(CNN)Overdose
deaths from prescription opioids such as OxyContin have quadrupled in
the United States since 1999, leading the Food and Drug Administration
to announce this week that these short-acting painkillers will be
required to carry a "black box" warning.
In another grim statistic related to opioid use, 135 people
were infected with HIV last year in rural Indiana, an outbreak linked
to injecting the prescription drug Opana. Experts have worried that
communities in the states of Kentucky and West Virginia could also be at risk of an HIV outbreak because of high rates of opioid abuse.
These
two trends have spurred a "great deal" of interest in drug policy in
the United States, said Dr. Chris Beyrer, director of the Johns Hopkins
Center for Public Health & Human Rights and president of the
International AIDS Society. In a new report, experts are urging sweeping
changes to drug policy, including decriminalizing minor drug offenses
and reducing aggressive policing.
In
a report published Thursday in The Lancet medical journal, Beyrer and
an international team of researchers assessed the growing body of
evidence for the public health impacts of programs such as opioid
substitution therapy and needle exchange programs. In addition to
criminal justice changes, the researchers made specific recommendations
for policy makers to improve access to services that can reduce the
spread of HIV and hepatitis C virus, also known as HCV.
"We
think there is the first opportunity in a generation to have meaningful
drug reform," said Beyrer, who led the research for the report , which was commissioned by The Lancet and Johns Hopkins University.
The
report comes weeks before the United Nations General Assembly Special
Session convenes on April 19 to discuss drug policy for the first time
since 1998.
"There is pressure
from a number of countries who feel the war on drugs has failed them,
particularly Central and South America, where there is some of the worst
drug-related violence," Beyrer said. "We sought to review all the
scientific evidence so it would be available to the U.N. member states
when this is being debated."
According
to the report, injection drug use has led to increases in new HIV and
HCV infections. Unsafe injection practices, such as sharing needles, are
linked to about 30% of HIV transmission
outside of sub-Saharan Africa. HCV transmission is also high among
people who inject drugs, and a study in the United States found that more than half of people got infected in the first year they were injecting.
The
report pointed to two main reasons for the high rates of infection
among injection drug users: high rates of incarceration and the
inability of people with HIV and HCV to access services that provide
antiretroviral therapy (in the case of HIV), needle exchange programs,
which provide drug users sterile syringes, and opioid substitution
therapy, which involves oral drugs such as methadone that are not
injected.
"We have the evidence to
show these things work" to reduce HIV and HCV infection, Beyrer said.
"We should not hold off programs in order to do more research, we should
be implementing the programs and rigorously evaluating them."
Although
needle exchange programs and opioid substitution therapy services are
available in some parts of the United States, it varies a lot by
geographical region, Beyrer said.
There
is at least one indication that access to needle exchange programs
could be expanded, as the report recommends. In January, the
long-standing ban on federal funding for these programs was lifted
through legislation suggested by Sen. Mitch McConnell and Rep. Hal
Rogers, both Republicans from Kentucky. A statement from McConnell's
office said that injection heroin and the opioid epidemic and rising HIV
and HCV rates were having a "devastating effect" in Kentucky and
throughout the United States.
The
report also recommends improving access to naloxone, which can prevent
death from opioid overdose and reverse other harmful effects. "Community
distribution of naloxone works, this is not psychoactive drug, there's
no opportunity for diversion," Beyrer said. "Drug users and family
members can be trained to administer [naloxene], lives can be saved."
The war on drugs
There
is good evidence that the public health approaches the United States is
taking to address drug use and drug-related harms are effective, even
though these approaches, such as needle exchange programs, need to be
scaled up so more people can use them, said Hannah Cooper, associate
professor of behavioral sciences and health education at the Rollins
School of Public Health at Emory University. Cooper was not involved in
creating the new report.
However
the opposite is true for the criminal justice approaches that are part
of the U.S. drug policy, including aggressive policing that puts
emphasis on arresting people for minor offenses and stop-and-frisk.
