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Special Edition

This week, the Daily Appeal has delved into the Justice Collaborative’s “Blueprint for a Safer and More Just America.” We have focused each day on one of the core principles and highlighted examples of promising practices from across the country that help further its goals.

Principle 4: Treat Addiction Like the Medical Issue That It Is

By any objective measure, the war on drugs is a failure. Over the last four decades, federal and state governments have poured an estimated $1 trillion into this effort. The regressive set of policies and policing practices that make up the drug war have failed to reduce drug use or availability. But what the drug war has successfully accomplished is driving up violent crime and crowding out more effective therapeutic solutions for dealing with drug addiction.

1. No person should be incarcerated for drug possession.

2. Decriminalize buprenorphine possession and ensure that every police officer and first responder carries naloxone to prevent opioid overdoses.

3. Legalize safe injection sites and open locations throughout the United States.

As Michelle Alexander recently wrote, “Drug law reform has never been an easier sell—especially now that opioid addiction is perceived as ravaging primarily white communities, generating far more compassion than black communities ever experienced during the crack epidemic in the late 1980s.” Lawmakers and prosecutors have expressed support for weaning themselves off incarceration as a response to drug use, but they have been far less eager to embrace evidence-backed alternatives, including safe injection facilities and medication-assisted treatment. Some jurisdictions, however, are making headway.

Last year, a group that included New York City Councilmember Stephen Levin staged a protest of Mayor Bill de Blasio’s reticence to support safe injection facilities. Their signs read: “While you wait, we die” and “End overdoses now.” [Nathan Riley / Gay City News] After the protests, the mayor changed his mind, and he has backed a proposal for four supervised injection sites in New York City. But plans are on hold while they await approval from Governor Andrew Cuomo. A spokesperson for the governor has said that the administration is waiting for the outcome of a Department of Justice lawsuit against a proposed safe injection site in Philadelphia. [Caroline Lewis / Gothamist]

At safe injection facilities, trained staff are available to administer anti-overdose medications, and social workers would also be present to offer counseling to those who wish to pursue treatment programs. More people die of overdoses in New York than the combined total of deaths by murder, suicide, and vehicle crashes. [William Neuman / New York Times]

“The nonprofit group, Safehouse, was formed last year to house the country’s first so-called safe injection site in Philadelphia,” writes Abby Goodnough for the New York Times. “San Francisco, New York, Seattle, Denver and Boston have also seriously considered safe injection sites as a way to reduce overdose deaths.” The lawsuit filed by the Department of Justice asks the court to declare injection sites illegal under the federal Controlled Substances Act, a law that makes it illegal “to manage or control any place, regardless of compensation, for the purpose of unlawfully using a controlled substance,” according to the complaint. [Abby Goodnough / New York Times]

“Public health experts now find themselves relitigating questions that in their view were settled decades ago, while political leaders worry that harm reduction—that is, mitigating the risks from drug use—means enabling drug use,” writes Josh Katz for the New York Times. The research shows unambiguously that another form of harm reduction, needle exchanges, which provide sterile syringes and a place to discard used syringes safely, “reduce the spread of bloodborne diseases like hepatitis C and HIV and do not increase drug use. They’ve been shown to reduce overdose deaths, decrease the number of needles discarded in public places and make it more likely that drug users enter treatment.” They also save taxpayer dollars—a recent study found that $10 million spent on needle exchanges could save over $70 million in averted HIV treatment costs alone. These programs also create relationships and engender trust between those struggling with substance use and the healthcare system. [Josh Katz / New York Times]

Medication-assisted treatment should be an even easier sell, but, as the New York Times editorial board fumed last month, limits on the availability of two medications in particular, methadone and buprenorphine, have created a denial of care “so pervasive and egregious” that it “amounts to a serious ethical breach on the part of both health care providers and the criminal justice system.”

In an email to the Daily Appeal, Dr. Kimberly Sue, medical director of the Harm Reduction Coalition, described the importance of providing methadone and buprenorphine in jails and prisons. “Being incarcerated, forcibly detoxed, and released from these settings actually places our patients at disproportionately high risk for relapse and death,” Dr. Sue wrote. “Discharge from jail or prison is a chaotic, unstable time and if patients have lost opioid tolerance as a consequence of jail policies in combination with a toxic street supply (fentanyl in the heroin or other drugs including cocaine), this could equate to significantly increased chances of overdose and death upon release.”

