Collateral Sanctions

A perennial favorite of drug warriors, bills that would require people receiving public benefits to submit to mandatory drug tests are being introduced in statehouses around the country again this year. In South Carolina, the focus is on people receiving unemployment benefits; in Kentucky, the focus is on people receiving any public assistance, including food stamps and state medical care. Meanwhile, in West Virginia, the author of last year's failed mandatory drug test bill for welfare recipients is back with a new, improved version. And in Florida, a similar drug testing bill is in the works.

Drug testing recipients of public assistance has a certain superficial appeal, especially to politicians willing to pander to culturally and fiscally conservative constituencies. But that appeal is usually found wanting in the face of questions about cost, practicality, and, most crucially, legality. Michigan is the only state to actually pass a law requiring mandatory drug testing to receive benefits, but that law was declared unconstitutional by a federal appeals court that held it violated the Fourth Amendment's protections against unreasonable searches.

That did not stop legislators in at least six states from introducing bills last year, and at least four states have seen bills filed or pre-filed so far this year.

In South Carolina, Sen. David Thomas (R-Greenville) has introduced S 920, which could cut off unemployment benefits for people who test positive for illegal drugs. Under the bill, anyone currently receiving benefits must submit to a drug test. If the test is positive, the benefits are cut off until the applicant completes drug treatment. The applicant must agree to random drug testing, and if he fails a random drug test, he must undergo a second round of treatment. He also loses benefits for a year.

"My concern is as much for those who are addicted or misusing drugs as for the folks that are paying the bills," Thomas told the Associated Press. "Ultimately, I think the question needs to be asked, 'Should unemployment be provided for people with ongoing drug problems, because they're using that unemployment money to feed the habit?'"

About 150,000 South Carolinians are currently receiving unemployment benefits. Testing each of them could run into the millions of dollars, and providing treatment for some percentage of them could prove costly as well.

Thomas' bill has been referred to the Senate Judiciary Committee. No hearings have been scheduled.

In Kentucky, the bill introduced by Rep. Lonnie Napier (R-Lancaster), HB 120, is even more ambitious that the South Carolina bill. It would require anyone seeking public assistance via cash, food stamps or the state medical assistance program to be drug tested. Nearly 740,000 Kentuckians receive food stamps and 748,000 receive medical assistance.

Under Napier's bill, all recipients would face an initial drug test and a random drug test at some point over the next year and every year they are receiving assistance. Those who test positive for a Schedule I controlled substance or a prescription drug not prescribed to them would be ineligible for benefits. The bill contains no provision for drug treatment, nor any provisions financing a million or more drug tests.

In West Virginia, Delegate Craig Blair (R-Berkeley), whose controversial bill to drug test welfare recipients was killed last year, is touting a new version of the bill, and this time, he has the backing of the House Republican caucus, which made the bill part of its 15-point legislative agenda this week. The new bill has some new twists: it calls for random drug testing of West Virginia elected officials, it would make drug testing of welfare recipients random instead of mandatory, and it would only apply to new welfare applicants. Under the new bill, randomly selected applicants who test positive could receive welfare benefits for two months, but after that, they would have to test clean or be in a drug treatment program or risk losing their benefits.

We will be watching these and any similar bills filed at statehouses around the country. Stay tuned!

Roughly 200,000 US veterans are in prison or jail, many of them there because of substance abuse or mental health issues, according to a new report released Wednesday. The report outlines the problem and suggests reforms that could ease the plight of American soldiers returning from the war zone and trying to make the transition back to civilian society.

VA Medical Center, Columbia, MO

The report, Healing a Broken System: Veterans Battling Addiction and Incarceration, comes at a critical time. With hundreds of thousands of soldiers currently deployed in Iraq and Afghanistan, the US faces a mounting challenge in caring for returning vets.

Many are returning home damaged by their experiences. According to the report, 30% of Iraq and Afghanistan veterans report symptoms of Post-Traumatic Stress Disorder (PTSD), traumatic brain injury, depression, mental illness, or other cognitive disability. These medical conditions, if left untreated, can contribute to problematic drug use, addiction, and fatal overdoses, as well as homelessness, suicide, and criminality, particular violations of the drug laws.

