Bexar County to give Narcan to addicts exiting jail, but many still won't call 911 for fear of felony arrest

Addicts leaving the county jail in San Antonio will now receive a dose of Narcan in case they overdose, the Express News reported. Overdoses are more common after incarceration because addicts may have lost some of their tolerance. That can cause people to overdose when they use the same amounts they used before. Funding for the program came from a federal grant.

Of course, folks can still be arrested for drug possession if they call 911 to report an overdose. A Bexar Sheriff's deputy told the paper that:

people shouldn’t be concerned about contacting authorities should a friend or family member overdose. 

“That’s the least of your worries at that point, ending up in jail,” he said. “You should be worried about surviving, or about leaving your child without a mother or father.”

That's easy to say, but it would mean more if Gov. Greg Abbott hadn't vetoed Good Samaritan legislation in 2015 that would have prevented 911-callers from being arrested for calling in an overdose.

In 2018, the Austin Statesman reported that, "similar laws in other states have resulted in as much as a 15 percent drop in opioid overdoses in the past five years, despite nationwide increases. The laws also do not appear to increase the number of drug users, the data shows."

That's shaping up as one of the worst and most destructive vetoes of Abbott's tenure so far.

White House backing for methadone in jails?

I don't understand the Trump Administration's position on the Drug War at all. Grits was under the impression that "beleaguered" Attorney General Jeff Sessions was ramping it back up, but then we see that the Administration apparently supports methadone treatment for addicts in county jails. From the New York Times:

maintenance treatments like methadone, if uninterrupted, are proven to reduce arrests and increase employment, and for many with addiction are the only thing that works. In July, a White House commission on opioid addiction called for increasing inmates’ access to addiction medication.

Somebody help me out here, I can't keep track any more: is that a liberal or a conservative position?

Grits also wanted to flag a medication being used on addicts in jails (or more often, as they are discharged), of which I hadn't previously heard:

A growing number of jails, especially in rural areas, have opted to treat inmates not while they are in jail, but on the way out, giving them a one-time shot of a newer medication, Vivitrol, as they are released. Vivitrol, which unlike methadone and Suboxone is not a narcotic and has no street value, blocks opioid receptors in the brain, making getting high nearly impossible. It is far more expensive, and far less proven, than methadone and Suboxone, but its manufacturer often gives it to jails free. Its effect lasts about a month.

The full Times story - "Opiod Users Are Filling Jails. Why Don't Jails Treat Them?" - is well worth a read. MORE: NPR covered Vivitrol this week as well, an alert reader informed me.

President Trump, Gov. Abbott and the 'Disposables'

Might a Trump Administration pivot on the opiod crisis spur Gov. Greg Abbott to change his position on Texas' Good Samaritan legislation, which he vetoed in 2015?  NBC-News reported this morning that:

President Donald Trump is expected to launch a commission Wednesday to address the nation's growing opioid epidemic, according to sources familiar with the planning. Trump will sign an executive order setting up the commission, which will be tasked with outlining recommendations and federal resources to tackle the drug addiction that kills an estimated 78 people a day. 

New Jersey Gov. Chris Christie will serve as chairman of the commission at the president's request. 

"The opioid initiative is one that's incredibly important to every family in every corner of this country," Christie said Wednesday on TODAY from outside the White House. 

He said his state is grappling with a rise in the rate of drug overdose deaths, which have surpassed murders and automobile accidents. (Ed. note: True for Texas, too.)

"What we need to come to grips with is addiction is a disease and no life is disposable. We can help people by giving them appropriate treatment," Christie added.

N.b. the "no life is disposable" line. Now contrast that with Gov. Abbott's position on a Good Samaritan law in Texas. He vetoed the legislation in 2015, claiming he was worried about condoning drug use if people gained immunity over and over. The authors have offered to change the bill to allow the immunity from prosecution to be used only once, but now the Governor has moved the goalposts, insisting that the bill only apply to Texans under 21 years old who have never been arrested for anything (not convicted, arrested).

