Responding to Holder on Heroin, Reformers Call for a Health Direction [FEATURE]

US Attorney General Eric Holder had heroin on his mind Monday, using his weekly video message and an accompanying press release to draw attention to rising heroin overdose deaths and vowing to combat the problem with a combination of law enforcement, treatment, prevention, and harm reduction measures. Drug reformers generally responded positively, but called on the Obama administration to seek comprehensive, science- and health-based solutions instead of engaging in more drug war.

Attorney General Holder takes on heroin (usdoj.gov)
"Addiction to heroin and other opiates -- including certain prescription pain-killers -- is impacting the lives of Americans in every state, in every region, and from every background and walk of life -- and all too often, with deadly results. Between 2006 and 2010, heroin overdose deaths increased by 45%," Holder said. "Scientific studies, federal, state and local investigations, addiction treatment providers, and victims reveal that the cycle of heroin abuse commonly begins with prescription opiate abuse. The transition to -- and increase in -- heroin abuse is a sad but not unpredictable symptom of the significant increase in prescription drug abuse we've seen over the past decade."

What Holder didn't mention is that the rise in prescription pain pill misuse is tied to a massive increase in prescribing opioids for pain in the past decade. A study published last fall found that between 2000 and 2010, the amount of opioids prescribed for non-cancer pain had nearly doubled, and that during the same period, the percentage of people complaining of pain who received prescriptions for opioids jumped from 11% to nearly 20%. But reining in prescriptions generally isn't the answer either.

But at the same time, a 2011 Institute of Medicine report found that while "opioid prescriptions for chronic non-cancer pain [in the US] have increased sharply… 29% of primary care physicians and 16% of pain specialists report they prescribe opioids less often than they think appropriate because of concerns about regulatory repercussions."

As the IOM report noted, having more opioid prescriptions doesn't necessarily mean that "patients who really need opioids [are] able to get them." Opioid misuse and under-use of opioids for pain treatment when they are needed are problems that coexist in society. Pain pill crackdowns have also been found to result in increased use of street heroin, as a Washington Post article last week reports -- two additional reasons advocates prefer public health approaches to heroin more than law enforcement -- and why great care should be taken with the law enforcement measures.

"It's clear that opiate addiction is an urgent -- and growing -- public health crisis. And that's why Justice Department officials, including the DEA, and other key federal, state, and local leaders, are fighting back aggressively," Holder continued. "Confronting this crisis will require a combination of enforcement and treatment. The Justice Department is committed to both."

Holder pointed to DEA efforts to prevent diversion of pharmaceutical pain-relievers to non-medical users, mentioning investigations of doctors, pharmacists, and distributors.

"With DEA as our lead agency, we have adopted a strategy to attack all levels of the supply chain to prevent pharmaceutical controlled substances from getting into the hands of non-medical users," Holder said.

Cooking heroin (wikimedia.org)
Holder also pointed out that DEA had opened some 4,500 heroin investigations since 2011 and promising more to come.

But, as Holder noted, "enforcement alone won't solve the problem," so the administration is working with civil society and law enforcement "to increase our support for education, prevention, and treatment."

And although he didn't use the words "harm reduction," Holder is also calling for some harm reduction measures. He urged law enforcement and medical first responders to carry the overdose reversal drug naloxone (Narcan) and signaled support for "911 Good Samaritan" laws, which grant immunity from criminal prosecution to those seeking medical help for someone experiencing an overdose.

Holder got restrained plaudits from drug reformers for his small steps toward harm reduction measures, but they called for a more comprehensive approach.

"Preventing fatal overdose requires a comprehensive solution," said Meghan Ralston, harm reduction manager for the Drug Policy Alliance. "While naloxone is an absolutely critical component, we need a scientific, health-based approach to truly address the roots of the problem. This includes improving access to effective, non-coercive drug treatment for everyone who wants it, as well as improving access to medication-assisted treatments such as methadone and buprenorphine."

Naloxone (Narcan) can reverse opiate overdoses (wikimedia.org)
Ralston also added that just making naloxone available to cops and EMTs wasn't good enough. Friends and family members, not "first responders," are most often the people who encounter others in the throes of life-threatening overdoses.

"While we applaud Attorney General Holder's clear support for expanding access to naloxone, particularly among law enforcement and 'first responders,' we urge him to clarify that he supports naloxone access for anyone who may be the first person to discover an opiate overdose in progress," she said.

But Law Enforcement Against Prohibition (LEAP), a group of law enforcement officials opposed to the war on drugs, applauded the move, which could help soften reflexive law enforcement opposition to carrying the overdose antidote, an attitude reflected in the the International Association of Chiefs of Police's opposition to all harm reduction measures.

"Police may not be the first to embrace change, but we are slowly evolving," said Lieutenant Commander Diane Goldstein (Ret.). "We cannot arrest our way out of a public health problem, and it's clear that the Attorney General is beginning to understand that and to embrace the role of harm reduction in reducing death, disease and addiction in our communities. We still have a long way to go, but this is a good sign."

