Might Texas revisit needle exchange pilots with Susan Reed gone, disease prevention in the news?

Grits wonders if - owing to recent events surrounding the Ebola scare and the outlandish costs of Hepatitis C treatment under new drug protocols - 2015 might be a year in which the Texas Legislature favorably revisits Rep. Ruth Jones-McLendon's legislation allowing local health authorities to create pilot needle-exchange programs? This session, her bill allowing such pilots in Bexar, Dallas, El Paso, Harris, Nueces, Travis, and Webb counties is HB 65.

Legislation authorizing a pilot needle-exchange program passed once before back in 2007. Rep. McLendon carried the bill in the House and Dr. Bob Deuell (who lost his primary in the spring and will not return next year) championed it in the Senate. The designated pilot location was McLendon's home county in Bexar; Governor Perry approved it and local officials looked forward to implementing it. But Bexar County District Attorney Susan Reed, who herself was ousted earlier this month in the general election, threatened to prosecute volunteers who participated in the pilot, effectively rescinding the Legislature's permission under authority of the executive branch. (See Grits coverage here, here, here, here, here, and here.)

Senator Deuell seemed to lose heart in the fight after 2009, when the bill passed the Senate but died sitting on the House calendar while Democrats chubbed over voter ID. The good doctor threw up his hands on the issue after that - there are plenty of other topics, after all, on which an East Texas Republican can expend his political capital - and the bill hasn't moved much since.

However, the political landscape surrounding the issue arguably has changed since then, for starters thanks to a renewed concern for preventive public-health strategies in light of the Ebola scare. A recent Texas Tribune headline, one of their last in the New York Times before that partnership ends, read, "Ebola scare behind it, Texas is bracing for the next viral crisis."

There are many possible methods of disease transmission and, just in recent decades, IV drug use has been a significant factor in the spread of both HIV and Hepatitis C. As the state considers comprehensive disease-prevention strategies (a Perry-appointed task force will release its Ebola-centered recommendations after the holiday), reviving the idea of pilot needle-exchange programs only makes sense. HIV/AIDS killed many thousands before treatments were found. And Hep C may end up costing the state untold sums thanks to a new drug called "Sovaldi," which cures the disease but costs in the neighborhood of $80,000 per patient. At those rates, it would run around $2 billion (with a "b") to treat every TDCJ prisoner with Hepatitis C if, say, courts ever ruled the state is obligated to provide the treatment as part of its basic standard of care for the disease. (When the state chooses to incarcerate someone, it assumes responsibility for their healthcare, federal courts have consistently found.)

All that to say, increasingly there are pragmatic public health and budgetary reasons, and perhaps even a bit of political momentum thanks to the Ebola scare, for the Lege to take a more expansive view toward the merits of preventive public-health strategies. Susan Reed is gone, or is about to be, and McLendon's permissive, local-control approach would let needle-exchange pilots happen in a way that would insulate legislators from on-the-ground decisions by local officials.

Texas Republicans should support local, pilot needle-exchange programs for the same reason Margaret Thatcher did: The public interest in disease prevention outweighs whatever principled disdain for addicts one might harbor. The election is over. It's time to govern.

Study: HIV rates higher around TDCJ prison units

The Huntsville Item brings word of a strange research finding related to HIV rates near TDCJ prison units ("HIV rates higher around TDCJ prisons," Jan. 8).

Areas surrounding Texas Department of Criminal Justice prison facilities have higher HIV rates than those that do not, according to a study released last spring.

Walker County was among those listed with high HIV rates in a study published in “The Professional Geographer” academic journal in May 2013. The study  titled “Vulnerable places: prison locations, socioeconomic status, and HIV infection in Texas” found that in ZIP codes with TDCJ prisons, HIV rates were significantly higher than those farther from the prisons.

“This is an important finding and suggests that prison facility locations might be considered a risk marker for places that are vulnerable to HIV infection and spread,” the study reads. “Prioritizing them for HIV surveillance and intervention will reduce the rate of new infections and help to accomplish the goals of (the National HIV/AIDS Strategy).”

The area in and around Walker County has the highest number of prison facilities in the state — a total of seven  and also elevated HIV rates — according to the Texas Department of State Health Services.

The TDSHS report from 2012 lists the HIV rate (cumulative number of people diagnosed) in Walker County as 150 per 100,000. The national rate sits at about 16 while the rate in Texas is slightly higher at 16.4, they say using data from the U.S. Census.

“The results ... indicate that areas in close proximity to TDCJ units have lower socioeconomic status and [higher] rates of HIV,” the study reads. “With increasing distance from TDCJ prison units, the HIV infection rate of the general public decreases.”

Huntsville was also listed in the top 25 cities (tied for 20th highest) in Texas in HIV infection and AIDS diagnoses, according to the TDSHS.

The researchers explain in the article that there isn’t a definite cause for this finding — likening it to a chicken-and-egg scenario.

“Do TDCJ facilities create high HIV rates by releasing prisoners (known to have high HIV rates) into the community or do TDCJ facilities locate in areas with high HIV rates?” the researchers ask. “There might not be an answer to this question.”

There could be a third possibility: Perhaps the relationship isn't between prisoners and the outlying community, but prison staff. There are only four regional release facilities where prisoners exit TDCJ, and most do so with a bus ticket back to their county of conviction where they have an appointment already set with their parole officer. If there's a correlation between HIV rates and prisons beyond those four facilities, perhaps it's because of prison staff, not the inmates. Who knows?

Notably, reported the Item, "Both TDCJ and state HIV totals have risen in the last 15 years. In 1996, TDCJ accounted for 1,377 inmates that were positive for the disease. In 2009, (the most recent data on TDCJ’s website) 2,453 inmates were positive for the virus." TDCJ doesn't test inmates for HIV while they're locked up unless they request it, but "inmates are tested prior to discharge to help set up HIV care while the inmate is transitioning from correctional care to the general public." If there's any sort of causal relationship going on here, it's going to be difficult to decipher.

Areas surrounding Texas Department of Criminal Justice prison facilities have higher HIV rates than those that do not, according to a study released last spring.

Walker County was among those listed with high HIV rates in a study published in “The Professional Geographer” academic journal in May 2013. The study  titled “Vulnerable places: prison locations, socioeconomic status, and HIV infection in Texas” found that in ZIP codes with TDCJ prisons, HIV rates were significantly higher than those farther from the prisons.

“This is an important finding and suggests that prison facility locations might be considered a risk marker for places that are vulnerable to HIV infection and spread,” the study reads. “Prioritizing them for HIV surveillance and intervention will reduce the rate of new infections and help to accomplish the goals of (the National HIV/AIDS Strategy).”

The area in and around Walker County has the highest number of prison facilities in the state — a total of seven  and also elevated HIV rates — according to the Texas Department of State Health Services.

The TDSHS report from 2012 lists the HIV rate (cumulative number of people diagnosed) in Walker County as 150 per 100,000. The national rate sits at about 16 while the rate in Texas is slightly higher at 16.4, they say using data from the U.S. Census.

“The results ... indicate that areas in close proximity to TDCJ units have lower socioeconomic status and rates of HIV,” the study reads. “With increasing distance from TDCJ prison units, the HIV infection rate of the general public decreases.”

Huntsville was also listed in the top 25 cities (tied for 20th highest) in Texas in HIV infection and AIDS diagnoses, according to the TDSHS.

The researchers explain in the article that there isn’t a definite cause for this finding — likening it to a chicken-and-egg scenario.