So if someone overdoses and they don't meet those criteria - if they've ever been arrested or if they're 21 or older - to Gov. Abbot their life is "disposable," to use Gov. Christie's term. Or at least that's the implication of the policy position Abbott's office has taken. Because of their age or their past bad acts, however minor, those people apparently deserve to die. 

Overdoses are statistically a greater contributor to "American carnage" than violent killers. In Texas, the number of overdose deaths in 2015 nearly doubled the statewide murder total. So even if the Good Samaritan bill had only a small impact, it could save many lives. Perhaps this news of a treatment-centered Trumpian opiod agenda will re-frame the question politically and cause Governor Abbott to reconsider which Texans he considers disposable. 

Go here if you'd like to send a message to Gov. Abbott asking him to support Texas' Good Samaritan legislation.

Priorities, choices, and poor drug-war outcomes

What a world we live in.

Asset forfeiture by the government now takes more money from people than burglars and the number of heroin deaths has surpassed gun homicides.

Can't blame Donald Trump for that, huh?

OTOH, one recalls that Gov. Greg Abbott last session vetoed "Good Samaritan" legislation which would have prevented prosecution of people who called 911 during an overdose, stayed with the victim, and cooperated with police. That would have helped prevent overdose deaths. When the bill comes back this time in the 85th Texas Legislature, they should pass it again and Greg Abbott should sign it.

In a related, poor state policy decision which likely resulted in more heroin deaths, the Texas Department of State Health Services recently failed to solicit a federal grant to pay for first responders to have access to Naloxone, an opiod antagonist with no significant side effects which can keep overdose victims from dying.

Similarly, the Lege has an opportunity this session to rein in asset forfeitures by law enforcement which are unrelated to a criminal conviction. The Texas Public Policy Foundation this week published a myth-busting document explaining why they can and should do so.

These sorts of statistics aren't just things that happen in the world, they're a result of government priorities and policy choices. If we want different outcomes, government must change both.

DOJ should intervene in Harris Co. bail litigation, and other brief notes

Here's a quick roundup of items which merit Grits readers attention even if they haven't made it into independent posts:

• The Houston Chronicle's Mike Ward explained to KUT "Why Texas could close even more prisons."
• A fine for an offense which doesn't exist highlights the absurdity and counterproductive incentives arising from debtors prison policies and practices.
• Jennifer Erschabek of the Texas Inmate Family Association had a column in the Houston Chronicle arguing that "Texas prison reform must get 'smart on people'." 
• Grits contributing writer and Texas Justice Initiative director Amanda Woog had a column on a website called The Conversation titled "Who dies in police custody?," describing how data gathering initiatives in Texas and California are providing a fuller picture of police shootings and deaths in custody for the first time.
• Harris County law enforcement does not use statutory authority to give tickets instead of arresting people for low-level pot offenses, but it's not because of District Attorney opposition, as elsewhere. Rather, it's because disparate computer systems won't support it, according to JoAnne Musick at Reasonable Doubt. "Issuing citations to approximately 14,500 people who could have qualified for cite and release in 2015 alone certainly would have lessened the burden on the jail."
• Texas' new law allowing broader use of life saving naloxone to prevent overdose deaths has been making a huge impact. This news make me even more unhappy about the Governor's veto of related "Good Samaritan" legislation which would have given people immunity from prosecution on drug charges if they called in an overdose to 911, stayed with the victim, and cooperated when authorities arrived. Even more lives could have been saved.
• The US Justice Department intervened in a Georgia lawsuit challenging the constitutionality of money bail. Note to Vanita Gupta: How about joining the Houston litigation?
• News that ramen noodles are a primary currency in prison is a sad commentary on conditions. This reminds me: I wonder if the Victoria County Jail has gone back to hot meals or are inmates still eating cold sandwiches after their nutritionist recommended an expanded menu?

Greg Abbott to veto harm reduction legislation

Grits was informed this afternoon by Rep. Ryan Guillen's staff that the governor will veto HB 225 creating a defense to prosecution for people who call 911 during a drug overdoses. Because, why would you want to prevent a drug user from dying? Twenty-four states and the District of Columbia have passed Good Samaritan laws that protect overdose witnesses and victims who request emergency medical assistance

The bill passed 140-4 in the Texas House and 30-1 in the Senate, so until now it didn't seem controversial.

