Sentinel Policy Surveillance: A New Front in Legal Epidemiology?

Paul Erwin, Associate Editor of the American Journal of Public Health, recently wrote about the establishment of a  Sentinel Practitioner Surveillance System for Policy Change Impact,  or what might be called “sentinel policy surveillance.” The network of twelve diverse health officers will be trying to identify and share instances of harmful impact from Trump administration policies.

Erwin is suitably circumspect about what such a network can do. It is, he writes, no replacement of research, and, indeed, may be reporting perceived or feared effects as often as real ones.  I found the idea intriguing to ruminate on, though.  What follows are some scattered thoughts about the concept. I hope readers will add theirs.  Mostly I am interested in how the practice fits with general policy surveillance and public health law researchContinue reading

Health Law Rankings — Another Perspective

Glenn and Mark recently published a list of most-cited health law scholars, using the methods generally used for these studies in legal academia.  Like any academic who steadfastly denigrates the importance of lists, I naturally checked right away to see where I ranked, which was somewhere so far down the list that only an outbeak of smallpox at the AALS meeting could ever get me into the top twenty.  Since I was still completely uninterested in this whole ranking issue, my next move was to look at the methods.  And this is where I did have a thought worth sharing.

The source of the data is the JRL library on Westlaw, which I believe primarily covers law reviews and other legal publications.   How often one is cited in law reviews is certainly a good measure of impact within legal scholarsip, but it does not capture (or support) health law as an interdisciplinary field.  Indeed, I think it is arguable that for many of us, our most important impact will be on research and scholarship in other fields.  Does our top-twenty list look different if we draw on a broader database of citations?

I can’t tell you.  That would be a lot of work.  But there is a way to do it “collectively.”  Google tracks citations that appear anywhere in the googleverse and reports them in Google Scholar — if you create a profile. Most of the people in the top 20 in the Hall-Cohen top 20 do not have Google Scholar Profiles, but a few do and the results suggest we might see some differences in impact ranking if we went beyond law reviews:

Name Hall/Cohen cites (rank) Google cites (rank) since 2012
Larry Gostin 510 (1) 7150 (1)
I. Glenn Cohen 320 (4) 1143 (3)
Frank Paquale 300 (6) 1081 (4)
Lars Noah 280 (9) 586 (5)
David Studdert 190 (19) 7129 (2)

Everyone gets many more cites from Google than Westlaw, which reflects some methodological differences but also shows a lot of extra-legal impact.  Larry Gostin is still on top, by quite a distance, but David Studdert — at the bottom of the law review top 20 — comes near to catching him.  (I may as well admit that the Google ranking puts yours truly well above Cohen but nowhere near Studdent and Gostin.)

Why does this matter?  The obvious point is the one I have already made: health law scholars should be aiming to make a difference in health policy, and that is not measured by law review citations alone. For us to thrive as a field, we need more than ever to be engaged with non-lawyers, as my colleagues and I argue for public health law here. Recognizing non-legal citations is also, in my experience, extremely important for supporting young scholars.  If all we recognize and seem to value are law review citations, then junior scholars will only write law review articles. That is not how we build a field of engaged, cross-disciplinary scholars and researchers.  I encourage junior scholars to create Google Scholar profiles and I use them when I am doing promotion and tenure reviews in this list-mad age.

One last point: Google Scholar profiles take about two minutes to create and a very minimal effort to curate (if you care to, you need to eliminate some dupes and misatributions).  Whether you like rankings or transdisciplinary impact, you can help the field at minimal cost by signing up.

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Making a Moral Case for Regulation

Valerie Braithwaite’s chapter in the ANU’s Press’s new Regulatory Theory: Foundations and Applications provides a general introduction to looking at regulation through a social lens.  If regulation is so great, she asks, why do so many people approach it with fear and loathing?

I won’t rehearse her argument here, but instead skip to some key points about how we who appreciate the social good provided by regulation can best make that case. One of ten suggestions she concludes with was particularly resonant to me: “Engage with dissent on moral grounds. Is it right morally to steer the flow of events in the way proposed?”

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Fantastic New Resource on Regulation

Peter Drahos and a roster of the minds that have made RegNet at the Australian National University the hub of regulatory research and theory have put (it seems) all they know into a new, FREE ebook, Regulatory Theory: Foundations and Applications.  It is a comprehensive account of the field, written to serve both as a reference for the essentials and a text book for classes in regulation and governance.  It even has a chapter on regulatory research methods in public health by this correspondent.