The idea is "a no-brainer," according to executive director Major Neill Franklin (Ret.). "It is simply immoral not to support something proven to save lives for political reasons," Franklin added. "Yes, police send a message when they choose not to carry naloxone. But that message is not 'don't do drugs,' it's 'if you make the wrong decisions in your life, we don't care about you.' That offends me both as a former cop and as a human being."

The nuanced pushback to Holder's law enforcement/prevention/treatment/hint of harm reduction approach is good as far as it goes, but it doesn't go far enough. Decriminalizing and destigmatizing now illicit drug use, as has been the case in Portugal, is an obvious next step, and removing the question of drugs from the purview of the criminal justice system altogether would be even better. Still, that a sitting attorney general is calling for treatment and harm reduction as well as law enforcement is a good thing, and for reformers to be calling him on not going far enough is a good thing, too.

Permission to Reprint: This article is licensed under a modified Creative Commons Attribution license.
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Treatment and harm reduction

Treatment and harm reduction measures need to be immediately implemented at every correctional facility in the United States, including the Federal Bureau of Prisons facilities. Medication assisted treatment must be made to every incarcerated person upon arrest, and continue into post release supervision. Established treatment protocols for correctional facilities and tight government regulation of these medications already exist; there is no reason to delay implementation. Medication assisted treatment has been proven to reduce recidivism and thereby lower the costs of incarceration, improve inmate health, reduce the incidence of injection related disease, and reduce overdose death post release. This affects me personally as I have been struggling with the BOP since last summer to obtain evidence-based treatment, which includes the option of medication assisted treatment, for my son. The Health Services Division of the BOP continues to deny my son medication assisted treatment, in spite of the fact that its use in corrections is specifically mentioned in the Second Chance Act of 2008 and promoted by multiple government agencies. This denial to my son of evidence-based practice affects not only my son, but tens of thousands of other inmates in our country, and effectively sabotages the efforts being made towards the ultimate goals of successful reentry, lowered rates of recidivism, and reduced spending on incarceration.

treatment and harm reduction

To Diana Goodwin,  I have just had a loved one put into the BOP system and am very worried about what he will find there in regards to his heroin addiction.  I esp. want him to get some medical treatment in withdrawal but don't know how to go about asking (demanding) this.  Do you know if there is anything I can do or who to talk to.  Reading all this on the internet is frightening and very inhumane.  No wonder there is such a high rate of recidivism and relapse into drug use.  Count me as one of the supporters of reform in this important area and if you know of anything I can do to facilitate this reform let me know....i am not shy!

Opiate Addiction Treatment in the BOP

Judy,

The BOP is more than 20 years behind in the treatment of addiction, especially of opiate addiction.  They tout their RDAP program, which is a Cognitive Behavioral Therapy program (CBT).  While CBT is still used and is considered to be a valid treatment option, the government's own health agencies have clearly stated that current evidence based practice in treatment also includes the option of medications such as methadone and buprenorphine.  Your loved one will likely/hopefully be detoxed, if not already, but then will get nothing in the way of treatment, at least not right away.  He/she will get a drug education class (this is not treatment) and then be offered the option to participate in the RDAP (some centers have a residential RDAP, all have a non-residential version) (however, he/she will have to wait a long time to get into the program, possibly YEARS!)  I have been advocating very strongly for my son to receive medication assisted treatment; I can fill you in if you'd like to know what I've done/what you can do.  You can contact me through Twitter: @justicereformer.  And, yes, there IS heroin, as well as other drugs, in prison.

Opiate Addiction Treatment in the BOP

Judy,

The BOP is more than 20 years behind in the treatment of addiction, especially of opiate addiction.  They tout their RDAP program, which is a Cognitive Behavioral Therapy program (CBT).  While CBT is still used and is considered to be a valid treatment option, the government's own health agencies have clearly stated that current evidence based practice in treatment also includes the option of medications such as methadone and buprenorphine.  Your loved one will likely/hopefully be detoxed, if not already, but then will get nothing in the way of treatment, at least not right away.  He/she will get a drug education class (this is not treatment) and then be offered the option to participate in the RDAP (some centers have a residential RDAP, all have a non-residential version) (however, he/she will have to wait a long time to get into the program, possibly YEARS!)  I have been advocating very strongly for my son to receive medication assisted treatment; I can fill you in if you'd like to know what I've done/what you can do.  You can contact me through Twitter: @justicereformer.  And, yes, there IS heroin, as well as other drugs, in prison.

treatment and harm reduction

To Diana Goodwin,  I have just had a loved one put into the BOP system and am very worried about what he will find there in regards to his heroin addiction.  I esp. want him to get some medical treatment in withdrawal but don't know how to go about asking (demanding) this.  Do you know if there is anything I can do or who to talk to.  Reading all this on the internet is frightening and very inhumane.  No wonder there is such a high rate of recidivism and relapse into drug use.  Count me as one of the supporters of reform in this important area and if you know of anything I can do to facilitate this reform let me know....i am not shy!

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