“Do TDCJ facilities create high HIV rates by releasing prisoners (known to have high HIV rates) into the community or do TDCJ facilities locate in areas with high HIV rates?” the researchers ask. “There might not be an answer to this question.” - See more at: http://www.itemonline.com/local/x1186916587/HIV-rates-higher-around-TDCJ-prisons#sthash.yi42Q8oJ.dpuf

On reentry, healthcare, privatization, sheep and goats

While I was on vacation last week, the state of Texas' prison healthcare was a big topic of discussion. A well-done story at the Fort Worth Star-Telegram yesterday focused on continuity of care for HIV positive inmates when they leave Texas prisons. Reporter Alex Branch wrote that:

studies show that HIV-positive prison inmates still regularly experience dangerous lapses in treatment after discharge.

[According to a study from several years ago,] 20 percent of inmates enrolled in an HIV clinic within 30 days of their release, and only 28 percent did so within 90 days.

It's a problem with consequences beyond the personal health of the offenders. Interruptions in medication increase the risk of transmission, can lead to medication-resistant strains of HIV and often require more costly treatment later.

Health officials have launched initiatives to end the lapses, including using telemedicine to connect HIV-positive prisoners with local AIDS organizations that can assist them when they return to their communities.

Why do inmates fail to keep up with their meds on the outside? Though the writer at one point says the problem is a lack of "personal responsibility," which I'm sure plays a role, the larger public policy reasons are fairly predictable:

Former prisoners report several obstacles to getting medication, AIDS outreach workers say. Many are unsure where they will live after discharge, lacking homes and families to which they can return.

Some don't even complete the bus trip home, using the $50 they are given at discharge to fall into previous bad behaviors, they say.

Those who have been incarcerated for a long time have little experience making doctor's appointments, filling prescriptions and understanding bureaucracies, said Shannon Hilgart, associate executive director at the AIDS Outreach Center.

"Navigating a hospital system is daunting if you have been incarcerated since 19 and never had to deal with it," she said. "Getting to a clinic, getting through the paperwork. ... It's a whole new learning process."

It's a "learning process," though, that until recently didn't begin until release, and then the inmate was on their own. Recent changes thanks to a renewed focus on reentry services for prisoners begun in 2009 have somewhat mitigated the problem, reported Branch:

State officials held a summit to discuss the issue and agreed on several strategies to link services offenders received in prison with those provided by organizations in communities, said Janina Daves, re-entry coordinator for the Texas HIV Medication Program, which spends $90 million annually supplying HIV medication to low-income Texans.

Prison officials are using medical discharge planners to help inmates complete applications for treatment programs before they're released, she said. Inmates are told how to contact the AIDS service organizations and given phone numbers to call if they run into difficulties.

As a result, "Since the state made changes, the agency has had more success in getting ex-offenders to continue medical regimens, officials said. Case managers, mental health counselors and nutritionists help clients set up medical appointments and live healthy lifestyles." Hopefully cuts to reentry services this legislative session won't roll back this successful and important effort. If they do, it will merely shift costs to local emergency rooms who will then have to deal with much sicker, more expensive patients down the line.

In other prison health news, Mike Ward at the Austin Statesman reports that legislators this week beat back a proposal to give the Governor control over decisions whether to privatize the prison healthcare system, after "critics of privatization feared that it would have allowed Perry to push ahead with outsourcing of the nearly $1 billion-a-year system, which has been plagued for years by mushrooming costs."

Ironically, though, private prison health providers have said they couldn't operate the system if the TDCJ health budget was slashed, which of course it was by 14%. So by most accounts, privatizing prison healthcare would cost more than the state has budgeted for the next biennium. Not only do most private vendors not have UTMB's telemedicine system, enabling access to health providers outside the unit, but they must build profit into their costs while the universities providing healthcare can do so covering only the cost of services.

Texas already has among the lowest per-inmate healthcare costs in the country. And carceral institutions elsewhere that have privatized health services have sometimes generated pitiful results. Plus, privatization of Medicaid and Medicare services has resulted in widespread fraud. At a minimum privatization would require a great deal more state oversight and supervision than  the Correctional Managed  Healthcare Committee affords now.

Finally, both last and least, attorney Edward Lane at the "Wichita Falls Law Enforcement Examiner" this week complained that, even if the Lege passes a $100 per year healthcare fee to be taken from prisoners' commissary accounts, it's still an outrage for prisoners to receive medical care at all, writing:

Many Texas residents who are law abiding citizens would be very happy to pay $100.00 a year for healthcare for their children and themselves. These same people are probably asking themselves why convicted criminals are getting such a good deal and they aren't.

As it stands now, the Texas Constitution  only guarantees one group of people in the Lone Star State healthcare......prisoners.

One Wichita Falls man was appalled to discover that prisoners receive free health and dental care.

"Why do convicted murderers and other felons get better healthcare than those of us on the outside of prison walls?  A person has to make less than $434 a month in the state of Georgia where I just moved from to receive free healthcare. There's something wrong with this picture!"

Another  Wichita Falls man exclaimed in anger,  "The worst of it is we (the taxpayers) have to pay their (convicts) medical bills after they've committed some crime."

These are common, if utterly uninformed sentiments. For starters, TDCJ doesn't provide healthcare for prisoners' children. And contrary to Lane's claim, there's nothing in the Texas Constitution about prisoner healthcare, which is requirement derived from the 8th Amendment by federal courts. That's not just for inmates' benefit, but for everyone's. Prisons are breeding grounds for disease and most inmates eventually get out (more than 70,000 per year are released from Texas prisons), meaning untreated illnesses will inevitably be spread into the free world.

The $100 fee is not a particularly major change: Mostly it shifts costs from sicker inmates to healthier ones: It a) replaces a $3 per visit copay already in place and b) doesn't apply if the inmate has no money in their commissary account, which their families pay for, not them. The sickest inmates' families might pay more than $100 per year at $3 a pop, under the old system, while a younger, healthier inmate would not normally reach that threshold. But given what healthcare actually costs, these are small amounts.

If many people in Wichita Falls are "appalled" or "angry" that the state pays for inmate healthcare, the writer should have also added that those same people are "ignorant" and "foolish." Grits has mentioned before on this question that Christ taught compassion for sick prisoners is one of the criteria by which, eventually, the sheep will be separated from the goats; I'd always considered Wichita Falls a church-going town, but those quoted in this story all appear to fall in the latter category. Are Wichita Falls residents also "appalled" that inmates don't get paid for their labor? That's the only way it'd be possible for them to pay for their own healthcare.

In any event, as California is learning, the US Supreme Court has long said that if the state chooses to incarcerate someone - to restrict their liberty, in other words - they're liable for their health needs. Want to pay less for inmate healthcare? Lock up fewer people or stop holding them as long.

What a stupid column, particularly coming from an attorney. I suggest Mr. Lane contact Baylor University and demand his law school tuition back.

Medication lapse for Harris jail inmates especially long for patients with HIV

Randall Patterson has a compelling story at the Houston Press ("Jail misery," Nov. 19) that demonstrates in human form what the US Justice Department said were unconstitutional flaws in the Harris County jail's healthcare system. He highlights the case of Monte Killian, who became extremely ill after the jail failed to get him AIDS medication in a timely fashion.

In telling Killian's story, though, Randall buried his lede. Deep in the article we find this juicy paragraph:

It turns out that everyone who enters the jail on prescription meds experiences a break in their regimen, and that lapses in HIV treatment tend to be especially long. Dr. Michael Seale, the jail's director of health services, acknowledged the importance of minimizing such delays but said, "You can't go ahead without appropriate information." Thus, the clinic's thorough routine: Instead of confirming an inmate's claim of HIV by simply calling the inmate's doctor, the jail finds it necessary to test the inmate all over again before prescribing medication.