I am hoping to conduct a serial book review over the next couple of weeks. Here goes:

The first chapter is an introduction to the field by Drahos and Martin Krygier. It usefully orients the reader to the breadth of the field, a breadth that reflects the spread of regulatory activity beyond the state and across networks. Attention to those two phenomena, indeed, is properly presented as the foundation of the field.  There is a bit of intellectual history, highlighting the sigificance of Ayres and Braithwaite’s Responsive Regulation, and the emergence of RegNet as an intellectual gathering place. (I saw that first hand, and had a little experience of RegNet collegiality, when I spent a semester there and ended up writing an article on Nodal Governance with Drahos and Clifford Shearing — still my most downloaded paper.) Continue reading

Housing Equity Week in Review

This week was all about fair housing. Particularly, the Affirmatively Further Fair Housing rule and recent attempts to dismantle it. Here’s the round-up for last week, January 29 – February 5, 2017:

We’ve talked a little about fair housing before. In case you missed it, we interviewed Christopher Bonastia about his book, “Knocking at the Door” back in November.

Did we miss any big housing, law and equity stories this week? Let us know!

Human Rights Advocacy under Attack

One of the world’s most important human rights law firms is now under attack from a government whose leader has, to put it mildly, a mixed record on human rights.  The firm is the Lawyer’s Collective, which has done some of the most important work within India on HIV, LGBT and gender issues.  The firm’s lawyers have also made great contributions internationally. Indira Jaising has served as a member of the UN Committee on the Elimination of Discrimination Against Women. Anand Grover was the UN Special Rapporteur on Right to Health from 2008 to 2014, during which service he issues several fearless reports that helped move the world forward towards an enabling environment for HIV among the most legally marginalized people.

On June 1, the Indian Union Ministry for Home Affairs suspended the firm’s license to receive foreign funding, contending that the Lawyer’s Collective had violated the Foreign Contribution Regulation Act. The Lawyer’s Collective faces the prospect of having their license cancelled permanently, which would seriously impact their work. Both the suspension order and the Lawyer’s Collective’s response have been widely reported in the Indian media. Continue reading

Changing How We Think (and Talk) About Public Health Law

By Scott Burris, JD

Marice Ashe, Donna Levin, Matthew Penn, Michelle Larkin and I have a new piece in the Annual Review of Public Health (also available on SSRN). We set out a “transdisciplinary model of public health law” that encompasses within the core of the field both the traditional public health law practice of lawyers and what we call “legal epidemiology” — all the important public health law functions (from policy design to evaluation) that are typically carried out by people without legal training. I hope you will take a look.

Why this article and a transdisciplinary model? The idea comes out of the experience that the authors have all had trying to promote public health law practice and research. We realized that in spite of the success of the field and its importance to public health, a lot of non-lawyers in public health training, practice and research were uncomfortable with law — even when their work had to do with enforcing it or evaluating its impact.

We realized that we as lawyers were making things worse, by adhering to a traditional view of public health law as purely a practice of lawyers. We found that acknowledging the work of non-lawyers in public health law, conceptualizing key public health law activities in scientific terms, and even borrowing some scientific practices for legal work, were effective ways to change attitudes and improve our impact. Many of us have articles in the pipeline on legal epidemiology, policy surveillance and “the five essential public health law services” that will show the model in action.

I don’t have to tell readers of this blog that public health law is a great field. I hope the concept of transdisciplinary model will help make it a truly integral part of public health.

Read the full article here.

Why Do Refugees Risk the Deadly Boat Crossing to Europe? It’s the Law

By Scott Burris

This morning I heard an NPR story that began, “Why do so many refugees from the Middle East risk the dangerous Mediterranean crossing in rickety boats?”  The answer, in the story, was an account of the miseries of a family stranded in Aleppo.  Why do people risk so much to flee? Because life is so bad where they are.

There is plenty of misery in the war-torn Middle East, but if the question is “why do people flee in dangerous boats run by ruthless smugglers,” NPR did not have the right answer.  Hans Rosling, the Swedish epidemiologist and humanitarian, has offered a better one: the EU regulation that requires airlines that fly in asylum seekers who do not qualify to fly them out again at the airline’s expense. (Watch his video here.) Airlines just won’t allow people without the proper visas to board, even if the law would. Yes, it’s the law that puts people on boats.  Flights from the region’s airports to Europe are cheaper than the deadly boats.  As we are seeing now, many if not most of these refugees qualify for asylum.  EU law does not require asylum seekers to have visas or be granted asylum before they board the plane.  But by placing the economic risk on the airlines, the EU essentially delegates the asylum decision to the most risk averse and least responsible player in the process.

