Faced with an ongoing drug overdose epidemic that may have peaked in recent months but is still killing around 100,000 Americans each year, with fentanyl implicated in the great majority of deaths, the nation's governors are moving to get a grip on the problem. On Tuesday, the National Governors Association (NGA) released a roadmap to help support governors and state officials in developing policy solutions to address unprecedented opioid overdose rates. Titled Implementing Best Practices Across the Continuum of Care to Prevent Overdose, the roadmap outlines concrete solutions across the full spectrum of health services, from the foundations, to prevention, harm reduction, treatment, and recovery.

By limiting their policy prescriptions to health services, the governors avoid tackling the prickly politics of drug prohibition and the role it plays in the overdose crisis. The words "legalization" and "decriminalization" do not appear once in the 79-page report. On the other hand, law enforcement is not mentioned as playing a role in addressing the problem, either.

Developed in coordination with the O'Neill Institute at Georgetown University Law Center, the roadmap is based on the contributions of more than 30 subject matter experts and 20 states and territories -- providing governors with specific, actionable recommendations to prevent overdose across five pillars of the Substance Use Disorder Continuum of Care.

This is not the first time the governors have addressed the topic. In fact, this report can be seen as an update to the NGA's 2016 Roadmap, which covered much of the same territory. The latest iteration, however, reflects the evolving nature of the ongoing drug overdose epidemic and includes strategies specific to the rise of illicitly manufactured fentanyl.

The continued attention is needed. From 2019 to 2021, overdose death rates increased in all 50 states; death rates in 40 states increased by more than 25 percent. The national overdose death rate in 2021 reached 32.4 per 100,000 people, compared to 6.1 in 1999. Overdose deaths among adolescents increased 109 percent from 2019 to 2021, despite low youth substance use rates.

For each of the five pillars -- foundations, prevention, harm reduction, treatment, and recovery -- the NGA roadmap makes specific recommendations:

Foundations

• Establish a state government coordinating body to set a statewide vision for overdose prevention.
• Invest in state infrastructure to maximize resources.
• Seek and include the perspectives and leadership of people with a variety of lived experiences.
• Invest in evaluation and test new ideas. Promote evidence-based requirements for funded prevention initiatives.
• Nurture and grow a mental health and substance use workforce that reflects the populations served.

Prevention

• Champion and invest in initiatives that support family cohesion and well-being.
• Promote evidence-based requirements for funded prevention initiatives.

Harm Reduction

• Maximize federal resources and braid funding to promote health and reduce harm for people who use drugs.
• Implement targeted and low-barrier distribution strategies for overdose reversal agents (ORAs) such as naloxone.
• Champion changes that allow for the distribution of harm reduction tools.

Treatment

• Implement and invest in policies and programs that expand Medication for Opioid Use Disorder (MOUD) access beyond the office setting.
• Implement and invest in evidence-based treatment and access models.
• Maximize federal funding resources for treatment.
• Assess state-level policies that restrict access.
• Make all MOUD treatment forms available to those involved in the criminal legal system.

Recovery

• Foster communities that support recovery.
• Champion changes to policies to establish recovery residence standards.
• Invest in small businesses and community-based organizations led by and employing people with lived experience who represent the communities they serve.

The roadmap goes into gritty, granular detail on each of these recommendations and policy-makers and advocates alike would be well advised to dig deeper. Overall, the NGA provides a progressive, evidence-based approach to dealing with drug overdoses. There is much to apply here.

Washington state is bordered on the north by British Columbia, which has decriminalized drug possession (at least for the next five years) under a federal waiver in January, and on the south by Oregon, which decriminalized drug possession by popular vote in 2020. But Washington state lawmakers this week made it clear that they would not be following their neighbors down the decriminalization path.

There has been an opening for drug decriminalization in the Washington ever since the state Supreme Court threw out the state's felony drug possession statute in 2021 in Washington v. Blake because it did not require the defendant to knowingly possess forbidden drugs. Rather than have no drug possession statute at all, the legislature that year produced a bill to make it a misdemeanor. That bill was set to expire on July 1.

This year, as the clocked ticked down, lawmakers debated a variety of possibilities from decriminalization to re-felonization, and at the session, a conference committee produced a version of the drug possession law, Senate Bill 5536, that called for making possession a gross misdemeanor (punishable by up to 364 days in jail, as opposed to 90 for a misdemeanor) and skimped on funding for treatment. No Republicans voted for the final version of the bill, saying it was soft on crime.

Democrats and progressives were angered by the imposition of the gross misdemeanor penalties and the levels of treatment funding. Enough disaffected Democrats voted no to kill it.

"The notion that this bill is soft on crime is ridiculous. The House caved to pressure to escalate the penalty back up from a misdemeanor to a gross misdemeanor, with diversions allowed only with the consent of the prosecutor," said Allison Holcomb, director of political strategies for the ACLU of Washington. "A gross misdemeanor carrying a penalty of up to 364 days and a $5,000 fine is harsher than the felony penalty that applied before the Blake decision. The standard range for a felony [drug possession] offense was 0-60 days for the first three offenses, lower even than a misdemeanor -- 90 days."

The session ended last month without a new drug law and that left open the possibility that the state would soon have no drug possession law at all. Gov. Jay Inslee (D) then called a special session to meet this week with the drug possession law as its sole agenda item.

On Tuesday, the legislature passed a revised version of SB 5536, and Gov. Inslee signed it into law that night.

