Xylazine: Advocates, Service Providers on High Alert
As friends to organizations whose missions are primarily centered on harm reduction and as an organization that recognizes and often seeks to break down the silos associated with HIV, Hepatitis C, and Substance Use Disorder as distinctive but intersecting health states, Community Access National Network (CANN) is sometimes skeptical as to “alerts” the United States law enforcement community might offer through various news media. The “rainbow fentanyl” hype from the fall of 2022 speaks to why advocates may find themselves questioning the veracity of these kinds of warnings. However, the issue of xylazine is unfortunately based in very tangible realities for the United States, which have been documented as far back as the 2000’s in Puerto Rico. The prevalence of xylazine is increasing across the country’s street-based drug supply, often times in combination with fentanyl – most significantly complicating efforts to reverse overdoses and causing wounds which are atypical to more common fentanyl or heroin use.
Last week I spent time discussing a friend’s personal (and social) sexual health and as conversation developed they expressed concern over the development of xylazine, sometimes known as “tranq dope” or “down”, becoming more prevalent in the illicit drug trade of their community. Planning for events and even social outtings are requiring them to consider carrying more doses of Narcan on them and they’re noticing a higher demand for fentanyl testing strips. They conveyed a familiarity with the strips being used to ensure the illicit substances being used were indeed fentanyl and not the animal tranquilizer that seems to be driving up fatal overdoses in the surrounding community. Our conversation wrapped up with my friend sharing with me a sentiment another friend had shared, “Crack sucked, opioids suck…but they were a progression. People knew what they were doing. This is innocent. People aren’t making these choices.”
And while some might moralize what making “those” choices might mean, ultimately the best approach to helping folks navigate substance use doesn’t come with judgment but an acceptance that we all cope with the world around us differently. History tells us readily that prohibition movements seldomly achieve their goals and, economically, criminalization is less beneficial than harm reduction measures in curbing illicit substance use. Harm reduction measures, when adequately situated and supported, link people who use drugs to care where wounds may be treated, safe supplies might be obtained, chains of transmission of infectious diseases are identified and interrupted, and, when someone is ready, linkage to substance use counseling is available. It is this intersection of interest where harm reduction and patient advocacy intersect.
Hard-won victories which have helped advocates create safer environments for people who use drugs may not be sufficient for handling this corruption of street supply, as the wounds being associated with xylazine are resulting in amputations, in part because of providers being less familiar with how these wounds are presenting, which may still be present even when someone is not injecting their substance of choice, but swallowing, smoking, or snorting it. Trust in hospital providers is slim because emergency rooms are received as hostile environments which do not typically offer substance use treatment referrals and where people who use drugs often experience provider biases, sometimes resulting in substandard care. Fear of withdrawal is also a compelling factor for avoiding necessary care, as community-based programs are trying to meet the needs of their clients, their communities, mostly on their own.
While Philadelphia’s struggle with xylazine infiltrating the street supply is well documented, other jurisdictions are seeing signs of the tranquilizer. Delaware firmly expects to see 2022’s fatal overdose tally surpass 2021’s, even as provisional data is still being cleaned. Similarly, Connecticut, New Hampshire, and Rhode Island among several other east coast states have identified xylazine in the local supply as well as fatal overdoses increasing.
In the face of these challenges, House Republicans have asked the Drug Enforcement Agency and (DEA) to “schedule” xylazine and if the agency doesn’t, they might seek legislation to schedule it anyways – a move advocates warn might only make the problem worse. “Scheduling” refers to introducing a specific substance to the “schedule” of illegal and illicit substances maintained under the Controlled Substances Act – thereby adding certain criminal enhancements to the possession, use, and distribution of the tranquilizer. The concern from advocates in such a move is it would encourage further addition of other synthetic adulterators into street supplies, just as we’re learning (and researching) how to handle xylazine. Dr. Ryan Marino, medical director of toxicology and addiction medicine at University Hospitals in Cleveland scolded, “This is more of the same short-sighted and reactionary political grandstanding that may help politicians but won’t help any American citizens and doesn’t solve any of our drug problems.”
