Supervised Consumption Facilities: Canada 44 U.S. 0

Rev. Alexander E. Sharp Uncategorized

Both the U.S. and Canada are in the throes of a deadly opioid epidemic. But there is a major difference.  Canada has life-saving sites where individuals are able to consume drugs under medical supervision. The U.S. has none. Last week, under the auspices of the Chicago Recovery Alliance, I traveled to Toronto as part of a group of service providers, state and county legislators, and law enforcement officials.  It was an extraordinary opportunity to view Canada’s supervised consumption facilities (SCFs) first hand and learn from them. The sheer number of Canadian facilities is striking. When I visited Insite in Vancouver three years ago, it was still the first and only SCF in North America.  Now 44 have been authorized in Canada. There are nine in Toronto alone. This did not happen overnight. The election of a liberal federal government in 2015 helped to open the door. Although conservatives gained power in Ontario in 2017 and have raised regulatory barriers and threatened to reduce funding it seems likely that SCFs are in Canada to stay. On the first day of our visit, we gathered at Moss Park OPS, an overdose prevention service much like a SCF.  Its staff have consulted closely with the surrounding business leaders and residents. They report that “Moss Park OPS has not received any direct complaints from neighbors or the stakeholders.” They add that “Toronto Police have been supportive of the establishment of overdose prevention facilities operating in the Moss Park Neighborhood.”   According to the Moss Park OPS, there is “long-standing and strong support in Toronto for the establishment of permanent supervised injection/consumption services…In March 2016 more than 50 Toronto community leaders signed a statement calling for the city to establish supervised injection services within existing community health and social service sites.”   Two of the three facilities the Chicago delegation visited were community health service centers, offering a broad array of services. The space for supervised consumption seemed one part of a continuum of health care responses.   That said, there is no requirement that those consuming drugs under supervision at an SCF accept other services.  For staff this is perhaps the essence of the harm reduction approach. They treat overdoses and prevent the spreading of disease.  Their approach is consistent with Jesus’ warning, “Judge not lest ye be judged.” What does this accomplish? During our visit, Thomas Kerr, Professor of Medicine at the University of Columbia, shared data showing that SISs save lives by preventing overdose deaths and they stem the spread of infectious diseases such as hepatitis. They have led neither to increased drug use nor to other crime. “The evidence is indisputable… in Canada there is no serious evidence against these facilities.” Something else of profound significance is happening as supervised consumption facilities gain traction. Drug use is increasingly being framed as a health rather than a criminal issue.  A service provider we met posed this question: “If someone is in our facility with drugs, we try to help them. If they possess drugs and are sitting on a park bench, they get arrested. How does that make any sense?” It does not, of course.  That is why the Canadian HIV/AIDS Legal Network has just issued a report in which its most prominent recommendation states, “The federal government should decriminalize activities related to drug use.” What I learned in Toronto is that supervised consumption facilities save lives, prevent disease, and respect human dignity.  Even without requiring behavioral change, these facilities can be an avenue to treatment. They have broad public support. When will this happen here? Rev. Alexander E. Sharp, Executive Director

