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Opioid Safety Is Focus of $1 Million-A-Year Educational Initiative

A group that represents patients living with pain has launched an initiative aimed at educating physicians and patients on how to prescribe and use opioids and other pain treatments safely. The $1 million-a-year project is called Pain Safety & Access for Everyone, or PainSAFE. It comes in response to a rise in deaths and overdoses related to opioid abuse and controversy over how the drugs are marketed.
Publication/Source: 
American Medical News (IL)
URL: 
http://www.ama-assn.org/amednews/2010/10/25/prsb1025.htm

FDA Approves Once-A-Month Injectable Drug to Fight Opiate Addiction

The US Food and Drug Administration (FDA) announced Tuesday that it had approved a once-a-month injectable drug for use in treating opiate addiction. The drug, marketed as Vivitrol, is a form of naloxone, an opioid atagonist that blocks the action of opioids on brain cells and is currently used in responding to overdoses.

In approving Vivitrol, the FDA cited a Russian study with 250 heroin addicts that found it reduces relapse rates and blocks cravings for narcotics. In that study, after six months, 86% of subjects taking Vivitrol had stayed off opiates and were functioning in work or school, compared to only 57% who were given a placebo.

Unlike methadone and buprenorphine, which are commonly used in opiate substitution treatments, Vivitrol is not addictive and does not maintain opiate dependency. Additionally, unlike those two substitutes, Vivitrol does not need to be taken daily, but is instead administered monthly via intramuscular injection.

The approval of Vivitrol for opiate addiction is "an important turning point in our approach to treatment," said Dr. Nora Volkow, head of the National Institute on Drug Abuse, in a statement greeting the FDA announcement.

Nearly 810,000 Americans are addicted to heroin, with more than twice that number using prescription opioids, such as Oxycontin and Vicodin, for non-prescription purposes, Volkow noted.

Washington, DC
United States

The Right to Survive Overdoses

Our friends at the Hungarian Civil Liberties Union, in honor of Overdose Awareness Day (August 31), have produced a new video, "Take Home Naloxone -- The Right to Survive Overdoses." There are many legal, political and attitudinal barriers that currently stand in the way of getting this life-saving medication to the people who need it, when they need it, and numerous lives have been needlessly lost as a result. You can help overcome those barriers by distributing this video and helping to eliminate the prejudices and inertia that currently stand in the way of Naloxone distribution.

Harm Reduction: Washington State 911 Good Samaritan Law to Prevent ODs Now in Effect

A law that provides some legal immunity for people who report a drug overdose in Washington state is now in effect, having kicked in on June 10. That makes Washington the second state to enact a "911 Good Samaritan Law." New Mexico was the first in 2007.

Under the measure, if someone overdoses and someone else seeks assistance, that person cannot be prosecuted for drug possession, nor can the person overdosing. Good Samaritans who manufactured or sold drugs could, however, be charged with those offenses.

The measure is aimed at reducing drug overdoses by removing the fear of arrest as an impediment to seeking medical help. According to the state Department of Health, there were 820 fatal drug overdoses in the state in 2006, more than double the 403 in 1999.

The bill also allows people to use the opioid agonist naloxone, which counteracts the effects of opiate overdoses, if it is used to help prevent an overdose.

Washington is the first state this year to pass a 911 Good Samaritan bill, but it may not be the last. According to the National Conference of State Legislatures, Hawaii, Massachusetts, Minnesota, and Rhode Island are considering similar measures.

Supporters of the new law held a press conference June 5 to tout its benefits. "In 2008, there were 794 drug overdose deaths in Washington state," said Dr. Caleb Banta-Green, a drug overdose researcher from the University of Washington. "These overdoses do not need to be fatal. Death often takes several hours to occur," and people are often present. He said more information on the law is available at http://www.stopoverdose.org.

"We're here today to encourage people who don't work in hospitals to help saves lives," Attorney General Rob McKenna said. "More people are dying now from prescription drug overdoses (than traffic accidents) and yet fewer people are aware of it," McKenna said. He said drug overdoses are a hidden problem because they aren't as visible as other problems.

Sen. Rosa Franklin, who worked to pass the bill, said she worked as a nurse before becoming a legislator and wanted to address a problem she saw and read about. She said this bill will save lives. "We can no longer... put our heads in the sand and say that drug overdose is not happening."

Alison Holcomb of the ACLU of Washington said drug overdoses wouldn't happen in an ideal world, and this law wouldn't be necessary. She said people do drugs to cope, find acceptance or escape. "We can continue to condemn such people as morally deviant and treat them as criminals," but, she said, that doesn't work. She said this law is an important step and a compromise agreement.

"My son, a bright, creative, compassionate and funny kid, began using prescription opiates... during his senior year of high school," John Gahagan said. Just weeks after graduation, his son died of a drug overdose. "The 911 Good Samaritan Law will save lives," he said, adding that his son was alone at the time of his overdose, but he knows parents of other teens who could have been saved. "This law will only be effective if there is awareness of it... Call 911 to save a life," he said.