The U.S. Food and Drug Administration (FDA) issued an alert to health care professionals in November 2022, and the Biden Administration’s other agencies are already beginning to tackle the subject. But, what will it amount to?
Federal and state funding is already largely prohibited from backing safe consumption sites and Canada’s advocate proposal of a “safe supply” would be an ever further stretch for politicians wishing to appear “tough on drugs” (but apparently lacking the empathy and expertise to be helpful to communities struggling with deaths). A congressional Research Service report, also shared in November 2022, offered some answers, ranging from treating safe consumption sites similarly to medical marijuana dispensaries, wherein the U.S. Department of Justice (DOJ) is prohibited from using resources to seek prosecution of those businesses so long as they comply with state law, lawmakers could opt to fund these sites, giving explicit endorsement of a well-proven intervention that has already saved hundreds of lives in New York, or Congressional leaders or the President might choose to actively pursue criminal litigation and legislation which explicitly outlaw safe consumption sites. The Biden Administration appears to be leaning toward non-enforcement, if the recent updates about the DOJ and Safehouse, an organization in Philadelphia, meeting an “amicable settlement” prove to be fruitful.
Because overdoses of the tranquilizer are also presenting atypically from more traditional fentanyl overdoses, community health workers are noticing Narcan is less effective in reversing these overdoses and even when they are effective, the person experiencing the overdose may not rouse as easily because of the contamination with xylazine. Some have reported oxygen supplements might help in stabilizing someone in need of emergency care in response to an overdose. This would prove an exceptional challenge for street-based workers but certainly something a safe consumption site would be able to have on hand. As states continue to develop their harm reduction policies and empower community-based organizations to respond to these crises, policymakers should evaluate things like ensuring adequate oxygen supplies for these entities and even their community partners (which might include businesses like bars) and increasing allowable and covered purchases of Narcan, as administering the overdose reversal medication is still highly recommended when encountering an overdose.
We urge our partners to keep a close eye on this issue at it continues to develop.
Despite All Evidence in Support of Harm Reduction, Stigma Drives Public Attitudes
Earlier this year, a false claim spurred outrage from commentators and politicians regarding federal grant dollars for harm reduction programs across the country. Shortly after, in April 2022, the U.S. Department of Justice (DOJ) issued guidance on how the Americans with Disability Act (ADA) provides protections for people with opioid use disorder (OUD), which may also apply broadly to people with substance use disorder (SUD). From local and national advocates to actions from the Biden Administration, as a nation, the United States is facing the greatest change in drug policy since the Nixon Administration introduced a national policy officer (“drug czar”) on the issue. Forty years after Nancy Reagan’s “Just say no” campaign and the abject failure of the D.A.R.E. (drug abuse resistance education) program, the United States’ “War on Drugs” has only succeeded in criminalizing a health status with, up until relatively recent history, with broad bipartisan support. The effort to combat the stigma sewn into the fabric of our social attitudes towards drug use and misuse is coming to a fever pitch.
Scrolling through my own social media, I can across Representative Malinda Brumfield White’s post regarding a methadone clinic opening in Bogalusa – expressing “concern” for the location. The comments were rife with assumptions as to what the clinic might “mean” for the area and opposition to its location. The animus voiced is the exact type of animus an industrious litigator might cite to prove the attitudes DOJ cited as discriminatory and might spur actions which could violate the ADA. This clinic didn’t pop up out of nowhere, Louisiana’s legislature ordered a needs assessment on the impacts of the opioid crisis in 2018 after the Governor Bobby Jindal ushered in closing of most of the clinics in the state. Subsequently, the state’s health department identified a need to establish at least 10 new harm reduction service providers, focusing on addiction treatment centers (specifically, medication assisted treatment). A request for proposals (RFP) was issued in late 2021 and signed with Behavioral Health Group (BHG) shortly thereafter. But it’s just now that the local electeds are making noise about the clinic – as the operation is getting set to open.
