Before the sun set, this group of mobile harm reduction workers had sent encrypted text messages to people in the area who needed these supplies, detailing times and locations for secret drop-offs. Everyone was told to look out for the gray car.

“We’ve been forced to work in the shadows.”

For the next several hours, I sat shotgun criss-crossing Kanawha (pronounced: Kuh-Naw) County, pulling into parking lots of big box stores and fast food restaurants which, for a brief moment, became sites of health care and civil disobedience. As we arrived at each parking lot, people would approach the car, warily at first. Once the car doors were open and the coast was deemed clear, the hand-offs quickened and people walked briskly away with a word of thanks and their injection supplies.

“It feels like we’re doing a drug deal,” one of the harm reduction workers said, driving to the next parking lot. “We’ve been forced to work in the shadows.”

***

For many people who use drugs, especially in rural states, harm reduction programs function as their only lifeline. Pharmacies refuse to sell syringes. Emergency departments send them home with little more than a brochure of phone numbers. Abandoned by mainstream health care institutions, syringe service programs keep them connected not only to health care, but to kind and caring people.

But that connection has been severed in West Virginia by a state law passed in April 2021. Passing out syringes without explicit approval from state health officials, local commissions and the county sheriff now carries misdemeanor charges, fines of up to $10,000 and possibly jail. For harm reduction programs to operate legally, they must also abide by a strict “one-to-one” rule, which means people can only receive one new syringe for every used one they return. By contrast, the Centers for Disease Control and Prevention promotes “needs-based” syringe programs, which are far more effective at reducing the spread of HIV and other infections. Since the new law took effect, several harm reduction programs have shuttered across West Virginia, leaving vast stretches of the state with no services whatsoever.

The crackdown on harm reduction and the resulting syringe scarcity has been catastrophic for public health. In 2018, only two new cases of HIV were detected in Charleston. But that year, state and local officials decided to shut down a syringe program. By 2020, 40 new people in Charleston who inject drugs were diagnosed with HIV—roughly the same number of new cases as in New York City, which is 47 times more populous. Epidemiologists familiar with West Virginia’s outbreak suggest these numbers are merely “the tip of the iceberg,” and that many more cases statewide have gone undiagnosed and undetected.

In these deserts of care resourceful people and organizations create scattered oases.

The devastation convinced the Charleston group to operate a mobile syringe program without permission, in defiance of the law. They’re taking on immense legal risk, which is why their names are being withheld.

Tents in front of a boarded-up home in Charleston, West Virginia.

West Virginia is far from the only state where harm reduction programs face political, legal and cultural obstacles. Across rural America, programs that distribute naloxone, sterile injection equipment and fentanyl test strips, and which make referrals to low-barrier prescribers of medications like methadone and buprenorphine, are chronically underfunded and struggle to meet the needs of their communities. Meth use, a major contributing factor to rural overdose, remains substantially overlooked. If neighborhood backlash doesn’t drive out harm reduction programs, then councils and state legislatures are more than happy to step in.

Today, demand for harm reduction services across America far outstrips supply and capacity, especially in remote parts of the country where syringe or methadone programs are hours and hours away. Still, rural America contains multitudes, and in these deserts of care resourceful people and organizations create scattered oases. In Charleston, that means breaking the law to distribute supplies to people who drive in from all over the state. Elsewhere, harm reductionists are leveraging online platforms and civic institutions as unlikely sounding as the church.

***

In Kanawha County, one tall woman with bleach-blonde hair was especially grateful for the injection supplies, she said. Earlier in the week she had run out of syringes and resorted to injecting methamphetamine in her neck using an intramuscular needle intended for naloxone, a process she described as horribly painful (the gauge of an IM syringe is far too big for veins).

In a McDonald’s parking lot, a man in his 30s wearing a flat-brimmed New Era hat asked if tonight’s kits had those little blue plastic vials of sterile water. “No, not this time,” one of the workers said, regretfully. The group couldn’t afford to order more water units. In yet another parking lot, the workers handed supplies to a friendly woman named Tabitha, who told all the workers to text her when they got home; like a mom to teenagers, she wanted to make sure they were safe.

“That’s mostly what we’re confronting out here—people’s pain.”  