Here’s the math.  The Abdullah Kurdi family of four, whose two children drowned, reportedly paid €2,000 each for the trip, well over $8,000, to get from Turkey to Greece.  On Travelocity today, German Wings had a flight from Istanbul to Berlin with seats at $84.

Building on 20 Years of Success: The Future Role of Law

By Scott Burris, JD

On this, the last day of National Public Health Week 2015, we’re looking forward by looking backward. There is nothing new about using law and policy to promote healthier environments, products and behavior. There is no good future for public health that does not include even more, and more effective, legal interventions.

Evan Anderson and I wrote in 2012 about the legal regulation of health-related behavior over the past half-century. The story we told offered several reasons for unabashed optimism about what law can do for health. The record is clear that law works, and works across a wide range of different health threats. We pointed to CDC lists of Great Public Health Achievements from the last century and the first decade of the 21st.   Every one of them — from high levels of vaccination, through motor vehicle safety and cancer prevention to maternal and child health – could not have been successful without law and policy. Continue reading

Courts as Ebola Educators

By Scott Burris

News in this afternoon is that a Maine state judge has lifted the quarantine order on nurse Kaci Hickox, saying that she “currently does not show symptoms of Ebola and is therefore not infectious.”

The ruling conforms to the best available scientific evidence and CDC recommendations.  It also shows the importance of judicial review as a check on the exercise of emergency powers. Hearkening back to the many school exclusion cases during the HIV epidemic, I hope it will help reassure a public confused by the gap between what CDC and other experts say is necessary and what some political leaders are doing.  The best way for government to keep our trust in this outbreak is to offer accurate information — and then behave accordingly.

Research Round-Up: New Publications from the PHLR SciVal Experts Community

In honor of last week’s National Public Health Week, we have a lot of fresh, new PHLR. The latest crop of papers from public health law researchers touch on a number of important points and issues including transportation safety, implementation, tobacco control, and media presentation of public health law. Check out Scott Burris’s brief summaries after the jump!

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Evidence in Policy Innovation

In the last few decades, there has been a broad effort to strengthen the use of evidence-based law as a tool for the promotion of population health. There are two major fronts in the campaign, each essential, and both largely successful, though much work also remains. One aims to increase the quantity and quality of empirical research on the health effects of existing policy choices. The other focuses on how best to get such knowledge into action in the form of policy and practice. In a new PHLR Theory Practice and Evidence paper, Evan Anderson and I draw attention to a third front: the formulation of new legal interventions. Though policy experimentation is inevitable, it has been the subject of relatively little systematic study. For proponents of evidence-based public health law, policy experimentation presents a paradox: if a legal intervention is truly innovative, there will not yet be direct evidence of its impact. Yet direct evidence from policy evaluations is never the only source of research knowledge relevant to a policy decision, even under conditions of novelty and uncertainty. And few interventions are truly new in a broad sense; in most instances, similarly designed laws have been deployed before, just not for the same specific purpose.

We use the case of youth sports concussion and Washington’s Lystedt Law as a case study of how even new legal strategies dealing with new problems can be built on evidence. We show  how evidence about the problem lawmakers are addressing, combined with widely-used analytic tools like the Haddon Matrix and an understanding of the generic mechanisms through which law influences behavior and outcomes, can bring existing research knowledge into the crafting of even very innovative legal interventions for newly perceived problems.  While we don’t expect the policy sausage factory to suddenly start looking like a research lab, there’s no question that legislators typically care about getting policy right and want evidence.  The point of our paper is to get the research world to think about ways we can help even when no one has yet studied the specific law at issue.

New PHLR (and George) Papers

Laura Brennan, Ross Brownson and Tracey Orleans have come out with an important paper reviewing the evidence on policy and environmental strategies for reducing childhood obesity. Twenty-four strategies and 2000 published and gray literature documents are covered.  This is a menu of more-or-less evidence backed ideas for intervention.

Sam Harper and colleagues come out with an interesting new argument for primary seat belt laws, based on a disparities analysis. Looking through the lens of education level, they  (well, we, since I am one of the authors) find that, while primary enforcement has a powerful affect at every educational level, the impact is greater on people with less education.  Thus, existing SES differentials in seat belt use could be reduced if all states (finally) went to primary enforcement.