Thankfully, a portion of the bill expanding access to naloxone, an opiod antagonist, passed as a standalone, SB 1462, and also went to the governor. Maybe that piece will make it through.

See prior Grits coverage here, here, and here, and the House Research Organization report (pdf, p. 21) on the bill. See also a detailed (88 page) fact sheet on Good Samaritan laws and overdose prevention from the Network for Public Health Law.

What a terrible decision. That doesn't bode well.

UPDATE (6/2): The bill has been formally vetoed. Reported the Texas Tribune, "In a veto statement Tuesday, Abbott said HB-225 lacks 'adequate protections to prevent its misuse by habitual drug abusers and drug dealers.' He noted his office came up with amendments to address the concern, but they did not make it into the final version of the bill." That's a bit of a half-truth. First, Abbott's people never raised concerns with the House author at all, waiting to intervene after the bill had already won overwhelming approval in the lower chamber. And second, some of Abbott's amendments were accepted, but the rest were designed to thwart the fundamental intent of the bill. Plus, his staff kept moving the target. Some observers believed Abbott's amendments would have made the bill worse than current law in terms of providing disincentives for calling 911 in an overdose emergency. Further, there's really no valid use case where "misuse" can even be credibly hypothesized, all the valid concerns were entirely addressed. But a veto doesn't need credible argument, just a stamp and a signature. 

MORE: See additional coverage from the Dallas Observer. 

Will Texas join conservative states adopting syringe exchange in 2015?

In the wake of the Texas House of Representatives approving syringe exchange legislation last week,* Grits was interested see this article in the New York Times about changing laws and attitudes on the topic in conservative states. Though the Texas vote wasn't mentioned, the Times' Carl Hulse reported:

Now, with a severe outbreak of H.I.V. and hepatitis due to a surge in heroin use in states including Indiana, Kentucky and West Virginia, the question of whether to let federal money support needle exchanges is back. Still, in contrast to a new willingness by state politicians to accept needle exchanges, Congress appears unlikely to overturn the moratorium even with drug problems hitting hard in states represented by those responsible for the spending bills that impose the ban. ...

Though evidence has mounted that needle exchanges are effective — the Centers for Disease Control and Prevention and the World Health Organization, among others, have recommended them — they have remained anathema to many politicians, particularly Republicans who have long framed opposition as an essential element of their antidrug image.

“As Republicans, we don’t want to look like we are facilitating drug use,” said Representative Tom Cole, the Oklahoma Republican who is chairman of the appropriations subcommittee that distributes health funding. “We want to get you help, but we want to do other things.”

While expressing reservations, Mr. Cole acknowledged that public funding of needle exchanges could be more cost effective than the potential public expense of treating increasing numbers of AIDS and hepatitis cases. He said he expected the issue to come up as Congress put its health spending bill together and, like [Rep. Harold] Rogers, said he was open to exploring the issue.

“If the evidence is such that it really makes a difference, it is something to look at,” Mr. Cole said.

To some Democrats, there is no question that the ban should be eliminated and that Republicans are stuck in the past when it comes to both drug and health policy.

“We should lift the ban,” said Representative Rosa DeLauro of Connecticut, a senior Democrat on the appropriations subcommittee. “Health, and not ideology, should be the determining factor.”

In Indiana, an epidemic of H.I.V. related to intravenous drug use in one southeastern county led Gov. Mike Pence, a former Republican House member and longtime supporter of the ban, to back away from his opposition. In March, he signed an executive order allowing a temporary needle exchange in Scott County. This month, he signed legislation allowing counties around the state to begin exchanges if officials can demonstrate that they would be an appropriate public health response. The Kentucky Legislature, on a bipartisan basis, also passed legislation allowing needle exchange programs.

Apparently Mr. Hulse didn't know about the Texas House's remarkable vote to approve syringe exchange pilots in seven counties on essentially conservative grounds - it would have fit perfectly into his story's narrative. But perhaps news of such programs spreading in conservative states will contribute to new momentum on the senate side, where the Texas bill still awaits referral to committee.

