Chad Sabora, BS, MS, JD Missouri Network for Opiate Reform and Recovery Drug Policy, Harm Reduction, and What s Next
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
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
The most common forms of harm reduction in the United States 1) Naloxone (narcan) access (50 of 50 states) Harm Reduction 2) Syringe access programs 3) 911 Good Samaritan Laws (39 of 50 states) 4) Medication assisted treatment*
Naloxone access programs started in the 90 s. Naloxone Access 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 Compelling data on the safety of the IN technique and effectiveness of communitybased 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. Green a,b,, Maya Doe-Simkins c
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, CDC, WHO, etc
The Cons of Syringe Access Programs
A Snapshot of Harm Reduction in Missouri Narcan distribution started in 2013 through Mo Network Kits distributed in the greater St. Louis area 10,000 1 cc vials 1,000 auto-injectors 100 Nasals Reported reversals to date 400 (75% reported were peer to peer)
Snapshot continued Syringe access program launched by Mo Network in 2015 Number of participants 50 (40 of 50 supplying access to 2 + more users) Needles in 400 Needles out 2,000 Percent of participants test for Hep C/HIV 100% Percent of participants entering treatment through our SAP 70% Goals Reduce transmission of Hep C and HIV and reduce Hep C costs to state; 38 M in 2014, 21 M in 2015, 43 M in 2015. Engage active users into treatment and safer using practices
Overdose Prevention in Treatment and Jails Naloxone training and referrals in Missouri started through Mo Network at Preferred Family Healthcare in 2015 1. Over 200 clients trained 2. Overdose prevention now standard in treatment modality (Naloxone being provided by Mo-Hope) Training in criminal justice begins in May 2017 through the SRT grant 1. Treatment courts, Veteran Courts, Mental Health Court, Family Court, every jail in the state (Over a 2 year period)
Services Provided by Mo Network Legislative reform Implementation of naloxone and good samaritan laws Monthly naloxone trainings and distribution (trainings always available by appointment) Reduced fee legal clinic Needle exchange Treatment referrals PAARI programs
Services Continued Drop-in center and basic need services (Hep. C, HIV testing, clothing, food, housing and employment assistance) Non-traditional support and activity groups Medication-Assisted treatment support groups General family support (dedicated group and guest lectures) Sober living scholarships
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?
What s Next? 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)
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 After That? 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)
Mo Networks legislative Agenda through 2020 2018 - Syringe Access Safe Injection facility Diversion program for non-users Access to tele-health treatment, ambulatory detox, and maintenance Parity???? 2019 - HAT (Heroin Assisted Treatment) 2019 - Mass Incarceration??????????????
What Is Stopping Us From All This Progress?