Even kids like paternalism?  Well, that may not be the best interpretation of this next study. Williams and McCartt surveyed New Jersey teenagers about three GDL requirements that are unique to that state: minimum licensing age of 17; application of full GDL rules to beginners younger than 21; and requiring license status decals on vehicle plates of GDL drivers.  84% liked licensing at 17, and 77% approved applying Gthe rules even to older novices.  The decal policy was approved by only 23% — but a PHLR study showed it works, so I say get used to it.

Two new tobacco law studies round out the week’s harvest.  Heikki et al. map the diffusion of health warning regulations since 1966, showing a big impact of the FCTC. Finally, in a paper that may start some arguments, Kevin Callison and Robert Kaestner report that adult smokers may not be as responsive to cigarette taxes as many believe.  They suggest it will take increases on the order of 100% to get a further 5% reduction in smoking rates.  Well, I’m okay with that.

Over on the George side of things, Peter Jacobson and Wendy Parmet have posted a thoughtful response to Larry Gostin’s Bloomberg commentary in the Hastings Center Report.  They are helping us move away from a habitual application of the paternalism critique and reminding us that public health can play in the democracy sandbox pretty well.

Down with Antipaternalism!

As the holidays approach, I have a chance to catch up on reading.  The Sept-Oct issue of the Hastings Center Report had a paper by Larry Gostin on Michael Bloomberg’s health policy career in New York, and I have seen some of a series of responses by other scholars that will appear in due course. With his usual facility, Gostin recounts the story of Bloomberg’s health department and its innovations in policy – it’s a great piece for a health law class.  The piece is also typical Gostin in its framing of the issue of paternalism as a key driver of opposition to many of Bloomberg’s initiatives.  And if it is typical Gostin, it is really representative of our field, since Gostin has both drawn on and helped reinforce a widely held belief that the politics of public health are strongly driven by a tension between individual liberty (inscribed legally in civil rights and culturally in individualism and antipaternalism) and public health.

In this framework, paternalism is a premise, not a hypothesis. Gostin writes, “The societal discomfort with Bloomberg’s agenda is grounded, at its core, in distrust of government influence on how autonomous adults conduct their lives.” He describes how health policy-makers are driven to rely on the harm principle to justify policies by “American antipathy toward paternalism.”  Yet, and this is also typical of the discourse in our field, he also follows the Sunstein-Thaler line that ultimately denies the empirical assumptions upon which anti-paternalist claims depend: “The public health approach rejects the idea that there is such a thing as unfettered free will, recognizing instead that the built environment, social networks, marketing, and a range of situational cues drive complex behaviors.”

Public health law has been stuck here for a while, accepting that public health policy has and always will be subject to the arbitrary dominion of a mass delusion of autonomy.  I think this log-jam is starting to break – and that proponents of effective health laws should be doing all they can to properly discredit and abandon this old trope.  A few signs:

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New Data on Drug Overdose Law

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By Scott Burris

Working with Corey Davis of the Network for Public Health Law, PHLR has completed and posted updated longitudinal datasets of state laws authorizing naloxone distribution and creating “Good Samaritan” immunity for callers reporting a drug overdose to 911. Take a look at www.lawatlas.org.

On the theory that an image beats a few hundred words, here’s a report on the state of the law:

George at APHA IV: Happy George

By Scott Burris

This is the last in a series summarizing a panel from the George collaborative of law professors at last week’s APHA meeting. My talk had a smiley icon for a title and a rant for a structure. I wanted to engage the audience with two very general ideas:  that public health legal interventions are popular, and that we are both factually and strategically wrong to buy into the framing of public health law controversies as turning on principled questions of paternalism or tensions between individual rights and collective welfare.

The first is a point I have made in past posts of one kind or another, and that Evan Anderson and I elaborate in our article just published in the Annual Review of Law and Social Science.  In that article, we point to the fact that Rs and Ds have been happily passing laws that regulate our behaviors, our environment and our machines for public health reasons for decades and show no signs of slowing down. In the talk, I also reference the Morain and Mello Health Affairs piece on pro-public-health public opinion. At PHLR, we are working on another aspect of all this, the fact that a lot of the controversy and complaint about “intrusive” measures often dies down once the new behavior is adopted.  We don’t have a paper on this yet, but just ask yourself who misses smoke-filled rooms, transfats, cars without airbags…   And of course, as Mayor Bloomberg makes his exit as the symbol of the local nanny state, it’s worth recalling his poor paterniated charges re-elected him twice.