Next, we pulled into a Wendy’s, which was not on the itinerary as an official drop-off site. There we saw two young men slouching on the curb, wearing black zip-up hoodies. The workers offered them supplies, which, it turned out, they needed. One of them, who told me his name was Chris, said, “Everyone’s passing around HIV. There’s no new rigs.”

“Charleston wears its pain on its sleeve,” one of the rogue workers said. “That’s mostly what we’re confronting out here—people’s pain.”  

***

Hundreds of vials of naloxone sat on an altar at the United Methodist Church in Columbus, Ohio. The opioid-overdose antidote was due to be blessed in a church service led by preacher and harm reductionist Blyth Barnow. Barnow cheekily titled her service “Naloxone Saves,” a play on the ubiquitous “Jesus Saves” bumper-sticker slogan. Wearing a black dress, she stood at the dais and began preaching the Christian theological basis for harm reduction, connecting naloxone distribution to key concepts like resurrection. This medicine, she said, gives ordinary people great power.

With the lights dimmed, Barnow invited those who’ve lost loved ones to overdose to light a candle in their memory. Across working-class communities in Ohio, where Barnow was born and raised, there are always people in the crowd who have lost family and friends. Overdose deaths recently jumped by 26 percent—to 5,585 lives lost in 2021. Like West Virginia, Ohio’s rate far exceeds the national average.

In the flickering orange glow, Barnow’s voice boomed, “We must step in and help to distribute lifesaving tools like naloxone, fentanyl testing strips, and sterile equipment. We must commit to lifting people up when systems let them fall.” She then read from Matthew, 10:5-8: “Cure the sick, raise the dead, cleanse the lepers, cast out demons. You received without payment; give without payment.”

In each service, Barnow encourages people sitting in the pews to come up to the altar and take as many naloxone kits as they need, for free. “The hope is, whatever naloxone I bring with me that I leave with none,” she said.

Photograph courtesy of Blyth Barnow

I asked Barnow, who is the Ohio associate director for Faith In Public Life, if her strategy was working. Have any churches denied her?

“We had one church that wasn’t comfortable doing naloxone distribution without the health department there,” Barnow said. “So the health department came and distributed [naloxone] based on their protocols and I distributed based on my protocols. The health department distributed 25 Narcan kits and I distributed 75 kits.” Barnow said the health department workers were stunned that she gave away triple what they did. “They had never distributed more than 25 kits.”

“It’s hard to read it as anything other than hate for people who use drugs. Oftentimes, when we get into the nuance, it’s actually people holding a great deal of hurt and grief.”

Health departments in Ohio tend to ask a lot of questions and collect a lot of “data,” Barnow explained, which may make people skittish. Her approach is to make people feel welcome and not ask questions. 

“Watching people walk away from the altar with an armful of [intramuscular] naloxone, sometimes taking 25 kits at a time, and seeing that happen in a church sanctuary during a church service, is just deeply meaningful to me.”

Much of her pastoral work, Barnow continued, involves “holding space” and “sitting in the mess” with people while they work through their own internal conflicts.

“A lot of times we see the objections or hostility to harm reduction and it’s hard to read it as anything other than hate for people who use drugs,” she said. “Oftentimes, when we get into the nuance, it’s actually people holding a great deal of hurt and grief that they have never been able to share with another person.”

***

With President Joe Biden in the White House, some had hopes that a landscape hostile to harm reduction would change. For the first time in US history, the federal government included harm reduction as a central tenet of its national drug policy strategy. In another first, Biden’s American Rescue Plan created $30 million worth of grants for harm reduction programs. After decades on the fringes of drug policy, harm reduction was finally being recognized as a valid, necessary and effective approach.

But the recent, albeit partial, embrace of harm reduction at the federal level has often not translated to support at the local level, where America’s streak of punitive, zero-tolerance, abstinence-based drug policy and treatment still holds considerable sway. And that’s particularly true in rural states where conservative values, at least on their face, appear to clash with the practice and principles of harm reduction, which are rooted in self-determination and bodily autonomy. Whereas conservatives prefer people to be self-reliant and free from dependency—in this context, perhaps, “clean and sober”—harm reductionists recognize the importance of interdependence, and try to attach as few strings as possible to help. Few US drug laws have caught up to harm reduction’s view.

Words on a home in Charleston read, in part, “NO SELLING OR BUYING DRUGS ALLOWED HERE LORD HAVE MERCY ON ALL OF US AND USA.”  

