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.