The Justice Department’s War on Supervised Drug Use

Tom Houseman Uncategorized

Supervised consumption facilities are one of the most important harm reduction tools available in fighting the opioid epidemic and saving the lives of people with substance use disorders. Unfortunately, the Department of Justice (DoJ) is doing everything in their power from stopping Philadelphia from opening the first legal such site in the United States. There are around one hundred legal, regulated supervised consumption facilities (SCF’s) around the world. Facilities have existed in Switzerland since 1986, in Australia since 2001, and in Vancouver, Canada since 2003. Insite, one of several sites in Canada, which has supervised nearly 4 million injections since it opened. Nobody has ever died of a drug overdose at Insite or any other public, legal SCF. In the United States, where more than 130 people die of drug overdoses every day, it is illegal to run any sort of supervised drug consumption facility. This illegality has done nothing to quell the opioid crisis or to stop people from injecting drugs. Some of the alternatives in the US include unlicensed, underground facilities, which inherently carry more risk. Otherwise, people are injecting drugs in public restrooms or in private, making it extremely difficult for them to receive assistance if they overdose. After decades of a failed War on Drugs, we are finally seeing a pivot from treating substance use disorders as a criminal justice issue to treating them as a public health issue. Unfortunately, not all public officials are on board. In particular, while the Trump Administration has preached the importance of addressing the opioid epidemic, their actions have sent more mixed messages. In February, they made it unequivocally clear that they will stand against progress. Over the last few years the possibility of opening SCF’s has been debated in San Francisco, Denver, and Pittsburgh. Earlier this month, the Rhode Island State Senate passed a bill authorizing a supervised consumption pilot program there. The bill is now being considered by the State House. Last year, when the Philadelphia-based organization Safehouse announced its plans to open a site at which people could inject drugs safely and with supervision, the proposal received the approval of District Attorney Larry Krasner, who made it clear that his office would not interfere with Safehouse in any way. The Department of Justice, unfortunately, had other plans. In February, the DoJ filed a lawsuit to stop Safehouse from moving forward with their plans. The suit, filed by U.S. Attorney William McSwain, points to a provision in the Controlled Substances Act, 21 U.S. Code Section 856, that was written in the 1980s to target “crack houses.” The provision makes it unlawful to “knowingly open, lease, rent, use, or maintain any place, whether permanently or temporarily, for the purpose of manufacturing, distributing, or using any controlled substance.” Safehouse argues that this provision should not apply to a medical facility like an SCF. It is represented by AIDS Law Project of Pennsylvania and DLA Piper attorney Ilana Eisenstein. In their counterclaim to the lawsuit, Safehouse’s legal defense team wrote that “Providing lifesaving medical services to individuals who are suffering from substance use disorder does not and constitutionally cannot violate Section 856.” In its opposition, the DoJ is sending a clear message. McSwain stated that the case “could be persuasive, or helpful authority to a judge in California, New York, Colorado, Washington State, or wherever this issue might come up.” Clearly, he wants every city around the country to know that an attempt to create a legal supervised consumption facility will result in a costly legal battle with the federal government. The fact that there is precedence in Canada to support the legality of SCF’s is reassuring. In 2011, the Supreme Court of Canada ruled that locally-run SCF’s are exempt from federal prosecution. Still, it is clear that McSwain believes that the Department of Justice has a strong case. He has argued that “Normalizing the use of deadly drugs like heroin and fentanyl is not the answer to solving the opioid epidemic.” But among public health advocates and researchers, the evidence is clear. “These facilities save lives,” Philadelphia Health Commissioner Tom Farley said about Safehouse’s proposal, “while serving as an entryway to drug treatment.” Hopefully, as visibility of the effectiveness of SCF’s increase, the idea will become more popular, and creation of such facilities in the United States more politically feasible. In the meantime, the Department of Justice’s lawsuit against Safehouse marks a serious turning point for harm reduction policies around the United States. Many cities and states have come around to increasing access to the overdose-reversing drug Naloxone, to syringe exchange programs, and to Good Samaritan laws that protect people who call emergency services in the event of an overdose. The opioid epidemic is a serious problem with no simple solutions, but there is considerable evidence that SCF’s work, will work in the United States, and do not incentivize drug use or lead to increased rates of use. How much longer will the Department of Justice ignore this evidence? How many lives will be needlessly lost in the meantime? Depending on how this lawsuit plays out, we may find out the answer soon. Tom Houseman, Policy Director

