Thursday, October 24, 2013

Harm Reduction, the Ultimate Goal

In the United States harm reduction was followed three basic themes:
-Syringe Exchange
-"Good Samaritan" Laws which offer immunity for people who respond to overdoses by contacting emergency services (immunity may be limited and not cover those on probation, in drug court, nor possession or distribution charges)
-Naloxone (narcan) access for people who use opioids

Radley Balko has a recent post about a Wisconsin state Rep whose daughter is a heroin addict. It was her experience which motivated him to sponsor a series of bills that moved forward harm reduction in Wisconsin:
The Milwaukee Journal Sentinel has the story of Wisconsin Republican state Rep. John Nygren, who is sponsoring a series of bills aimed at addressing and minimizing the damage from heroin overdoses. Two of the policies he's pushing are somewhat controversial. The first would offer limited immunity for people who call 911 or bring overdose patients to an emergency room. The sensible theory behind the policy is that people are reluctant to report overdoses if doing so could subject them to criminal charges. The other would expand those with access to Narcan, a medication that reverses the effects of an overdose.

Nygren is sponsoring these laws after confronting his daughter's heroin habit, and her near fatal overdose in 2009. Unfortunately, that sort of brush with the drug war's collateral damage is sometimes what it takes to make politicians see the light. But good on Nygen for coming around.

The Good Samaritan policy is understandably controversial, although it's certainly a sound approach. You're sacrificing a possible low-level drug prosecution in order to save a life. You'd think that even an ardent drug warrior would find that to be a satisfactory trade.

Or perhaps not. Some drug policies over the years have reflected more of a "better dead than high" approach to addiction. Consider the Narcan policy. If there's a medication out there that can prevent heroin overdose deaths, you'd think policymakers would want it distributed far and wide. But that hasn't been the case. There's a history here in which both the federal government and state governments have tried to restrict Narcan's availability. Consider this quote from Dr. Bertha Madras, deputy director of the White House Office on National Drug Control Policy during the George W. Bush administration.
    "Sometimes having an overdose, being in an emergency room, having that contact with a health care professional is enough to make a person snap into the reality of the situation and snap into having someone give them services."
In other words, withholding lifesaving medication from overdose patients may be just what addicts need to kick the habit for good. Yes, it could also kill them. But at least at that point, they'll no longer be getting high.

Daughter's Heroin Habit Moves Wisconsin Lawmaker To Sponsor Good Samaritan Law

Offering immunity for people who try to save addicts lives and expanding access to naloxone are important measures. Yet these "controversial" measures (if it was saving the lives of any other population it wouldn't be controversial) are doing little more that chipping away some of the worst aspects of the drug war. Rep Nygren's daughter went through the stereotypical junkie experience:

Cassie Nygren's parents divorced when she was 3.

As a teen, she experimented with alcohol and marijuana. She also says she was sexually abused.

At 15, she became pregnant and later gave up her daughter for adoption.

"I had just turned 16 and for her to leave me and be put into a vehicle of somebody else's and driven away was the hardest thing that I've ever had to do," she says. "I know that it was best. I know that it was a selfless thing to do. I know that she's loved and safe, and I wouldn't ask for anything more. However, it affected me, and it was never dealt with."

Months after she gave birth, she says, she started using Oxycontin, a commonly abused prescription narcotic painkiller. A friend introduced her to the drug, she says.

"I loved it right away," she says. "It gave me a feeling of being numb, no pain. It filled a void of emptiness that I had had, and right away I was hooked. The way I started was snorting....By 18, I was shooting heroin."

To feed her drug habit, she stole from her family.

"I don't think even any dollar amount could answer how much I've stolen and robbed from them," she says. "Not just in expenses or valuable things but our trust."

She cries as she recalls stealing her dad's Jaycees ring and pawning it for $150.

"It breaks my heart and to have admitted that to him was extremely hard," she says.

Cassie Nygren confessed to her father about her drug problems during a dinner at a local pizza restaurant.

"She looked terrible," he says. "Face white, pale, sunken in. And she's a pretty girl. You could basically see it on her face."

The family got her into treatment, but it didn't stick. She was in and out of several programs.

"A smart kid with a bright future ended up not graduating from high school," John Nygren says. "She got her GED later."

And she spent time in jail. The prosecutor, Marinette County Assistant District Attorney Kent Hoffmann, says his approach in Cassie Nygren's case "was to send her to prison to save her life."

After serving her prison sentence, Cassie Nygren violated her extended supervision several times. The latest was over the summer when she left town with an ex-boyfriend. They went to Texas, where she was picked up during a routine traffic stop.

She says she was trying to break away so that she could live a clean life with a friend in Texas. She says she now knows it was a mistake to leave.

John Nygren and his ex-wife worry about what will happen to their daughter. Amy Harris says she has seen encouraging changes in recent weeks.
 Marinette lawmaker confronts daughter's heroin addiction, seeks new legislation

Cassie Nygren

A traumatized girl deals with her mental pain by self-medicating with opiates. Because real drug education on how to use drugs safely is nonexistent, and only the most concentrated and therefore dangerous formulations are available to users (oxycontin and heroin instead of opium or poppy pod tea), the chance of overdosing is high. Cassie Nygren's story, the overdosing, stealing, jail, the in-and-out of ineffective treatment programs, is far from unique. It could even be called the stereotypical junkie story, but it doesn't need to be.

If Cassie Nygren was offered heroin maintenance she could have been kept from overdosing, stealing from her family and out of jail. She might even go to school and become a productive member of society. Expanding opiate maintenance beyond methadone and buprenorphine to include the full spectrum of available opioids would probably do more to lessen the problems of opiate prohibition than any other measure (short of full legalization). The black market would be dramatically reduced and users would no longer be criminalized. Because heroin is relatively harmless in and of itself, most of the health problems that are common in heroin users would disappear. The acquisitive crime and prostitution that is so common among destitute addicts would be dramatically reduced. The hard working addicts who hold down a job only to see a sizable portion of their paycheck go to supporting their habit would keep that money, improving the quality of life of their families. Accidental overdoses would be rare, and would be promptly treated by clinic staff.

The cost of pharmaceutical heroin, morphine and the other semi-synthetic opiates is negligible. The savings in criminal justice costs, crime averted and health savings more than compensates for the cost of running opiate maintenance clinics. The only real cost to society is that we would have to stop persecuting addicts and give them the drugs they want.

Opiate maintenance using the individual's opioid of choice is the form of harm reduction that has the most benefit for the individual and society. I urge all drug reformers to move the discussion beyond (but not abandon!) clean syringes, safe injection facilities and "Good Samaritan" laws and adopt maintenance prescribing as the most important harm reduction goal.

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