Washington State 911 Good Samaritan Law to Prevent ODs Now in Effect

A law that provides some legal immunity for people who report a drug overdose in Washington state is now in effect. That makes Washington the second state to enact a "911 Good Samaritan Law." New Mexico was the first in 2007. Under the measure, if someone overdoses and someone else seeks assistance, that person cannot be prosecuted for drug possession, nor can the person overdosing. Good Samaritans could, however, be charged with manufacturing or selling drugs. The measure is aimed at reducing drug overdoses by removing the fear of arrest as an impediment to seeking medical help. According to the state Department of Health, there were 820 fatal drug overdoses in the state in 2006, more than double the 403 in 1999. The bill also allows people to use the opioid agonist naloxone, which counteracts the effects of opiate overdoses, if it is used to help prevent an overdose. Washington is the first state this year to pass a 911 Good Samaritan bill, but it may not be the last. According to the National Conference of State Legislatures, Hawaii, Massachusetts, Minnesota, and Rhode Island are considering similar measures. Supporters of the new law held a press conference Monday to tout its benefits. “In 2008, there were 794 drug overdose deaths in Washington state,” said Dr. Caleb Banta-Green, a drug overdose researcher from the University of Washington. “These overdoses do not need to be fatal. Death often takes several hours to occur,” and people are often present. He said more information on the law is available at www.stopoverdose.org. “We’re here today to encourage people who don’t work in hospitals to help saves lives,” Attorney General Rob McKenna said. “More people are dying now from prescription drug overdoses (than traffic accidents) and yet fewer people are aware of it,” McKenna said. He said drug overdoses are a hidden problem because they aren’t as visible as, for example, traffic accidents.. Sen. Rosa Franklin, who worked to pass the bill, said she worked as a nurse before becoming a legislator and wanted to address a problem she saw and read about. She said this bill will save lives. “We can no longer … put our heads in the sand and say that drug overdose is not happening.” Alison Holcomb of the ACLU of Washington said drug overdoses wouldn’t happen in an ideal world, and this law wouldn’t be necessary. She said people do drugs to cope, find acceptance or escape. “We can continue to condemn such people as morally deviant and treat them as criminals,” but, she said, that doesn’t work. She said this law is an important step and a compromise agreement. “My son, a bright, creative, compassionate and funny kid, began using prescription opiates … during his senior year of high school,” John Gahagan said. Just weeks after graduation, his son died of a drug overdose. “The 911 Good Samaritan Law will save lives,” he said, adding that his son was alone at the time of his overdose, but he knows parents of other teens who could have been saved. “This law will only be effective if there is awareness of it … Call 911 to save a life,” he said.
Location: 
WA
United States

Feature: Pennsylvania Lawmakers' Aim at Reducing Methadone Deaths, But Shoot Wide

Late last month, Pennsylvania state Senate Republicans -- and one Senate Democrat -- held a press conference at the statehouse in Harrisburg to roll out their "Methadone Accountability Package." The package, they said, aims at increasing safety and fiscal accountability and reducing the illicit use of methadone and methadone overdose deaths. A related Senate resolution is also calling for a moratorium on new methadone treatment centers. But methadone treatment advocates and researchers are cautioning that the package may be unnecessary, and are calling for any legislation on methadone to be based on facts and scientific evidence -- rather than overheated rhetoric and anecdotes.

Drug overdoses have risen nationally in recent years, with the increase generally being attributed to increased use of prescription medications such as methadone and buprenorphine. Advocates have suggested overdose prevention approaches such as "Good Samaritan" policies protecting people who call for help -- Washington state's legislature enacted one this week -- or distribution of the overdose antidote naloxone, as ways of stemming the tide. But the PA package announced this week goes a different direction.

http://www.stopthedrugwar.org/files/pamethadonebills.jpg
the dark side: legislators seeking dramatic methadone restrictions
While the bundle of bills addresses keeping track of methadone-related deaths (SB 1293), diversion control (SB 1376), driving while using methadone (SB 1377, SB 1378), and micromanaging methadone maintenance treatment (SB 1382, SB 1383), the bill that strikes most directly at methadone maintenance treatment for opiate-dependent individuals, is SB 1294, the Methadone Addiction Prevention and Treatment Act, introduced by Sen. Mike Stack (D-District 5). Stack's bill would mandate that:

  • Potential patients be addicted to opiates for at least one year before methadone treatment is considered;
  • Potential patients must have twice failed other forms of treatment;
  • Patients have a written plan with goals and dates to be free from drug dependence, including methadone, within two to three years;
  • Patients must have a designated driver come with them to the clinic for the first two weeks of treatment; and
  • Driving under the influence of more than the prescribed dose of methadone be a violation of state driving under the influence laws.

"Pennsylvania needs better laws to prevent methadone abuse and provide patients with the proper protections and treatment plans they need to achieve a lifetime of sobriety," Sen. Stack said. "This package of bills is a solid step toward achieving those goals."

"Pennsylvania's law has not kept pace with the changes in the prescription of methadone -- and too frequently with deadly consequences," said Sen. John Eichelberger (R-District 30). "Methadone is a drug with its own unique properties. One pill or one dose can kill a non- or low-opiate-tolerant person. Even a day or two after the drug is taken, it has led to fatalities for those who mix alcohol or other drugs."

The senators cited reports from the National Drug Intelligence Center that unlawful diversion of methadone had more than doubled between 2003 and 2007 and from the National Center for Health Statistics that the number of methadone overdose deaths had increased nearly five-fold, with OD deaths among young people (15-24) increasing eleven-fold.

Not so fast, say experts. "Let's be careful about this; there are a lot of lives at stake here," said Eric Hulsey, director of performance, evaluation, and program development at the Institute for Research, Education, and Training in Addictions in Pittsburgh. "If the intention behind this stuff is better clinical care, that's a great thing, but we have to caution that it needs to be grounded on evidence-based practice."

Hulsey and National Association for Medication Assisted Recovery president Roxanne Baker also questioned some of the specifics in SB 1294. For Baker, the objections are a bill-killer.

"I would have to oppose this bill because it's too restrictive," she said. "There are already state and federal regulations on methadone treatment centers. Medicine is best left to doctors, not legislators."

Baker objected to the bill's provision for pushing methadone maintenance patients to get off the drug. "They really push the methadone abstinence schedule, don't they," she said. "Here in California, they just say it would be 'harmful to the patient' to taper off. I don't know why that needs to be in there; they don't make you taper off thyroid medication or insulin."

Hulsey didn't see a lot of evidence that methadone maintenance clinics are behind the problems being cited by the politicians. "Methadone prescribing has gone up seven-fold around the country, and we've seen all these methadone overdoses. Most of the federal reports and researchers have concluded that this is coming from the pain management clinics, yet everyone wants to crack down on the methadone treatment clinics."

Methadone treatment clinics are operated under different and stricter sets of regulations than pain clinics, Hulsey said. "It's unclear what the pain clinics are doing to prevent adverse incidents at their facilities, but it is clear that most diverted meds are coming from pain management, therefore, let's legislate against methadone maintenance clinics?"