Charged: A Damning Portrait of The Role Prosecutors Play in Mass Incarceration

Tom Houseman Mandatory Minimums, Uncategorized

Mass incarceration didn’t happen overnight. Since 1980, the prison population in the United States has increased by more 500 percent, and only in the last few years has the number of people imprisoned at either a state or federal prison leveled off. There is certainly enough credit to go around for the rapid expansion of America’s incarceration system. Between the War on Drugs policies of the seventies and eighties and the “tough on crime” initiatives of the nineties, the blame is largely placed on policy makers, and with good reason. But in her recent book, Charged: The New Movement to Transform American Prosecution and End Mass Incarceration, journalist Emily Bazelon asks us to shift our gaze from the people crafting the policy to the people enforcing it: prosecutors. Most people imagine the court system as being a triangle in which prosecutors and defenders are, as Bazelon writes, “points… on the same plane, with the judge poised above them.” The evidence laid out in Charged shows that this is clearly not the case. Prosecutors play a crucial role in determining what crime a person will be charged with when they are arrested. This decision is largely arbitrary, but it can mean the difference between a multi-year prison sentence and never having to spend a night behind bars. Prosecutors also have control over the other two most crucial factors that will determine whether and for how long a person will spend time in prison: plea deals, and bail. Bazelon points out that by demanding excessively high bail (a point on which judges virtually always defer to the prosecutor), prosecutors can push somebody to plead guilty to a crime they didn’t commit. As a result, the number of people who never get their day in court is staggering. What is most troubling about the work of prosecutors is the adversarial role they take against the defense in criminal cases. Despite how they are presented on TV and in movies, the goal of prosecutors shouldn’t be winning cases, but rather seeking truth. Yet when prosecutors are rewarded for winning cases, and are trained to view defendants as the enemy, they become willing to subvert justice in pursuit of victory. Sometimes this effect is subconscious; Bazelon describes the “tunnel vision” that prosecutors get as they become unwilling to examine evidence that could exonerate a defendant. This psychological effect is reinforced by the culture of prosecutors and district attorney, and the politicization of their jobs. If a prosecutor lets somebody off with a light sentence and they reoffend, it could destroy their career or cost them reelection. Better, it seems, to err on the side of overcharging. Often, however, prosecutorial malfeasance is more direct and deliberate. Charged goes into detail about the Brady rule, which requires prosecutors to share evidence beneficial to the defense. That was not always mandatory, and the lengths to which prosecutors go to get around the Brady rule is astonishing. If Charged simply rattled off statistics about how prosecutors stuff prisons with people who may be innocent, it would be sufficiently damning. But it is Bazelon’s journalistic abilities and storytelling prowess that elevate it to a truly haunting call to action. The book’s throughlines are two stories that reveal the two major problems with America’s prosecutorial system: one exemplifies the structural flaws of a punitive institution that is unforgiving and arbitrary; the other is a horror story of an overzealous prosecutor who will go to any lengths to secure a conviction. Kevin is a young black man living in a Brooklyn public housing project who took credit for possessing a gun as a way to protect a friend. The prosecutor handling the case had complete control over whether the state charged Kevin with criminal possession of a weapon in the second degree (mandatory minimum sentence three and a half years), third degree (two years), or fourth degree (a misdemeanor, no jail time). Bazelon follows Kevin through the kafkaesque New York City gun court that is meant to expedite these cases, but instead merely strips nuance from complex situations. Through the youth diversion program YCP, Kevin is allowed to stay out of prison, but the lengths to which he must go to appease judges and, more importantly, prosecutors, is absurd. Constantly forced to toe the line and with the fear of a lengthy prison sentence hanging over his head, Kevin’s case stretches on for years. Noura, by contrast, is a white teenager in Memphis, who becomes the target of District Attorney Amy Weirich. After her mother is found murdered, Noura becomes the only suspect, despite nothing but circumstantial evidence tying her to the case. Weirich’s methods are ethically and constitutionally dubious, showing that she prioritizes defeating Noura in court over finding out who killed Noura’s mother. As Bazelon shows, this behavior is not anomalous, and not only is it rarely punished, but it is often rewarded. The stories that unspool in Charged—and the data behind them—reveal just how broken our criminal justice system is. But while Bazelon offers no happy endings or tidy resolutions, she does show the promise of a new generation of District Attorneys determined to reform the prosecutorial landscape. Winning elections on waves of support, progress has already been made in Chicago by Kim Foxx, in Philadelphia by Larry Krasner, and in other cities around the country. Every proposal by these firebrand reformers is met with resistance by a system designed to defend the status quo, but while progress is slow, they are already making a difference.The prosecutorial system is deeply ingrained in America’s courts, and the Supreme Court has given District Attorneys stunning amounts of power and leeway in how they handle cases. In Charged, Bazelon lays out the facts unflinchingly, but also offers a way forward, as well as realistic alternatives that can drastically reduce the prison population without sacrificing public safety. Bazelon’s book is more than an indictment of a dangerous and broken system, it is a call to action that nobody who reads it will be able to resist. Tom Houseman, Policy Director