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George at APHA III

By Scott Burris

One of the themes of what we might call Georgian Legal Scholarship has been the neglect of public health as a core object of government. This is a theme Wendy Parmet set out at length in Populations, Public Health and the Law, and that Renee Landers took up at APHA.

Landers’ timely example was the ACA and its individual mandate, which has been characterized in litigation as a mandate to purchase an “unwanted” product in violation of individual liberty, exceeding Congress’s power under the Commerce Clause, not a valid exercise of Congress’s Taxing Power, and an intrusion on the prerogatives of the States.  The Chief Justice’s opinion in the Supreme Court’s decision in NFIB v. Sebelius, upholding the individual mandate, but declaring the structure of the Medicaid expansion a violation of the Tenth Amendment, provides her many examples of the focus on these legal abstractions. She also points to language from the joint dissent that indicates the same limited perspective.   Absent from the opinions was acknowledgment of the significant public health problems—human suffering—that the ACA was designed to address.  As she sees it, a focus on abstractions over lived experience has resulted in millions of intended beneficiaries of the ACA being left out of the Medicaid expansion because 26 states have taken advantage of the ability to opt out of the Medicaid expansion.

Landers argued that this was not a problem confined to the ACA case. Courts have reasoned in similar ways in recent public health preemption, First Amendment and abortion cases, showing a disregard for real human situations or scientific and economic evidence.   To her, these recent examples echo the approach of the courts in the early part of the twentieth century when the Lochner case defined judicial review of economic and public health regulation, as Wendy Parmet has discussed in Populations, Public Health, and the Law.  Public health lawyers and scholars, she concluded, must work to demonstrate for courts that role of economic regulation in promoting the public health, elevate the concerns of real people above legal abstractions, and lift the mask on punitive measures masquerading as public health laws.

Tomorrow: Happy George

George at APHA II

By Scott Burris

(Second in a series of posts on the George Project session at APHA last week.)

Lindsay Wiley, who has been writing some interesting stuff lately about the democratic foundations of public health, used her talk to discuss Building and Honoring Coalitions in Controversial Times. Part of the George discussion has been directed to changing the public health law conversation from a set of complaints about setbacks to an exploration of new possibilities.  In thinking about the pivot from challenges to opportunities, Wiley has been focusing on opportunities to protect and strengthen coalitions across progressive advocacy communities and with other potential allies.

This issue arises in a range of contexts: from health and environmental issues surrounding food production, marketing, and labeling to employers’ and private health plans’ efforts to cut costs by providing incentives for healthy behavior. Wiley’s presentation focused on recent tensions between public health advocates and civil rights, anti-poverty, and anti-hunger groups. Within the public health community, she argued, we in public health law tend to automatically see public health goals as compatible with broader social justice goals. We claim social justice as the moral foundation of public health practice and advocacy.  But over the last few years – intensifying in the last several months – that synergy has been threatened.

Wiley discussed three recent controversies: the soda industry’s framing of the legal challenge to the NYC soda portion rule as a civil rights issue; anti-hunger and anti-poverty groups’ vehement opposition to proposed restrictions on the use of SNAP benefits to purchase unhealthy foods and beverages; and opposition to primary enforcement seatbelt laws based on concerns about racial profiling. Wiley’s examination of these events suggests that in some instances, the public health community needs to work more closely with civil rights and anti-poverty groups to promote a more progressive, ecological approach to public health issues and to make the case for health disparities as a civil rights and anti-poverty issue (rather than simply claiming civil rights or anti-poverty as public health issues). In other instances, public health advocates may be picking the wrong battles altogether, siding with groups who want to penalize socially and economically disadvantaged communities without working to facilitate healthier options in those communities. But in some instances, public health advocates have been able to forge compromises that result in a true win-win: promoting public health goals while also achieving reforms in other areas.

Like Wendy Parmet’s talk, described yesterday, Lindsay Wiley’s challenges the comfortable notion that public health is automatically given credit for its high moral standards and good social intentions. She doesn’t say we can’t occupy the moral high ground, but we may have to work harder to get there, and she has some practical ideas about how to do it.

Tomorrow: Renee Landers’s talk.

