The nation's most populous state is on the verge of approving safe injection sites in some of its largest cities. A bill that would do just that, Senate Bill 57, narrowly won its final vote in the legislature Monday, and Gov. Gavin Newsom (D) has previously signaled that he was "very open" to the law.

The bill authored by Sen. Scott Wiener (D-San Francisco) authorizes what it calls "overdose prevention programs" (or safe injection sites) as pilot programs in San Francisco, Oakland, the city of Los Angeles, and Los Angeles County. In each of those jurisdictions, city councils or boards of supervisors have requested inclusion in the bill and will decide whether and how to participate. The pilot program will run for five years, through January 1, 2028.

The legality of safe injection sites under federal law remains unclear. During the Trump administration, the Justice Department strongly opposed them and successfully blocked an effort to open one in Philadelphia, but the Biden administration Justice Department has expressed openness to the harm reduction intervention.

That uncertainty did not stop New York City from opening the first government-approved safe injection sites last November or Rhode Island passing legislation and following suit in March, although the Rhode Island sites are being hobbled by a lack of funding after legislators mandated that no government funds be used to operate them. And that uncertainty has not deterred lawmakers in Sacramento, either.

The California bill overcame extensive pushback, primarily from law enforcement, which argued that the sites failed to provide a strong enough path to drug treatment. Similar objections killed three previous attempts to pass safe injection site legislation by Sen. Susan Eggman (D-Stockton), including a 2018 bill that passed the legislature only to be vetoed by then-Gov. Jerry Brown (D).

It was supported by a broad coalition of organizations including the Drug Policy Alliance, San Francisco AIDS Foundation, California Society of Addiction Medicine, National Harm Reduction Coalition, Healthright 360, Tarzana Treatment Center, and the California Association of Alcohol & Drug Program Executives.

Support for the bill was also heightened by significant increases in drug use and overdoses since the beginning of the coronavirus pandemic. San Francisco saw a record number of overdose deaths in 2020, with 711 deaths total. In 2021, 640 people died of overdoses, and the city is on track to exceed that number this year. Statewide, approximately 10,000 people died of drug overdoses from April 2020 to April 2021.

"California -- like our nation as a whole -- is experiencing a dramatic and preventable increase in overdose deaths, and we need every available tool to help people stay alive and get healthy," said Senator Wiener after the final vote. "Safe consumption sites are a proven model to help people avoid overdose deaths, reduce HIV and hepatitis transmission, reduce syringe litter, and help people access treatment. This legislation isn't about whether we want people to use drugs. Rather, it's an acknowledgment that people *are* using drugs, and our choice is whether we want to make every effort to help them survive and get healthy. The time has come for California to adopt this proven overdose death prevention strategy."

Safe injection sites have been operating for decades in Europe, Canada, and Australia and have a proven safety track record. At the 170 safe injection sites that have operated around the world, not a single overdose death has been reported. In New York City, in the first three months of operation, staff at these sites were able to halt over 150 overdoses.

Safe injection sites are a proven harm reduction intervention that saves lives without increasing crime or disorder. The Biden administration does not appear to be inclined to claim they violate federal law and has made no move against the sites operating in New York and Rhode Island. It appears the path is open. All Gov. Newsom has to do is pick up his pen and sign the bill.

Chronicle Book Review: Opium's Orphans: The 200-Year History of the War on Drugs by P.E. Caquet (2022, Reaktion Books, 400 pp., $35.00 HB)

The history of drug prohibition is increasingly well-trodden territory, but with Opium's Orphans, British historian P.E. Caquet brings a fascinating new perspective embedded in a sweeping narrative and fortified with an erudite grasp of the broad global historical context. Although Asian bans on opium pre-dated 19th Century China (the Thai monarchy announced a ban in the 1400s), for Caquet, the critical moment in what became a linear trajectory toward global drug prohibition a century later came when the Qing emperor banned opium in 1813 and imposed severe penalties on anything to do with it, including possessing it. Precisely 100 years later, after two Opium Wars imposed opium on the empire followed by decades of diplomatic wrangling over how to suppress the trade (and for moralizing Americans, how to win favor with China), the 1913 Hague Opium Convention ushered in the modern war on drugs with its targeting not just of opium (and coca) producers or sellers but also of mere users for criminal prosecution. It urged countries to enact such laws, and they did.