Grits wondered before session whether changing political dynamics regarding the drug war and disease prevention might give needle exchange legislation new legs. Apparently that's the case, and not just in Texas.

*Your correspondent supported this legislation on behalf of the Texas Criminal Justice Coalition.

Overdose prevention legislation soon headed to governor

As Texas' needle exchange legislation heads from the House to the Senate, another harm reduction bill - HB 225 by Guillen, aka the Good Samaritan overdose prevention bill - has passed both chambers and is all but on its way to the governor's desk. Your correspondent supported the bill in both chambers on behalf of the Texas Criminal Justice Coalition.

The Good Samaritan piece of this bill creates a defense to prosecution for people who dial 911 during an overdose if they stay on the scene, cooperate with police, etc.. The bill had never moved far in past sessions but this year rocketed through the system early, with nearly unanimous support. Along the way, Sen. West's legislation expanding access to naloxone for first responders and people with a prescription got tacked onto the bill, creating a more comprehensive overdose prevention package which enjoyed wide support. Sen. Lois Kolkhorst was the lone "no" vote in the senate, joining four House members who opposed the bill.

Now, there's just one vote left who matters: Gov. Greg Abbott. Given news this spring that the state has dramatically under-counted opiod overdoses and the unquestioned effectiveness of naloxone at saving lives, it's hard to see a downside to the governor signing it, or an upside to making this his first veto. But you never know.

For more background on these naloxone access and Good Samaritan laws, see this extensive and detailed fact sheet from the Network for Public Health Law.

News of TX overdose undercount bolsters 'Good Samaritan' bill

As the Texas Senate Criminal Justice Committee prepares to hear overdose prevention legislation (HB 225 by Guillen/Watson) on Tuesday, news comes that the state has dramatically and systematically undercounted overdose deaths in recent years.

The Houston Chronicle's Lise Olsen and the Austin Statesman's Mary Ann Roser this week (April 24) coauthored an important and impressive feature documenting how Texas dramatically undercounts overdose deaths, particularly those stemming from prescription opiates. "Overdose deaths from all drugs have skyrocketed nationwide in the last decade, outpacing even motor vehicle accident fatalities, according to the Centers for Disease Control and Prevention," they reported. But prescription opiods account for the largest source of the increase.

Last summer, Dr. David Lakey, then the Texas Department of State Health Services commissioner, told a Senate committee studying the problem that Texas has one of the nation's lowest prescription drug fatality rates and that his data showed deaths had peaked in 2006. But Lakey was referring only to deaths involving certain painkillers, not all prescription drugs. His report did not include information from medical examiners, who use drug screens to identify many more overdoses, according to a joint investigation by the Houston Chronicle and the Austin American-Statesman.

Only 622 deaths reported across Texas in 2013 were specifically blamed on opioids - mostly painkillers, based on death certificate data cited by Lakey's department.

But 798 prescription-drug related deaths were recorded by local medical examiners that year in just 17 of the state's 254 counties, the Chronicle and Statesman found. The newspapers found that medical examiner reports in Harris, Travis, Dallas, Tarrant and El Paso counties, as well as some smaller counties, attribute many more deaths to prescription drug overdoses than the state has counted in opioid overdoses.

The reporters determined that, "the state's method of tracking the problem undercounts deaths in every major county across Texas." E.g.:

In Travis County, which includes Austin, the state reported 17 deaths from prescription painkillers in its preliminary count of death certificates for 2013, but the administrator of the county's Medical Examiner's Office hand-counted 114 deaths involving all prescription drugs that year.

In Tarrant County, which includes Fort Worth, the medical examiner's office recorded 44 deaths in 2013 involving specific prescription drugs and another 57 fatalities from "mixed drugs." The state's count was 24 opioid overdoses.

Counties where justices of the peace determine cause of death instead of a medical examiner exacerbate the undercount. Some of that is because JPs are unqualified to make such a determination, while there are also economic incentives to undercount: "Many justices of the peace hail from counties with tight budgets, so there can be pressure to reduce the number of cases they send to a medical examiner for an autopsy."