So often, policy and laws that materially affect the lives of people who use drugs are decided not in Washington, DC, but in city councils, town halls, police departments and the pages of local newspapers. In Alabama, for instance, a new state law prevents telemedicine providers from prescribing a controlled substance unless the patient has had an in-person appointment within the previous 12 months. As a result, rural patients receiving buprenorphine remotely have been scrambling to find a doctor nearby.

In dense urban centers as well as sparsely populated rural areas, harm reduction programs are in the public’s crosshairs— frequently viewed as “enabling” and “coddling” people who use drugs, as prolonging addiction rather than spurring recovery. Harm reduction’s growth has put it on a collision course with America’s dominant paradigms.

“Rural and remote areas are really left out of the harm reduction equation.”

“That’s the climate that we are responding to right now,” said Jamie Favaro, the 42-year-old founder of NEXT Distro, an online platform that sends harm reduction supplies through the mail.

Like the underground syringe program in Charleston, NEXT Distro has found a way to get supplies to those in need, whose numbers have only swelled during the COVID-19 pandemic. Thousands of requests for injection supplies come from people in rural neighborhoods and small towns that lack the services of major metropolitan areas. These locations might be served by just one pharmacy, which may choose to not distribute naloxone, which may not dispense syringes without a prescription, and which might not even stock opioid use disorder medications like buprenorphine. State paraphernalia laws, meanwhile, criminalize the possession of fentanyl test strips, syringes and other supplies.

“Rural and remote areas are really left out of the harm reduction equation,” Favaro told Filter. That’s where NEXT comes in, mailing out the supplies to places without brick-and-mortar syringe programs. The legal assault on harm reduction and public health is perhaps most stark in Tennessee, from where Favaro receives numerous requests for supplies.

“In Tennessee, we call it the ‘Slate of Hate,’” said Lesly-Marie Buer, a harm reductionist and medical anthropologist from Knoxville. “It’s the anti-abortion, anti-trans, anti-LGBTQ legislation that comes up every year.”

This unified conservative caucus invariably targets harm reduction, too. Most recently, Tennessee legislators attempted to require that every single syringe program in the state receive a public written letter of support from local law enforcement. “Let me just tell you, that’s not going to happen,” Buer said. “It would be political suicide for a sheriff or police chief to support harm reduction.”

Out of Tennessee’s 95 counties, only seven are home to legally sanctioned syringe service programs, the majority located in densely populated metro areas. And unlike neighboring states, such as Kentucky, Tennessee has not expanded Medicaid, leaving over 100,000 residents without health insurance and access to critical care. The 10,000 square miles of West Tennessee, in particular, are a harm reduction and health care desert.

Map of Tenessee counties with syringe service programs via Tennessee Department of Health

In rural Tennessee counties, syringe programs must also be sited 2,000 feet away from any school or park. The state also recently criminalized homelessness, making it a felony for any unhoused person to camp on public land. Critics of the new law say the unhoused population is simply being pushed further from public view, and away from services that could be of help. These barriers on the ground make the work of NEXT Distro all the more salient.

To access supplies through NEXT, people are asked to fill out an “enrollment” form, which helps NEXT assess their needs. One question asks enrollees how often they have shared syringes with another person in the past month. The responses horrify Favaro. “In states like Pennsylvania, West Virginia, Tennessee, Ohio, we’re seeing up to 40 percent of people reporting active syringe sharing ‘all of the time’ or ‘most of the time.’” High levels of syringe sharing, Favaro explained, account for the ever-expanding clusters of HIV and hepatitis C in rural America.

“Never in my lifetime would I think I’d see young people my age dying of HIV.”

“I was 17 years old when I got my first job at an HIV drop-in site,” said Brooke Parker, an outreach worker for Charleston’s Ryan White Program. “I’m 37 now, and never in my lifetime would I think I’d see young people my age dying of HIV.” But, that’s exactly what she is seeing now. Part of Parker’s job is to ensure people living with HIV can access antiretroviral medication, but she cannot offer her clients one of the most powerful tools to prevent HIV from spreading: sterile syringes.

