Harm reduction is a movement for social justice built on a belief in, and respect for, the rights of people who use drugs. Harm reduction is also a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use. Although those working in harm reduction believe that drug criminalization maximizes harm, the focus of most harm reduction policy and practice is in the borderlands between legalization and prohibition. To quote an old social justice slogan, harm reduction is the art of "building a new society in the vacant lots of the old." And those lots are filling up, due to the hard work of people around the world. Here are 10 of the most important harm reduction developments in North America in 2013:
1. "Needle Exchange" in the US Turns 25
A quarter of a century ago, public health activists started doing needle exchange in Tacoma, WA, San Francisco, CA, and New York, NY. These efforts, now referred to as 'syringe access programs', spread and continued and have been widely recognized as the single most successful HIV prevention intervention. To date, however, they are legally excluded from receiving access to the federal funding enjoyed by all other HIV prevention efforts. Perhaps in 2014, we can report that the federal funding ban for syringe access programs was finally lifted for good.
2. States Decriminalize Syringes to Increase Safe Syringe Access
Syringe access policy varies by state, and this year, community organizing led the Nevada legislature to finally pave the way for syringe access programs and over the counter pharmacy sales by fully decriminalizing syringes, making it one of the strongest state enabling laws for syringe access programming. North Carolina partially decriminalized syringes to protect law enforcement from needlestick injury, but without legalizing their existing syringe access programs, yet.
3. Laws Passed in Six States to End Overdose Epidemic by Providing Antidote
Opioid overdose has surpassed auto accidents as the leading cause of accidental death in the US. New laws were passed this year in six states to encourage health care providers and community programs to widely distribute naloxone to treat opioid overdose incidents. Additionally, new programs started providing naloxone access in Colorado, Vermont, North Carolina, Kentucky, Ohio, New Jersey, Minnesota, and Missouri this year. Naloxone is used in opioid overdoses to counteract life-threatening depression of the central nervous system and respiratory system, allowing an overdosing person to breathe normally. Although traditionally administered by emergency response personnel, naloxone can be administered by minimally trained laypeople, which makes it ideal for treating overdose in people who have been prescribed opioid pain medication and in people who use heroin and other illicit opioids.
4. Opioid Overdose Antidote Provided by Rhode Island Walgreens Pharmacists Directly to Patients
2013 saw a statewide scale up of a collaborative pharmacy practice agreement for naloxone, bringing naloxone to all 26 Walgreens stores in Rhode Island and training 80 Walgreens pharmacists in how to counsel patients on, train in, and dispense naloxone (without a prescription) to anyone who asks for it.
5. Federal Agencies Declare Support for Peer-Delivered Naloxone Distribution
Under the Bush Administration, officials in the Office of National Drug Control Policy (ONDCP) opposed peer-delivered naloxone. Then Deputy Director Bertha Madras said drug users "aren't likely to be competent to deal with an overdose emergency", and stated that "rescue programs might take away the drug user's motivation to get into detoxification and drug treatment". Obama's White House Office of National Drug Control Policy takes a position 180 degrees from Madras, supports overdose prevention and naloxone programs, and included them in the 2013 Drug Control Strategy. Also this year, the drug treament agency of the federal government, the Substance Abuse and Mental Health Services Administration (SAMHSA) published their long-awaited "Opioid Overdose Prevention Toolkit" which has five components targeting first responders, community members, patients, prescribers, and overdose survivors and their family members. The toolkit provides information on naloxone distribution and prescription and overdose prevention. Peer-delivered naloxone distribution has definitely gone from an underground movement to a mainstream-supported strategy in 2013. Next year, perhaps we can report some funding for this critical yet unfunded lifesaver.
6. Jail-Based Overdose Prevention and Naloxone Distribution Begins
Opiate overdoses are all too common among people released from jail due to decreased tolerance. In March 2013, the Harm Reduction Coalition's Drug Overdose Prevention and Education (DOPE) Project began providing naloxone to inmates of the San Francisco County Jail as they were discharged. The DOPE Project, in collaboration with SFDPH's Jail Health Services, conducts overdose prevention trainings inside the jail, and is able to put naloxone kits in the property of inmates who choose to participate for pick up when they are released. This is the first non-research study in the country to begin providing naloxone directly to inmates as they re-enter the community.
7. Good Samaritan Laws for People Witnessing Overdoses Gain Traction, Law Enforcement Support
Community activists have been working to get Good Samaritan laws passed to protect people from arrest and prosecution for drug possession when they call 911 to report an overdose. Fourteen states have now enacted these laws, as have ninety college campuses. The Florida effort in 2012 was notably initiated by Palm Beach police, a harbinger of change in law enforcement support for harm reduction measures.