Not that cracking down on pain clinics is the answer either, according to NAMA's Baker. Pointing out that methadone maintenance clinics are not the problem is fine, she said, but let's not be too quick to go after pain doctors. Citing the massive under-treatment of chronic pain in this country and her own decades-long experience with methadone in both the treatment and the pain clinic milieus, she said methadone patients already face enough barriers.

"I've been taking methadone since 1974," she said. "I stood in those methadone treatment lines, but now I get my medication from a pain specialist. A lot of people want to do that because they treat you better -- if you can find one who will treat you at all."

And that is a problem, Baker said. "A lot of doctors don't want to treat pain patients because they have the DEA breathing down their necks. We don't need more obstacles."

"This is misdirected legislation," said Mark Parrino, president of the American Association for the Treatment of Opioid Dependence. "Methadone treatment programs have been functioning for more than 40 years with a considerable degree of safety. There have been at least four federal studies showing that increasing methadone mortality is based on that fact that it is increasingly being used in pain management. If the legislation doesn't address the cause of the problem, it has no basis for existing."

"The science doesn't support a hard and fast rule to get off licit opiates," said Hulsey. "It can be very dangerous to put arbitrary deadlines on that. Treatment has to be individualized to promote recovery."

For Hulsey, the bill's requirement that potential patients first twice fail at treatment is just not good policy. "I am not aware of science that supports 'you fail first' policies," he said. "If you go to the expert consensus guidelines for management of methadone facilities, and more importantly, accepted patient placement criteria, you must demonstrate a year's dependency, as well as other thresholds, and that is what should determine appropriate placement. 'Fail first' doesn't capture the full range of factors that experts have agreed upon as the best approach for opiate-dependent individuals."

The consensus guidelines Hulsey cited were SAMSHA/CSAT's Treatment Improvement Protocol 43 and the American Society of Addiction Medicine's Patient Placement Criteria.

"Those are the gold standard for treatment," he said. "They provide a six-dimensional approach to dependence, and you would need to meet those criteria to be appropriately placed in methadone maintenance. It's not appropriate for everybody. Some people may require a detox approach rather than long-term maintenance."

For Hulsey, having the designated driver requirement for new patients was "good risk management," but creating methadone-impaired driving offenses seemed unnecessary. "There are already laws on the books regarding impairment," he said.

Nobody thought the moratorium on new methadone maintenance clinics was a smart move. "They shouldn't do that," said NAMA's Baker. "They don't put moratoriums on doctors who prescribe treatments for diabetics. But there is a lot of NIMBYism in Pennsylvania."

"Addiction is a chronic disease that is treatable when appropriate evidence-based treatment approaches are applied," said Hulsey. "We want to promote recovery and support people rather than limiting access. If we limit the treatment opportunities, we make these people criminals."

Parrino didn't think much of the moratorium idea, either. "You can have a moratorium, but that doesn't reduce the demand for treatment, so what's the rationale for restricting access to care? Do we think the number of people who need this has capped out? That state has to be careful saying that a moratorium seems smart, especially when the problem is not related to the treatment programs you're dealing with," he said.

But methadone maintenance clinics make convenient targets for a number of reasons, said Parrino. "There is NIMBYism, and there is a general stigma about treating addiction, which increases markedly when you talk about the use of medications to treat opiate addiction," he pointed out.

"And elected officials always feel like 'we must do something,'" he continued. "But unless the legislature is able to be more precise in identifying the problem and how to deal with it, I would suggest that they are not addressing the real source of the problem, but doing what seems manageable and convenient. It's easy to say let's put more restrictions on top of a system that is already highly regulated, but pain doctors aren't regulated at all."

So faced with mounting methadone mortality and increasing diversion not linked to methadone maintenance clinics, Pennsylvania legislators are aiming squarely at those clinics. The legislature and the people of Pennsylvania would be better served if this package of bills went back to the drawing board.

Feature: Schwarzenegger Trying to Gut California Methadone Funding in Budget Move

With California facing a $19 billion budget deficit, Gov. Arnold Schwarzenegger (R) last month proposed saving the state $53 million by cutting off Medi-Cal funding for methadone maintenance for most heroin addicts. That would cause the loss of more than $60 million in matching federal funds. The move was fiercely resisted by methadone advocates -- including a former drug czar -- and public policy analysts, and the proposal was defeated last week in committee votes in the state Senate and Assembly.

But California gives the governor the power to veto individual budget items, so advocates are not resting yet. Instead they are reaching out to the administration in hopes they can enlighten it and persuade the budget axe-wielding Schwarzenegger to aim elsewhere.

Schwarzenegger isn't the first top-tier elected official to go after methadone maintenance. Back in 1999, then New York City Mayor Rudy Giuliani vowed to wean all of the city's methadone patients off it in three months. While Giuliani acted for ideological rather than budgetary reasons -- he said he wanted "drug freedom," not drug dependence -- the pugnacious mayor later changed his tune, admitting the idea was "maybe somewhat unrealistic."

http://stopthedrugwar.org/files/harm-reduction-superheroes-vancouver.jpg
superheroes for harm reduction: ''Methadone Man'' public awareness campaign during last February's Olympics in Vancouver. You're needed everywhere, Methadone Man.
Currently, nearly 150 methadone clinics provide the heroin substitute to some 35,000 addicts, 55% of whom are on Medi-Cal. Advocates and treatment providers said that clinics would be forced to close if the proposal passed, affecting not only the Medi-Cal patients, but also patients who paid out of their own pockets or through private insurance to be able to get maintenance methadone.

"Methadone isn't a cure," said Roxanne Baker, president of the National Alliance of Methadone Advocates (NAMA), "but much like thyroid medication, as long as you keep taking it, it keeps your disease in check, and opiate addiction is a disease. When you mess with your brain with painkillers, it then doesn't produce the endorphins it should. It's not a matter of will power, it's a disease. You need something to replace those endorphins, whether its methadone, suboxone, or even prescription heroin, although I doubt we'll ever see that here."