“An increase in acute [hepatitis C] infection in individuals 30 years of age or younger over the past decade has occurred in both nonurban and urban counties,” Dr. Stuart C. Gordon, director of hepatology at Wayne State University School of Medicine in Detroit, wrote in 2019. “But the incidence of infection has been twice as high in rural areas than urban ones.”

A sharps container in Charleston.  

Favaro’s voice carried with a mix of sadness and anger over the phone. “Right now, NEXT is receiving about 160 to 200 applications every week for our program,” she said, describing the surging demand as “incredibly overwhelming.” Lacking financial support—NEXT did not win a slice of the $30 million federal pie for harm reduction programs—it’s virtually impossible for Favaro to serve all applicants. NEXT is forced to triage and prioritize only those in severe need. “People just cannot access the supplies they need to be safe,” Favaro said.

***

Blyth Barnow, who identifies as queer, didn’t always have a warm view of religious institutions. She vividly remembers a minister condemning her partner who died of an overdose at their own funeral service. “My friends kept dying and I kept going to awful, awful funerals,” she told me. After years of running away from Christianity, Barnow decided to run toward it. “You’re a shitty pastor, so Imma be the fuckin’ pastor,” she thought. That eventually led to her project to spread harm reduction and drug policy reform through the church, showing churchgoers how their faith actually aligns with these goals.

Her Naloxone Saves service recontextualizes overdose prevention as an act of resurrection, her way of living into the harm reduction maxim of “meeting people where they’re at.” She uses the language, symbolism and principles of Christian theology to engage her faith community around harm reduction, melding worldviews often deemed immiscible, like oil and vinegar. But Barnow views churches across the Midwest as a potential vehicle to preach the gospel of harm reduction.

“I wasn’t born a harm reductionist,” Barnow laughed. “It took some convincing for me.” And yet, “It was through harm reduction that I came to understand that resurrection was a real thing.”

Getting churches on board with harm reduction can be an uphill climb. So is getting harm reduction on board with the church. Barnow attended seminary school in Berkeley, California while working at the Harm Reduction Coalition in Oakland. “I went to seminary as a harm reductionist, as a queer person, as a person raised working class and poor, whose partner was trans,” Barnow said. “A lot of my community has been deeply and negatively impacted by the institutional Christian church and far-right wing Christianity.”

It illustrates how cultures which, on their surface, appear to be hostile to harm reduction can be mobilized to advance it. 

So she’s not surprised when people in harm reduction are wary of involving the church in their work. “Like anything, it’s a slow trust-building operation.” Forging that trust has led to thousands of doses of naloxone distributed directly to communities hit hard by overdose deaths.

Barnow’s battle involved changing Ohio laws that placed onerous restrictions on distributing naloxone. Community-based programs seeking to do so required special permission through a Terminal Distributor of a Dangerous Drug (TDDD) license. This posed a major obstacle to scaling up desperately needed low-barrier naloxone distribution.

Barnow organized to change Ohio’s naloxone law by building power between the faith community and grassroots harm reduction organizations. Working together, this coalition slowly made inroads with key groups like the state’s Board of Pharmacy, and then approached state legislators.

In 2020, after years of painstaking work, Ohio’s new naloxone law allowed for more direct, community-based distribution, enabling Barnow to give away hundreds of naloxone kits through churches. It illustrates how cultures which, on their surface, appear to be hostile to harm reduction can be mobilized to advance it. 

***

West Virginia, home to “the most concerning” HIV outbreak in the nation and one of the highest rates of hepatitis C, has an overdose death rate more than double the national average. Methadone, proven to reduce mortality among people with opioid use disorder by 50 percent or more, is heavily restricted: Just nine clinics operate in the entire state, forcing people to drive enormous distances to access the medication that could save their lives.

“We have people at the methadone clinic where I go coming from two hours away, everyday,” Mandy Cavender, a 37-year-old resident of Charleston, told Filter. “Some of them pay cash money, $25.50 per day to dose. That’s on top of the gas money to get there. People come from way out there—it’s crazy.”

“Had I just been able to go to the needle exchange and get what I needed, I wouldn’t have HIV today.”

Not long after Charleston shut down multiple harm reduction programs, Cavender learned she was HIV-positive. She believes it could have been prevented.