What began at the Hague would eventually grow into an international anti-drug bureaucracy, first in the League of Nations and then in United Nations bodies such as the Commission on Narcotic Drugs and the International Narcotics Control Board. But it is a global prohibition regime that has, Caquet writes, straight-jacketed itself with an opium-based perspective that has proven unable or unwilling to recognize the differences among the substances over which it seeks dominion, reflexively resorting to opium and its addiction model. Drugs such as amphetamines, psychedelics, and marijuana don't really fit that model -- they are the orphans of the book's title -- and in a different world would be differently regulated.

But Opium's Orphans isn't just dry diplomatic history. Caquet delves deep into the social, cultural, and political forces driving drug use and drug policies. His description of the spread of opium smoking among Chinese elites before it spread into the masses and became declasse is both finely detailed and strangely evocative of the trajectory of cocaine use in the United States in the 1970s, when it was the stuff of rock musicians and Hollywood stars before going middle class and then spreading among the urban poor in the form of crack.

Along the way, we encounter opium merchants and colonial opium monopolies, crusading missionary moralists, and early Western proponents of recreational drug use, such as Confessions of an English Opium Eater author Thomas De Quincey and the French habitues of mid-19th Century hashish clubs. More contemporaneously, we also meet the men who achieved international notoriety in the trade in prohibited drugs, "drug lords" such as Khun Sa in the Golden Triangle, Pablo Escobar in Colombia and El Chapo Guzman in Mexico, as well as the people whose job it is to hunt them down. Caquet notes that no matter how often a drug lord is removed -- jailed or killed, in most cases -- the impact on the trade is negligible.

For Caquet, drug prohibition as a global phenomenon peaked with the adoption of the 1961 Single Convention on Narcotic Drugs. Coming as it did amidst a post-World War II decline in drug use around the world, the treaty criminalizing coca, cocaine, opium and opioids, and marijuana seemed to ratify a successful global prohibitionist effort. (In the US, in the 1950s, when domestic drug use was at low ebb, Congress passed tough new drug laws.) But before the decade was over, drug prohibition was under flamboyant challenge from the likes of LSD guru Timothy Leary and a horde of hippie pot smokers. The prohibitionist consensus was seeing its first cracks.

And the prohibitionist response was to crack down even harder, which in turn begat its own backlash. Drug use of all sorts began rising around the world in the 1960s and hasn't let up yet, and the increasingly omnivorous drug war machine grew right along with it, as did the wealth and power of the illicit groups that provided the drugs the world demanded. As the negative impacts of the global drug war -- from the current opioid overdose crisis in the US to the prisons filled with drug offenders to the bloody killing fields of Colombia and Mexico -- grew ever more undeniable, the critiques grew ever sharper.

In recent years, the UN anti-drug bureaucrats have been forced to grudgingly accept the notion of harm reduction, although they protest bitterly over such interventions as safe injection sites. For them, harm reduction is less of an erosion of the drug war consensus than all that talk of drug legalization. As Caquet notes, perhaps a tad unfairly, harm reduction doesn't seek to confront drug prohibition head-on, but to mitigate its harms.

