Missouri Network for Opiate Reform and Recovery Drug Policy, Harm Reduction, and What’s Next __________________________ Chad Sabora, BS, MA, JD Missouri Network for Opiate Reform and Recovery

The start or lack thereof of Drug Policy in the United States The Harrison Narcotics (1914): restricted manufacture and sale of marijuana, cocaine, heroin, and morphine. Physicians who were prescribing “maintenance” drugs for SUDs were harshly punished. Webb et al. v. United States (1919): Supreme Court ruled against maintenance as a legitimate form of treatment; America’s first federal drug policy Mandatory Sentencing : The Boggs Act of 1951, The Daniel Act of 1956, Anti- Drug Abuse act of 1986 (It changed the system of federal supervised release from a rehabilitative system into a punitive system) The Controlled Substance Act of 1970

Drug Policy Continued June 17th, 1971 THE WAR ON DRUGS (The only time when more money went to treatment rather than enforcement)

Harm Reduction

Harm Reduction

I may not agree with the choices you are making or how you are living your life but it does not mean that I won’t help you learn how to reduce the harm you may cause to yourself, others, and society Harm Reduction

The most common forms of harm reduction in the United States Naloxone (narcan) access (47 of 50 states) Syringe access programs 911 Good Samaritan Laws (37 of 50 states) Medication assisted treatment* Harm Reduction

Naloxone Access Naloxone access programs started in the 90’s. Now we have 136 programs that manage 644 naloxone distribution sites throughout the US (Wheeler et al., 2015). However, in 2013, 20 states did not have a single OOPR program and 9 states had less than 1 person per 100,000 population equipped with a naloxone rescue kit. Eleven of the 20 states had drug overdose death rates higher than the national median (Wheeler et al., 2015).

Naloxone Access

Peer to Peer Naloxone Access In 2013, 20 states did not have a single OOPR program and 9 states had less than 1 person per 100,000 population equipped with a naloxone rescue kit. Eleven of the 20 states had drug overdose death rates higher than the national median (Wheeler et al., 2015) Compelling data on the safety of the IN technique and effectiveness of community-based opioid overdose prevention and response (OOPR) come from an interrupted time-series analysis of the association of OOPR implementation and community-level outcomes, which demonstrated a 27–46% reduction in opioid overdose mortality Drug users were responsible for nearly 90% of the overdose rescues in that study, similar to findings from an evaluation in San Francisco (Rowe et al., 2015). Opioid overdose and naloxone: The antidote to an epidemic? Traci C. Greena,b,∗, Maya Doe-Simkinsc

Syringe Access Programs

The Pros of Syringe Access Programs Reduction in transmission of Hepatitis C Reduction in transmission of HIV Reduction in discarded needles Engaging those in addiction where they are at Participants in SAP’s are 5 times more likely to enter treatment (Hagan, McGough, Thiede, et al., 2000, Journal of Substance Abuse Treatment, 19, 247-252) Supported by the Surgeon General, DCD, WHO, etc… The Pros of Syringe Access Programs

The Cons of Syringe Access Programs

Can Harm Reduction and 12 steps ever co-exist? “At the last trustee meeting that we both attended, he [Bill Wilson] spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. . . . He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps.”  (1991) Dr. Vincent Dole ANY QUESTIONS?

Supervised Injection Facilities (SIFs): “controlled health care settings where people can more safely inject drugs under clinical supervision and receive health care, counseling and referrals to health and social services, including drug treatment” - Approx. 100 SIFs (Switzerland, Germany, the Netherlands, Norway, Luxembourg, Spain, Denmark, Australia and Canada- none in United States) Increased entry into treatment (especially among those who distrust the treatment system) and delivery of medical and social services Reduced public injecting = increased public safety Reduced risk behavior (i.e., syringe sharing, unsafe sex) Reduced prevalence and harms of bacterial infection Reduced overdose deaths No increase in community drug use, initiation into injection drug use, drug-related crime **Cost savings from reduced disease, overdose deaths, and need for emergency medical services (Drug Policy Alliance) What’s Next?

Heroin-Assisted Treatment (HAT): prescribe Heroin for use under medical supervision to treat long-term users of illicit opioids - Switzerland, the United Kingdom, Germany, the Netherlands, Canada Switzerland – the pioneer of HAT: Health outcomes for HAT participants significantly improved Heroin dosage stabilized (usually in 2-3 months) rather than increasing Illicit heroin and cocaine consumption was significantly reduced Large reduction in fundraising-related criminal activity among HAT participants (This benefit alone exceeded the cost of treatment) Initiation of new heroin use fell and street dealing and recruitment by “user-dealers” declined Entry into treatment other than HAT (especially methadone) increased (Transform Drug Policy Foundation, 2017) After That?

What Is Stopping Us From All This Progress?