8. Newly-Approved Hepatitis C Treatments Move Closer to Making Interferon-Free Cure a Reality for People Who Inject Drugs.
Hepatitis C remains endemic among people who inject drugs, with chronic infection rates of 70% or more among long-term injectors. While new infections have declined dramatically since peaking in the 1980s, due in part to the expansion of syringe access programs, several states report a new wave of hepatitis C infections among younger injectors. While hepatitis C is curable, treatment has traditionally required use of interferon, a drug with significant psychological and physical side effects that does not work for everyone and is difficult to tolerate for many, particularly current and former substance users. In December, the US Food and Drug Administration (FDA) approved a new hepatitis C medication sofosbuvir (Sovaldi, Gilead Sciences, Inc), which can be used without interferon for some people. Other therapies in development offer hope that all people with hepatitis C will have interferon-free treatment options available by the end of 2014.
9. Community Organizes to Mandate Hepatitis C Testing in New York
An estimated 3-4 million people are infected with the hepatitis C virus, and three quarters of them are unaware of it. Baby boomers - those born between 1945 and 1965 - make up over 70% of people with chronic infection, and are at highest risk of liver complications. Following CDC's 2012 recommendation of a one-time hepatitis C test for all baby boomers, a coalition of harm reduction workers, people who use drugs, and other allies passed a bill in New York mandating that doctors inform their patients and offer a hepatitis C test. As better-tolerated treatments with high cure rates become available, this legislation ensures that thousands of lives that may have been lost to liver cancer and other hepatitis C complications are diagnosed and treated.
10. Montreal Approved to Open Four Supervised Injection Sites
There are approximately 90 supervised injection sites worldwide in Europe and Australia, and only one in North America: InSite in Vancouver, British Columbia. After InSite's long legal fight with their conservative government, Canada's Supreme Court ruled in 2009 that the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs on InSite's premises, allowing the facility to stay open indefinitely. In 2009, the site recorded 276,178 visits (an average of 702 visits per day) by 5,447 unique users; 484 overdoses occurred with no fatalities, due to intervention by medical staff. This month, Montreal was given permission to open four injection sites of their own, ensuring that Vancouver's InSite is the first but not the last legal supervised injection site in North America. Perhaps we finally succeed in opening one in the US in 2014.
Hilary McQuie is Regional Director of the Harm Reduction Coalition, and is based in Oakland, CA http://harmreduction.org/
1. "Needle Exchange" in the US Turns 25
A quarter of a century ago, public health activists started doing needle exchange in Tacoma, WA, San Francisco, CA, and New York, NY. These efforts, now referred to as 'syringe access programs', spread and continued and have been widely recognized as the single most successful HIV prevention intervention. To date, however, they are legally excluded from receiving access to the federal funding enjoyed by all other HIV prevention efforts. Perhaps in 2014, we can report that the federal funding ban for syringe access programs was finally lifted for good.
2. States Decriminalize Syringes to Increase Safe Syringe Access
Syringe access policy varies by state, and this year, community organizing led the Nevada legislature to finally pave the way for syringe access programs and over the counter pharmacy sales by fully decriminalizing syringes, making it one of the strongest state enabling laws for syringe access programming. North Carolina partially decriminalized syringes to protect law enforcement from needlestick injury, but without legalizing their existing syringe access programs, yet.
3. Laws Passed in Six States to End Overdose Epidemic by Providing Antidote
Opioid overdose has surpassed auto accidents as the leading cause of accidental death in the US. New laws were passed this year in six states to encourage health care providers and community programs to widely distribute naloxone to treat opioid overdose incidents. Additionally, new programs started providing naloxone access in Colorado, Vermont, North Carolina, Kentucky, Ohio, New Jersey, Minnesota, and Missouri this year. Naloxone is used in opioid overdoses to counteract life-threatening depression of the central nervous system and respiratory system, allowing an overdosing person to breathe normally. Although traditionally administered by emergency response personnel, naloxone can be administered by minimally trained laypeople, which makes it ideal for treating overdose in people who have been prescribed opioid pain medication and in people who use heroin and other illicit opioids.
4. Opioid Overdose Antidote Provided by Rhode Island Walgreens Pharmacists Directly to Patients
2013 saw a statewide scale up of a collaborative pharmacy practice agreement for naloxone, bringing naloxone to all 26 Walgreens stores in Rhode Island and training 80 Walgreens pharmacists in how to counsel patients on, train in, and dispense naloxone (without a prescription) to anyone who asks for it.