Meanwhile, in California, Governor Gavin Newsom is rumored to be thinking about vetoing SB57, a piece of well-supported state legislation that would allow for pilot project locations for safe consumption sites. The project would be the largest yet seen, after New York allowed for a similar project last year, and is facing tough opposition even after the bill passed out of the state’s legislature, with a concerted campaign urging Governor Newsome to veto the bill. New York expanded their project this year thanks in large part due to the success of reversing hundreds of overdoses already.
Vermont’s Governor has already vetoed a similar bill. Though, that veto also axed additional funding for multiple modalities of harm reduction, including ones already existing in Vermont, Governor Phil Scott specifically cited the safe consumption sites projects as “counterintuitive” – a statement rooted in stigma (his assertation that data did not exist to support the project is false – see previous links on New York’s success). A bill in Kentucky to initiate a pilot project didn’t even get a committee hearing this year. And Rhode Island is finally finding a way to fund safe consumption sites – by using the state’s opioid settlement dollars. Rhode Island had already passed a law allowing study of safe consumptions sites, the legislation just did not include any funding to do so and those entities interested in opening sites were hard strapped to find enough private funding to open.
In other states, advocates are playing slower “games”, taking time to further educate their legislatures and communities. In North Carolina, experts took time to both debunk the claim the Biden Administration was pushing on smoking pipes but also how those same tools would be an improvement in harm reduction offerings already existing in the state. In Massachusetts, elected representatives are supportive of safe consumption sites but elected law enforcement isn’t. Those same elected law enforcement officials are peddling stigmatizing ideas with ominous sound bites like “let’s ask people in neighborhoods where they already exist and see if they feel it’s safer.” When there’s no one there to challenge these ideas, or journalists’ follow up questions aren’t answered, the dark clouds gather around pious suburbanites as if their own families aren’t one or two degrees of separation from experiencing the damaging impacts of an unabated overdose crisis.
Decades old attitudes which moralize a health condition as a personal failing and threat to our families hasn’t worked. Indeed, overdose deaths and non-fatal morbidities are on the rise…again. Despite having the tools, decades of behavioral intervention study, and a desperate need to address this issue, we keep seeing the same approached used over and over again – stigmatize, criminalize, and isolate. Our elected officials have an obligation to both educate themselves and advocate for more effective policy. The families affected by the opioid crisis, substance use disorder, Hepatitis C, and HIV are the voters and constituents these representatives are tasked to…represent. As advocates trudge on in sharing stories, we must leverage what we know to be true. This is indeed a moral fight – it is immoral and unethical to allow people to die with a callousness of disinterest, even triumph as if those deaths are somehow “deserved”. While our lawmakers are returning home as the federal legislative session comes to a brief break, they must also take this moment to lead their constituents in making the moral choice and support comprehensive harm reduction policies and programs.
Improving Liver Health for People Who Inject Drugs
A recently published study in the Annals of Internal Medicine found that providing Hepatitis C treatment to people who inject drugs (PWID) showed significant improvement in liver health outcomes when provided with community-based access to care and treatment. The study, which drew its cohort from Baltimore and collected data from 2006 to 2019, found a particular value to participants in low-barrier access to care – a mainstay of harm reduction advocates.
The qualifying condition for participants was a chronic HCV diagnosis, with the majority of participants being Black, assigned male at birth, and not having an HIV diagnosis. Within the last 6 months of the participants’ lives prior to study enrollment, 54% had injected drugs and 27% were on methadone. 56% of participants also scored as having had severe, harmful, or hazardous alcohol use. The initial rate of cirrhosis was 15%, rising to 19% in 2015 and dropping dramatically in 2019 to 8%, with the rate of detectable HCV RNA reducing from 100% in 2006 to 48% in 2019. Self-reported treatment also increased from 3% to 39% across the study period. Some of the most significant findings of the study were specific to broader outcomes – those with undetectable HCV RNA were 72% less likely to develop cirrhosis and were at 46% lower risk of all-cause mortality. While 430 of the participants died across the span of the study, 394 had chronic HCV and 36 had no detectable HCV RNA. 29% of those deaths were categorized as from drugs or trauma, 41% from chronic illness, and 6% from liver disease/cirrhosis.