The bill signed into law maintains drug possession as a gross misdemeanor, but limits jail terms to 180 days -- not the 364-day term typical for that level offense. And it creates a new offense of public drug use with the same penalties. For both offenses, the maximum fine was lowered to $1,000.

It also includes $44 million to expand treatment and recovery efforts, more than double the $20 million allocated in the original bill.

But to appeal to conservatives, it also allows localities to continue to prohibit harm reduction services, including needle exchanges and safe injection sites, and it continues to give courts and prosecutors some discretion in a new pretrial diversion program, including jailing defendants who repeatedly reject drug treatment.

"This bill is not designed to fill our jails, it's designed to fill our treatment centers," said Inslee as he signed the bill. "And the investments we're making will create treatment resources in small townships and big cities. This is a statewide solution to a statewide problem."

Some progressives who voted for the bill still had concerns. State Sen. Yasmin Trudeau (D-Tacoma) said the state was still relying on the criminal justice system to bully people into treatment that too often isn't there.

"We don't have the infrastructure to offer services to everyone who will need it, and that gives me great pause," Trudeau said.

But veteran drug reformer state Rep. Roger Goodman (D-Kirkland) called it "a fair compromise that addresses urgent concerns about public disorder but follows evidence-based practices in helping people in need."

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."

The Fiscal Year 2022 Omnibus appropriations bill signed into law by President Biden on Tuesday has drug reform and civil rights groups fuming over both what was left out and what made the final cut. The bill extends class-wide scheduling and harsh criminal penalties for fentanyl-related substances, underfunds harm reduction services, and still includes a rider that bars the District of Columbia from taxing and regulating marijuana sales.

"We're deeply disappointed in House and Senate leadership for allowing this version of the bill to move forward and neglecting this rare opportunity to advance long overdue reforms," the Drug Policy Alliance (DPA) said in a press release after the bill passed Congress last week.

Congress ended up allocating a measly $18 million for the Centers for Disease Control and Prevention's Infectious Disease and the Opioid Epidemic program that supports needle exchange and overdose prevention program. While the figure is a $5 million increase over the last year, it fails to respond to urgent need to expand harm reduction services.

"With an overdose crisis that claimed more than 100,000 lives in 2021 alone, we urgently need to employ evidence-based services to save lives. Syringe services programs directly reach people at highest risk for overdose, HIV, hepatitis C and other infections, as well as other harms associated with drug use. It's past time that lawmakers prioritize making more of these lifesaving harm reduction services available," said DPA deputy director of National Affairs Grant Smith.

While Congress is not paying enough attention to harm reduction, its move to extend the Trump-era temporary class-wide scheduling of fentanyl-related substances will only increase the harms of criminal justice system exposure for people of color while failing to address the overdose crisis, civil rights advocates said. The Leadership Conference on Civil and Human Rights, a coalition of more than 230 national groups, wrote a January letter to the White House opposing the move, and its members are not happy now.

"During the protests calling for police accountability and criminal-legal reform in 2020, many lawmakers on both sides of the aisle promised to pursue racial equity. This scheduling policy flies directly in the face of those promises," said Sakira Cook, senior director of the justice reform program at The Leadership Conference on Civil and Human Rights in a press release following the vote. "For too long Black and Brown people and their communities have suffered from under-resourcing and over policing, due in large part to the war on drugs. Congress must stop trying to perpetuate mass incarceration and instead advance policies that actually help our communities navigate the overdose crisis as a public health issue."

"We are disappointed that Congress has continued the temporary class-wide scheduling of fentanyl-related substances instead of preventing opioid deaths through comprehensive legislation," said Marta Nelson, director of government strategy at the Vera Institute of Justice. "We urge Congress to use this time to work on a permanent solution -- one that saves lives through public health measures, narrows the definition of fentanyl-related substances subject to criminal prosecution, and removes mandatory minimum punishments. We must change our current approach to this crisis in a way that addresses public safety needs and the needs of communities of color."

"It's hard to believe Congress extended this 'temporary' policy yet again. Overdoses have only skyrocketed since it came into force. It is time to let this expire now," said Laura Pitter, deputy director of the US Program at Human Rights Watch. "Congress already has the tools they need to prosecute cases involving fentanyl-related substances. This cruel, over-broad approach hasn't helped, and continues to disproportionately impact Black and brown communities."

And then, there is the issue of marijuana in the nation's capital. DC residents overwhelmingly approved the Initiative 71 marijuana legalization measure in November 2014, but because the District, as a federal territory, cannot control its own budget, Congress has been able to block the District from being able to implement taxed and regulated marijuana sales. The "Harris rider," named after conservative Rep. Andy Harris (R-MD), frustratingly remains intact despite Democratic control of both houses of Congress.

"We are very disappointed that Congress continues to prevent residents of DC from regulating cannabis despite their urgent and repeated requests for reform. Instead, Congress is forcing the District to maintain a gray market in which cannabis can be legally possessed and consumed by adults, but it cannot be legally sold, regulated, or tested, said Toi Hutchinson, President and CEO of the Marijuana Policy Project in a press release. "This places consumers at risk, and entrepreneurs who live in this minority-majority community are denied the ability to open businesses that are available in every other legal cannabis jurisdiction."

That's a whole lot of disappointment and frustration with the Democratic leadership of the Congress. There may be more to come. The SAFE Banking Act remains stalled, and even Senate Majority Leader Chuck Schumer's (D-NY) proposed marijuana legalization bill doesn't look like it has enough votes to pass. This could end up being a year to forget when it comes to responsible drug policies from Congress.