Enacting the proposed cuts would be "a disaster," said Baker. "There would be no methadone programs left. More than half the patients statewide are on drug MediCal, and they wouldn't even have a place to go. A lot of these people have their lives in order. This is somebody's brother, somebody's aunt, somebody's mom. Please don't take this from us."

Last week, Clinton-era drug czar Gen. Barry McCaffrey flew into the state to hold a press conference denouncing the cut. "Dumping tens of thousands of opiate addicts back on the street would be an immediate disaster to law enforcement, and to the families of people who have become stable, functioning adults" thanks to methadone, said McCaffrey, who has a consulting firm and serves on the board of directors of an organization that treats chemical dependency.

Legislators were listening, not only to McCaffrey, but to the methadone treatment community. A Senate Budget Committee hearing last week proved tough going for Schwarzenegger's representatives.

"This measure would eliminate the drug MediCal program with the exception of the perinatal and youth funding," said John Wardlaw from the state Department of Finance. "This is not an easy reduction in any way. We are at the point where we are making very difficult reductions."

Committee Chair Denise Moreno Ducheny (D-San Diego) wasn't buying it. "How much federal funding are you giving up?" she asked.

"Sixty-six million dollars," Wardlaw said.

"We save $53 million and lose $66 million?" asked Ducheny.

"That is correct, ma'am."

Ducheny just stared at him for a few uncomfortable moments before moving on to the next witness.

"There would be cost shifts in the area of corrections and child welfare services," Greg Tallivant of the legislative analysts' office told the solons. "The day the clinic closes, those people have to do something. If they can't make it to the next methadone clinic, heroin would be the next choice. You would see people arrested. You would see prison costs and child welfare costs go up."

Assemblyman Mark Leno (D-San Francisco) was visibly irritated by the proposal. "There is a complete lack of interest in any cost-benefit analysis here," he said. "This is reckless and cavalier. It doesn't really make much sense. We have 171,000 people addicted to drugs. This will increase our crime rate; it's a recipe for disaster on our streets. Does the governor have no interest in this or does he not believe that this will impact the safety of our children and communities? We've already zero-funded the base Proposition 36 program. The outcome of this is to have drug offenders with no jail and no treatment."

"This is really a short-sighted proposal that shifts costs from funding treatment to funding law enforcement, jails, and prisons," said Jason Kletter, a member of the Bay Area Addiction Research Team (BAART), which is in turn a member of California Opioid Maintenance Providers (COMP), a nonprofit organization representing opioid maintenance treatment centers. "It is a public safety issue, to say nothing of the humanitarian crisis it would provoke," he said.

"We think if this happened many clinics would close, and the folks who lose access to care would likely relapse and cost the system much, much more in a short time," said Kletter. "We see relapse rates of 80% within a year when clinics close, so it wouldn't even be like we'd be kicking the can three or four years down the road."

"This would have the biggest impact on programs that have a high percentage of Medi-Cal beneficiaries in treatment and would be unable to stay open because more than half their patients, and thus, their revenues, are gone," said Kletter. "You would have a fundamental dismantling of the system."

The cost incurred would be staggering, Kletter said."If 80% relapse in same year, we know that the state will incur $700 million to $1 billion in new costs in the criminal justice system," he said, citing a study from the 1990s that found each dollar invested in treatment produced a seven-dollar return. "The state wants to save $53 million by eliminating drug Medi-Cal and will also turn away more than $60 million in matching funds. That's $115 total program cost. A seven-to-one return on that is close to a billion dollars. "With 80% relapse, we could end up seeing $700 million in new criminal justice and prison costs."

"It's a terrible proposal," said Glenn Backes, a Sacramento-based public policy analyst who works with the Drug Policy Alliance at the Capitol. "California Democrats in both houses have said so. The Senate Republicans didn't do a cost-benefit analysis; they just said we can't afford to give out subsidized health care."

But in reality, the situation is even worse, said Backes. "They've killed Proposition 36 funding, drug courts are being slashed. According to the governor's finance director, that's 171,000 patients. The cost-benefit for this is worse than nil. If only one out of a thousand relapses and goes to prison, you've already lost money because prison is so much more expensive than treatment. If only one out of a thousand gets Hep C, the taxpayer loses. If only one out of a thousand gets HIV, the taxpayer loses."

It's easy to lose the human side in all the numbers, Backes said. "If only one out of a thousand ODs and dies, that's 170 California families who have lost a loved one."

And the battle continues. "While both the Senate and the Assembly budget committees have rejected the governor's proposal, in California, the governor has a line item veto," said Kletter. "We are continuing to try to work with the administration to explain the impact of this kind of proposal and get them to understand it is a public safety and cost-shifting issue. We haven't had any direct meeting with them yet, but that's next on our agenda. We want to educate them about them dire consequences of this sort of action."

Even if advocates many to salvage the drug Medi-Cal program, they would be well-advised to be searching for alternative funding sources, and how better than to take money from the drug war? Tough times call for creative solutions, and Backes has one: Use federal Byrne Justice Assistance Grants to fund treatment instead of drug task forces. Every dollar funding more drug war arrests costs $10 additional in spending for courts and prisons, he said.

"Historically, Byrne grant funds have been given to task forces to increase arrests," Backes noted. "The Drug Policy Alliance position is that Byrne funds would be better spent on almost anything other than doing low-level drug sweeps. We would rather see that money go into treatment for people in the system."

Feature: Obama's First National Drug Strategy -- The Good, the Bad, and the Ugly

A leaked draft of the overdue 2010 National Drug Strategy was published by Newsweek over the weekend, and it reveals some positive shifts away from Bush-era drug policy paradigms and toward more progressive and pragmatic approaches. But there is a lot of continuity as well, and despite the Obama administration's rhetorical shift away from the "war on drugs," the drug war juggernaut is still rolling along.