The man is a historian, not a policymaker, and his response to questions about what to do now is "I wouldn't start from here." Still, at the end of it all, he has a trio of observations: First, supply reduction ("suppression" is his word) does not work. Sure, you can successfully wipe out poppies in Thailand or Turkey, but they just pop up somewhere else, like the Golden Triangle or Afghanistan. That's the infamous balloon effect. Second, "criminalization of the drug user has been a huge historical blunder." It has no impact on drug use levels, is cruel and inhumane, and it didn't have to be that way. A century ago, countries could have agreed to regulate the drug trade; instead, they tried to eradicate it in an ever-escalating, never-ending crusade. Third, illicit drugs as a group should be seen "as a historical category, not a scientific one." Different substances demand different approaches.

Opium's Orphans is a fascinating, provocative, and nuanced account of the mess we've gotten ourselves into. Now, we continue the work of trying to get out of that mess.

Five Texas cities will vote on non-binding marijuana reform measures this fall, the New York legislative session ends without passing a safe injection site bill, and more.

Marijuana Policy

New York Bill to Crack Down on Illicit Marijuana Possession and Sales Dies. The Senate last week approved Senate Bill 9452, which would expand the state Office of Cannabis Management's authority to seize illicit marijuana and the Department of Taxation and Finance's authority to civilly penalize people for selling marijuana illegally. But the bill died without action in the Assembly as the legislative session came to an end. The bill aimed at "grey market" operators -- retail outlets that are selling weed without being licensed. No licenses for pot shops have been issued yet. The bill would have made it a Class A misdemeanor for distributors and retailers to sell weed without a license. Fines for possession of illicit marijuana would have doubled to $400 per ounce of flower and $1,000 for each illicit plant.

Five Texas Cities Will Vote on Marijuana Reforms. Ground Game Texas, which is pushing for marijuana reform across the state, announced last Friday that it had gathered enough signatures to qualify a non-binding decriminalization initiative in the Central Texas town of Harker Heights, bringing to five the number of towns in the state that will have a chance to vote on marijuana reform this year. The other cities are Elgin, Killeen, and San Marcos in Central Texas and Denton in North Texas.

Harm Reduction

New York Safe Injection Site Bill Dies as Session Ends. A bill that would have paved the way for safe injection sites in the state, Assembly Bill 224, had died as the legislative session ends. The bill managed to win an Assembly committee vote, but went no further. Other harm reduction bills also died, including one that would require treatment providers to offer clients access to buprenorphine (Senate Bill 6746) and another that would have decriminalized buprenorphine (Assembly Bill 646). On the other hand, a bill that would eliminate copays at methadone clinics for people with private insurance (Senate Bill 5690) passed.

International

Afghan Taliban Launch Campaign to Eradicate Poppy Crop. Two months after issuing an edict banning opium poppy cultivation in the country, the Taliban has announced it has begun a campaign to eradicate poppy production, with the goal of wiping out the country's massive yield of opium and heroin. For all of this century, Afghanistan has been the world's leading opium and heroin producer, accounting for more than 80 percent of global output. People violating the ban "will be arrested and tried according to Sharia laws in relevant courts," said Taliban deputy interior minister for counternarcotics, Mullah Abdul Haq Akhund. But with the country in profound economic crisis after the departure of Western troops and economic aid last summer, the ban threatens one of the country's most vibrant economic sectors and the livelihoods of millions of poor farm and day laborer families. "If we are not allowed to cultivate this crop, we will not earn anything," one farmer told the Associated Press. Nonetheless, "We are committed to bringing poppy cultivation to zero," said Interior Ministry spokesman Abdul Nafi Takor.

On May 11, the Centers for Disease Control and Prevention (CDC) released data showing that more than 107,000 people died of drug overdoses in 2021, the most overdose deaths ever recorded in a single year. The figure marks a 15 percent increase over 2020, with the number of overdose deaths more than quadrupling since 1999. And this is only provisional data; the actual death toll could be even higher.

More people died of drug overdoses last year than from gunfire and traffic accidents combined, and the ever-rising death toll is leading to ever-louder calls for effective policy prescriptions and harm reduction interventions to reduce the carnage.

