single year, largely driven by injection drug use. Critics have charged that the state government’s slow response and monthslong refusal to permit needle exchanges only made the crisis worse.

"Closing the exchange now, they warn, could lead to a new wave of HIV and hepatitis C cases and increased drug overdoses. Nationally, too, many are worried it could trigger a broader wave of closures. Scott County’s syringe exchange was hailed as a success in 2015 and paved the way for other programs to open across the country. Many fear that shuttering the program, similarly, could inspire activists from coast to coast seeking to close syringe exchanges in their communities.

...

"The new debate in Indiana comes amid a wave of anti-syringe-exchange activism across the country, including a controversial new law in West Virginia that critics say could force many local programs there to close. West Virginia is experiencing a worst-in-the-nation HIV outbreak not unlike Indiana’s six years ago.

...

"Despite the reduced rates of transmission, Scott County is still among those most vulnerable to HIV outbreaks, according to the Centers for Disease Control and Prevention. It sits at the western edge of the country’s largest HIV hotspot: An area spanning several hundred miles that includes parts of Indiana, Kentucky, Ohio, West Virginia, Virginia, and Tennessee, where much of the HIV transmission is thought to be driven by injection drug use.

"Still, neighbors and local lawmakers there have sought to close the exchange, citing fears it encourages or facilitates drug use and crime (data shows that such programs do not). They have also charged that syringe exchanges lead to hazardous litter, like stray needles — a problem that, in some cases, harm reduction advocates have acknowledged and pledged to help address."

Can heroin be used responsibly? Is the war on drugs worse than the crime?

 The psychologist Carl Hart, who studies drug addiction, has a book in which he describes his own careful use of heroin, and suggests that pharmacology isn't fate:

Drug Use for Grown-Ups. Chasing Liberty in the Land of Fear.

The New Yorker has an article about him and the book in its latest issue.

Is There a Case for Legalizing Heroin? The addiction researcher Carl Hart argues against the distinction between hard and soft drugs.   By Benjamin Wallace-Wells

Here's a description of a drug injection clinic in Switzerland that caught my eye:

"In Geneva, he met a physician who invited him to visit a heroin-maintenance clinic with which she was affiliated. Hart spent several months there in 2015, watching heroin users behave as efficiently and functionally as the weighted gears in a watch. Patients checked in twice a day for injections, during one period that began at seven in the morning and another at five in the afternoon. In between, many of them went to work. The patients were each assigned a cubby to stash their respective belongings, and often one would leave a beer there, to drink after injection. Hart noticed that though American doctors worried endlessly over the harms of mixing booze and opioids, it didn’t seem a very big deal to the Swiss users, maybe because they knew the exact dose of heroin they were getting and could trust its purity. When one patient had to attend a wedding in less enlightened England, utterly lacking in injection clinics, she carefully planned out her doses and travel arrangements so she could make the trip. When Hart told me about the Geneva injection clinic, he spoke about it in the way that liberal parents speak about Montessori schools—as a fanatically engineered expression of trust. Of the users, Hart said, “They were always on time.”

"Shortly after visiting the clinic, Hart began regularly snorting heroin, as he recounts in a new book, “Drug Use for Grown-Ups.” 

America's "war on drugs" appears to be winding down after this election

 Vox has the story:

Election Day was a major rejection of the war on drugs--In every state where marijuana legalization or another drug policy reform was on the ballot, it won.  By German Lopez

"In every state where a ballot measure asked Americans to reconsider the drug war, voters sided with reformers. In Arizona, Montana, New Jersey, and South Dakota, voters legalized marijuana for recreational purposes. In Mississippi and South Dakota (separate from the full legalization measure), voters legalized medical marijuana.

"In Oregon, voters decriminalized — but not legalized — all drugs, including cocaine and heroin. Also in Oregon, voters legalized the use of psilocybin, a psychedelic drug found in magic mushrooms, for supervised therapeutic uses.

"In Washington, DC, voters in effect decriminalized psychedelic plants, following the lead of several other cities.

"With its vote, Oregon became the first state in the US to decriminalize all drugs in modern times. And marijuana is now legalized in 15 states and DC, although DC still doesn’t allow sales."

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

Update: and here's Kristof in the NYT:

Republicans and Democrats Agree: End the War on Drugs--Voters in red and blue states may be in accord on nothing else, but they passed measures to liberalize drug laws.  By Nicholas Kristof

"In Arizona, Mississippi, Montana, New Jersey and South Dakota, voters decisively passed measures liberalizing marijuana laws. Marijuana will now be legal for medical use in about 35 states and for recreational use in 15 states.