The Dangerous War on Syringe Exchange Programs

Tom Houseman Drug Education, Harm Reduction, Uncategorized

In a 1996 episode of the tv show Spin City, Deputy Mayor Mike Flaherty (Michael J. Fox) is discussing a proposed syringe exchange program with city hall’s Head of Minority Affairs, Carter Heywood (Michael Boatman). Flaherty would rather the city stick with its old plan of handing out AIDS prevention pamphlets, because “it’s almost impossible to inject narcotics with a pamphlet.” The scene is played for laughs, but there is an underlying truth.  The US government has historically avoided harm reduction policies in favor of strategies that are less controversial, but also woefully ineffective. Syringe exchange programs have existed in the United States since the 1980s. They were created by community activists, without government support, as a response to the AIDS crisis. Since HIV is transmitted through blood, distributing clean needles reduced the risk that somebody could become infected with HIV after sharing a needle previously used by an HIV-positive person. Indeed, countless studies have shown that access to clean needles drastically reduces infection rates of not just HIV, but infections such as Hepatitis as well. In addition, those who repeatedly reuse needles risk a variety of infections. By providing drug users with clean, sterilized needles, syringe exchange programs are one of the most effective forms of harm reduction. As the opioid epidemic leads to increased rates of heroin use, syringe exchange programs are more important than ever. Unfortunately, draconian laws at the federal level and in many states make it extremely difficult for syringe exchange programs to help the people who need them most. U.S. Code Title 21 Section 863, also known as the “drug paraphernalia statute,” bans the distribution of drug paraphernalia. The Department of Justice defines drug paraphernalia as “any equipment that is used to produce, conceal, and consume illicit drugs,” a category broad enough that they mention “miniature spoons” as potential paraphernalia. Many states have similar laws, also vague enough that syringes are not always necessarily included. Even when syringe exchange programs are exempt, funding them publicly is an additional hurdle. Until 2016, it was illegal to use any federal funds to support syringe exchange programs. Even now, while funding these programs with federal money is legal, the money cannot be specifically used to purchase needles, a piece of legal tightrope-walking meant to deflect criticism that the government is “soft on drugs.” There are 15 states in which it is illegal to run a syringe exchange program, a diagonal stripe across the country from Idaho to Florida. In these states, which make up the bulk of the Midwest and the Southeast, drug paraphernalia laws forbid individuals from selling or distributing syringes if they have reason to believe that they will be used for illegal drug use. But even in states where syringe exchange programs are legal, hurdles created by state and local governments, as well as local law enforcement, make it unnecessarily difficult for harm reduction organizations to ensure that drug users have access to clean syringes. Illinois is one of the few states in the Midwest that allows syringe exchanges, but the onerous restrictions placed on these programs make the work far more difficult than it should be. Organizations like The Chicago Recovery Alliance must obtain a “research exemption” in order to distribute syringes, a barrier that makes it harder for them to reach the people who need them most.   And there is, in fact, no need for more research on the efficacy of syringe exchange programs. Mountains of evidence show that such programs are cost effective for cities and states and that access to clean syringes lowers rates of HIV infection without leading to increased rates of drug use. Effective syringe exchange programs save lives and make communities safer. This has not stopped towns from shutting down needle exchange programs, or preventing them from opening, based on unfounded fears. Last year the mayor of Charleston, West Virginia forced a local syringe exchange program to shut down, claiming that too many used syringes were being found unreturned. This was a baseless claim; 9 out of every 10 needles distributed were returned to the program. Earlier this month, Scientific American dug into why so few syringe exchange programs exist in Virginia, one of the states hit hardest by the opioid crisis. One of the issues, they found, is that “the law [requires] any local community to obtain formal written consent from local law enforcement officers for programs to operate,” and “continues to criminalize possession of even sterile syringes” for the program’s customers. As a result, only three of the seventy-five eligible counties in Virginia have a syringe exchange program. The opioid epidemic is worsening by the year; more people are going to be using heroin, often without the resources they need to stay safe. Harm reduction is about helping people stay safe while offering them whatever support and assistance they need. No program does that more effectively than syringe exchange programs, yet too many states are stuck in a War on Drugs mindset that punishes and stigmatizes drug use. That approach has failed, and harm reduction is one of the new strategies that must be embraced. In the fictional world of Spin City, Deputy Mayor Flaherty shoots down the idea of a needle exchange program. “We are in a war against drugs, in case you haven’t noticed,” he tells Haywood. “That’s the same war we’ve been fighting the last forty years?” Haywood asks sarcastically. “How we doing?” More than twenty years after this scene was first shown on television, it seems that too many politicians have the same answer to that question as Michael J. Fox’s character did at the time: “Any day now.” Tom Houseman, Policy Director