Opioids were implicated in nearly 80,000 overdose deaths, with synthetic opioids, primarily fentanyl and its derivatives, involved in more than 68,000. Cocaine was mentioned in more than 23,000 overdose deaths and psychostimulants, primarily methamphetamine, mentioned in more than 30,000.

To its credit, the Biden administration has recognized the urgency of the problem, embracing harm reduction interventions such as needle exchanges, drug testing, and access to the opioid overdose reversal drug naloxone in its 2022 National Drug Control Strategy. The strategy includes $30 million for harm reduction grants, but also $300 million increases for the DEA and Customs and Border Patrol. While the prohibitionist impulse remains strong, at least the administration has explicitly recognized the need for harm reduction.

But that isn't enough, advocates say.

"New data from CDC has confirmed our worst fears. The combined pressures of the COVID-19 pandemic, an increasingly potent illicit drug supply, and an overwhelmed and under-resourced public health system have driven the overdose crisis to catastrophic levels," said Daliah Heller, Vice President of Drug Use Initiatives at Vital Strategies, in a statement.

>Vital Strategies is a global public health organization that in February, launched "Support Harm Reduction," a campaign to highlight five key interventions for preventing overdose that many people in the United States still don’t have access to: naloxone, drug checking resources, medications for opioid use disorder, safer drug use supplies, and overdose prevention centers. 

>"What we’re doing now isn’t working, because the decades-old punitive response to drug use still predominates: The transition to a health-first, harm reduction approach has been slow and piecemeal," Heller continued. "Anemic levels of funding and policy support are woefully insufficient to stem the tide of overdose we are experiencing. These data are an urgent call to action for government at all levels: we need to mount a massive public health response to overdose that centers harm reduction and support instead of criminalization and punishment for people who use drugs.  

"Far too few people have access to any of the five key interventions we know will reduce overdose deaths," Heller added. "Most of these services are available in some form, in some locations in the majority of states, but they all need to be massively scaled up with an emergency investment. Until such actions are taken, the continued escalation of this overdose crisis seems inevitable," she said.

"The devastating rise in overdose deaths is falling most heavily on Black and Indigenous communities, where the need for relief now is more urgent than ever before," Heller noted. "A massive surge in funding and support for a harm reduction public health response will save lives immediately, engaging people who use drugs with lifesaving resources and support. The time for action is now."

Likewise, the new CDC numbers prompted the Drug Policy Alliance (DPA) to call on Congress to urgently support harm reduction services and move toward drug decriminalization.

"Once again, we are devastated by these numbers," said Jules Netherland, DPA Managing Director of the Department of Research & Academic Engagement. "Over 107,000 of our friends, family and neighbors lost their lives to drug overdose last year. And sadly, we know the numbers will only continue to climb unless our policymakers actually do what is necessary to curb them. The United States has spent over 50 years and well over a trillion dollars on criminalization - and this is where it has gotten us. It's clearly not working. It's time we start investing where it actually matters - in our communities, specifically Black, Latinx and Indigenous communities where we are now seeing the sharpest rise in overdose deaths. The evidence shows us, that in order to actually make a difference, we have to replace these approaches with those centered in public health, such as drug decriminalization coupled with increased access to evidence-based treatment and harm reduction services, overdose prevention centers, and legal regulation and safer supply to reduce the likelihood of accidental overdose," Nederland said.

It is time for safe injection sites, too, DPA insisted.
 
"We are grateful that the Biden Administration has embraced harm reduction as part of their National Drug Control Strategy, but we need to see that commitment met with Congressional funding and a massive scaling up of these health services," Nederland said. "It's also essential that Overdose Prevention Centers be implemented, which decades of evidence-based, peer-reviewed studies and utilization in over 14 countries show us are one of the most effective ways to save lives now. While it may not always be politically convenient, it’s time to be guided by the evidence about what works. Overdose deaths are avoidable and a policy failure—it’s time we stop recycling the same policies that got us here and take the actions that are necessary to save lives."