That's the critical piece - the element that makes this a public policy story that potentially affects everybody instead of just something that happened to Monte Killian. In September, the Texas Commission on Jail Standards cited failure to dispense prescription meds as one of the reasons the jail failed inspection, Patterson reports.

There are many situations where for public health reasons you wouldn't want to interrupt somebody's ongoing medication. AIDS patients are certainly one: Jails are unhealthy places and somebody without a natural immune system is in big trouble. And for obvious reasons, you don't want to keep mental health patients off their drugs for too long. For that matter, failure to keep somebody on antibiotics could cause jails to become incubators for antibiotic-resistant infections, which then migrate back to the free world.

That's an important glitch, plus it's a waste of resources to re-test inmates before prescribing medications. It would be quicker, easier and less expensive for everybody to rely on the private docs' diagnosis and prescription regimen until jail docs find reason to dispute it. That would also avoid medication delays that are getting the jail in trouble with the Justice Department and state jail regulators.

What strategies work to keep HIV+ ex-prisoners on their meds?

From the abstract to an article in the Journal of the American Medical Association, we get a bit more information about the shockingly high rates of HIV positive inmates who stop receiving anti-retroviral drugs when they leave prison. Researchers fear such inmates could become the source of drug-resistant HIV strains, which would be a grave outcome indeed.

Reuters reported that just 5.4% of former HIV+ inmates filled their prescriptions after ten days. Only 17.7% had done so within 30 days, and 30.0% after 60 days - still a strikingly low figure with 70% still off their antiretroviral medication two months after they leave prison.

There's a practical, public safety aspect to this that can't be ignored: The creation of drug-resistant HIV would be a very, very bad thing.

On the bright side, the study identified two variables that improve the chances HIV+ ex-prisoners get back on their meds after leaving confinement.

First, according to the abstract "Inmates released on parole were more likely to fill a prescription within 30 days ... and 60 days" by significant margins.

Even higher compliance rates, though, came because: "Inmates who received assistance completing a Texas AIDS Drug Assistance Program application were more likely to fill a prescription within 10 days," 30 days and 60 days. (See "Results" at the bottom of this page for the statistical details.)

In other words, HIV+ inmates on parole were slightly more likely to get their medication, presumably because they're under supervision, but they were much more likely to do so, especially in the short-term, if they're told where they can get help paying for the (quite expensive) drugs.

That makes a lot of sense, and it points to possible legislative solutions.

Perhaps there's some way to leverage stimulus funds designated for law enforcement or health services to go into the (already strapped) AIDS Drug Assistance Program, designating additional money to pay for indigent ex-prisoners to get that compliance rate somewhere closer to 100%? We're talking about a relatively small number of folks - an average of 700 or so people per year; that's a small price to pay for TDCJ to avoid becoming the source of some terrible, new medical scourge.

Once TDCJ has started an HIV+ prisoner on antiretroviral medications, making sure they're signed up to get their meds on the outside seems like as important a public safety function as locking prisoners up in the first place. The same could be said for mentally ill prisoners, for whom I'd like to see a similar study performed. More attention should be paid to that transition.

This is one of those moments when "an ounce of prevention is worth a pound of cure." I could make that argument for quite a few other reentry services, but in this instance it's particularly true.

Drug interruptions upon leaving prison could create drug-resistant HIV strains

HIV/AIDS is the number one killer of Texas prison inmates, and TDCJ spends about half its pharmacy budget on HIV medications, but many ex-prisoners don't keep taking the drugs once they get out, according to a new study from UTMB. Reported Reuters:

Results of a new study show that major interruptions in HIV drug treatment occur after release from prison.

Within 60 days of release from prison, just 30 percent of HIV-infected inmates in the Texas Department of Criminal Justice system filled a prescription for antiretroviral drug therapy, researchers report in Wednesday's issue of the Journal of the American Medical Association.

Moreover, 90 percent or more of inmates did not fill a prescription soon enough to avoid an interruption in their antiretroviral therapy, according to the report.

"These remarkably high rates of lengthy HIV treatment interruptions are troublesome from a public health perspective," study investigator Dr. Jacques Baillargeon, from the University of Texas Medical Branch, Galveston, noted in a written statement.

"Several studies suggest that many released inmates who discontinue antiretroviral therapy also resume high-risk behaviors such as injection drug use or unsafe sex," Baillargeon added, "and this combination may result not only in poor clinical outcomes for these individuals but also in the creation of drug-resistant HIV reservoirs in the general community."

The study involved 2115 HIV-infected inmates who were receiving antiretroviral therapy prior to their release from prison between January 2004 and December 2007.

Just 5.4 percent of inmates filled an antiretroviral prescription within 10 days of release, the researchers found.

HIV drugs are expensive so for prisoners with no access to health insurance it's not surprising if most stop taking them. But that also sets the stage for a significant public health crisis.

It's easy to say we shouldn't care about prisoners healthcare, but surely everybody should care about the possible "creation of drug-resistant HIV reservoirs in the general community."

I don't know if the solution is to provide meds to parolees with HIV or how this situation might be addressed, but it'd be a catastrophe of enormous proportions if Texas prisons became the breeding ground for some scary, new drug-resistant HIV strain.

Dallas court identifies "deadly weapon" that can't kill you

According to the Center for Disease Control, reported The New York Times ("Prison for man with HIV who spit on police officer," May 16), "Although there have been rare cases of transmission through severe bites, 'contact with saliva, tears or sweat has never been shown to result in transmission of H.I.V..'”

Even so, a homeless man was sentenced to 35 years in prison in Dallas for "harassing a public servant with a deadly weapon: his saliva." What's more, "Because of the deadly weapon finding, the man, Willie Campbell, 42, of Dallas, will not be eligible for parole until he has served half his sentence."

So to flesh out the logic, you can't contract HIV from spit, but spit is a deadly weapon because it might transmit HIV? Huh? I'm amazed Dallas DA Craig Watkins' office pursued that line of argument, and more amazed still that a judge bought into it.

According to Chapter 22.05 of the penal code, an offender engages in "deadly conduct" if "he recklessly engages in conduct that places another in imminent danger of serious bodily injury." So if the Center for Disease Control says saliva "has never been shown to result in transmission of H.I.V.,” where, exactly, is the "imminent threat of serious bodily injury"?

Mr. Campbell sounds like a seriously disturbed person, a homeless alcoholic and possibly mentally ill to boot, to judge by his screaming outbursts in the courtroom." Even so, although spitting at an officer was both obnoxious and assaultive, on its face the act doesn't seem to meet the definition of "deadly conduct."

In any event, unless some appellate court decides differently, add "spit" to the list of bizarre items deemed deadly weapons under Texas' statute.

MORE: From Simple Justice.

AIDS drugs, healthcare for elderly inmates driving TDCJ medical costs

Here's a mind blowing statistic about health care costs in Texas prisons that came out at yesterday's Senate Criminal Justice Committee hearing: A whopping 48% of TDCJ's total pharmacy budget goes to pay for drugs for inmates with HIV.

Chairman Whitmire asked the Correctional Managed Health Care Committee executive director Alan Hightower to compile for him a list of the top ten most expensive inmates in terms of medical costs and their parole status. The assumption is that the state is eating high medical costs for inmates who could be released and treated safely in the free world. According to Sen. Whitmire, TDCJ recommends about 70 or more inmates per month for medical-based parole, but the parole board on average releases just 10% of them.

A past analysis showed the most expensive inmates cost the state more than $1 million per year in healthcare costs, so it'll be interesting to learn whether it's still true that TDCJ's most expensive inmates are mostly eligible for parole.

