Legislative priorities: Reforming opioid and heroin laws

Policy goal: The ultimate goal of reforming these laws is to focus on harm reduction rather than penalization, decrease the atmosphere of fear, and help prevent unnecessary death.

Specific policy aims:

  1. Support Good Samaritan laws
  2. Provide standing prescription for naloxone and opiod overdose reversal medications
  3. Work towards creating safer injection sites for drug users
  4. Extend legal clean needle exchange programs to cover all 50 states and rescind the ban on federal funding for syringes
  5. Work with general practice physicians and pain-specialists to rewrite the guidelines for prescribing opioid painkillers

Information for specific policy aims:

The leading cause of accidental death in America is drug overdoses, specifically opioid overdoses.  As prescriptions for these types of painkillers have risen over the years, as has the death toll from overdoses.  This was brought up in the presidential primary in New Hampshire with stories from candidates including New Jersey Governor Chris Christie and at least a passing mention of the other Republican contenders.  In 2014, there were 28,647 deaths from opioid drugs.  This represents 61% of all drug overdose deaths in 2014.  The number of overdoses from opioids has more than tripled since 2000.  Unfortunately, the epidemic is growing as opposed to slowing.

With that in mind, we need ways to be able to get victims of drug overdoses to the hospital so that they can be treated as soon as possible.  As in most medical emergencies, time is of the essence.  More than half of drug overdoses occur in front of another witness but only 10-56% of individuals are willing to call 911 for help.  Even with that in mind, people are only willing to call 911 after efforts of reviving the victim are unsuccessful.  In most cases this fear comes in the form of penalties to those who are witnesses to the overdose.  Law enforcement can, in most states, charge people with drug or paraphernalia possession and/or being under the influence when they arrive on the scene.

Twenty states and the District of Columbia provide some type of immunity for people acting as “Good Samaritans” and are calling the authorities to handle a medical emergency.  They are offered protection from being charged with being under the influence, drug possession, or possession of paraphanaelia.  They are not immune from trafficking drug charges or large quantities of drugs (intent to sell).  This is a commonsense practice that can save hundreds, if not, thousands of lives.

Another practice that can be effective in reducing the number of deaths related to opioids would be to allow for standing prescriptions of the opioid reversal drug, naloxone.  Naloxone is an injection that is available at 0.4 mg/ml to 1-mg/ml solution.  It can be administered into a vein, into a muscle, or under the skin.  There is work being done to make naloxone into a spray.  There is also a tablet that may be created for naloxone, as well.  It only produces effects if opioids are present in the body.  A dose of naloxone will compete with an opioid on the receptor and will partially or completely reverse the opioid effect.  Naloxone will produce withdrawal symptoms within minutes and will subside after about 2 hours.  But because it does not last very long, there may be a need for repeated doses of naloxone to be able to positively reverse the drug overdose.  It is not a habit forming drug.

While there are those who think that prescribing Naloxone will further the drug overdose epidemic, I find this line of argument mainly unfounded.  The National Institutes of Health (NIH) found that 35% of those surveyed would feel more comfortable using greater amounts of heroin if Naloxone were readily available.  In the same study, 90% of users had reported witnessing an overdose and providing lay remedies to revive the victim.  While the 35% of those who may feel more comfortable using a greater amount of heroin, the ones who have tried to revive a victim would be able to save many lives if Naloxone was available.  87% reported that they would be willing to participate in a training program and 84% would carry naloxone after training.

The American Medical Association (AMA) has endorsed policies that would strengthen community programs to both train and educate health care workers and opioid users about the use of naloxone.  The European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) found evidence that take-home naloxone programs decrease overdose-related mortality.

The CDC has provided training for people to use this drug since 1996.  They’ve trained over 53,000 people and have used it to reverse over 10,000 drug overdoses.  The most successful program has been San Francisco which has over 3,600 prescriptions filled since 2013 and have saved 916 lives.  Some states, such as Washington, have passed laws that allow for anyone at risk of having or witnessing a drug overdose to obtain a prescription.

We should adopt this practice of providing those at risk of witnessing an overdose to have a prescription of Naloxone and to allow for a standing prescription of Naloxone on pharmacies.  In order to do so, we will need to put in rules so that doctors cannot be held liable if a patient overdoses and naloxone is not administered in time to be able to save the patient.  The availability of the prescription would not be enough, we would need to provide additional community training to overcome the potential risks of take-home Naloxone.  The NIH study found that 62% of heroin users would be less likely to call 911 for an overdose and 30% might leave an overdose victim after naloxone revival.  We would need to work with specialists and the medical community to provide additional training so that the Naloxone resuscitation will be as effective as humanly possible.  West Virginia has expanded the use of Naloxone to reduce deaths with opioid overdoses and we will have to look to West Virginia to see how their programs work to ensure that any similar programs will be administered correctly.

While we are in the middle of an opioid abuse epidemic, there are a number of opioid addicts who move to use heroin.  The dangers of heroin include the danger of needles, specifically dirty needles.  Dirty needles can lead to outbreaks of HIV, hepatitis, and other blood-borne pathogens.  Needle exchange programs allow people to trade dirty needles in exchange for free sterile needles.  Beyond that, they serve as safe spaces for drug users to try to access medical care and referrals to drug treatment programs.  Federal funding for these programs have been banned since 1988.