While the study mentions 200,000 vets behind bars, the number is most likely much higher. That's because owing to problems in data collection -- a problem in itself -- the last year for which hard numbers on vets behind bars is available was 2004. Since then, more than a million more vets have returned from their deployments and mustered out.

The report had its genesis about a year and a half ago, when the Drug Policy Alliance (DPA) teamed up with a classroom of law students at Northeastern University in Boston to investigate the obstacles veterans were facing in obtaining adequate access to mental health and substance abuse services. In addition to a series of surprising and dramatic findings, the report also includes a list of specific recommendations about how to improve services for vets suffering mental health and substance abuse issues.

"We learned that far too many returning vets are falling victim to the war on drugs because of barriers to effective treatment," said DPA's Dan Abrahamson at a Wednesday press conference. "There are nearly a quarter million vets behind bars right now for crimes motivated in part by mental health or drug addiction problems. One third of returning vets report symptoms of Post-Traumatic Stress Disorder (PTSD). Also, vets suffer from traumatic brain injury, depression, and mental illness at higher rates than normal. All of those are contributory factors to substance abuse and drug addiction, as well as overdose, homelessness, suicide, and being arrested for a non-violent drug offense."

In the battle theater, soldiers are supposed to function despite high stress, and the military is more than willing to prescribe them whatever it takes to keep them fighting. But it's a different story when the vets come home.

"Service-related drug dependency is being talked about quite a bit in the veterans community, but is not well understood outside the military," said Tom Tarantino, an Iraq war veteran and now legislative associate for Iraq and Afghanistan Veterans of America. "The ease of obtaining prescriptions in theater is staggering," he explained. "I know crack dealers who are more discriminating about issuing drugs than some of the medics I saw in Iraq. It's alarming how many people were just given anti-depressants instead of asking whether they were really fit for duty," said the veterans' lobbyist.

"Sometimes, it's just a matter of expediency and life in a combat zone, but then you have vets coming back from an environment where meds are very loosely prescribed and they are confronted with a medical system much more stringent about issuing drugs," Tarantino explained. "And that can cause problems."

"Let's be smarter than the problem," said veterans' advocate Guy Gambill. "We can't afford not to be. We arrest too many people and incarcerate them for too long. Then the mark of a criminal record keeps them from getting jobs, housing, and other services, and then the recidivism rate goes up."

There are things that can be done, Gambill said. States can change their incarceration policies. Localities can be more proactive.

"Chicago police and the LAPD are doing front-end interventions," Gambill noted. "In LA, trained peer specialists are doing ride-alongs with the LAPD so the officers will recognize Iraq and Afghanistan war vets. In Chicago, police are doing crisis intervention training, and the first hundred of them are all Iraq and Afghanistan vets. They'll try to grab these guys at first contact and get them into treatment instead of jail. These sorts of peer-led interventions work very well. We need to catch this on the front end, so we don't have 200,000 homeless vets on the streets like we do now."

Another stumbling block is the Department of Veterans Affairs current policy on drug treatment for vets. The VA is willing to offer treatment, but not for vets behind bars.

"We need the Department of Veterans Affairs to lift their ban on drug treatment of incarcerated vets," said Tarantino. "We're pleased that the department now has a justice coordinator at every VA hospital, but they're waiting outside the prison door, not inside, when the vets need it most. This is a regulation they can change with the stroke of a pen," he said.

Yet another problem for vets, especially those with substance abuse issues, is the lack of access to proven treatments. And because the insurance provided to soldiers by the armed forces also covers their families, lack of access to treatment affects them as well.

"Vets don't qualify for substance abuse treatment unless they are diagnosed with PTSD," said Abel Moreno, a former Army sergeant who saw service in both theaters and who now works with veterans through his organization Vets 4 Vets. "We are fighting two wars at once. It's obvious PTSD exists, and it's clear there are going to be substance abuse issues. We've created a subgenre among today's vets where there is a pain pill-popping mitigation ideal. We need quantified data so we can attack this situation head on," he said.