The Committee expressed concern that inmates who could be released into a hospice or nursing home facility (where the feds through Medicaid would pay 2/3 of the cost), are being held in TDCJ even though they're bedridden and immobile. Dee Wilson of the Office on Offenders with Medical or Mental Impairments told senators that "many" offenders recommended for medical release pass away before the parole board gets around to their case. Around 40 inmates per month die in Texas prisons.

Magic Johnson Goes to Texas Prison for "Wall Talk"

Here's one sports star I never expected to see in prison, even with all the professional athletes out there in trouble with the law: Basketball legend Earvin "Magic" Johnson. Fortunately, he was just visiting the Darrington Unit to participate in TDCJ's "peer education program, 'Wall Talk,'" filming a video that will be shown to "at risk" offenders. The prisoners Johnson met with are "trained to 'spread the word,' ... [to] help educate fellow offenders about preventive health care as it relates to HIV/AIDS, tuberculosis, hepatitis A, B and C, as well as diabetes and staph infections." Good for him! Also, good for TDCJ for using peer education to supplement top-down approaches to its longstanding healthcare failings; they have to try something! Johnson and TDCJ "filmed a discussion he had with a group of offenders. The resultant DVD will be used to disseminate his message further into at-risk communities"

As Bexar prepares to pilot needle exchange, Vancouver CA models the future of harm reduction

One of the more interesting presentations I saw last week in New Orleans at the Drug Policy Alliance conference centered on implementing ground-level harm reduction strategies, a topic that interests me especially as Bexar County prepares to launch Texas' first legal needle exchange operation in San Antonio. (Last I heard, Bexar officials hoped their county's needle exchange pilot program will begin early next year.)

Vancouver launched its needle exchange programs, said the city's Drug Policy Coordinator Donald MacPherson, because of a spike in overdose deaths in the late 1990s topping 200 per year at its height. Like similar programs elsewhere, Vancouver saw a decline in both overdoses and HIV transmissions among injection drug users after implementing needle exchange, and more addicts referred to treatment.

Observing these successes, MacPherson said, the city took the idea one step further, creating a "supervised injection site" where addicts can use illegal drugs in a clean environment under nurses' supervision. The facility teaches addicts how to protect themselves from disease transmission and encourages them to enter drug treatment. According to this brochure from the Vancouver program, called "insite," more than 7,000 people have used the facility to inject drugs since its inception.

people using insite are more likely to enter withdrawal management (detox) programs, and people using insite who also talk with addiction counselors are even more likely to enter detox. In fact, one in five regular visitors to insite began a detox program, showing that insite is a proven entry-point for the Downtown Eastside’s highest risk injection drug users. Detox programs are an important marker of addiction treatment system use, as most addiction treatment programs first require people to complete a detox program.

This notion may seem radical from where Texas sits now, but from all appearances the idea (which was imported from Switzerland) works surprisingly well at reducing both drug use and the harms associated with it. "It hasn’t been difficult to convince injection drug users that insite offers a safe, clean place to inject drugs," reports the insite brochure. Overall program results were analyzed in a study published in the Canadian Medical Association Journal, reported CBC News, finding that

the three-year-old Supervised Injection Site in the Downtown Eastside has been a great success.

The injection site, which drew about 5,000 users in its first year of operation, is a place where people can safely go to inject illegal drugs while being supervised by nurses.

"By all criteria, the Vancouver facility has both saved lives and contributed toward the decreased use of illicit drugs and the reduced spread of HIV infection and other blood-borne infections," Mark Wainberg, the director of the McGill University AIDS Centre in Montreal, wrote in a commentary published alongside the study.

The study — conducted by Dr. Evan Wood, a professor of epidemiology at the University of British Columbia, and his colleagues — found that drug users who visited the site at least once a week were more willing to enter detoxification programs.

These data make me optimistic about San Antonio's legislatively approved pilot program to exchange clean needles, which I see as an important first step toward implementing policies to reduce drug demand and the harms associated with addiction. Prison, by contrast, does neither of those things.

Vancouver's experience shows that not only do harm reduction principles work but they can be expanded beyond just needle swapping, and indeed may be the best available method for convincing serious addicts to seek treatment.

Vancouver's model demonstrates that its possible to scale up harm reduction strategies to demonstrably reduce deaths and addiction in a major city. Indeed, the idea of a safe injection site strikes me as the epitome of the harm reduction model - a much more civilized, humane, and rights respecting mentality than Texas' current "trail 'em, nail 'em, and jail 'em" approach. Every major Texas city has thousands of addicts who inject illegal drugs, and if all society offers them is prison, they're more likely to remain in the shadows.

In closing, I found these data interesting about the Vancouver supervised injection site, and was especially encouraged to see that 453 overdoses at the site occurred during a two year stretch with no fatalities. By contrast, that many overdoses out on the street or in some run-down shooting gallery would be much more likely to result in morbid outcomes. Here are some other statistics worthy of note for those interested the Vancouver supervised injection site:

Other research results show*:

• 7,278 unique individuals registered at Insite
• Women made up 26 per cent of clients
• Aboriginal people made up 18 per cent of clients
• Heroin was used in 41 per cent of injections
• Cocaine was used in 27 per cent of injections
• Morphine was used in 12 per cent of injections
• 453 overdoses resulted in no fatalities
• 4,084 referrals were made with 40 per cent of them made to addiction counselling
• Referral to withdrawal management: 368
• Referral to methadone maintenance: 2 per week
• Daily average visits: 607
• Average number of visits per month, per person: 11
• Busiest day: May 25, 2005 (933 visits in 18 hours)
• Number of nursing care interventions: 6,227
• Number of nursing interventions for abscess care: 2,055

*All totals or averages are for the two-year period from April 1, 2004 to March 31, 2006.

All of Texas pays for Bexar DA Susan Reed's stubborn needle exchange stance

Here's a good reason why Bexar County DA Susan Reed should relent and allow a needle exchange program to operate in San Antonio: It doesn't cost her a dime but could save the state and the county jail a boatload of money in future healthcare costs.

Let's not lose sight of why needle exchange programs matter to the average non-drug using Texan: If we fail to prevent HIV and Hep C among IV drug users on the front end, taxpayers usually wind up paying many times that amount down the line - every prevented case avoids hundreds of thousands of dollars in medical care.

Inmates in the Texas Department of Criminal Justice have an HIV infection rate five times higher than the general public; medications for the 1.7% of HIV-infected inmates account for more than 40% of the pharmaceutical budget under Texas' correctional managed health care contract.

Who pays for that? Those are your tax dollars, folks, paying for some of the most expensive medical treatments around. According to a 2005 USDOJ Office of Justice Policy Bulletin:

HIV-infected inmates [in FY 2003] were concentrated in a small number of States. New York (5,000), Florida (3,112), and Texas (2,460) held the largest number of HIV-positive inmates. These three States housed nearly half (48.0%) of all HIV-infected inmates in State prisons in 2003.

Indeed, not only do Texas prisons and jails house a disproportionate share of inmates with HIV, they're also acquiring full blown AIDS more frequently than in other states, perhaps because of longer prison terms, health care inadequacies or who knows what other reason:

Seventeen States and the Federal system reported an increase in the number of confirmed AIDS cases, led by Texas (up 219) and Florida (191).

So our folks with HIV tend to be getting sicker, perhaps because they're staying longer, meaning our costs are that much higher.

That's why this San Antonio needle exchange pilot is important for the whole state, not just Bexar County. And it's why the hubris of one District Attorney with apparently too much time on her hands shouldn't stop the project from going forward.