In January of 2016,a new omnibus budget was passed to allow public health departments and nonprofit organizations to use federal funding for needle-exchange programs in high risk areas, as flagged by the CDC.  The budget would not allow these health departments and public health organizations to be able to pay for the syringes.

The CDC stated a health goal for 100% coverage providing all injections are performed with a sterile syringe.  The Drug Policy Alliance found that we are far short of this goal.  The estimates of sterile syringe coverage in major metropolitan areas are from 0.03% to 22% with a mean of 3.2%.  There are about 0.9 to 2 billion injections nationally each year but there are only about 43 million sterile syringes distributed by needle exchange programs annually.

According to the Substance Abuse and Mental Health Services Administration, there are an estimated 350,000 regular injection drug users in America.  Drug users still deserve to be able to be safe from diseases and not risk contracting blood-borne pathogens.   After taking out mother-to-child HIV transmission cases, about 35% of all AIDS infections can be attributed to injection drug use.  This can almost directly be linked to the lack of availability of clean needles.  The CDC has reported that the one-time use of sterile syringes remains the most effective way to limit HIV transmission associated with injection drug use.

HIV and AIDS are not the only diseases that injection drug users are at risk of contracting.  The most prevalent other diseases are hepatitis B and hepatitis C.  While these diseases are not as common in the United States as they are in other portions of the world, there are an estimated 800,000 to 1.4 million people in the United States with chronic hepatitis B and hepatitis C, according to the National Institutes of Health.  According to the Hepatitis B Foundation, about 40,000 people will become newly infected with Hepatitis B each year.  The death rate, according to the CDC, is 0.7% from the cases that they studied.  From the same set of cases, the CDC found that 61.6% of cases caused hospitalization.  Hepatitis C actually seems to be more dangerous.  The CDC found that in 2007, the number of deaths associated with hepatitis C surpassed the number of deaths by HIV.  This number has only increased since 2007.  The CDC believes that this number is even underestimating the actual death total.  They noted that the “mortality burden is likely much greater than these numbers suggest because death certificate validation studies have concluded that only a fraction of HCV-infected decedents have HCV listed on their death certificate, even when pre-mortem evidence of serious liver disease is present.”  In 2014, a total of 2,194 cases of acute hepatitis C were reported to the CDC from 40 states.

In a 2000 report by former United States Surgeon General David Satcher, “there is conclusive scientific evidence that syringe exchange programs, as part of a comprehensive HIV prevention strategy, are an effective public health intervention that reduces transmission of HIV.”  In a study cited by the World Health Organization (WHO) found “an 18.6% annual decrease in the HIV rate in 36 cities with [needle exchanges] compared to an 8.1% annual increase in 67 cities that did not contain [needle exchange programs].”  In a study by Don C. Des Jarlais et. Al in the American Journal of Public Health, they found that over a 12-year period in New York City there was a decrease in new cases of HIV among injection drug users while the number of syringes exchanged in the needle exchange programs increased from 250,000 to over 3 million.

Needle exchange programs are cost effective programs to help reduce public risk.  The cost of treating a person with HIV is estimated at $190,000 according to the CDC.  There is another estimate of treating HIV patients from the US Conference of Mayors.  They estimated that the lifetime cost would be $120,000 from diagnosis to death.  The average city cost to run needle exchange program would be about $131,000.  Unfortunately, that current estimation might be understating it.  The needle exchange program would have to be expanded to provide adequate syringe coverage and would need to be expanded from its current setup.  Franklin Laufer in his article Cost-Effectiveness of Syringe Exchange as an HIV Prevention Strategy estimated that 87 HIV infections were averted as a direct result of the needle exchange program.

As previously mentioned, needle exchange programs do not only exchange clean needles for dirty needles.  97% of these programs provide public health services such as substance abuse treatment, counseling, sex education, HIV counseling and testing, tuberculosis screening, and primary health care.  Because of the various treatment and services they offer, they seem to be leading to a more conducive environment to reduce drug abuse.  The NIH found that needle exchange programs lead to a “reduction in risk behaviors as high as 80 percent in injecting drug users.”  In a Seattle study, they found that needle exchange participants were five times more likely to enter drug treatment than drug users who do not participate in the program.  Surgeon General Satcher concluded that needle exchange programs successfully refer clients into substance abuse programs.

Based on the evidence, needle exchange programs are a cost effective way to reduce the harm for drug users limiting their chances of contracting HIV, AIDS, or hepatitis while providing health care and substance abuse counseling for injection drug users.  There does not seem to be any scientific evidence that there is an increase in drug use because of these programs or that drug users feel more empowered to be able to use drugs because of these programs.  Absent substantial evidence that this is the case, we should be increasing federal funding for these programs and rescind the ban on purchasing syringes for these programs.  We should also be funding community outreach programs to work with local law enforcement, teachers, health care providers, and community activists to essentially help design needle exchange programs that are specific to each community.  The single biggest driver of success of these programs is the extent to which the community buys into the program.  Getting local organizers and activists to help design the program will help with the success of the programs.