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sign of the leaker?
That doesn't quite jibe with Office of National Drug Control Policy (ONDCP -- the drug czar's office) director Gil Kerlikowske's words when he announced in April 2009 that the phrase "war on drugs" was no longer in favor. "Regardless of how you try to explain to people it's a 'war on drugs' or a 'war on a product,' people see a war as a war on them. We're not at war with people in this country."

The leak was reported by long-time Washington insider and Newsweek columnist Michael Isikoff, who mentioned it almost off-handedly in a piece asserting "The White House Drug Czar's Diminished Status." Isikoff asserted in the piece that the unveiling of the strategy had been delayed because Kerlikowske didn't have the clout to get President Obama to schedule a joint appearance to release it. His office had been downgraded from cabinet level, Isikoff noted.

That sparked an angry retort from UCLA professor Mark Kleiman, a burr under the saddle to prohibitionists and anti-prohibitionists alike for his heterodox views on drug policy. In a blog post, Kleiman seemed personally offended at the leak, twice referring to the leaker as "a jerk," defending the new drug strategy as innovative if bound by interagency politics, and deriding Isikoff's article as "gossipy."

Kleiman also suggested strongly that the leaker was none other than former John Walters on the basis of an editing mark on the document that had his name on it. But Walters has not confirmed that, and others have point out it could have been a current staffer who is using the same computer Walters used while in office.

On the plus side, the draft strategy embraces some harm reduction programs, such as needle exchanges and the use of naloxone to prevent overdoses, although without ever uttering the words "harm reduction." There is also a renewed emphasis on prevention and treatment, with slight spending increases. But again reality fails to live up to rhetoric, with overall federal drug control spending maintaining the long-lived 2:1 ration in spending for law enforcement, eradication, and interdiction versus that for treatment and prevention.

The strategy also promotes alternatives to incarceration, such drug courts, community courts and the like and for the first time hints that it recognizes the harms that can be caused by the punitive approach to drug policy. And it explicitly calls for reform of the sentencing disparity for crack and powder cocaine offenses.

It sets a number of measurable goals related to reducing drug use. By 2015, ONDCP vows to cut last month drug use by young adults by 10% and cut last month use by teens, lifetime use by 8th graders, and the number of chronic drug users by 15%.

The 2010 goals of a 15% reduction reflect diminishing expectations after years of more ambitious drug use reduction goals followed by the drug policy establishment's inability to achieve them. That could inoculate the Obama administration from the kind of criticism faced by the Clinton administration back in the 1990s when it did set much more ambitious goals.

The Clinton administration's 1998 National Drug Control Strategy called for a "ten-year conceptual framework to reduce drug use and drug availability by 50%." That didn't happen. That strategy put the number of drug users at 13.5 million, but instead of decreasing, according to the 2008 National Household Survey on Drug Abuse and Health, by 2007 the number of drug users was at 20.1 million.

While Clinton took criticism from Republicans that his goals were not ambitious enough -- Newt Gingrich said we should just wipe out drugs -- the Bush administration set similar goals, and achieved similarly modest results. The Bush administration's 2002 National Drug Control Strategy sought a 25% reduction in drug use by both teenagers and adults within five years. While teen drug use declined from 11.6% in 2002 to 9.3% in 2007, then drug czar Walters missed his goal. He did less well with adult use almost unchanged, at 6.3% in 2000 and 5.9% in 2007.

The draft strategy, however, remains wedded to law enforcement, eradication, and interdiction, calls for strong federal support for local drug task forces, and explicitly rejects marijuana legalization. It also seeks to make drugged driving a top priority, which would be especially problematic if the administration adopts per se zero tolerance measures (meaning the presence of any metabolites of a controlled substance could result in a driver's arrest whether he was actually impaired or not).

Still, while the draft strategy is definitely a mixed bag, a pair of keen observers of ONDCP and federal drug policy pronounced themselves fairly pleased overall. While still heavy on the law enforcement side, the first Obama national drug strategy is a far cry from the propaganda-driven documents of Bush era drug czar John Walters.

The Good

"This is somewhat of a surprise, because for the first time they have included reducing the funds associated with the drug war in their strategy, although not in a big way, they're calling for reform of the crack/powder cocaine sentencing disparity, and they are calling for the reform of laws that penalize people," said Bill Piper, national affairs director for the Drug Policy Alliance. "This is the first time they've included anything recognizing that some of our policies are creating harm," he added.

"The stuff about syringe exchange and naloxone for overdose prevention is pretty good. It's the first time they've embraced any part of harm reduction, even though they don't use that name," Piper noted.

"I'm also impressed with the section on alternatives to incarceration," said Piper. "They basically said most drug users don't belong in jail, and a lot of dealers don't, either. It's still wedded to the criminal justice system, but it's good that they looked at so many different things -- drug courts, community courts, Operation Highpoint (warning dealers to desist instead of just arresting them as a means of breaking up open-air drug markets), programs for veterans. They seem interested in finding out what works, which is an evidence-based approach that had been lacking in previous strategies."

The Status Quo

"Drug war reformers have eagerly been waiting the release of President Obama's first National Drug Control Strategy," noted Matthew Robinson, professor of Government and Justice Studies at Appalachian State University and coauthor (with Renee Scherlen) of "Lies, Damned Lies, and Drug War Statistics: A Critical Analysis of Claims Made by the ONDCP." "Would it put Obama's and Kerlikowske's words into action, or would it be more of the same in terms of federal drug control policy? The answer is yes. And no. There is real, meaningful, exciting change proposed in the 2010 Strategy. But there's a lot of the status quo, too," he said.

"The first sentence of the Strategy hints at status quo approaches to federal drug control policy; it announces 'a blueprint for reducing illicit drug use and its harmful consequences in America,'" Robinson said. "That ONDCP will still focus on drug use (as opposed to abuse) is unfortunate, for the fact remains that most drug use is normal, recreational, pro-social, and even beneficial to users; it does not usually lead to bad outcomes for users, including abuse or addiction," he said.