The study itself did not depend on distribution of treatment to patients but rather, it sought to assess how patients engaged in care in community-based settings and what accessing services through these settings means for patient health outcomes. The study’s findings aren’t particularly surprising for anyone familiar with providing services to communities which are often marginalized. Indeed, for communities and patients experiencing poverty or living in health care deserts, also coinciding with red-lined neighborhoods and thus associated with Black communities, access to “traditional” health care settings is limited or not meaningfully existent. Trust of traditional health care and even public health services is equally limited due to historical traumas, including forced sterilization, concerns for law enforcement engagement, and – perhaps most directly – due to provider bias. Community-based, low-barrier care in light of these realities and lived-experiences are simply…more welcoming.
In recognizing a sense of welcoming, observers should also recognize the sense of safety patients to these settings feel – that trust in tangible for patients. It’s also important to recognize a particular failure in federal funding focuses in entities that may claim being based in a particular community but are not necessarily required to hire providers or staff from the service area or served populations. Indeed, during a recent O’Neill Institute call, this distinction was of particular complaint. Funding is typically awarded to larger entities rather than smaller ones and holds no particular requirement for staff to be reflective of the patient population. For those larger entities, they tend to also be stuck in programming with limited creativity, are explicitly tied to specific clinical outcomes, and extraordinarily strict and onerous reporting requirements. Those requirements can and do translate into administrative barriers for patients and limit the creativity that may also translate less directly or immediately to measurable health outcomes. The complaints were broad, generally stating a need to take a more diverse approach that looked at longer-term investments into patient health through relationship building.
Those relationships are critical to the success of patients and introducing the ideas behind “harm reduction”. Another barrier to successful harm reduction can be found in particular state and federal policies which may run contrary to the best practices identified by academics and advocates. In this, the details matter. For example, most “good Samaritan” laws maintain a carve out of exception for drug dealers in reporting overdoses – even if they wanted to help, they could be prosecuted for homicide if a person dies, discouraging intervention from the course. For states with syringe exchanges (now facing conservative backlash by way of moralizing substance use rather than viewing substance use as a health condition), many still maintain paraphernalia laws which means patients engaging with syringe exchange programs can be arrested and charged either going to or coming from accessing services at syringe exchange sites.
Community Access National Network’s HIV-HCV Co-Infection Watch monitors certain state-level harm reduction measures in an effort to provide a resource to advocates and our Annual Monitoring Report discusses these nuances. Advocates know well the positive health outcomes for patient and communities when public health programs are designed with long-term investments are made and comprehensive approaches are taken. State and federal law and policy makers would do well to reconcile the conflicts between these and strive to achieve a policy environment which fosters the development of creative, safe, low-barrier care and reduces risks to people who inject drugs.
Addressing the Intersection of HIV and Methamphetamine Use
A recent convening, hosted by the O’Neill Institute, found government representatives, service providers, and community advocates discussing methamphetamine use among gay/bisexual men, transgender women, and transgender men under the lens of exploring stigma, sexual health, and HIV. The intersectionality between HIV and Methamphetamine, commonly known as “meth”, is significantly associated with greater risk for HIV transmission and numerous co-morbidities for people living with HIV.
Attendees received updates on existing data and policy relevant to methamphetamine use. Often overshadowed by the opioid epidemic, wherein the “gaps” in epidemiological data explicitly on meth use were glaringly obvious and largely dependent on supplemental data gathered during HIV outreach activities or related to broader assessments of substance use. Similarly obvious were the reasons why these data would be challenging to gather: law enforcement. According to the Substance Abuse and Mental Health Data Archive (SAMHDA), in 2019, more than 400,000 people who use methamphetamine were arrested and booked into jail for at least one time during the previous twelve (12) months. While the convening focused on gay, bisexual, and other men who have sex with men (MSM), transgender women, and transgender men, federal data found similar rates of methamphetamine use among heterosexual men and MSM. Additionally, there was no statistical difference in methamphetamine use between heterosexual women and lesbian-identified women. There was however an increase in self-reported methamphetamine use among bisexual women. Data provided did not distinguish between cisgender and transgender people, an issue explained as participants in data gathering were not asked necessarily asked questions regarding their sexual or gender identity, rather this information was largely assumed unless a participant disclosed otherwise.