The effectiveness and safety of medication-assisted treatment (MAT) in jails and prisons is well established. New York City has had a MAT program at Rikers Island for over 30 years. More recently, in 2016, Rhode Island began offering methadone and buprenorphine, as well as naltrexone, in all of its correctional facilities. In Rhode Island as well as at Rikers, people are allowed to stay on methadone or buprenorphine if they have been on those medications. They are also screened for opioid use disorder and offered treatment. In Rhode Island, people are also offered treatment prerelease, as a safeguard against relapse post-release.  [Erick Trickey / Politico]

The results of Rhode Island’s program have been remarkable. A small study found that overdose deaths among people recently released from prison in 2017, after the program started, fell 61 percent compared with the same period the previous year. Nine people died in 2017, but 26 died in 2016. Dr. Josiah Rich, a professor at Brown University’s medical school and co-director of Rhode Island’s Center for Prisoner Health and Human Rights, told Politico, “The magnitude of that drop in mortality is almost unheard of in public health.” [Erick Trickey / Politico]

Judges are also beginning to push back against inhumane and unscientific jail policies. Last month, a federal judge in Maine issued a preliminary injunction in favor of a woman scheduled to start a jail sentence on Monday. According to the Portland Press Herald, there were 418 drug overdose deaths in the state in 2017 and a projected 376 deaths in 2018. The ACLU won a previous settlement in September regarding the provision of MAT for a man entering a state prison and the governor has ordered the state to look into broader access in prison.

Brenda Smith, the plaintiff in the recent case, has been on buprenorphine since 2014. Her doctor, after an unsuccessful attempt at tapering her use of the medication, has kept her on a maintenance dose that allows her to live a healthy, stable life. In her order, U.S. District Judge Nancy Torresen noted what Smith had been able to accomplish because of treatment: “With the help of her medication, Ms. Smith has been in active recovery for her opioid use disorder for approximately ten years. … Smith has regained custody of her four children, secured stable housing for her family, and obtained employment. She has earned her high school diploma and has begun to take college courses. … It has been five years since her last use.” [Smith v. Aroostook County]

For people with opioid use disorder, appropriate treatment can be the difference between life and death. As Judge Torresen noted in her order, “People who are engaged in treatment are three times less likely to die than those who remain untreated.” The deaths that are prevented are also those of people in custody. Medication-assisted treatment has been shown to lower the risk of death by overdose or suicide and result in an “overall 75 percent reduction in all-cause in-custody mortality.” [Smith v. Aroostook County]

Dr. Sue of the Harm Reduction Coalition criticized the belief “that methadone or buprenorphine is substituting one drug for another.” The reality, she wrote, is “this medication is lifesaving, similar to insulin for patients with diabetes or statin therapy for high cholesterol to prevent a fatal heart attack. Sheriffs and judges like drug court judges would never deny these categories of medications to patients or feel empowered to make these decisions, however, because opioid use disorder is viewed so differently (as a sin, a moral failing, a bad choice) many of these professionals feel entitled to determine medical treatment.”

A guide released last year by the National Sheriffs’ Association suggests that medication is a crucial part of treatment for those with drug use disorder in local jails, and some sheriffs are taking note. Last year, Franklin County House of Correction became the first jail in Massachusetts to offer buprenorphine in an opioid use treatment program. After beginning its program—which includes screening, counseling, and post-release support services—Franklin County saw a 35 percent drop in opioid overdose deaths from 2016 to 2017, according to the sheriff’s office. “Jails are really America’s ground zero for the opioid crisis,” an assistant superintendent with the sheriff’s office told the Associated Press. “It’s the perfect opportunity to make a public health intervention.” [Philip Marcelo / Associated Press]

A few months ago, a federal judge in Massachusetts pushed the state further when it ruled that the Essex County jail must administer prescription methadone to Geoffrey Pesce, who was facing a 60-day sentence for a probation violation. Experts describe the ruling as a first of its kind. In the preliminary injunction, the judge found that denial of the medication would constitute a violation of the Americans with Disabilities Act and the constitutional bar on cruel and unusual punishment. The ACLU of Massachusetts brought the lawsuit on behalf of Pesce, whose years-long struggle with heroin use was brought to an end when he began taking methadone two years ago. Under the jail’s policy, he would have had to endure a forced withdrawal. The decision is limited to Pesce’s treatment and the program in Essex County, but Jessie Rossman of the ACLU told the Boston Globe: “We also hope that jails and prisons throughout the Commonwealth see this as a good time to look at and change their policies to ensure … access to medically prescribed treatment.” [Felice J. Freyer / Boston Globe]

But it’s not all good news in Massachusetts. Last summer, its highest court refused to adopt the mainstream medical understanding of substance use as a disease and relapse as a symptom of that disease. The opportunity to do so came in the case of Julie Eldred, jailed for 10 days in 2016 for opioid use while on probation. Eldred argued that punishment for her relapse was cruel and unusual. The court sidestepped the question of how to view relapse by saying it was not timely raised but affirmed that a judge can order a defendant to remain drug-free as a condition of probation and “must have the authority to detain a defendant” who has violated probation by using drugs. The case had drawn national attention from the proponents of a public health approach to substance use disorder and relapse, and from law enforcement and supporters of treatment courts who argued that graduated sanctions, including incarceration, were necessary. [Jan Hoffman / New York Times]

Thanks for reading. We’ll see you on Monday.

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