With nearly 47,000 Americans dying of drug overdoses in 2014 -- more than from gunshots or car crashes -- the problem of heroin and prescription opioid (pain pill) addiction is getting well-deserved attention. From community town halls to state capitals, as well as in Congress and on the rival presidential campaigns, the crisis is spawning demands for solutions.

[inline:dan-morhaim-180px.jpg caption="Dan Morhaim" align=left]The response, in general, has been more sympathetic than to earlier waves of hard drug use, such as heroin in the 1960s or crack cocaine in the 1980s, which brought down the harsh drug war policies of Nixon and Reagan. Now, there are more calls for drug treatment than for further law enforcement crackdowns, police departments are carrying overdose reversal drugs, and public health agencies are taking on a more prominent role.

But addicts continue to be arrested, with all the deleterious consequences that entails, and, when it comes to policy, the problem of addiction remains largely in the realm of criminal justice. Harm reduction practices proven in other parts of the world improve both the lives of drug users and those of the communities they live in continue to be shunted aside in the US.

That could change in at least one state. Veteran Maryland Delegate Dan Morhaim (D-Baltimore County) has just introduced a paradigm-shifting package of bills that would begin to move the state's posture toward drug use from prohibition to public health and harm reduction. Morhaim, a practicing physician with three decades of frontline hospital ERs, brings to his approach a vision formed by that experience.

If enacted, Morhaim's package would mark a radical, but commonsensical, humane, and scientifically-supported shift in Maryland's drug policies. Here's what it includes:

• Emergency Room Treatment on Demand. House Bill 908 provides treatment on demand in emergency rooms and hospital settings. The bill requires acute care hospitals to have a counselor available or on-call at all times and specified arrangements for transferring patients to appropriate treatment settings. Addicted patients make up a large percentage of uninsured visits to ERs, making them an ideal place for initial therapeutic contact.
• Safe Consumption Sites. House Bill 1212 allows individuals to use drugs in approved facilities while supervised by trained staff who also provide sterile equipment, monitor the person for overdose and offer treatment referrals. Similar on-going programs in Australia, Canada, and several European countries have eliminated overdose deaths, reduced the spread of disease, and provided points of accessto the most hard-to-reach drug users.
• Drug Decriminalization. House Bill 1219 decriminalizes the possession and use of small quantities of drugs: one gram of meth or heroin, two grams of cocaine, 10 hits of MDMA, 150 micrograms of LSD. The object is to keep otherwise non-criminal drug users out of the criminal justice system, saving resources and avoiding saddling more residents with criminal records.
• Heroin Maintenance. House Bill 1267 allows a four-year pilot study of "poly-morphone assisted treatment" with pharmaceutical grade opioids, including heroin, to treat under medical supervision a small number of hardcore users who have proven resistant to other forms of treatment. Ongoing heroin maintenance programs in several European countries have been shown to reduce illegal drug use, decrease crime, reduce the black market for heroin, and lead to less chaotic lives for their participants.

The package didn't exactly come out of nowhere. Morhaim's experiences in the ER, where he dealt not only with direct consequences of drug use -- overdoses, infections -- but also direct consequences of drug prohibition -- old women injured in muggings for black market drug money, the toll of dead and wounded in black market drug turf battles -- colored his approach.

[image:2 caption:true align:right]"I'm a physician, not a prosecuting attorney," Morhaim told the Chronicle. "I come at this from a public health perspective. We talk about 'surges' to fight this and that, but what we haven't had in this country is a surge in the public health approach, real, substantive public health. This is different, and some will see it as controversial, but I'm comfortable with that. This is something that's really corroding the heart and soul of our society."

He wasn't alone.

"I've had a lot of conversations, and my district has generally been very supportive of these kind of innovative things. No negative feedback. There's a broad consensus that the war on drugs is a failure," Morhaim said. "People are really cognizant of that. And I'm an Emergency Room physician at a Level II trauma center, I've also done healthcare for the homeless. I've been on the front lines, seen the carnage, the death, the violence, and the way this affects the families, and I'm speaking from true experience, and people respect that."