“Had I just been able to go to the needle exchange and get what I needed, I never would have bought a bag of points on the street and I wouldn’t have HIV today,” she said. “Now I have something I have to live with for the rest of my life.” Cavender is both saddened and enraged by the state’s crackdown. “The cops and the city shut them down so hard,” she said, “which was one of the stupidest things they could have ever done.” 

Failure to contain HIV in more urban areas like Charleston has led to its spread in more rural parts of the state. Mountain State Spotlight, an investigative news outlet in West Virginia, reported that new HIV cases were found in 29 West Virginia counties last year, many of them rural and many of which had not seen a new case in years.

“Did you see the McDonald’s right up the street? The little park right next to it?” Cavender asked me. The pitch of her warm Southern drawl deepened. “That’s AIDS Park,” she said. “The walkways made of bricks with names on them. Every one of those names is someone who passed away from AIDS.”

One brick read simply: “In memory of Gary.” Another read: “Garden Friend Edie Maine Ashley.”

Standing on those bricks in the park, the ornate dome of West Virginia’s capitol building looms in the distance. “It’s not a secret, the IV drug use around here is extremely serious,” Cavender said.

I asked Cavender why she thought politicians, law enforcement and parts of the community came down so hard to shut programs dedicated to preventing even more names from being etched into those bricks. Her answer was chilling.

“The amount of homeless people, street people, got really high here,” she said. “It made everything so visible.”

Top photograph of Brooke Parker on her HIV outreach beat and all photographs unless otherwise stated by Zachary Siegel

Correction, August 24: This article has been edited to correct Jamie Favaro’s age.

R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter. Filter‘s Editorial Independence Policy applies.

The post “Where They’re At”—Harm Reduction in Rural America appeared first on Filter.

If you don’t dispose of your leftover medications or e-cigarettes, they may “fall into the wrong hands,” warned Republican Texas Senator John Cornyn. Plugging its local take back day program on Twitter, Minnesota’s Hennepin County Sheriff claimed “prescription opioids remain one of the major gateways to addiction.” A local Indiana news outlet reported the DEA’s Take Back Day advertisement verbatim: “The Drug Take Back initiative aims to prevent prescription drug abuse and theft through proper disposal.”

These programs prevent neither addiction nor overdose deaths.

Of all the DEA’s drug-war activities, from reckless no-knock raids to warrantless surveillance and the arbitrary seizing of billions of dollars in private property, Drug Take Back Day sounds rather innocuous, even quaint. Ordinary Americans are simply being asked to perform a public service by safely disposing of medication they no longer want or need. Safe disposal of medication, after all, is important for the environment. Active pharmaceutical ingredients have been detected in water and soil, posing risks to humans and wildlife. The Food and Drug Administration and the Environmental Protection Agency have easy steps to discard medications in an environmentally conscious way, in addition to many pharmacies now having permanent drop-off boxes for unwanted drugs.

If Drug Take Back Day was merely framed to the public as a way to protect people, animals and the environment from pharmaceutical pollution—akin to sharps containers—then it wouldn’t warrant much attention or scrutiny. We could acknowledge the importance of safe disposal for the environment and simply move on. But the DEA, police departments and politicians claim that Drug Take Back Day is vital to the nation’s response to the overdose crisis that took more than 96,000 lives in the last year.

There’s just one problem: These programs prevent neither addiction nor overdose deaths.

Notably absent from the DEA’s Drug Take Back Day publicity is the quantity of actual controlled substances the program acquires. Raking in nearly a million pounds of vitamins and expired blood pressure medication certainly does nothing to prevent addiction and overdose. One 2017 study by researchers at Wake Forest University found that a mere 5 percent of medications collected were controlled substances that carry a risk of addiction. What this study did that few others had previously done was compare the amount of controlled substances dispensed to the total given back. The researchers found that take back programs collected less than 1 percent of the controlled substances that were dispensed.

Drug Take Back Day accomplishes little by way of preventing overdose deaths as well. In 2010, the first year of the national take back day program, roughly 14,500 overdose deaths involved a prescription opioid. In 2019, the latest year for which full data exists, deaths involving a prescription opioid remained steady at 14,139. (It should be noted that such deaths overwhelmingly involved prescription opioids in combination with other substances.)

At best, these programs are a fig-leaf that perpetuates false perceptions. At worst they could be pushing even more people to the illicit, adulterated market.