The article mentioned legislation by Sen. Charles Schwertner "to better monitor patients who may be 'doctor shopping' for drugs." That bill passed the senate two weeks ago but has yet to be referred to committee in the House. But they failed to mention HB 225 by Guillen/Watson, which will be one of the first House bills taken up by the Senate Criminal Justice Committee when they hear the bill on Tuesday. That legislation would authorize use of the opiod antagonist naloxone (an antidote with no known side effects which is highly effective for heroin and many prescription pain medications) by first responders and adults with a prescription. It would also create a "Good Samaritan" provision - a defense to prosecution for people who call 911 in response to an overdose. (N.b., your correspondent supported HB 225 in the House on behalf of the Texas Criminal Justice Coalition.)

This joint feature from the Chronicle and Statesman makes the arguments for such overdose prevention legislation much more immediate and poignant. Since they didn't mention Guillen's Good Samaritan bill, I doubt the story was timed to benefit that legislation. But it's certainly a timely and helpful coincidence. For more background on HB 225, see recent coverage from NPR, prior Grits coverage and the House Research Organization report (pdf, p. 21) on the bill. MORE: See a brand new, detailed (88 page) fact sheet on precisely these topics from the Network for Public Health Law.

Texas House moving harm reduction measures

There were a couple of positive developments on the harm reduction front in the Texas House this week involving bills your correspondent supported in committee:

Good Samaritan bill moves to Senate
On Tuesday, the lower chamber approved HB 225 creating a defense to prosecution when someone calls 911 in response to an overdose, stays at the scene, and cooperates with police - so called "Good Samaritan" legislation. It passed by a 140-4 margin. This is an important sleeper issue, as "overdosing on medications and illicit drugs has been a bigger killer in the U.S. than car crashes or gun deaths at more than 120 per day," according to coverage of the bill from Texas Public Radio. The legislation also authorizes first responders and folks with prescriptions to use naloxone, an opiod antagonist that can save lives during emergency situations but which itself is non-addictive and causes no known side effects. The bill is now in the Senate where its companion was referred to the Criminal Justice Committee.

Unanimous committee support for needle exchange bill
After some initial confusion and a motion to reconsider, CSHB 65 authorizing privately funded and operated needle exchange pilots in several counties passed out of the County Affairs Committee yesterday on a 9-0 vote. See supportive coverage of the bill out of San Antonio and an earlier Grits analysis. HB 65 had seemingly stalled before conservatives threw their support behind language which eliminated all public funding and empowered counties and hospital districts only to authorize other organizations to operate needle exchanges - county government won't operate the programs. Volunteers with authorized needle exchanges will be exempt from prosecution under the paraphernalia laws and the bill includes some reporting requirements for participating organizations on the back end. Indiana of all places, recently suspended that state's ban on needle exchanges in response to a public health crisis.

Solutions for Texas' "Overdose Crisis"

A new briefing paper (pdf) from the Drug Policy Alliance hones in on Texas drug overdoses, pointing out that, "Between 1999 and 2007, overdose deaths increased by more than 250 percent. Statewide, accidental poisoning (most commonly due to drug overdose) is the third-leading cause of injuryrelated death in Texas, behind car crashes and suicide. While a majority of these poisoning victims are middle age adults or older (ages 35-54), almost one-third (31.4%) were either youth or young adults (ages 15-34)."

Most of these, says DPA, are preventable deaths: "over half of all accidental overdose deaths in Houston in the past five years could have been prevented if the overdose reversal medication naloxone, coupled with overdose prevention education, had been available to people at risk of an opiate overdose and their loved ones."

Our current approaches to the problem, however, may be making things worse, says DPA: "Despite the severity of this epidemic, the steps the state has taken to date have been ineffective, and even counterproductive. Texas has largely focused on punitive measures, like prosecuting people who use drugs with someone that later overdoses, such as the case of Kristin Metz, a 29-year-old woman sentenced to 10 years for injecting her best friend with heroin, at the friend’s request."

Among the group's policy recommendations are to expand access to drugs that counter the effects of opiate overdose: "Naloxone, or Narcan, is a life saving tool used to reverse opiate-based drug overdoses. Naloxone has been FDAapproved since 1971, and presents no potential for abuse as it has no pharmacological effect; it also has no effect if it is taken by a person that does not have opiates in their system. It needs to be made more readily available to those who may be in a position to respond to an overdose."