It's not only in failing to provide drug treatment absent a PTSD diagnosis where the DOD falls down, said Dr. Bob Newman, MD, director of the Rothschild Chemical Dependency Institute at Beth Israel Medical Center in New York City. "Tricare, the Department of Defense insurance plan refuses to pay for maintenance treatment of addiction with methadone or buprenorphine," he noted. "Maintenance therapy is not a new idea. It's endorsed by agencies such as NIDA, SAMHSA, the Institute of Medicine, and the World Health Organization. The US government supports this, yet DOD has an insurance plan that excludes maintenance treatment without explanation. That's outrageous," he said.

Tricare insures not only military personnel, but also their families. Tricare's refusal to pay for maintenance therapy nearly cost Teresa Bridges her daughter. Teresa's daughter, Amanda, married a soldier, Sgt. Shawn Dressler. Dressler was killed in combat shortly after the couple were wed, and Amanda retreated into a haze of Lortab and Tramitol. Tricare paid for her treatment, but after a year, her doctor noted on her records that she was being subscribed maintenance doses of Suboxone.

"Suddenly, Tricare dropped her like a hot potato," Bridges said. "Tricare believes taking Suboxone is just substituting one addictive drug for another -- at least that's what they told me. Amanda has done well on Suboxone, and if she stops taking it, she will eventually relapse. Fortunately, she is now in a temporary assistance program, but that will end after a year."

There are potential reforms that could ease the plight of returning vets, the report said. Among them are:

• Changes in state and federal statutes to focus on treatment instead of incarceration for veterans who commit nonviolent drug-related offenses.
• Adoption by government agencies of overdose prevention programs and policies targeting veterans who misuse substances or take prescription medications.
• Significantly expanded access for veterans to medication-assisted therapies such as methadone and buprenorphine to treat opioid dependence.

"The care and feeding and support of vets is a national concern and responsibility," said Gen. Stephen Xenakis, MD, Special Adviser to the Chairman of the Joint Chiefs for Staff, Warrior & Family Support . "We are looking to knit together all the various services and institutions so that the soldier who has served and come home and ends up having problems or maybe ended up incarcerated gets treatment from all the sources available."

One of the big problems, said Tarantino, is lack of hard information. He noted that the Justice Department numbers in the report are from 2004. "In 2004, there were over one million fewer vets than there are today," he said. "We don't know how many vets are behind bars right now. We have no method for tracking vets unless they interact with some social services. We need to have DOD and DOJ compare lists. We need data," he said.

Lack of coordination among agencies dealing with vets is part of the problem, said Xenakis. "We need to better configure what we're doing," he said. "Records are not shared. The Department of Justice doesn't have access to Department of Defense records. We need to get organized so we can track people over time."

That effort has the support of the Pentagon, Xenakis said. "Our leadership heartily endorses this," he said. "It is really important that this information that this information is out there now, and that we follow it with the best action plans we can create. As a country, we have a responsibility to support our vets."

Waimea, Hawaii, resident Kimberly Reyes died July 27 at Hilo Medical Center, 10 days after her insurance provider denied the liver transplant she needed because she had tested positive for marijuana in a series of toxicology tests. Reyes was not a registered medical marijuana user, but her family told the Honolulu Advertiser she had used it to deal with nausea, pain, and disorientation caused by the hepatitis that killed her.

Reyes' attorney, Ted Herhold of San Francisco, told the Observer that the diagnostic test results were the sole basis for Hawaii Medical Service Association's (HMSA) denial of transplant coverage. Reyes' husband Robin, and her mother, Noni Kuhns, said the decision was based on failure to comply with HMSA's policy forbidding drug use, but that neither HMSA nor her doctors had told her just what that policy was.

"Just because someone takes a hit off of a joint doesn't mean that it should be the end of their life -- this is not a reason to deny life," said Kuhns.

HMSA has refused to comment or provide its policies on drug use and transplant approval.

Denial of transplants to marijuana users has happened before. Last year, Seattle-area musician Timothy Garon died after being refused a transplant because of doctor-recommended medical marijuana use. In 2003, Oregon resident Dave Myers was removed from a transplant list merely for Marinol, a prescription medicine related to marijuana.