"Just like under the leadership of Director John Walters, Kerlikowske's ONDCP characterizes its drug control approaches as 'balanced,' yet FY 2011 federal drug control spending is still imbalanced in favor of supply side measures (64%), while the demand side measures of treatment and prevention will only receive 36% of the budget," Robinson pointed out. "In FY 2010, the percentages were 65% and 35%, respectively. Perhaps when Barack Obama said 'Change we can believe in,' what he really meant was 'Change you can believe in, one percentage point at a time.'"

There is also much of the status quo in funding levels, Robinson said. "There will also be plenty of drug war funding left in this 'non-war on drugs.' For example, FY 2011 federal drug control spending includes $3.8 billion for the Department of Homeland Security (which includes Customs and Border Protection spending), more than $3.4 billion for the Department of Justice (which includes Drug Enforcement Agency spending), and nearly $1.6 billion for the Department of Defense (which includes military spending). Thus, the drug war will continue on under President Obama even if White House officials do not refer to federal drug control policy as a 'war on drugs,'" he noted.

The Bad

"ONDCP repeatedly stresses the importance of reducing supply of drugs into the United States through crop eradication and interdiction efforts, international collaboration, disruption of drug smuggling organizations, and so forth," Robinson noted. "It still promotes efforts like Plan Colombia, the Southwest Border Counternarcotics Strategy, and many other similar programs aimed at eradicating drugs in foreign countries and preventing them from entering the United States. The bottom line here is that the 'non war on drugs' will still look and feel like a war on drugs under President Obama, especially to citizens of the foreign nations where the United States does the bulk of its drug war fighting."

"They are still wedded to interdiction and eradication," said Piper. "There is no recognition that they aren't very effective and do more harm than good. Coming only a couple of weeks after the drug czar testified under oath that eradication in Colombia and Afghanistan and elsewhere had no impact on the availability of drugs in the US, to then put out a strategy embracing what he said was least effective is quite disturbing."

"The ringing endorsement of per se standards for drugged driving is potentially troubling," said Piper. "It looks a lot like zero tolerance. We have to look at this also in the context of new performance measures, which are missing from the draft. In the introduction, they talk about setting goals for reducing drug use and that they went to set other performance measures, such as for reducing drug overdoses and drugged driving. If they actually say they're going to reduce drugged driving by such and such an amount with a certain number of years, that will be more important. We'll have to see what makes it into the final draft."

"They took a gratuitous shot at marijuana reform," Piper noted. "It was unfortunate they felt the need to bash something that half of Americans support and to do it in the way they did, listing a litany of Reefer Madness allegations and connecting marijuana to virtually every problem in America. That was really unfortunate."

More Good

There are some changes in spending priorities. "Spending on prevention will grow 13.4% from FY 2010 to FY 2011, while spending on treatment will grow 3.7%," Robinson noted. "The growth in treatment is surprisingly small given that ONDCP notes that 90% of people who need treatment do not receive it. Increases are much smaller for spending on interdiction (an increase of 2.4%), domestic law enforcement (an increase of 1.9%), and international spending (an increase of 0.9%). This is evidence of a shift in federal drug control strategy under President Obama; there will be a greater effort to prevent drug use in the first place as well as treat those that become addicted to drugs than there ever was under President Bush."

Robinson also lauded the Obama administration for more clarity in the strategy than was evident under either Clinton or Bush. "Obama's first Strategy clearly states its guiding principles, each of which is followed by a specific set of actions to be initiated and implemented over time to achieve goals and objectives related to its principles. Of course, this is Obama's first Strategy, so in subsequent years, there will be more data presented for evaluation purposes, and it should become easier to decipher the ideology that will drive the 'non war on drugs' under President Obama," he said.

But he suggested that ideology still plays too big a role. "ONDCP hints at its ideology when it claims that programs such as 'interdiction, anti-trafficking initiatives, drug crop reduction, intelligence sharing and partner nation capacity building... have proven effective in the past.' It offers almost no evidence that this is the case other than some very limited, short-term data on potential cocaine production in Colombia. ONDCP claims it is declining, yet only offers data from 2007 to 2008. Kerlikowske's ONDCP seems ready to accept the dominant drug war ideology of Walters that supply side measures work -- even when long-term data show they do not."

Robinson also lauded ONDCP's apparent revelation that drug addiction is a disease. "Obama's first strategy embraces a new approach to achieving federal drug control goals of 'reducing illicit drug consumption' and 'reducing the consequences of illicit drug use in the United States,' one that is evidence-based and public health oriented," Robinson said. "ONDCP recognizes that drug addiction is a disease and it specifies that federal drug control policy should be assisted by parties in all of the systems that relate to drug use and abuse, including families, schools, communities, faith-based organizations, the medical profession, and so forth. This is certainly a change from the Bush Administration, which repeatedly characterized drug use as a moral or personal failing."

While the Obama drug strategy may have its faults, said Robinson, it is a qualitative improvement over Bush era drug strategies. "Under the Bush Administration, ONDCP came across as downright dismissive of data, evidence, and science, unless it was used to generate fear and increased punitive responses to drug-related behaviors. Honestly, there is very little of this in Obama's first strategy, aside from the usual drugs produce crime, disorder, family disruption, illness, addiction, death, and terrorism argument that has for so long been employed by ONDCP," he said. "Instead, the Strategy is hopeful in tone and lays out dozens of concrete programs and policies that aim to prevent drug use among young people (through public education programs, mentoring initiatives, increasing collaboration between public health and safety organizations); treat adults who have developed drug abuse and addiction problems (though screening and intervention by medical personnel, increased investments in addiction treatment, new treatment medications); and, for the first time, invest heavily in recovery efforts that are restorative in nature and aimed at giving addicts a new lease on life," he noted.

"ONDCP also seems to suddenly have a better grasp on why the vast majority of people who need treatment do not get it," said Robinson. "Under Walters, ONDCP claimed that drug users were in denial and needed to be compassionately coerced to seek treatment. In the 2010 Strategy, ONDCP outlines numerous problems with delivery of treatment services including problems with the nation's health care systems generally. The 2010 Strategy seems so much better informed about the realities of drug treatment than previous Strategy reports," he added.