...

"Under the new Oregon measure, manufacturing or selling drugs will still be crimes, but possession of small amounts of heroin, cocaine or methamphetamine would be equivalent to a traffic ticket. The aim is to steer people into treatment so that they can get help with their addictions."

Opioid deaths in Canada during the pandemic, and what to do about it.

 Canada has a different political culture than the U.S., and attitudes towards drug abuse are one place in which that shows through clearly.

The Washington Post has the story--drug overdoses have risen during the pandemic:

Canada’s other health crisis: As overdoses surge, officials call on government to decriminalize illicit drugs

By Amanda Coletta

"a growing chorus, including top public health officials, the premier of British Columbia and the nation’s police chiefs, is calling on Prime Minister Justin Trudeau to decriminalize the possession of illicit drugs for personal use.

...

"British Columbia, the epicenter of the crisis, recorded its deadliest month in May — and then surpassed it in June. Nearly four times as many people in the province have died of a suspected overdose this year as have died of the coronavirus.

...

"Border closures have disrupted drug markets, making the street supply more unpredictable and toxic. Authorities have urged people to stay at home, pushing some to use drugs alone, without anyone nearby to help when dosages go wrong. Some supervised consumption sites and treatment centers have reduced operations, cutting people off from support networks.

...

"For the pandemic, officials have marshaled extraordinary financial resources and provided daily updates. Lawmakers have stood side-by-side with public health officials, largely deferring to their advice.

"But they’ve not always backed the remedies those same officials have offered to fight overdoses.

...

"“The most important thing we can do is make it okay for people to talk about their drug use and to seek assistance for it,” Henry said. “Labeling somebody a criminal is one of those major barriers that keeps people hiding and afraid and ashamed.”

... 

"That followed an extraordinary endorsement from the Canadian Association of Chiefs of Police, which said police resources would be better spent on cracking down on drug trafficking, illegal production and importation than on pursuing users.

"The chiefs said that arresting people for simple possession has been “ineffective” and that police should instead direct users to ­social services and health care, which could reduce recidivism and ancillary crimes."

Safe injection sites: surreptitious harm reduction, in the NEJM

When healthcare interventions must be conducted secretly, it's likely that something is very wrong with the law.

A letter in the New England Journal of Medicine brings us up to date on safe injection sites, to combat deaths from drug overdoses.

Evaluation of an Unsanctioned Safe Consumption Site in the United States

by Alex H. Kral, Ph.D., Barrot H. Lambdin, Ph.D., Lynn D. Wenger, M.S.W., M.P.H., and 

Pete J. Davidson, Ph.D.    July 8, 2020

"Nearly 70,000 people in the United States die each year from a drug overdose.1 Opioid-involved overdose deaths may be preventable by the timely administration of naloxone. Eleven countries have responded to health concerns regarding people who use drugs by opening sanctioned safe consumption sites; however, no such sites exist yet in the United States. Safe consumption sites provide a space for people to bring preobtained drugs and use them with sterile supplies under clean conditions and with safe disposal of used drug equipment. These sites provide monitoring by staff equipped and trained in the use of naloxone to reverse overdose. Most sanctioned sites can also provide related services, including voluntary screening for infectious diseases, peer counseling, wound care, and referral to other social and medical services, such as substance use treatment. 

...

"In September 2014, in response to a local opioid overdose crisis, an organization in an undisclosed U.S. city opened an unsanctioned safe consumption site. 

"Although this evaluation was limited to one city and one site that is unsanctioned, and therefore the findings cannot be generalized, our results suggest that implementing sanctioned safe consumption sites in the United States could reduce mortality from opioid-involved overdose. Sanctioning sites could allow persons to link to other medical and social services, including treatment for substance use, and facilitate rigorous evaluation of their implementation and effect on reducing problems such as public injection of drugs and improperly discarded syringes."

Fighting addiction in Seattle, where incarceration isn't the treatment of choice

Here's Kristof in yesterday's NY Times:

Seattle Has Figured Out How to End the War on Drugs
While other cities are jailing drug users, Seattle has found another way.

"SEATTLE — On gritty streets where heroin, fentanyl and meth stride like Death Eaters, where for decades both drugs and the war on drugs have wrecked lives, the city of Seattle is pioneering a bold approach to narcotics that should be a model for America.

"Anyone caught here with a small amount of drugs — even heroin — isn’t typically prosecuted. Instead, that person is steered toward social services to get help.