Following the data sharing, patient advocates and service providers discussed their perspectives on what to consider in assessing policy and federally funded programs. Presenters highlighted their own lived-experiences as influencing their ideas on where policies and programs have succeeded and failed – largely coming to an unspoken consensus that we must do at least something differently than we are today. One presenter stated existing funding structures tend to reward large entities which is perceived to be at the expense of small service entities, which may or may not be trusted by people who use substances. Another focused on the contrary policy priorities being voiced by the Biden Administration between supporting harm reduction and supporting law enforcement – giving an explicit voice from community advocates that law enforcement often poses a threat of harm to drug users. Presenters also pointed out the need to distinguish between recreational use, misuse, and addiction, as the stigma associated with substance use often conflates these experiences with one another, when the reality is very, very different. For my part, I shared the idea that existing funding designs associated with HIV, where substance use harm reduction is largely aligned both on issues advocacy and service provision, may perpetuate social stigma by prioritizing the experiences and work of health care providers over that of patients – especially with regard to metrics of “success”. A reworking of funding and program designs and incentives that look at addressing health disparities from a human rights lens is necessary. Envisioning Ryan White programs as workforce development and community investment programs in addition to being public health programs, recognizing the potential detriment of a consolidating provider market and the need to incentivize provider diversification, and shifting funding and goals to better reflect efforts to meet the needs of communities as those communities define them.
Lastly, presenters shared honest assessments of “on the ground” perspectives and what programs are working. With meaningful geographic and demographic diversity represented on the final panel, confirming sentiments of the previous one, presenters discussed novel (and often underfunded) approaches to ensuring affected communities are receiving high quality sexual health education, linkage to care, and low-barrier interventions for those people are seeking them. Panelists discussed the need for policy makers and funding to reinforce those novel programs which do work and to consider novel metrics to better capture these successes. From reinvestments in the Ballroom scene as a safe and empowering space of expression to the successful effort from affected Latino communities in Texas to engage with their state health department, educating health care administrators and providers on the necessity of harm reduction, these programs which originate from the priorities of communities, rather than from the dictates of statehouses are already doing more and going farther than traditional programming.
So…why don’t we have more of this?
To learn more about the initiatives of the O’Neill Institute at Georgetown University, click here.
Biden’s State of the Union: Bold Promises on Public Health
On March 1st, President Biden delivered his first State of the Union Address to both chambers of Congress and the American people at large. Amid a slew of foreign and domestic policy proclamations, particular attention should be afforded to the statements and commitments made about addressing the COVID-19 pandemic and public health, more broadly. Championing the landmark legislation that was the American Rescue Plan, the President laid out how the legislation’s programming reduced food pantry lines, increased employment, and how expansion of the Affordable Care Act’s subsidies resulted in lower insurance premiums for many Americans. In addressing the COVID-19 pandemic, Biden also recognized a sobering outcome that will shake the nation: within the next few weeks, the United States’ official COVID death toll will surpass one million people. Though the President misstated the moment in that those empty seats at dinner tables will be more than a million; on average each COVID death has impacted 9 other people, including orphaning children across the country. Biden then shifted the address, citing the Centers for Disease Control and Prevention’s recent announcement of adjust masking guidelines and metrics of risk, trying to signal a much-needed political win in the fight against COVID. However, immediately following these statements, the President also focused on providing the country with another round of free at-home COVID-19 tests and implementing a tactic already well-known in the HIV space: test-to-treat, with added bonus of the program following the COVID vaccine model and having no out-of-pocket expense for patients.