"The strategy also repeatedly calls for meaningful change in areas such as alternatives to incarceration for nonviolent, low-level drug offenders; drug testing in courts (and schools, unfortunately, in spite of data showing it is ineffective); and reentry programs for inmates who need help finding jobs and places to live upon release from prison or jail. ONDCP also implicitly acknowledges that that federal drug control policy imposes costs on families (including the break-up of families), and shows with real data that costs are greater economically for imprisonment of mothers and foster care for their children than family-based treatment," Robinson noted.

"ONDCP makes the case that we are wasting a lot of money dealing with the consequences of drug use and abuse when this money would be better spent preventing use and abuse in the first place. Drug policy reformers will embrace this claim," Robinson predicted.

"The strategy also calls for a renewed emphasis on prescription drug abuse, which it calls 'the fastest growing drug problem in the United States,'" Robinson pointed out. "Here, as in the past, ONDCP suggests regulation is the answer because prescription drugs have legitimate uses that should not be restricted merely because some people use them illegally. And, as in the past, ONDCP does not consider this approach for marijuana, which also has legitimate medicinal users in spite of the fact that some people use it illegally," he said.

The Verdict

"President Obama's first National Drug Control Strategy offers real, meaningful, exciting change," Robinson summed up. "Whether this change amounts to 'change we can believe in' will be debated by drug policy reformers. For those who support demand side measures, many will embrace the 2010 Strategy and call for even greater funding for prevention and treatment. For those who support harm reduction measures such as needled exchange, methadone maintenance and so forth, there will be celebration. Yet, for those who support real alternatives to federal drug control policy such as legalization or decriminalization, all will be disappointed. And even if Obama officials will not refer to its drug control policies as a 'war on drugs,' they still amount to just that."

Feature: Reed College in the Crosshairs of Prosecutorial Drug Crackdown

While Oregon sees hundreds of drug overdose deaths a year -- from both illegal and prescription drugs -- a pair of publicity-seeking state and federal prosecutors have made a small Portland liberal arts college where two students have died of heroin overdoses in the past two years the public focus of their attack on the drug trade. Last week, Reed College President Colin Diver was summoned to the federal courthouse in downtown Portland, where he was warned that the school could face a cutoff of federal funds, including student loans, if it is not found to be taking "adequate steps to combat illegal drug activity," starting with this weekend's annual school year-end bash, Renn Fayre, which the prosecutors vowed will be filled with undercover police determined to quash drug use and sales.

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Renn Fayre (sarako on flickr.com)
According to the Oregon State Medical Examiner, 119 people died from heroin overdoses in 2008 and 127 in 2009. Including prescription drug overdoses, 492 Oregonians died of ODs in 2008, 270 from prescription opiates. For some reason, the State Medical Examiner did not include prescription drug deaths in the 2009 figures.

In Multnomah County alone, where Reed is located, 63 people died of heroin overdoses in 2008 and 71 in 2009. That's more than one a week for both years. But no other single overdose or pair of overdose deaths has excited the reaction displayed by state and federal prosecutors who went after Reed last week.

Reed makes an excellent target for drug warriors. For decades, the academically rigorous school has had a reputation as a counterculture haven where drug use is accepted. While that reputation is overblown and outdated, students say, it makes the college a handy lightning rod for those engaged in the culture wars.

Enter US Attorney for Oregon Dwight Holton and Multnomah County (Portland) District Attorney Michael Schrunk. In an email to Divers that they asked be forwarded to the Reed community, the prosecutorial pair used the deaths of the two students as a battle cry for a crackdown.

After lamenting the loss of the students, they wrote: "But while now may be a time for reflection and grief, it is also a time for action. It is now time for the Reed community to abandon the myth that drug use is a safe and acceptable form of exploration. It is time for Renn Fayre and Reed to adopt a zero tolerance policy prohibiting illegal drugs flat-out."

It isn't beatnik days anymore, prosecutors wrote, in a bid to appeal to Reed's countercultural heritage: "The illegal drug trade has changed radically since the days when giants like Alan (sic) Ginsberg and Gary Snyder '51 roamed campus here. The fact is that the drug trade is now fueled by one of the most potent forces in the West: greed."

The pair then explained at length how "drug cartels" are "targeting middle class and wealthier kids," then went on to say they made no distinction between non-lethal drug like marijuana and drugs like heroin. "Don't get sucked in by this bogus Siren call. The fact is that if the Reed community insists that this is 'not our problem' and tries to draw distinctions between 'hard' and other drugs, you will send the message that drug use can be safe... It is time for the Reed community to embrace the notion that drug use is not safe and it will not be tolerated -- without fine print, without provisos, and without conditions."

They then issued a blunt warning: "As the top federal prosecutor in Oregon and the Multnomah County District attorney, we have a responsibility to this community -- including you and your families. We cannot, and we will not stand by if drug use is tolerated on your campus. We cannot, and we will not stand by if Renn Fayre is a repeat of years past -- where even in the wake of Alejandro Lluch's death drug use and distribution were allegedly rampant."

Finally, the prosecutorial pair gallantly offered their assistance: "We stand ready to help in any way we can. If need be, we will use all the tools available to us in federal and state law enforcement. We owe that to the people of our community, including you."

A suitably cowed President Diver responded with his own email to the Reed community: "My message regarding drug use at Renn Fayre 2010 is very simple: Do not use illegal drugs. That means no marijuana, hallucinogens, designer drugs, cocaine, amphetamines, opiates, or other illegal substances."

Diver said he got a forceful and direct message from the prosecutors: "Shut down illegal drug use and distribution at Reed College, starting with Renn Fayre. Based on ongoing criminal investigations, including conversations with current and former students and other sources, these officials have heard numerous allegations about drug use at Reed, and particularly at Renn Fayre."

Diver also mentioned the threats he received: "In the course of the conversation, the US Attorney pointedly referred to a federal statute that makes it a criminal and civil offense for anyone knowingly to operate any facility for the purpose of using illegal drugs. We were also reminded of federal legislation that allows all federal funding -- including student loans -- to be withdrawn from any college or university that fails to take adequate steps to combat illegal drug activity."