"This model is becoming the consensus preference among public health experts in the U.S. and abroad. Still, it shocks many Americans to see no criminal penalty for using drugs illegally, so it takes courage and vision to adopt this approach: a partial retreat in the war on drugs coupled with a stepped-up campaign against addiction.

"The war on drugs has been one of America’s most grievous mistakes, resulting in as many citizens with arrest records as with college diplomas. At last count, an American was arrested for drug possession every 25 seconds, yet the mass incarceration this leads to has not turned the tide on narcotics.
...
"In effect, Seattle is decriminalizing the use of hard drugs. It is relying less on the criminal justice toolbox to deal with hard drugs and more on the public health toolbox.
...
"As I see it, the problem is that while Seattle has done an outstanding job halting the war on drugs, it hasn’t done well in financing the war on addiction. It closed the law enforcement toolbox without fully opening the public health toolbox.

"Local officials found that in a world of competing budget silos, money saved from jails can’t easily be reallocated to treatment. This is so even though researchers repeatedly find that drug treatment pays for itself by saving huge amounts of taxpayer money, not to mention lives. One study found that substance abuse treatment in California paid for itself seven times over in reduced crime and other savings.

Clean needle exchange programs may be both helpful and harmful

Here's a recent NBER working paper that looks at the effects of opening a place where intravenous drug users can get clean needles--it finds that this reduces blood borne disease, but may in fact increase drug use.

Are Syringe Exchange Programs Helpful or Harmful? New Evidence in the Wake of the Opioid Epidemic
by Analisa Packham
NBER Working Paper No. 26111,  July 2019

Abstract: "In light of the recent opioid crisis, many public health entities have called for an expansion in syringe exchange programs (SEPs), which provide access to sterile syringes and facilitate safe needle disposal for injection drug users. This paper investigates the effects of recent SEP openings on HIV diagnoses and drug-related overdoses in the wake of the opioid crisis. I find that SEP openings decrease HIV diagnoses by up to 18.2 percent. However, I present new evidence that SEPs increase rates of opioid-related mortality and hospitalizations, suggesting that needle exchanges alone may be less effective than other interventions at stimulating recovery."


"From an economic standpoint,SEPs have the potential to create large positive externalities by reducing the stock of used needles on the streets and preventing the spread of disease. Conversely, by providing clean needles to drug users, reducing the stigma of using drugs and/or creating a safe environment for networking with other users, SEPs may also generate untended consequences. In particular, lowering the cost of obtaining needles and other supplies incentivizes drug users to inject more frequently, potentially exacerbating rates of opioid misuse and abuse. 

"In this paper, I test the causal relationships between SEP openings and drug-related health and crime outcomes. Because no official national directory of SEPs exist, I construct a hand collected dataset on program locations and opening dates to identify areas exposed to SEPs within the last ten years. In particular, using health outcomes data from the CDC, I compare rates of HIV, drug- and opioid-related deaths, opioid-related overdoses, and drug-related crime in counties with SEP openings to other counties without SEPs before and after the initial year of implementation. I find that SEPs decrease the number of HIV cases in some areas, and that  this effect grows over time. However, estimates also indicate that SEP openings increase drug-related mortality. … Effects are largest in rural and high-poverty areas, suggesting that those with larger geographic or financial obstacles  to substance abuse treatment are most affected by such programs."

Fighting trafficking by decriminalizing sex work in Mexico City

The Guardian has the story:

Mexico City will decriminalize sex work in move against trafficking

"Mexico City lawmakers have given the green light to decriminalize sex work in the capital, hoping it will be a first step to a crackdown on sex trafficking that traps thousands of Mexican women and children.

"Lawmakers in Mexico City’s congress on Friday voted 38-0, with eight abstentions, in favor of a bill to remove a line in the civic culture law which said prostitutes and their clients can be fined or arrested if neighbors complained.

"Temistocles Villanueva, a local representative with the ruling center-left Morena party, said the new law recognized that people had the right to engage in sex work.

“It’s a first step that has to lead to regulation of sex work, to fight human trafficking and strengthen the rights of sex workers,” he said. “Exercising sexuality in our country is still a taboo topic that few of us dare to talk about.“

"Sex work is allowed in much of Mexico but states have different and sometimes unclear rules, meaning workers frequently operate in legal vacuums which can leave them vulnerable to exploitation and trafficking by crime gangs.

"Mexico is a source, transit and destination country for men, women, and children subjected to sex trafficking and forced labor, with Mexican women and children the most at risk from sex trafficking, according to the US state department."