Meanwhile, during this same period, deaths involving heroin, illicit fentanyl and meth have soared to new heights. Dr. Stefan Kantrowitz, an addiction medicine physician in New York, succinctly described Drug Take Back Day as “hygiene theater” for opioid use disorder.

At best, drug take back programs are an anodyne, feel-good fig-leaf that perpetuates false perceptions about the DEA’s role in the overdose crisis, and the nature of the crisis more broadly. At worst, at a time when harm reductionists are increasingly calling for safe supply, these programs could be pushing even more people to the illicit, adulterated market where the vast majority of overdose deaths occur. If someone loses their stash because their parents, say, zealously delivered it to the DEA, what is that person likely to do next?

Writing in the New York Times, Leo Beletsky and Jeremiah Goulka (my colleagues at Northeastern University’s Health in Justice Action Lab), argue that the DEA’s draconian tactics have, in fact, fueled the overdose crisis. Contrary to the pop-culture image of DEA agents working deep undercover to disrupt drug traffickers, the DEA actually plays a far more unsexy role in our everyday lives: regulating and overseeing the pharmaceutical supply chain.

Doctors are increasingly uncomfortable prescribing opioids to patients even when pain relief is medically indicated, citing fear of the DEA. The DEA also makes medications like buprenorphine and methadone difficult for doctors to prescribe and for people who use drugs to obtain. “Because of [the DEA’s] incompetence, the opioid crisis has gone from bad to worse,” Beletsky and Goulka write.

Focusing on the prescription drug supply has missed, and continues to miss, the forest for the trees. It’s hardly true that prescription opioids are a “major gateway” to heroin. “Heroin as an initiating opioid now exceeds hydrocodone and oxycodone,” according to a 2017 paper on how people get their start on opioids.

That trend is reflected in ever grimmer mortality statistics: The vast majority of “overdose” deaths today involve a mix of multiple substances that are not supplied from medicine cabinets with a few leftover Percocets. The illicit drug supply now contains uber-potent, Illicitly manufactured fentanyl (and its many analogues), methamphetamine and obscure benzodiazepines. The record-breaking levels of overdose deaths are due to this deadly combination of substances that leave even the most experienced drug users vulnerable to fatal overdoses.

As the activist Garth Mullins, host of the excellent Crackdown podcast, recently told Filter, “We need more pharmaceutical opioids, not less.” Drug take back days achieve little and could easily be making a dire situation worse.

Image via the DEA

The post Rx Drug Take Back Days Are Unhelpful at Best, Harmful at Worst appeared first on Filter.

The Biden administration is officially tapping Dr. Rahul Gupta as director of the Office of National Drug Control Policy, a White House spokesperson confirmed to Filter. Gupta became a nationally recognized health policy expert during his role as West Virginia’s public health commissioner from 2015 to 2018, where he led the state’s response to its own surging overdose crisis.

Gupta will replace Regina LaBelle, the ONDCP’s current acting director, if confirmed by the Senate. He directed Filter’s request for comment to an ONDCP spokesperson.

“President Biden’s nomination of Dr. Rahul Gupta to be the first physician ever to lead the White House Office of National Drug Control Policy is another historic step in the Administration’s efforts to turn the tide of our nation’s addiction and overdose epidemic,” the spokesperson told Filter. “Dr. Gupta brings firsthand experience as a medical doctor and public health official using evidence-based strategies to address the overdose epidemic in West Virginia. We hope he will be confirmed by the Senate soon.”

It remains to be seen whether as “drug czar” Gupta will take more pro-harm reduction positions than he did in West Virginia.

Filter broke the news in March that Gupta was the leading candidate for the role, reporting that harm reduction experts and activists have been critical of his drug policy record. In 2018, he supported the closure of a low-barrier syringe service program. West Virginia is not only struggling to prevent soaring overdose deaths, but is now facing multiple outbreaks of HIV and hepatitis C, driven by a lack of harm reduction infrastructure and access to sterile syringes for people who use drugs. In February, the Centers for Disease Control and Prevention described Kanawha County’s HIV outbreak as “the most concerning in the United States.”

It remains to be seen whether as “drug czar” Gupta will take more pro-harm reduction positions and support local harm reduction organizations that are facing political backlash across the country.