On Wednesday, Diver was forced to clarify. According to Inside Higher Education News, the US Attorney only cited the federal crack house statute, under which Reed could face large fines, not the Drug-Free Schools Act, which is the statute that could impact student loans, Diver said. While the US Attorney "referred to federal legislation that could be applied to the college if it failed to crack down more forcefully," he never cited the Drug-Free Schools Act, Diver conceded.

In his email to the Reed community, Diver also delivered a more immediate warning: "We have been told that, during next weekend's Renn Fayre celebration, undercover Portland police officers will be circulating on campus, uniformed Portland police officers will be on alert to respond immediately to calls, and prosecutors stand ready to process criminal charges."

The prosecutorial shakedown has stirred controversy both on campus and in the broader Portland community, with many defending Reed's students, while others say the "druggies" need to be brought under control. In any case, Reed's reputation has complicated its relations with law enforcement.

"There's always a market here for a 'Reed is strange and weird' story," Bear Wilner-Nugent, a Reed alumnus, one-time director of Renn Fayre, and Portland criminal lawyer told USA Today this week. "I think it's going to scare students using drugs to be more underground. I think it's going to discourage students from seeking help for drug problems. It's a waste of resources on what is a tiny fingernail clipping in the drug problem," he said. "It's showboating."

Wilner-Nugent will be attending Renn Fayre again this year, and he said it compares favorably with end-of-semester parties at other schools. "There's a less macho attitude to it, there is less drinking and so you don't see the sexual harassment compared to other institutions," he said. "They are busting one of the saner and healthier college parties in the nation."

"This is the first time any college president has been threatened with the loss of federal funding because of campus drug use, so that's pretty interesting," said Jon Perri, West Coast coordinator for Students for Sensible Drug Policy (SSDP). "We need to be criticizing those prosecutors, as well as law enforcement, for sending in undercover agents and spreading misinformation about drug dealers coming in to target rich white kids. And we need to keep after Reed President Divers, who after his sit-down with prosecutors, basically said don't do illegal drugs, then mentioned a long list of drugs that doesn't include alcohol, which does more harm," Perri pointed out.

"Our chapter there is actively participating in the planning for Renn Fayre, and they will be waging a Good Samaritan policy campaign, while the feds are coming in and trying to do the same old stuff," Perri. "Reed SSDP is trying to pitch it as instead of trying to increase penalties, try something that will save lives."

Perri said he worked with students at Reed to reactivate the Good Samaritan campaign after the second student death. Good Samaritan policies allow drug overdose victims or their friends to seek help without fear of arrest, or, in the case of colleges, academic discipline. "I encouraged them to get it back up and running," he said. "They were wary of starting a campaign because they didn't want to be seen as politicizing those kids' deaths, but that's what the prosecutors have now done."

While by all accounts there has been drug use at Renn Fayre in past years, it is a much milder, less raucous event than many end-of-year campus parties, with a penchant for hallucinogens -- not heroin -- and an abundance of weed. Renn Fayre also features full-body human chess, softball tournaments, a great feast, and lots of music. And alcohol for those over 21.

"Everyone here fears that come Saturday there could be mass arrests for marijuana possession and underage drinking," said Reed SSDP chapter head McKenzie Warren. "It some senses, it's not totally surprising because there has been a lot of local press aimed at Reed, but there is a lot of worry," she reported. "ODs happen all the time, but the homeless population isn't going to get the same focus as a well-known private liberal arts college," said Warren. "Over the years, Reed earned a reputation as a crazy drug-taking school. Maybe it once was, way back in the 1970s, but these days the reputation outstrips the reality."

Reed SSDP is working with other campus groups to protect students from the tender ministrations of law enforcement, Warren said. "We have a number of groups working on harm reduction this weekend, we've had a Reed alumni who is a lawyer come and give talks on how to deal with the police, especially with respect to dorm rooms, and we printed up 1,500 ACLU know your rights cards. We've also been putting up flyers and posters."

And it will push for a full-fledged Good Samaritan policy. "We have only half a Good Samaritan policy," said Warren. "The school just adopted a new implementation plan for our drug policy, and it differentiates pot and alcohol from harder drugs. There is a Good Samaritan policy for alcohol and marijuana, but not for harder drugs. The administration is trying to crack down."

A Good Samaritan policy for alcohol makes sense; for marijuana, the need for it is much less. But a Good Samaritan policy that excludes the drugs that are most likely to kill people doesn't make much sense. There is work to be done at Reed, and the Good Samaritan battle looks like a good way to counter the weight of the prosecutorial offensive.

Harm Reduction: Washington State "911 Good Samaritan Law" to Go Into Effect in June

Washington Gov. Christine Gregoire (D) Wednesday signed into law a measure that provides some legal immunity for people who report a drug overdose. That makes Washington the second state to enact a "911 Good Samaritan Law." New Mexico was the first in 2007.

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Washington State House, Olympia
Under the measure, if someone overdoses and someone else seeks assistance, that person cannot be prosecuted for drug possession, nor can the person overdosing. Good Samaritans could, however, be charged with manufacturing or selling drugs.

The measure is aimed at reducing drug overdoses by removing the fear of arrest as an impediment to seeking medical help. According to the state Department of Health, there were 820 fatal drug overdoses in the state in 2006, more than double the 403 in 1999.

The bill also allows people to use the opioid agonist naloxone, which counteracts the effects of opiate overdoses, if it is used to help prevent an overdose.

"We're going to save lives," Rep. Roger Goodman (D-Kirkland) told Senate sponsor Sen. Rosa Franklin (D-Tacoma) after the bill signing.

"It might take the fear out of calling for help," Franklin said.

Washington is the first state this year to pass a 911 Good Samaritan bill, but it may not be the last. According to the National Conference of State Legislatures, Hawaii, Massachusetts, Minnesota, and Rhode Island are considering similar measures.

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