There is strong evidence these approaches are actually harmful, Cooper
said.
Aggressive policing and mass
incarceration are a product of the war on drugs that Richard Nixon
declared and Ronald Reagan funded and implemented, Cooper said. But
rather than being a war on drugs, these policies were really a war on
racial equality.
"The timing of
Nixon declaring the war on drugs was not that long after the fall of Jim
Crow [laws that enforced segregation], and I would say that people in
the white power structure were trying to find ways to maintain hierarchy
and the war on drugs was a perfect way to do that, and it was highly
successful," said Cooper, who studies the effects of socioeconomic
status and incarceration on health and drug use.
A top Nixon aide told a reporter that the war on drugs was a strategy to target "blacks and hippies" and "disrupt those communities," in a 22-year-old interview that was recently published in Harper's Magazine.
The
report by Beyrer and his colleagues highlighted evidence of racial
discrimination in incarceration rates for nonviolent drug offenses. For
example, one in 13 black men
between the ages of 30 and 34 were in prison in 2011 compared with one
in 36 Hispanic and one in 90 white males, despite the fact there was
similar prevalence of drug use between these three groups.
There
are a number of ways that "excessive use of incarceration," as the
report stated, can have public health harms. For one, the rates of HIV,
HCV, hepatitis B virus and tuberculosis are between two and 10 times
higher in prisons than in the community, and these diseases can spread
between prisoners, for example through injection drug use, which can
occur despite restrictions.
When
people go to prison, it can have public health effects on the community
they come from. "One implication of removing a lot of men from the
community is that you destabilize the sexual relationships [which can
lead to] concurrent partnerships and high-risk partnerships," Cooper
said.
Could the U.S. decriminalize minor drug offenses?
One
of the key recommendations of the new report is to decriminalize minor,
nonviolent drug offenses, which includes use, possession and petty
sale. The report points to evidence from European countries. After
decriminalizing minor drug offenses and scaling up HIV prevention
services, Portugal reduced its rates of incarceration and HIV and did not see an increase in rates of drug use.
There is already some evidence decriminalization is at least possible in the United States.
There
are four states that have decriminalized possession of cannabis, Beyrer
said , and in these states, the rates of young people -- and
disproportionately black and Latino youth -- going to jail and getting a
criminal record will probably decrease.
"As
so often happens in the U.S., it is harder to do things at a federal
policy level particularly in areas where there is social and political
controversy, and the states are often the innovators," he added.
The
recommendations in the report are "basically long overdue," said Dr.
Don Des Jarlais, professor of psychiatry and preventive medicine at the
Icahn School of Medicine at Mount Sinai, who was not involved in the new
report.
"We should not criminalize
personal drug use and put users in prison. We've known that for quite a
while, there is mounting evidence, that it is not a protective policy
for dealing with individual drug users...it is not a cure and creates
many social problems," Des Jarlais said.
Although
it would represent a big shift in the criminal justice system, Des
Jarlais thinks it is possible to decriminalize minor drug offenses and
it would save money and allow law enforcement to focus on much more
serious crimes.
Even without a change at the federal level, it could still be possible to reduce the number of arrests for minor drug offenses.
"Officers
have a tremendous amount of discretion in terms of how they choose to
enforce laws on the book so police departments can deprioritize
enforcing drug laws or to prioritize collaborating with drug treatment
programs so instead of arresting people, they make sure that people who
use illegal drugs are connected to public health programs and services,"
Cooper said. These changes come from above, from shifts in policy at
the police commissioner and local government levels, she added.
The impact of this report
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The
report could have a number of effects on drug policy, including
increasing awareness in the public, among voters and among social
movements, including Black Lives Matter, Cooper said.
Although
the United States, and in particular the current Congress, is
"relatively impervious to international guidelines," the report comes at
an important time, before the U.N. General Assembly Special Session.
"I
think the U.N. General Assembly can have a very powerful effect in
terms of setting standards and providing guidance for member states,"
Cooper said.
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