“The Biden Administration has made enhancing evidence-based harm reduction efforts one of ONDCP’s top priorities,” Robin Pollini, associate professor at West Virginia University’s Department of Behavioral Medicine & Psychiatry, told Filter. “I sincerely hope Dr. Gupta will embrace the opportunity to lead on that issue. And I would ask that he bring that leadership without delay back to West Virginia, where anti-harm reduction laws at both the state and local levels are literally killing our loved ones, friends, and neighbors.”

Gupta is set to take on the federal government’s top drug policy job during a historic year of record-breaking overdose deaths, driven primarily by the presence of illicitly manufactured fentanyl in the unregulated drug supply, as well as stimulants like methamphetamine. However, President Barack Obama  previously downgraded the role of director of the drug policy office from a Cabinet-level position, diminishing its power and influence.

“Hopefully, Dr. Gupta will take advantage of the growing political support of harm reduction strategies.”

“It is my hope that the full power of federal resources and influence will be directed at addressing these crises through full implementation of evidence-based harm reduction strategies including syringe service programs, naloxone distribution, integration of medication treatments (i.e., buprenorphine & methadone) with syringe programs, safe consumption sites and safe supply interventions,” Ricky Bluthenthal, associate dean for social justice and a professor in the Department of Population and Public Health Sciences at University of Southern California, told Filter.

“Dr. Gupta, if appointed, would have an excellent opportunity to lead such an effort. The well-being of hundreds of thousand individuals, their family members and communities depends on a comprehensive federal response to these multiple, preventable ailments. Hopefully, Dr. Gupta will take advantage of the growing political support of harm reduction strategies.”

Earlier this year, the Biden administration laid out the federal government’s drug policy priorities, which for the first time in the 33-year history of the office included harm reduction interventions and racial equity, in addition to status quo supply reduction and interdiction strategies. President Biden’s American Rescue Plan also included a historic $30 million investment for syringe service programs and community-based harm reduction organizations, funding that experts say is desperately needed while overdoses surge during the COVID-19 pandemic.

“Supply reduction was a very emphasized, some might say, over-emphasized, part of US drug policy for generations,” Dan Ciccarone, a physician-researcher at the University of California San Francisco School of Medicine, told Filter. “Now they’re bringing a more balanced approach to prevention, which includes harm reduction as well as treatment. This is where we need to go.”

For decades, US drug policy has prioritized brute-force drug war tactics, leading to the mass incarceration of Black and Brown communities while achieving little by way of reducing the harms of drug use. Despite robust investment in drug interdiction at the US-Mexico border and criminalization at home, drugs are cheaper, more potent, and more accessible than ever. One analysis by Pew Charitable Trusts found that drug imprisonment rates do not correlate with reductions in drug use, drug sales or overdose deaths, highlighting the urgent need for a radical new approach.

“We are grateful that President Biden has chosen someone with a public health background to lead ONDCP and look forward to working with him to implement critical harm reduction interventions—including safe consumption sites, syringe services programs and more—that have the power to save countless lives,” Kassandra Frederique, the executive director of the Drug Policy Alliance, told Filter.

“As an X-waivered [buprenorphine] provider himself, Dr. Gupta understands the barriers people face in being able to access lifesaving medications for opioid use disorder and why more must be done, especially for Black, Latinx and Indigenous communities that have disproportionately borne the brunt of this crisis. With over 90,000 lives lost last year alone, it’s disappointing it took this long to lock in the position, but all the more reason why we have no time to waste—and must get to work now.”

“If you look at Gupta as a complete package, there’s far more upside than downside.”

As West Virginia’s health commissioner, Gupta implemented the state’s medical marijuana program and, according to Marijuana Moment, touted the medical and health benefits of cannabis. On the other hand, he was lukewarm at best about the harm reduction potential of vaping, emphasizing the idea that manufacturers were trying to get kids “hooked.”

“The bottom line on Gupta,” Ciccarone said, “is that people in public office do a variety of things as public servants. It’s easy to say, ‘Oh, you messed up over here and you messed up over there.’ But if you look at Gupta as a complete package, the pros and cons of all the things he did while in West Virginia, there’s far more upside than downside. He talks openly about mistakes he’s made and what he’ll do differently in national office, which to me was very moving.”