Not only did Morhaim have support in his community, he had support from a strong group of advocates and experts.

"As things were coming to a head, Delegate Morhaim reached out to us at the Drug Policy Alliance (DPA)," said DPA staff attorney Lindsay LaSalle, who was involved in developing the proposals. "He said he felt like he could offer progressive solutions to the crisis and he wanted our subject matter expertise to help develop those proposals."

DPA, Law Enforcement Against Prohibition (LEAP), whose executive director, Neill Franklin, is a former Baltimore police officer, and the Open Society Foundations joined with academics, lawyers, doctors, and harm reductionists to develop and refine the policy proposals that became the bill package. Local institutions of higher learning, including the University of Maryland, the University of Baltimore, and Johns Hopkins University, had academics involved in the effort as well.

Passing the bills won't be easy, and it's not likely to happen this year, but Morhaim and his supporters are playing to win in the not-too-distant future.

"Dan is currently on the second year of a four year term," LaSalle said. "These bills were introduced strategically this term with the understanding that it would be a year of educating colleagues and generating positive media coverage. This is always a long game; we don't expect passage this year, but we hope to gain traction on one or more of these in the next two or three years."

"I've been in the legislature a long time, and I've learned you just have to be persistent, you listen and address concerns, maybe you accept an amendment to a bill," Morhaim said.

He pointed to the successful effort to get medical marijuana through the legislature.

"On that, people had suggestions, and we said let's fix it in the bill," he recalled. "Law enforcement didn't oppose it because I sat down and worked with them."

He also recalled legislative battles he had fought -- and won -- around smoking in restaurants and the use of safety seats for children.

"Banning smoking in restaurants seemed impossible in 1995, but now it's commonplace," he said. "The same with kids safety seats. Both of those were hard-fought on the political level, but when we talk to people, we can convince them. These things take time, but when you recognize what's not working, then you can explore what is. People are looking for answers."

Although Morhaim's package of bills is the most comprehensive, explicit harm reduction interventions are being considered in other places, too. California will see a safe consumption site bill introduced next week, and activists and officials in a number of cities, including New York City, San Francisco, and Seattle are laying the groundwork for such facilities at the local level.

"We're getting traction on these issues," said LaSalle. "Nevada was the first state with a heroin-assisted treatment bill, and while it didn't get out of committee, we had robust hearings, with international experts. And that California bill will be moving forward this session. Drug treatment and harm reduction don't always go hand in hand, but in this case the treatment community is cosponsoring or officially supporting safe consumption sites."

Meanwhile, some states are moving in the opposite direction. In Maine, the administration of Tea Party Gov. Paul Le Page (R) is seeking to reverse a law passed last year that defelonized drug possession. (The rambunctious Republican has also called for guillotining drug dealers, blamed black drug dealers for impregnating white Maine girls, and called for vigilantes to shoot drug dealers.) And next door in New Hampshire, the attorney general wants to start charging heroin suppliers with murder in the event of fatal overdoses. Prosecutors in other states have also dusted off long-unused statutes to bring murder or manslaughter charges.

"We need to ask those people why they're doubling down on a failed policy," said LaSalle. "Why would this work now when it's just more of the same that's been in place for four decades, and now we have use and overdoses and Hep C increasing."

"I understand the impulse to 'Do Something!' in response, and because criminalization has been our go-to response, it seems logical that increasing penalties or prosecutions is a way to solve the problem, but we know, we have shown, that it is not. It's frustrating."

It can be worse than frustrating, too, LaSalle noted.

"Using murder charges as a whipping stick in the case of overdoses is really counterproductive," she said. "If the goal is to reduce overdoses, this is going to reduce the likelihood of anyone calling 911. Maybe they shared their stash, and if they could face murder charges, they now have a serious disincentive to call."

Clearly, the war on drugs is not over. But after half a century of relying predominantly on the forces of repression to deal with drug use, a new vision, both smarter and more humane, is emerging. Now comes the political fight to enact it.