George at APHA I

By Scott Burris

The “George Project” is a loose collaborative of law professors working to promote the fair and effective use of law for public health. It has been described here. Last week, four George participants formed a panel to report on their intellectual adventures in the sometimes dicey world of public health law.  This week, I will report on their comments in a series of posts.

Wendy Parmet’s presentation, Beyond Paternalism: Public Health as Preemption, began by noting the agreement among George collaborators on the need to respond to the normative attacks being waged against public health laws. At the moment, the most salient of these is the “nanny-state critique,” which condemns public health law as inappropriately paternalistic. After reviewing some of the responses that scholars have offered to that charge, Parmet focused on the one recently proposed by fellow Georgians Lindsay Wiley and Micah Berman (and Doug Blanke) — namely that we need to frame public health as a manifestation of the democratic process. Parmet developed that theme by arguing that public health law is not simply a restriction of liberty, as the nanny-state critique presumes; it is also a manifestation of citizens’ positive liberty to self-govern. Or, to put it another way, public health law is the product of citizens exercising their rights to self-governance to provide the conditions by which they can be healthy.

After suggesting that public health can be viewed as an exercise of self-governance, Parmet looked briefly at two recent public health law cases. New York Statewide Coalition of Hispanic Chambers of Commerce v. N.Y.C. Department of Health, 110 A.D. 3d 1 (N.Y. App. Div. 2013), struck down New York City’s ban on large sugary sodas. Cleveland v. Ohio, 989 N.E.2d 1072 (Ohio. App. 2013), struck down an Ohio state law designed to preempt a Cleveland ordinance banning trans fats. In comparing the two cases, Parmet focused on the fact that the court in the New York case emphasized what it saw as the overreaching of a public health agency; in the Ohio case, the court noted that the state was improperly undermining the power of the city council to protect the health of Cleveland’s citizens. Although these are only two state law cases that depend on the particularities of state law, Parmet asked whether the fact that the New York City regulation emerged from an administrative agency without legislative support while the Cleveland ordinance was enacted by the city’s council was significant? Could it be that laws that emerge from a democratic process are more secure than equally paternalistic administrative regulations? More broadly, might the paternalism critique be masking a discomfort with the bureaucracy, expertise, and the administrative state?

Parmet concluded by arguing the public health needs to look in the mirror. Have we in public health undermined our own cause by treating public health law as a technical tool that experts can apply to achieve scientifically-validated outcomes? In so doing, have we lost sight of the fact that public health law is or should be a tool that citizens can use to improve the health of their own communities?

My own talk, which I will describe in a later post, was also about how public health is popular, but in the less profound sense of that word.  What I really liked about this panel, and Wendy Parmet’s talk exemplified this, was the willingness not only to point out how courts and commentators are neglecting the democratic roots of public health, but also how we in public health may be settling for overly simplified (and empirically false) explanations for our legal and political setbacks.

Tomorrow: Lindsey Wiley’s talk.

Another Legislative Win for Opioid Death Prevention

By Scott Burris

The rising public and legislative awareness of opioid overdose has been a case study in the twists and turns of culture, risk perception and the role of evidence in policy making. An interesting case study, which does not mean I understand what happened or why.

I first got involved in overdose through Dan Abrahamson, the Legal Director at the Drug Policy Alliance. This was back in 1999 or 2000, and a group of drug researchers and drug policy people convened a meeting in Seattle to discuss the chronic, neglected problem of overdose among heroin users.  There were a few health people who were highly aware of the human and economic costs, and the scale of the problem. Karl Sporer, a San Francisco ER doc, was one of the few publishing on the problem. One of the interesting ideas discussed at the meeting was distributing naloxone, the standard antidote for opioid overdose, directly to heroin users. New Mexico, which had the nation’s highest OD death rates, was trying it as a way to deal with the great distances that divided rural heroin users from EMS assistance. With Joanna Norland and Brian Edlin, I ended up writing an analysis of the legality of distributing this prescription drug to drug users.

In the next few years, led by people like Dan Bigg of the Chicago Recovery Alliance, needle exchange programs in urban areas began naloxone programs. They were spurred in 2006 when several US cities experienced an epidemic of overdose tied to the adulteration of the heroin supply with a synthetic opioid, fentanyl. By May, 2009, 57 naloxone programs were operating in 17 U.S. states.  That year, DPA funded a group of scientists and practitioners to brainstorm on how to increase drug users’ access to this life-saving intervention.  Continue reading