However, suggestions which cost new money, regrettably, will be difficult to pass in the 82nd Texas Legislature because of the massive budget shortfall. But DPA did suggest one excellent idea that would cost no new money and which could immediately start to save lives:

911 Good Samaritan Laws encourage people to call 911 by creating an exemption from arrest, charge or prosecution for possession of small amounts of drugs or alcohol when needing or calling for medical assistance in the event of an overdose. The policy prioritizes saving lives over arrests for minor drug or alcohol law violations. Such laws are essential because overdose fatalities often occur when peers delay or forego calling 911 out of fear of arrest or police involvement, which researchers identify as the most significant barrier to the ideal first response of calling emergency services.

Such legislation does not protect people from arrest for other offenses, such as selling or trafficking drugs. This policy protects only the caller and overdose victim from arrest and prosecution for simple drug possession, possession of paraphernalia, and/or being under the influence.

Texas’ neighbor, New Mexico, became the first state in the nation to adopt a life-saving Good Samaritan law in 2007. Washington passed a Good Samaritan law in 2009 and several other states are considering similar legislation.

In fact, Good Samaritan policies for alcohol and/or other drugs are already saving lives at many of Texas’s major universities, including the University of Texas at Austin, Rice University, Baylor University, Southern Methodist University, and Texas Christian University, as well as nearly one hundred other college campuses nationwide. SMU’s decision to adopt a Good Samaritan policy for alcohol and other drugs was a direct response to the tragic overdose deaths of several students in recent years. According to school officials, the policy appears to be working: students are less reluctant to call for help now that they do not face student conduct sanctions.

This suggestion raises the question: Should the goal of drug policy be to save lives or maximize punishment? Historically, it's been the latter, but to me the approaches suggested by DPA make a lot of sense.

UPDATE: Via Sifting the Haystack, "8th Annual Harm Reduction Conference Comes to Texas Nov. 18-21."

Prescription drugs kill more people than illegal ones; new harm reduction strategies needed

Lately on this blog, discussions of "harm reduction" have centered around the Attorney General's nonsensical legal opinion and Bexar District Attorney Susan Reed's efforts to bully out of existence a legislatively approved needle exchange program in San Antonio. But to judge by newly available data, drugs targeted via needle exchange programs cause less "harm" to the general public than the ones distributed by pharmacists.

The biggest public safety threats related to illegal drugs in the United States arise from drug enforcement strategies that force the product to be delivered through a black market, resulting in violent conflicts among distributors, dangerously impure products, coercion and bribery of police, and a variety of other anti-social outcomes. Purely from a safety perspective, however, new data reveals that prescription drugs cause more deaths related to the drugs' actual effects, reports the New York Times ("Legal drugs kill far more than illegal, Florida says" June 15):

An analysis of autopsies in 2007 released this week by the Florida Medical Examiners Commission found that the rate of deaths caused by prescription drugs was three times the rate of deaths caused by all illicit drugs combined.

Law enforcement officials said that the shift toward prescription-drug abuse, which began here about eight years ago, showed no sign of letting up and that the state must do more to control it.

“You have health care providers involved, you have doctor shoppers, and then there are crimes like robbing drug shipments,” said Jeff Beasley, a drug intelligence inspector for the Florida Department of Law Enforcement, which co-sponsored the study. “There is a multitude of ways to get these drugs, and that’s what makes things complicated.”

The report’s findings track with similar studies by the federal Drug Enforcement Administration, which has found that roughly seven million Americans are abusing prescription drugs. If accurate, that would be an increase of 80 percent in six years and more than the total abusing cocaine, heroin, hallucinogens, Ecstasy and inhalants.

The Florida report analyzed 168,900 deaths statewide. Cocaine, heroin and all methamphetamines caused 989 deaths, it found, while legal opioids — strong painkillers in brand-name drugs like Vicodin and OxyContin — caused 2,328.

