The Opioid Crisis Requires Evidence-Based Solutions, Part III: How the President’s Commission on Combating Drug Addiction Dismissed Harm Reduction Strategies

By Mason Marks

Drug overdose is a leading cause of death in Americans under 50. Opioids are responsible for most drug-related deaths killing an estimated 91 people each day. In Part I of this three-part series, I discuss how the President’s Commission on Combatting Drug Addiction and the Opioid Crisis misinterpreted scientific studies and used data to support unfounded conclusions. In Part II I explore how the Commission dismissed medical interventions used successfully in the U.S. and abroad such as kratom and ibogaine. In this third part of the series, I explain how the Commission ignored increasingly proven harm reduction strategies such as drug checking and safe injection facilities (SIFs).

In its final report released November 1, 2017, the President’s Commission acknowledged that “synthetic opioids, especially fentanyl analogs, are by far the most problematic substances because they are emerging as a leading cause of opioid overdose deaths in the United States.” While speaking before the House Oversight Committee last month, the Governor of Maryland Larry Hogan stated that of the 1180 overdose deaths in his state this year, 850 (72%) were due to synthetic opioids. Street drugs are often contaminated with fentanyl and other synthetics. Dealers add them to heroin, and buyers may not be aware that they are consuming adulterated drugs. As a result, they can be caught off guard by their potency, which contributes to respiratory depression and death. Synthetic opioids such as fentanyl are responsible for the sharpest rise in opioid-related mortality (see blue line in Fig. 1 below).

Figure 1: Drug Overdose Deaths Between 2000 and 2016 as Reported by the National Institute on Drug Abuse

Given the risks of synthetic opioids and their growing contribution to opioid-related deaths, solutions are needed to identify when they are present in the illicit drug supply. As a result, it is noteworthy that the Commission ignored harm reduction strategies such as drug checking, which could reduce deaths due to consumption of contaminated opioids. Many countries including Austria, Belgium, Switzerland, Portugal, Spain, Switzerland, and the Netherlands offer free and confidential drug checking (also known as pill testing) to drug users. Drug checking could reduce consumption of adulterated drugs and provides opportunities to support and counsel users who may otherwise receive no contact with medical or public health professionals. Drug checking is also a valuable source of information about the pricing, availability, effects, and composition of street drugs. This information can be used to further our understanding of drug use and its effects.

Some experts argue that drug dealers will be less likely to add dangerous adulterants to their products if they know that consumers have a mechanism to test their contents. The identification of drug contents can alert authorities to the presence of synthetic opioids, which can lead to public warnings and announcements that may further drive dealers to withdraw deadly additives from the market. The practice can also improve law enforcement efforts to reduce the illegal importation and sale of synthetic opioids. Dr. Carl Hart, Chair of the Department of Psychology at Columbia University, supports the use of free and anonymous drug checking in the United States. In a Scientific American article, he argues that the opioid crisis is a distinctly American problem. According to Hart, “Throughout Europe and other regions where opioids are readily available, people are not dying at comparable rates as those in the U.S., largely because addiction is not treated as a crime but as a public health problem.” Drug checking is one example of how European countries approach drug abuse from a public health angle rather than a punitive law enforcement perspective.

Critics of drug checking argue that it could normalize drug use or “send the wrong message” to potential users. For instance, the practice could create the appearance of safety when in fact the drugs being consumed are dangerous. Even public health experts acknowledge that drug checking is not a panacea. Only a fraction of drug users will use the service or listen to the results. However, drug checking has produced positive results in Europe. According to Dr. Artur Schroers, Head of Addiction Services for Rhineland-Palatinate, one of Germanies 16 states, pill-testing promotes prevention, safeguards public health, and improves drug monitoring. At the very least, drug checking should be added to the discussion on how to combat the U.S. opioid crisis. Yet the Opioid Commission completely ignored this available option.

Supervised injection facilities (SIFs), arguably a more controversial option than drug checking, were also ignored by the President’s Opioid Commission. SIFs provide a place for people to inject drugs under professional supervision to minimize the risk of HIV and hepatitis C infection, drug overdose, and death. They are primarily used in Switzerland, Canada, and Australia. However, the City of Denver is taking steps to become the first U.S. city to offer SIFs. In November, a plan for a pilot program won unanimous approval from a bipartisan ten-member legislative committee. However, the City’s General Assembly must approve the plan in January 2018 for it to move forward. Seattle and San Francisco are considering similar proposals. The State of Vermont is also considering using SIFs. On November 29, 2017, a commission of health and law enforcement professionals, led by State’s Attorney General Sarah George, recommended that Vermont make SIFs a part of its opioid strategy. However, the Vermont Commissioner of Public Safety and the Vermont Association of Police Chiefs disagree. The Commissioner stated, “Facilitating the ongoing use of heroin through SIFs sends the wrong message, at the wrong time, to the wrong people.” However, critics of SIFs have little evidence to support their positions.

Figure 2: Heroin syringe and needle on the sidewalk. Photo by Eric Molina from New York City [CC BY 2.0  http://creativecommons.org/licenses/by/2…)], via Wikimedia Commons

A 2014 review published in the journal Drug and Alcohol Dependence, examined the outcome of 75 studies and concluded that SIFs are an effective harm-reduction strategy not associated with increased drug use or crime. In early 2017, the Massachusetts Medical Society published its analysis of SIFs. It found that peer-reviewed research published in leading academic journals, such as JAMA and the New England Journal of Medicine, supports the conclusion that SIFs produce positive outcomes such as reduced mortality and increased access to drug treatment. If supervised injection facilities are being considered in multiple U.S. states and cities, and are already in use countries around the world, then they should have been presented as an option by the Opioid Commission.

How could the Opioid Commission’s final report omit any mention of drug checking and SIFs when these tools have been successfully deployed in other countries and their use is increasingly supported by scientific evidence? The Commission was formed to research the best ways to combat a serious epidemic. However, only one member of the Commission, Professor Bertha Madras, has formal scientific training. As a result, it should perhaps come as no surprise that the Commission misinterpreted scientific studies and made recommendations that appear to be rooted in emotion rather than science and reason. Consider supervised injection facilities. Evidence suggests that SIFs reduce drug related deaths and are not associated with increased drug use or crime. Admittedly, there could be an “ick factor” associated with SIFs, and overly zealous drug control advocates could find them repugnant. However, when thousands of lives are at stake, emotional reactions to SIFs must be weighed against the scientific evidence. If the evidence suggests that SIFs are effective, then lawmakers must be courageous and allow their decisions to be guided by science rather than emotions such as disgust.

 

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About masonmarks

Mason Marks is a Visiting Fellow at the Information Society Project at Yale Law School. His research focuses on health law, privacy, and intellectual property. He is particularly interested in the application of artificial intelligence to clinical decision making in healthcare, emerging issues in health data privacy, and comparative privacy law. Mason’s legal and technology writing has been featured in WIRED, the NYU Journal of Legislation and Public Policy, and Harvard Law School’s Bill of Health where he is a regular contributor. Mason has been invited to speak at Yale Law School, Yale Medical School, Harvard Law School, Harvard Medical School, Arizona State College of Law, Seton Hall Law School, and the Yale Whitney Humanities Center. Mason received his J.D. from Vanderbilt Law School. He is a member of the California Bar and practiced intellectual property law in the San Francisco Bay Area. Prior to law school, he received his M.D. from Tufts University and his B.A. in biology from Amherst College.