The program ideals outlined in the days that followed found some confusion, need for clarity, and even some professional association bickering. Public health professionals who have long advocated for more robust responses to the pandemic took to news outlets to vent their frustrations and the American Medical Association drew derision on social media for their statement discouraging pharmacists prescription and provision of COVID antivirals. Pharmacists have long been a target for HIV advocates, especially in terms of increasing pre-exposure prophylaxis (PrEP) access and decreasing test to treat initiation delays. Wouldn’t it be nice if this COVID program provided a model outside of vaccination in which pharmacists could also serve a more robust role in facilitating seamless treatment and prevention? The meaningful hiccups the administration and advocates should keep a close eye on in this regard is the labor shortage of pharmacists, closing of more rural locations for chain pharmacies, and any developments around anti-competitive practices of pharmacy benefit managers (PBMs) associated with pharmacies. Consequences of these will extend beyond immediate COVID programming and ideal HIV programming.
The President also made statements referring to medication costs and price controls and needing to make sure more Americans could afford their care. However, details were lacking and if any recent effort is indicative, singularly focusing on manufacturer list prices won’t address patient costs or get much anywhere. Buyer beware, some proposals in the apparently sunk Build Back better legislation would also cut provider compensation in public payer programs, a dire consequence as the nation struggles with health care staffing shortages. Those shortages should be noted in detail because the American Rescue Plan provided funding meant to supplement the financial demands of staffing a pandemic and there’s good reason to suspect administrators, rather than providers, enjoyed the fruits of that labor. Further, most Americans experience their out-of-pocket costs of care due to the benefit design of their insurer (and PBM), not the manufacturer list price. Indeed, the Biden Administration appears to eb as insurer friendly as the Obama admin. To impact the costs facing patients more meaningfully at the pharmacy counter and other burdens in accessing medication, the Biden administration should focus more on developing patient protections via the regulatory process, limiting the aggressive utilization management (or deny-first coverage) policies, increasing formulary restrictions, and discriminatory plan design. Some of the tools for doing so already exist, but the federal government has yet to curb the tactics of payers in avoiding their responsibilities under the ACA’s medical-loss-ratio rules or ensure payers are not inappropriately applying cost-sharing for qualifying preventative medications and services.
The President also became the first to mention “harm reduction” in a State of the Union Address. Urging Congress to pass the Mainstreaming Addiction Treatment Act (MAT Act), President Biden is seeking to fulfill his commitments to address the opioid epidemic and move toward modernizing domestic drug policy. In a sign of acknowledgment of the scope and size of substance use epidemic in the country, Biden endorsed recovery programs and recognized the more than 23 million people struggling with addiction in the country. Immediately following the MAT Act mention, the President moved on to address of a lesser defined but equally important need in encouraging commitment to a robust set of policy ideals aimed at meeting the mental health needs of the country.
All these good things can easily be outweighed by what wasn’t mentioned. President Biden did not mention any interest in extending another round of stimulus payments, despite the program resulting in one of the largest reductions in poverty in US history. And while there was focus on rebuilding the nation’s health care staffing, no mention was afforded to rebuilding the nation’s public health infrastructure. Meanwhile, we’ve known for quite some time poverty as a notable association with HIV and decreasing poverty also decreases HIV risks and prevalence, data remains in the decline with regard to HIV and STI screenings, Hepatitis C rates are still on the rise, and inconsistencies in PrEP usage during the height of initial COVID waves likely foretells a more diverse at-risk community. Even the government’s own HIV.gov webpage dedicated to the State of the Union fails to mention any HIV or HCV specific programming efforts associated with the address.
While there’s much to celebrate about the President’s COVID goals, advocates should be cautious about projecting those goals onto other public health efforts. Afterall, COVID proved we could provide more up to date reporting than the 2 year delays we typically see in HIV and HCV surveillance, but we haven’t. COVID-related telemedicine expansion was welcomed by patients across the nation but Congress is poised to claw back those gains. For many of us, while the state of the union is improving coming out of the Omicron wave of the COVID-19 pandemic, much work remains. Including reminding this administration that it is empowered to protect patients, access to and affordability of care, an obligation to invest in public health programs beyond COVID and has committed to advancing efforts to End the HIV Epidemic.