See prior related Grits coverage:

• Bexar officials should blow off DA's needle exchange gripes
• Prosecutors disagree whether Bexar DA justified in blocking needle exchange
• Bexar county judge elated to pioneer first Texas needle exchange
• Wow! Texas House approves needle exchange for Bexar County
• Needle exchange bill pits small government conservatives vs. authoritarian wing

Prosecutors disagree whether Bexar DA justified in blocking needle exchange

An interesting debate has broken out at the Texas prosecutors user forum between Williamson County DA John Bradley and another Texas prosecutor over the question of the propriety of Bexar County DA Susan Reed's blustering announcement that participants in a needle exchange program approved by the Legislature would be subject to arrest. (This morning I suggested a way local officials might be able to work around her opposition.)

Not everybody at the DA's shop was against letting the needle exchange operate. Prosecutor Greg Gilleland declared:

What's the beef? The clear legislative intent was for this program to proceed as a trial program. It is a great idea, and the monies we as a society pay for uninsured medical care for HIV and Hep indigent patients greatly outweighs the cost of the needles.

Doesn't this exchange pretty much clarify the matter for a speedy AG opinion? ...

It's not like the IV abusers will not abuse IV drugs because they are not getting clean needles. They'll just keep using dirty ones. The multi-million dollar question is will the addicts avail themselves of the program, as many other states claim they do?

I don't know if this is a viable solution to the HIV and Hep epidemics that rage amongst the IV using population, but it sure makes sense to try it and see if it helps. It seems common sense that if we can prevent some of these folks from burdening our already bustin'-at-the-seams public healthcare system, more money could then be spend on indigent health care for those who did not catch their disease through IV drug abuse.

Not to mention saving hundreds or thousands from the horrible disease process involved in these diseases.

Ah, I thought, to myself, a prosecutorial breath of fresh air - actual respect for the law and legislative intent. But Bradley fired back that the Lege and the Governor approving a needle exchange program wasn't enough, that law enforcement had no discretion but to prosecute program participants:

I would guess that the elected DA of Bexar County doesn't feel that it is her job to declare immunity from prosecution in the absence of actual law saying so. While the statements of legislators are nice, they are not supported in any manner by an actual, written defense. Legislative intent, alone, is not law. Legislative intent, when combined with an ambiguous statute, might help. Here, there is no defense or immunity, ambiguous or otherwise.

I was pleased to see Gilleland made the same connection I would have in response:

"I kind of like it when prosecutors stick to the applying the law rather than making it up to suit situations."

Isn't that what critics accused many prosecutors of doing with the ucw (unlawfully carrying a weapon) law from the previous session?

Yessirree Bob, you've hit the nail on the head, sir. This is exactly the same issue: Will prosecutors do what the Legislature tells them to or do they think they're above the law?

The Legislature does its thing in 140 days, everybody knows they can only get so much done, and reasonable people then figure out how to make it work in the intervening 19 months. Welcome to Texas government! But some prosecutors just wanted to throw up barriers. An Assistant County Attorney from Boerne replied that she understood the positives of needle exchange programs, but:

My point is, why is it legal for the government to hand out syringes FOR THE PURPOSE OF ILLEGAL DRUG USE but not legal for a citizen to possess it for that same purpose? Especially when just possessing it is a Class C but delivering it with intent for injection is a Class A?

Why? It's simple. Because the Legislature CHANGED THE LAW! What else do you need? Possession of dirty needles is illegal except for participants in the needle exchange program. Other states have figured out how to make allowances, it can't be that hard to draw the line. DA John Bradley wants to push the envelope in the opposite direction the Lege intended, asking:

Can we prosecute for possession of the trace amount of illegal drugs in the needles? Or, is the defendant also getting immunity for that felony, too?

Again the obvious answer is, no, not for needles brought to the legislatively sanctioned needle exchange site. How difficult is it to be flexible and work with public health offiicials to make the program work? Instead these characters seem to go out of their way to find creative interpretations to sabotage the program.

Since the last time I quoted the DA's user forum they took the post down, I've cut and pasted the text and uploaded it to a Google document here.

Bexar County Judge Elated at Opportunity to Pioneer Texas Needle Exchange

Finally, with the passage of SB 10 with an amendment by San Antonio state Rep. Ruth Jones McLendon, Texas will no longer be the only state in the nation without a single, legal needle exchange. We'll now have one.

After SB 308 by Deuell allowing local governments to decide the question passed the Texas Senate, that bill died in committee but was resurrected as a single-county pilot project in Bexar County (San Antonio). I just received this press release from Rep. McLendon which quotes Bexar County Judge Nelson Wolff enthusiastically embracing the idea:

(San Antonio) -- State Representative Ruth Jones McClendon (House District 120, D-San Antonio) announced today that a legislative proposal has passed which would allow a pilot program so that public health care providers in Bexar county can evaluate the effects of a safe needle-exchange program as one means of combating the spread of hepatitis, HIV, and other infectious diseases. Her proposal was presented as an amendment to Senate Bill 10, a lengthy bill authored by Senator Jane Nelson (State Senate District 12, R-Lewisville), which addressees various aspects of examining state and local Medicaid and uncompensated health care costs in Texas. After signature by the Governor, it will take effect on September 1.

This Session, Senator (and physician) Robert Deuell (Senate District 2, Greenville) and Representative McClendon and filed companion bills (S.B.308 and H.B.856) to help prevent the spread of infectious diseases such as hepatitis and HIV, and reduce the drain on local health authorities for the enormous costs of treatment. Nelson Wolff, Judge of the Bexar County Commissioners Court, said enthusiastically, "Last year Bexar County spent more than $4 million on HIV/AIDS services. A needle exchange program will not only save lives but also taxpayers' dollars. We appreciate Rep. McClendon's courageous leadership, which could mean the difference between life and death for hundreds of Bexar County citizens." Studies show that the life expectancy of a person with HIV has risen to 24.2 years, and lifetime treatment costs are at least $385,000.

Representative McClendon said, "The public health and safety of Texas requires that we offer public health programs that prevent the spread of infectious diseases. Fiscal responsibility also requires that preventive programs be made available, and this is just one way that we can begin curbing the spread of hepatitis and HIV in geometric proportions." This development would permit Bexar County health authorities and their contracting agencies to establish and administer a safe-distribution and exchange programs for syringes and needles. Such programs have proved highly successful across the nation, including Hawaii, New York, Connecticut, and have helped cut the spread of HIV infections dramatically.

Texas has long awaited authorization for this type of disease-prevention program: Texas Monthly reported in its April, 2007 issue that Texas was the only state that did not allow this type of measure to help prevent the spread of infectious diseases. Opponents object to needle exchange programs (sometimes called NEP's or SEP's), on the basis that they allow users of intravenous drugs to continue an addictive habit; however, those who favor the programs emphasize that when a person can exchange dirty needles for clean ones, this helps keep uninfected persons stay that way. Also, NEP's offer the program sponsors with recurring opportunities to make rehabilitation and recovery available to the needle user; this has also has proved highly successful. As Representative McClendon emphasized, "This is not about increasing the number of intravenous drug users or helping them perpetuate an unfortunate addiction; it is about helping people stay free from infection. The Texas Medical Association, the Texas Hospital Association, the Texas Pharmacy Association, and many local officials and health care providers who treat infectious diseases supported this legislative concept."

This legislation has failed in Texas every year since the early '90s, so this was an enormous "get"- especially since McLendon convinced Rep. Dianne Delisi (R-Temple), who'd stalled the bill in the Public Health commitee, to agree to the pilot program. If needle exchange can show success in preventing disease and reducing costs in San Antonio, there's a good chance Texas will expand legal needle exchange programs to other cities in the future.