5. Federal Agencies Declare Support for Peer-Delivered Naloxone Distribution
Under the Bush Administration, officials in the Office of National Drug Control Policy (ONDCP) opposed peer-delivered naloxone. Then Deputy Director Bertha Madras said drug users "aren't likely to be competent to deal with an overdose emergency", and stated that "rescue programs might take away the drug user's motivation to get into detoxification and drug treatment". Obama's White House Office of National Drug Control Policy takes a position 180 degrees from Madras, supports overdose prevention and naloxone programs, and included them in the 2013 Drug Control Strategy. Also this year, the drug treament agency of the federal government, the Substance Abuse and Mental Health Services Administration (SAMHSA) published their long-awaited "Opioid Overdose Prevention Toolkit" which has five components targeting first responders, community members, patients, prescribers, and overdose survivors and their family members. The toolkit provides information on naloxone distribution and prescription and overdose prevention. Peer-delivered naloxone distribution has definitely gone from an underground movement to a mainstream-supported strategy in 2013. Next year, perhaps we can report some funding for this critical yet unfunded lifesaver.
6. Jail-Based Overdose Prevention and Naloxone Distribution Begins
Opiate overdoses are all too common among people released from jail due to decreased tolerance. In March 2013, the Harm Reduction Coalition's Drug Overdose Prevention and Education (DOPE) Project began providing naloxone to inmates of the San Francisco County Jail as they were discharged. The DOPE Project, in collaboration with SFDPH's Jail Health Services, conducts overdose prevention trainings inside the jail, and is able to put naloxone kits in the property of inmates who choose to participate for pick up when they are released. This is the first non-research study in the country to begin providing naloxone directly to inmates as they re-enter the community.
7. Good Samaritan Laws for People Witnessing Overdoses Gain Traction, Law Enforcement Support
Community activists have been working to get Good Samaritan laws passed to protect people from arrest and prosecution for drug possession when they call 911 to report an overdose. Fourteen states have now enacted these laws, as have ninety college campuses. The Florida effort in 2012 was notably initiated by Palm Beach police, a harbinger of change in law enforcement support for harm reduction measures.
8. Newly-Approved Hepatitis C Treatments Move Closer to Making Interferon-Free Cure a Reality for People Who Inject Drugs.
Hepatitis C remains endemic among people who inject drugs, with chronic infection rates of 70% or more among long-term injectors. While new infections have declined dramatically since peaking in the 1980s, due in part to the expansion of syringe access programs, several states report a new wave of hepatitis C infections among younger injectors. While hepatitis C is curable, treatment has traditionally required use of interferon, a drug with significant psychological and physical side effects that does not work for everyone and is difficult to tolerate for many, particularly current and former substance users. In December, the US Food and Drug Administration (FDA) approved a new hepatitis C medication sofosbuvir (Sovaldi, Gilead Sciences, Inc), which can be used without interferon for some people. Other therapies in development offer hope that all people with hepatitis C will have interferon-free treatment options available by the end of 2014.
9. Community Organizes to Mandate Hepatitis C Testing in New York
An estimated 3-4 million people are infected with the hepatitis C virus, and three quarters of them are unaware of it. Baby boomers - those born between 1945 and 1965 - make up over 70% of people with chronic infection, and are at highest risk of liver complications. Following CDC's 2012 recommendation of a one-time hepatitis C test for all baby boomers, a coalition of harm reduction workers, people who use drugs, and other allies passed a bill in New York mandating that doctors inform their patients and offer a hepatitis C test. As better-tolerated treatments with high cure rates become available, this legislation ensures that thousands of lives that may have been lost to liver cancer and other hepatitis C complications are diagnosed and treated.
10. Montreal Approved to Open Four Supervised Injection Sites
There are approximately 90 supervised injection sites worldwide in Europe and Australia, and only one in North America: InSite in Vancouver, British Columbia. After InSite's long legal fight with their conservative government, Canada's Supreme Court ruled in 2009 that the potential denial of health services and the correlative increase in the risk of death and disease to injection drug users outweigh any benefit that might be derived from maintaining an absolute prohibition on possession of illegal drugs on InSite's premises, allowing the facility to stay open indefinitely. In 2009, the site recorded 276,178 visits (an average of 702 visits per day) by 5,447 unique users; 484 overdoses occurred with no fatalities, due to intervention by medical staff. This month, Montreal was given permission to open four injection sites of their own, ensuring that Vancouver's InSite is the first but not the last legal supervised injection site in North America. Perhaps we finally succeed in opening one in the US in 2014.
Hilary McQuie is Regional Director of the Harm Reduction Coalition, and is based in Oakland, CA http://harmreduction.org/