Biden Drug Policy Agenda: NIH Invests in Harm Reduction
On December 29th, 2021, the National Institute of Health (NIH) issued two new requests for application (RFA), one for the establishment of a “Harm Reduction Network” and another for a data coordination center in support of the network. The idea the NIH proposes is to develop and test new harm reduction strategies, examining the efficacy of existing harm reduction models, effective implementation of harm reduction strategies, and examining new models targeting diversified settings and delivery models of harm reduction services. The data coordination center will focus on meeting with relevant stakeholders, defining common metrics, developing research and clinical practice models, and otherwise analyzing the landscape of harm reduction across the nation. This move represents the “investigative” phase of the Biden Drug Policy Agenda.
Of note, the NIH very specifically cites interest in exploring the impacts of decriminalization and safe consumption sites as harm reduction policies and syringe service programs (including vending machines and mail programs), community based infectious disease services and prevention programs (specifically mentioning HIV and HCV), naloxone programs, and fentanyl testing strip programs.
In discussing decriminalization as a policy, much existing work is focused on marijuana decriminalization (either for medical or recreational use) in which several states have progressed in passing legislation in recent years. However, few of these pieces of legislation address people who are incarcerated currently or previous criminal records or restitution to these people for imprisonment related to possession, use, or distribution of marijuana. This has left an extraordinarily inequitable landscape with regard to marijuana as an industry – white guys are getting rich for what Black men and women are being imprisoned for. But none of this speaks to the motivation of NIH in these RFAs: reducing fatal and non-fatal overdose deaths and marijuana isn’t typically associated with these types of outcomes. Rather, state drug paraphernalia laws may be more apt at addressing these issues. For example, Louisiana’s statute outlines anything used to test a substance’s “purity” as prohibited and criminal. Decriminalization efforts should be broadly construed for applications and not just focus on particular illicit substances but also the items substance users may access to consume products safely. Indeed, being able to “test” a substance is a well-established mechanism for users to reduce potential harms.
Similarly, safe consumption sites have long faced an uphill battle in the United States due to the “crack house” provision of the Controlled Substances Act (CSA), exemplified by the legal fight Safehouse of Pennsylvania is currently facing. Safehouse argues the relevant provision of the CSA doesn’t apply to them; the language makes it a crime to own or operate a property meant for the consumption of illegal or illicit substances, Safehouse argues they operate for the purposes of saving (a religious calling protected by the Religious Freedom Restoration Act), not drug consumption. The most effective way to save lives is by offering services where they’re needed most, including overdose reversal, housing and recovery linkage to care, syringe exchange, and HIV screenings. The Office of National Control Policy has expressed support for safe consumption sites, generally speaking, but refuses to address the legal issues Safehouse is facing. The clear lack of alignment between OFNCP and the Department of Justice has left advocates more than a tad frustrated. What’s important to note about the CSA’s “crack house” provision is the reason users gather is often related both to enjoyment of experience but also safety; they’re “unsanctioned” consumption sites, as users have until recently had to rely upon their own networks for safety. Like with any issue of access to care, sanctioned safe consumption sites pose the potential to further existing health disparities. As states warm up to the idea of supervised consumption as a service to the community, policy makers and program planners need to consider those areas which exist as medical deserts may very well be the same areas in which safe consumption sites need to exist.
Biden’s drug police agenda has numerous other items of note, including strengthening protections for people with substance use histories in the labor market under the Americans with Disabilities Act, addressing the illicit and illegal drugs supply in the country, and preventing youth from engaging in drug use. Arguably, a key component missing in much of these discussions is how to protect the interests of drug users and strengthen families struggling with substance use disorder. Under the existing punitive approach, drug users are isolated from their families by way of criminal and family courts, isolating them from a core source of social support. A common refrain in recovery, “addiction is a disease of isolation”, also has decent behavioral science research support. Separating people from their families, when those families are generally well-situated to provide necessary support, operates in direct contrast to addressing the needs of a drug user and only sets them up for failure. The Biden administration needs to evaluate family strengthening policies and incentives, including education directives and best policy practices to family courts and child protection agencies as part of this effort and the NIH initiatives should consider qualifying and quantifying how policies in these areas intersect with other harm reduction efforts.
While these initiatives and this funding opportunity is a good start. The Biden administration has a long way to go to fulfilling campaign promises and we’re already twenty-five percent of the way through his first term.