Among legislators, Rep. McLendon, Rep. Coleman, Rep. Delisi, Sen. Deuell, Sen. Nelson, Sen. Janek, Sen. West, and many others stepped up to make this happen. Others whose involvement was critical were Deuell's staffer Scot Kibbe, McLendon's staffer Janis Reinken, activist Tracey Hays (Austin Harm Reduction Coalition and ACLUTX), and Bill Martin, Texas Monthly's religion writer who wrote an editorial in that publication this spring supporting needle exchange. I should also mention that Glen Maxey carried this legislation doggedly for years, pushing it when nobody thought it had a prayer. It wouldn't this year without his pioneering work in years past.

I was proud of the Senate and the House when they both approved needle exchange for the first time ever on record votes (23-8 in the Senate, and 71-60 in the House). The quite-conservative Dr. Deuell has done such a good job re-framing the issue and defusing opposition, I wouldn't expect this to turn into an election issue for needle exchange supporters, or if it happens I think such ill-informed arguments can be easily beaten back. If that's accurate, and Bexar's outcomes follow patterns in the other 49 states at preventing disease and getting addicts into treatment, one assumes that would make it easier for advocates to come back to the 81st Texas Legislature in 18 months to take another bite at the apple.

See prior Grits coverage:

• Wow! Texas House approves needle exchange for Bexar County
  
• Needle exchange pits small government Republicans vs. authoritarian wing
• Lone Star Times: Delisi needle exchange stance shows why GOP may lose majority
• Delisi: Research, Smesearch, I don't wanna
• Texas Senate prescribes voluntary needle exchange programs
• Dr. Deuell prescribes needle exchange legislation
• Texas Monthly messengers pro-needle exchange article to senators
• GOP doctor files needle exchange bill in the Senate

Delisi: Research, Smesearch, I Don't Wanna

Though there's still technically time for it to pass, the Houston Chronicle is already writing obituaries for pending needle exchange legislation at the Texas Lege. What a disappointment!

Even though the bill was supported by a 7-1 margin in the Senate committee (including conservative Chair Jane Nelson), even though 60% of GOP senators voted for it, the House chair whose committee heard Texas' pending needle exchange legislation this week refuses to let her committee vote on it, she told the Houston Chronicle ("No hope for needle exchange legislation," May 17).

SB 308 would empower local governments to decide whether to allow nonprofit needle exchange operations, and for the first time ever the legislation passed the Senate. House Public Health Chair Dianne Delisi gave the bill a public hearing the other day, but now tells the press she won't allow it to receive a final committee vote, presumably because she fears a majority of committee members support it.

Nobody testified against this bill in either chamber's committee hearing, yet somehow Delisi's fears persist that there's something wrong with needle exchange that none of the extensive research supporting the concept has revealed to experts and researchers everywhere else in the nation and for that matter across the globe:

"I have not been persuaded that the public health benefits outweigh the concerns of many members, myself included, of providing needles for those that are using illegal drugs," she said.

Texas is the only state in the country that does not allow a needle-exchange program for drug users.

Delisi is from Temple, where I suppose the problem of IV drug use isn't as immediate as it is in urban districts. But in neighborhoods where injection drug use is common, everywhere it's been implemented needle exchange saves lives and tax dollars. Delisi could still at least give her colleagues a chance to decide the matter, given that a super-duper-majority of the Senate, as Dan Patrick would put it, approved of the idea.

A week ago I said the needle exchange bill pitted small government Republicans against the party's more authoritarian wing - score one, I guess, for the authoritarian side.

One of the fascinating debates of the 80th session has been the Governor's back and forth with the Legislature over a vaccine for young girls to prevent a sexually transmitted disease that causes cervical cancer. The Governor's recent statement about HPV vaccine was so apropos to the needle exchange debate, I substituted needles for the vaccine in this quote to show that the argument for both policies is identical. Said Governor Perry:

it is the tone of this debate that has disturbed me most. The notion of forgiveness and grace has been totally lost in this debate. People make wrong choices. Our society is full of such individuals who have found redemption from past mistakes.

But if we had a vaccine for lung cancer, would we stop its widespread use because it might send a message that it is okay to engage in an unhealthy behavior like smoking?

The sad irony is, if you or I had a family member suffering from [HIV acquired from a dirty needle], there is no treatment we would rob them of if it could take away the pain and bring them back to health. And yet, we won't provide them [clean needles] that can prevent all that pain and suffering - that death sentence - to begin with because of the message it might send? What about a message of grace, compassion and forgiveness for anyone who has made wrong choices? Have we lost sight of that? (Bracketed items substituted)

Have we, indeed? Sen. Robert Deuell, who deserves tremendous credit for sponsoring and working hard on the bill (he changed his position on the subject four years ago, he has said, after he reviewed the medical evidence), made similar points to Governor Perry regarding compassion for the ill vs. moralizing against the sinner. As reported here, Deuell told the Senate Health and Human Services Committee:

"Ronald Reagan said that 'facts are stubborn things,'" Deuell reminded his fellow commitee members, and the facts, he said, are that every medical study ever performed found that these programs reduce transmission of HIV and Hep C. What's more, he said, no medical study has ever shown that needle exchange programs promote drug use. In fact 20% of participants seek drug treamtent through such programs.

Deuell told the committee he supports the bill "both as a physician and a Christian." SB 308 doesn't support drug use, he said, but sends a message that "every human life has value." "My faith does not allow me to give up on anyone," he declared.

Some people's faith, I guess, is stronger than others. It's a shame one person could unilaterally derail the will of the Senate, her own committee, and in my estimation probably the rest of the House.

Damn. Damn. Damn. I H-A-T-E May of odd numbered years.

The worst part is, Delisi is simply wrong, and Dr. Deuell is unquestionably right. If her "concerns" can't be addressed by existing research they are likely not based on rational argument but a fear of being perceived as caring about drug users. However, on the off chance that Rep. Delisi or anybody else might care what the research really says, here are a few key links on the topic compiled over at Sifting the Haystack:

• 8 Major Government-Funded Reports

• Opportunity Lost

• Return on Investment in Needle and Syringe Programs in Australia

• World Health Organization: Provision of Sterile Injecting Equipment to Reduce HIV Transmission

• ABA Report: Deregulation of Hypodermic Needles and Syringes as a Public Health Measure: A Report on Emerging Law and Policy in the United States

UPDATE: The conservative Lone Star Times blog call Delisi's decision to block the bill "Repub grandstanding at its finest."

Needle exchange bill pits small government Republicans vs. authoritarian wing

Paul Burka noticed that that Governor Rick Perry took an odd swipe this week at needle exchange legislation authored by Republican state Sen. Bob Deuell, which recently passed out of the Texas Senate. SB 308 is scheduled for a hearing in the House Public Health Committee on Monday.

Contrary to many naysayers' predictions, Committee Chair Diane Delisi's decision to grant the bill a hearing means the bill is still very much alive. IMO it has a good chance to make it all the way to the Governor's desk, which would mean that Perry's opinions become much more important on the matter.

Unfortunately an issue that should be focused on health concerns has been dragged into an unrelated, highly controversial debate. In a speech regarding legislation to override his executive order on the controversial HPV vaccine, Perry offered his first public pronouncement on the needle exchange bill in an odd and highly polticized fashion:

"It is also confounding that some members of the legislature who complained my executive order encourages sexual promiscuity later voted for a needle exchange program that provides free needles to drug addicts. If we are worried about the messages we send, it would seem that the mission of discouraging illegal drugs would be just as significant, if not moreso, than discouraging sexual activity among a population that is mostly not engaged in sexual activity yet (girls entering the sixth grade)."