Drugs with benzodiazepine, mainly depressants like Valium and Xanax, led to 743 deaths. Alcohol was the most commonly occurring drug, appearing in the bodies of 4,179 of the dead and judged the cause of death of 466 — fewer than cocaine (843) but more than methamphetamine (25) and marijuana (0).

The study also found that while the number of people who died with heroin in their bodies increased 14 percent in 2007, to 110, deaths related to the opioid oxycodone increased 36 percent, to 1,253.

Florida scrutinizes drug-related deaths more closely than do other states, and so there is little basis for comparison with them.

The implications of this shift are enormous: More than one in five people in Texas prisons are there for crimes related to illegal drug sales or possession, but those strategies don't affect the drugs killing the most people. The same tactics could never be applied en masse to prescription drug abuse - the economies of scale would quickly overwhelm police and prisons. It would also tick off powerful political constituencies like doctors and drug companies who hire armies of lobbyists to promote their interests, as opposed to their Mexican drug cartel counterparts who just hire armies.

The substitution effect here is palpable: People abuse prescription drugs largely because of the stigma and legal difficulties arising from gaining access to illegal ones, even though they're not as safe. So to that extent, the shift toward prescription drug abuse counts as a drug war "success," but only if you redefine the term "success" to mean causing more deaths instead of preventing them. (The Economist recently declared it a success to shift people from using meth to cocaine, but the Florida study says coke is much more dangerous to users than crank; by that logic, to judge by these data, it'd be a public safety success to get people to shift from Vicodin or Xanax to marijuana, which didn't kill any Floridians last year.)

"Harm reduction" historically focused on illegal drugs, but what if that's not main source of drug-related harm? What's needed now, apparently, are more addiction treatment resources and harm reduction strategies aimed at legal prescription drugs.

Federal crack sentencing changes won't much affect Texas; changes to state drug laws still needed

The much-ballyhooed SCOTUS decision on crack sentencing disparities will have little effect overall in Texas, reports the Houston Chronicle ("Crack ruling of little effect locally," Dec. 17) because the vast majority of drug cases come through state courts:

Since July 2006, there have been just over 1,400 drug-related convictions by federal prosecutors in South Texas, according to data from the U.S. Department of Justice.

In contrast, the Harris County District Clerk's office said nearly 35,000 convictions for drug offenses were secured in county courts from Jan. 1, 2005, through Dec. 31, 2006, the most recent data available.

That's 35,000 convictions for drug offenses over two years in one Texas county, folks, albeit the county whose size and punitive judiciary exert an exceptional and negative influence on state policy. Legislative testimony earlier this year revealed that about 85% of felony drug cases in Houston - 12,000 out of 14,000 drug indictments in 2006 - were for possessing less than a gram of a controlled substance, or less powder than is in a Sweet-N-Low packet. The recent SCOTUS ruling won't affect any of those cases.

Indeed, the flood of low-level court cases in Houston led long-time State District Judge Michael McSpadden in recent years to implore the Legislature and Governor Perry to reduce drug possession sentences for small amounts, declaring that "These minor offenses are now overwhelming every felony docket, and the courts necessarily spend less time on the more important, violent crimes."

Not only that, every one of those convicted of a felony loses access to many employment and housing options that might otherwise help them pull themselves up by their own bootstraps.

Texas doesn't suffer statutory crack sentencing disparities like in the federal system, but that doesn't mean there's no problem with racial disparities in enforcing existing drug laws, most especially for black people. "Blacks make up 11 percent of the population of Texas," reported the Chronicle, "yet 46 percent of drug offenders serving time in the state's prisons are black, according to figures provided by the Texas Department of Criminal Justice."

The existence of racial disparities in Texas drug enforcement is obvious; the reasons for it, less so. We could debate here all day the reasons for racial disparities without reaching any firm conclusion. I don't know the answer to that complicated question.

But in an era when Texas prisons are completely full and severely understaffed, a bigger overall problem for law abiding citizens of all races, as Judge McSpadden indicates, is that the excessive focus of state and local policing, judicial, and incarceration resources on drug crimes reduces resources available to incarcerate more serious offenders, including violent criminals. That makes everyone less safe, including, disproportionately, black victims of violent crime.

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.