Medicinal Cannabis and the Opioid Epidemic

grygielny Marijuana Legalization, Medical Marijuana, Uncategorized

There is no silver bullet for solving the opioid epidemic. The Centers for Disease Control estimates that every day more than ninety people in the United States die due to opioid misuse. Opioid overdose is now the most common cause of death in the US, responsible for more annual deaths than vehicular accidents or homicides. Two recent studies add to the mountain of evidence that medicinal cannabis can be a part of reversing that trend. When President Trump declared the opioid epidemic to be a Public Health Emergency, it was a sign that the government was willing to get serious about tackling this problem. Even as federal funding has been increased to deal with the opioid crisis, Trump and Attorney General Sessions have rejected one of the most important steps that they could take: removing cannabis from the list of Schedule 1 drugs. The Controlled Substances Act was signed in 1970 as President Richard Nixon was ramping up the War on Drugs. This act created the Federal Drug Scheduling System, which classifies drugs by both their medical value and potential for abuse. Cannabis is classified as a Schedule 1 drug, signifying that it has no medical value and high potential for abuse. Scientists and doctors have spent the ensuing decades proving the federal government wrong. Despite restrictions on how cannabis can be used in research, evidence has continually demonstrated the medical value of cannabis. As a form of pain management, a way to lessen symptoms, and, in some cases, a way to aid in recovery, cannabis has been proven to be able to treat or help in the treatment of HIV, arthritis, asthma, epilepsy, glaucoma, and multiple sclerosis. There are multiple cannabis infused products like CBD juice, available on many websites. Now, new evidence indicates that cannabis can be used to fight the opioid epidemic. Two recent studies have examined the impact that legalizing medical cannabis at the state level has had on rates of opioid prescriptions and overdose deaths. In Association Between US State Medical Cannabis Laws and Opioid Prescribing in the Medicare Part D Population, researchers found that in states with medical cannabis laws there are significantly fewer people being prescribed opioids under Medicare than in those without. In states with medical cannabis dispensaries that enable even easier access to the drug, those rates are even lower. A second study, Medical Cannabis Laws and Opioid Analgesic Overdose Mortality in the United States, 1999-2010, demonstrates that states with medical cannabis laws had rates of opioid overdose mortality nearly 25 percent lower than in states where medical cannabis is illegal. This difference was more pronounced the longer a state had allowed doctors to prescribe cannabis to patients. Despite this evidence, those fighting against cannabis legalization continue to deny its health benefits. A South Carolina medical cannabis bill never received a vote in the state house, despite the fact that in one poll nearly 80 percent of respondents supported its legalization. Opponents of a similar bill in Kentucky have demanded more research on the drug’s long-term effects and questioned whether legalization actually would reduce opioid use. In Utah, a ballot initiative will give voters the opportunity to decide this November whether or not medical cannabis should be legal in their state. A recent poll by The Salt Lake Tribune found that more than three-fourths of Utah voters support the initiative, indicating that it is likely to pass. However, the bill faces considerable pushback. Governor Herbert has voiced his opposition, demanding more research before he would be willing to consider the medical benefits of cannabis. Because of its federal Schedule 1 classification, cannabis is technically illegal even in the twenty-nine states that permit doctors to prescribe it. To save lives we need every possible tool at our disposal, but with a ban on cannabis, and severe restrictions on even studying its benefits, the federal government is stunting its ability to help those most in need. From my own experience, when I visited the closest dispensary to utah it was obvious how the legalisation of Medical Cannabis had positively impacted those patients able to gain access to the dispensary. Without question the more we learn and experience, the more the need to legalize cannabis and remove it from the list of Schedule 1 drugs becomes clear. What remains to be seen, however, is if those in power will continue to ignore that evidence, or if they will finally make things right. Tom Houseman