I responded in the comments to Burka's piece that such critics overlooked important differences between the two pieces of legislation:

A key difference is that the needle exchange bill has a zero fiscal note - it only allows nonprofits to do it if local government lets them. Taxpayers wouldn't finance anything.

With the HPV vaccine, the executive order would have cost in the mid-nine figures to implement and the decision didn't go through the regular legislative or budgeting process. To me, that's what makes the Governor's argument a red herring - he ignores the obvious differences that makes his comparison inapplicable.

Later in the day Sen. Bob Deuell, who I find to be a contemplative, open minded conservative who I really like (even though he was the Senate sponsor of Jessica's Law), issued his own response to the Governor, which I reprint in its entirety here:

May 9, 2007

The Honorable Rick Perry
Governor of Texas
1100 Congress, Room 2S.1
Austin, Texas 78701

Dear Governor Perry:

During your statement on May 8 regarding HB 1098, you included the following sentence:

"I am also mystified by the argument that making this vaccine widely available encourages promiscuity, especially from legislators who voted for a needle exchange program that encourages drug addicts to continue to abuse illegal drugs."

I would respectfully suggest that you have been misinformed on needle exchange programs. I know of no research that indicates needle exchange programs encourage drug use. On the contrary, numerous studies, including reports from the U.S. Surgeon General and the National Institutes of Health, have concluded that needle exchange programs do not increase drug use and may actually decrease it. One study, published in the Journal of Substance Abuse Treatment, found new participants in an exchange program in Seattle were five times more likely to enter treatment than those who had never used the exchange.

My legislation permitting voluntary needle exchange programs, SB 308, did not have a single witness testify against it. If it really did increase drug use, there would have been numerous anti-drug groups attending the hearing and working against it. Instead, many of these groups are working for the passage of this bill. They see this as a way to establish contact with injection drug users so they can get them into rehabilitation.

I would also call to your attention the significant impact needle exchange programs can have on reducing HIV and Hepatitis C rates. About half of new HIV infections and 40% of Hepatitis C infections come, directly or indirectly, from injection drug use. A new case of HIV will cost about $385,000 over the patients' lifetime and Medicaid will pick up the tab for much of this. The cost to Medicaid for Hepatitis C in Texas is about $30 million per year. The National Institutes of Health estimates that needle exchange programs reduce HIV transmission rates by about 30%. As you can see, that can save a lot of lives and money in our state.

Given these facts, it is easy to understand why 49 states now allow voluntary needle exchange programs. I am pleased that the Texas Senate made the wise and compassionate decision last month to join the rest of the nation in allowing these programs.

I would be happy to discuss this issue with you at your convenience. I would also encourage you to talk about the concept of needle exchange with anyone who works in the area of disease prevention or drug abuse. I am confident you will find the facts support this idea and that it is time for Texas to permit it.

Sincerely,
Robert F. Deuell, M.D.
District Two

Sen. Deuell has studied this issue carefully and armed himself with all the necessary facts to quell opposition, at least if critics like Gov. Perry give him a chance to present them. The best evidence of the East Texas doctor's persuasiveness was Sen. Jane Nelson's decision to change her vote - she opposed identical legislation in 2003 and 2005 when Sen. Jon Lindsay carried it, but this year supported Deuell's bill.

I'm personally excited this legislation has moved so far, even receiving unlikely but welcome support from the conservative Lone Start Times blog. Governor Perry's apparent slap against the bill doesn't worry me that much. The rest of his comments actually framed arguments in terms that support needle exchange as a concept. He declared:

[I]t is the tone of this debate that has disturbed me most. The notion of forgiveness and grace has been totally lost in this debate. People make wrong choices. Our society is full of such individuals who have found redemption from past mistakes.

But if we had a vaccine for lung cancer, would we stop its widespread use because it might send a message that it is okay to engage in an unhealthy behavior like smoking?

The sad irony is, if you or I had a family member suffering from cervical cancer, there is no treatment we would rob them of if it could take away the pain and bring them back to health. And yet, we won't provide them the vaccine that can prevent all that pain and suffering - that death sentence - to begin with because of the message it might send? What about a message of grace, compassion and forgiveness for anyone who has made wrong choices? Have we lost sight of that?

Those are the identical reasons the Governor should support allowing voluntary, local needle exchanges. That's one reason why, if Dr. Deuell's SB 308 makes it to the Governor's desk, I still harbor hope that Rick Perry might still approve it based on these stated values of "grace, compassion and forgiveness for anyone who has made wrong choices."

Supporters of establishing legal Texas needle exchange programs have never been closer to achieving their goals, but the process is far from over. Here are the members of the House Public Health Committee. If any of these folks represent you, call and ask them to support SB 308 on Monday. And if you only have time to make one phone call on this, it's probably particularly important to ask Committee Chair Dianne Delisi to support the legislation, or at least allow it to receive a vote.

See prior, related Grits coverage:

• Texas Senate prescribes needle exchange
• Texas Monthly messengers pro-needle exchange article to Texas state senators
• Dr. Deuell prescribes needle exchange bill
• GOP doctor files needle exchange in the Senate
• League of Women Voters Backs Needle Exchange

Texas Senate prescribes voluntary needle exchange programs

What an odd turn of events - for years in the '90s when liberal Rep. Glen Maxey carried needle exchange legislation in a Democratic led House of Representatives, he never could pass the bill. It took a Republican Senate and bill sponsor to give the idea legs at the Texas Legislature. Who woulda thought?

Counterintuitive or not, the Texas Senate this morning accepted Dr. Robert Deuell's prescription to allow local governments to operate or approve voluntary needle exchange programs! That's the first time legislation supporting needle exchange has ever passed either chamber in the Texas Legislature. Bill supporters included Senate Health and Human Services Chair Jane Nelson who opposed the legislation in years past. In all, twelve Republicans joined 11 Democrats on a final vote of 23-8 to pass SB 308 out of the Senate.

In committee, Sen. Deuell gave one of the best performances of the session, I thought - his eloquent and passionate opening remarks set the tone for the debate and explain why he was able to convince so many of his fellow Republicans to join his cause. I was so pleased to see the Senate floor vote I went back and watched his opening again. (You can watch the April 12 committee hearing here. SB 308 was taken up 1 hour 39 minutes into the hearing.)

"Ronald Reagan said that 'facts are stubborn things,'" Deuell reminded his fellow commitee members, and the facts, he said, are that every medical study ever performed found that these programs reduce transmission of HIV and Hep C. What's more, he said, no medical study has ever shown that needle exchange programs promote drug use. In fact 20% of participants seek drug treamtent through such programs.

Deuell told the committee he supports the bill "both as a physician and a Christian." SB 308 doesn't support drug use, he said, but sends a message that "every human life has value." "My faith does not allow me to give up on anyone," he declared.

Thank you and congrats to Sen. Deuell and to all the bill's supporters. Kudos are also in order for Jon Lindsay who tirelessly carried the bill for several sessions before he retired - the bill's strong showing in the Senate in 2005 definitely laid the groundwork for today's vote. Finally, Chair Jane Nelson deserves thanks and credit for her leadership and, as Sen. Janek put it, a "courageous" vote - her and Deuell's gravitas in the Senate has a lot to do with why that bill passed, IMO.

Now the bill heads to the House, but before that, here's the list of senators who voted for SB 308 - if one of them represents you, be sure to call or write to them to say you appreciate their vote:

Averitt(R); Carona(R); Deuell(R); Duncan(R); Ellis, Rodney(D); Eltife(R); Gallegos(D); Harris(R); Hegar(R); Hinojosa(D); Janek(R); Lucio(D); Nelson(R); Nichols(R); Seliger(R); Shapleigh(D); Uresti(D); Van de Putte(D); Watson(D); Wentworth(R); West(D) Whitmire(D); Zaffirini(D)

UPDATE: See initial coverage in the SA Express News, the Dallas News, at Texas Politics blog, and at BurkaBlog

Dr. Deuell prescribes needle exchange bill for Texas

UPDATE: This bill passed out of committee on a 7-1 vote. Amazingly, not one person spoke against the legislation! Sen. Dan Patrick was the only no vote, though he did not explain his opposition. But both Chair Jane Nelson and Sen. Kyle Janek backed the bill after failing to support it in previous sessions. Janek, who is a physician, said the bill would protect not just drug addicts but also healthcare workers. Sen. Deuell's opening statement on the bill was excellent: "My faith does not allow me to give up on anyone," he declared. Congratulations to Sen. Deuell and all SB 308's supporters.

I'm excited to point out that Sen. Bob Deuell's SB 308 allowing local governments to decide whether to operate needle exchange operations will get a hearing this morning in the Senate Health and Human Services Committee. With a Republican physician as bill sponsor there's a chance support for this bill might finally galvanize in the Senate - a majority of senators supported the bill in 2005, but not quite the 2/3 needed for passage.

The Texas Medical Association supports the bill, and the idea has been endorsed by many major medical groups. Deuell's legislation was given a boost from Texas Monthly's Evan Smith having an article and letter on the subject messengered to senators last month. Even the conservative blog, The Lone Star Times, came out in favor of the bill this spring. The Drug Policy Alliance sent out an action alert to its Texas membership that included an excellent summation of why the bill makes sense from the perspective of economics and public health:

Texas has the fourth highest rate of HIV/AIDS infections, almost 400,000 people infected with hepatitis C, and about 100,000 injection drug users who turn to the streets and alleyways to find and share scarce syringes. 20-25% of Texas HIV cases can be traced to syringe sharing, and hepatitis C is present in the blood of 70-90% of injection drug users. Texas must enact effective and inexpensive measures to stem the spread of these diseases.

From 2001-2005, Texas spent $377 million Medicaid dollars treating HIV/AIDS, and $134 million treating hepatitis C. As both diseases continue to spread and the costs compound, Texas health care providers continue to struggle to meet the needs of ailing patients as budgets get cut, access to health care decreases and effective prevention measures are overlooked. SB 308 is an effective and proven way to significantly decrease the amount of tax payer dollars necessary to treat preventable infections. A 2006 study estimated that every HIV infection averted will save over $300,000 health care dollars. If syringe exchange programs prevented just 5% of the average 4,000 HIV cases identified in Texas each year, we would avert $60 million in long-term HIV treatment costs.

Syringe exchange programs not only decrease HIV/AIDS, but also cast a net to pull high risk populations into social services and support networks that can provide addiction treatment assistance, disease testing and prevention information, and trusted contact with health care providers.

This is the third session in a row the bill was carried in the Senate by a Repubican; the previous two terms Sen. Jon Lindsay, a former Harris County Judge, now retired, carried the ball. You can go here to watch the live broadcast at 4:30 p.m., or if you want to watch later the video will be posted here soon after the hearing is completed.

Texas Monthly messengers pro-needle exchange article to state senators

Sometimes, when your story won't break quite soon enough to affect current events, an editor of a monthly magazine must take matters into his own hands.

Upon hearing that the Senate Health and Human Services Committee might soon hear Sen. Bob Deuell's SB 308 allowing local governments the option to approve needle exchange programs, Texas Monthly editor Evan Smith dashed off a note alerting Lt. Gov. David Dewhurst and all Texas state senators and their staff to an article in the upcoming issue of TM by Bill Martin (here's a link to a free media preview of the story) exploring why Texas is the last state not to allow syringe exchange programs to operate legally.

I heard about the note and article and asked Evan for a copy, which he graciously provided. His note read:

"Dear _____________

I'm writing because I understand the Texas Senate will take up the issue of needle-exchange programs at a committee hearing tomorrow. The April issue of TEXAS MONTHLY contains a substantial piece by writer-at-large William Martin, a senior fellow at the Baker Institute of Public Policy at Rice University, that makes the case for such programs--and laments the fact that Texas is the only state in the U.S. that does not permit this life-saving, disease-combatting practice. Although it's unusual for us to release a story not yet printed in our magazine, I thought it was important that you see this one immediately and consider it as you begin your conversation, so I've taken the liberty of sending you the attached copy.

Bully for him. Read the story for yourself to see what he sent the senators. It's a good one. Martin speaks to both Sen. Deuell, a medical doctor, and bill's sponsor from the 79th Legislature, retired Houston senator Jon Lindsay, a Republican stalwart and former Harris County Judge. Wrote Martin:

Though some were surprised that Lindsay would sponsor the bill, he called it “a no-brainer.” “I talked to doctors and medical people, people who worked at clinics,” he explained. “They convinced me that it made sense to get dirty needles off the street. It wasn’t a hard sell at all. And of course, there is the side benefit of getting users in contact with clinics and medical professionals.” As for why the bill failed in 2005, he said that too many socially conservative legislators “are afraid of their shadow. They’re afraid they’ll be branded as catering to druggies and don’t want that to be a potential campaign issue. That’s the bottom line that is causing the hang-up. A large number of them don’t understand the issue. It’s more of a knee-jerk reaction.”

Maybe this year with Dr. Deuell leading the charge the bill will have easier sledding. From his comments in this article and in committee last year, he appears to be an ardent and able advocate for syringe exchange programs:

“There is absolutely no reason to oppose a needle exchange program,” Deuell said. “The research is there. People who oppose it think it will encourage drug use. Research has shown it does not. It serves to prevent transmission of HIV and other blood-borne diseases such as hepatitis B and C, and it actually brings addicts to treatment, if they so desire.” Deuell also stressed that allowing greater access to sterile syringes “is going to cost the state less money. It costs us a fortune to treat HIV and hepatitis C. It’s breaking the budget.”

That's a strong message and Deuell is a great messenger. Perhaps that combination will ward off some of the knee jerk attacks on the bill. Even conservatives at the Lone Star Times came out in favor of the legislation, to the surprise of some. Wrote blogger David Benzion:

Our current approach stinks, and I’m urging my State Senator to do the fiscally prudent–dare I say compassionate and even Christian thing–and sign on to this measure.

As Martin notes in TM, there is little formal opposition to this bill except legislators' own fear. Between Dr. Deuell's public championing of the idea, Texas Monthly's timely publicity, and the lack of a hard-right backlash, this bill appears to have a lot of momentum in the Senate.

One minor correction to Martin's article. He wrote that "The Health and Human Services Committee sent the bill forward with only one dissenting vote, but it never came to a vote on the Senate floor." Actually, Lindsay got the bill to the floor but could only muster 17 votes, not the 20 it needed for passage, see the Senate Journal entry for SB 127. Senators Averitt, Duncan and Eltife joined Deuell, Lindsay and Senate Democrats in 2005 to support it. Deuell improves his chances a bit with Kyle Janek's support, mentioned in the TM article, and will just need to pick up three more votes to pass the bill in the Senate.

In other words, he's within spitting distance.

I'll bet not a lot of people thought this bill had a chance of moving this session. But some really good people are working on it, and sometimes the stars are just aligned. Here's hoping that's true this session for SB 308.