Gupta’s nomination happens to coincide with the CDC’s much anticipated release of 2020 overdose mortality data, which is expected to show that 2020 was the worst year on record for drug overdose deaths. According to preliminary CDC data, an estimated 91,000 people died from a drug overdose in the 12 months leading up to November, a 30 percent jump from the previous year.

“We can hold Gupta to the fact that he has said he will ‘champion’ harm reduction,” Ciccarone said.

Photograph of the White House by David Mark from Pixabay

DPA previously provided a restricted grant to The Influence Foundation, which operates Filter, to support a Drug War Journalism Diversity Fellowship.

The post Biden Picks Dr. Rahul Gupta to Lead Federal Drug Policy During Historic Overdose Crisis  appeared first on Filter.

Dr. Gupta, an internal medicine physician, led Biden’s drug policy transition team, and is currently the senior vice president and chief medical and health officer at March of Dimes, a nonprofit that focuses on improving the health of mothers and their children.

But Dr. Gupta previously led West Virginia’s response to the overdose crisis, as the state’s public health commissioner from 2015 to 2018. And it’s his actions (or rather, inaction) in this role that raise questions about his suitability for the ONDCP post—especially since Biden’s current ONDCP has expressed a commitment to compassionate harm reduction principles, a major departure from past federal drug policy agendas.

West Virginia currently leads the nation in overdose fatalities, according to the the Centers for Disease Control and Prevention. And Gupta was praised by local and national press for his efforts to reverse West Virginia’s alarming overdose death rate. In May 2018, Politico Magazine described him as “a data-driven health commissioner” who “figured out a way to slow overdose deaths.”

While Gupta earned accolades for his overdose efforts, public health and harm reduction experts question his response to another urgent health crisis plaguing West Virginia: the spread of blood-borne viruses like HIV and hepatitis.

Facing the known risk of a massive viral outbreak linked to syringe sharing, Dr. Gupta put politics above the health of vulnerable and stigmatized people, public health experts say.

“Under Dr. Gupta’s leadership the West Virginia Bureau of Public Health unjustifiably decertified what I considered to be a very well-run harm reduction program.”

In 2015, when Gupta took office, the CDC found that half of West Virginia’s 55 counties were at risk of an HIV outbreak due to a lack of sterile syringes available for people who use drugs. West Virginia also had the highest rate of hepatitis C infections in 2015. Today, West Virginia is experiencing multiple HIV and hepatitis C outbreaks. The CDC’s grim assessment of West Virginia years ago has materialized, but experts say it didn’t have to.

“The most concerning aspect, to me, is that under Dr. Gupta’s leadership the West Virginia Bureau of Public Health unjustifiably decertified what I considered to be a very well-run harm reduction program,” Robin Pollini, a professor at West Virginia University who has studied harm reduction programs around the country, told Filter. “And the result of that is Charleston now has what CDC says is the most ‘concerning’ HIV outbreak in the US.”

The CDC also said that the outbreak in Kanawha County requires “immediate action.” This would normally entail the creation of a robust syringe service program to contain the spread of the virus. Instead, public health officials and politicians in West Virginia have stirred up a toxic backlash against harm reduction programs, and refuse to implement evidence-based responses like low-barrier syringe services.

In March 2018, under Gupta’s watch, the harm reduction program run by the Kanawha-Charleston Health Department was shut down by Charleston’s then-Mayor Danny Jones. Jones described Charleston’s harm reduction program as a “mini-mall for junkies and drug dealers,” and blamed harm reduction for a spike in crime. “It wasn’t a needle exchange. It was a needle mill. And crime in this city skyrocketed,” Jones said on WBUR’s Here & Now, a nationally syndicated radio program.

To seal the fate of future harm reduction programs, and further his political narrative that the Charleston program was mismanaged and led to more crime, Jones requested that West Virginia’s state health department conduct an audit of the now-shuttered program.

Gupta told a local news station that the audit “should be a lesson for other needle exchanges.”

Gupta obliged and, in May 2018, his department published a highly critical 62-page audit of the program. The audit criticized the program for petty offenses, like not tracking the number of condoms that were distributed and not collecting enough data about participants who accessed sterile syringes. The audit also cited unverified reports of an “increase” in needlestick injuries attributed to syringe litter, feeding into Jones’s anti-harm reduction crusade.

After the Charleston program was shut down, Gupta told a local news station that the audit “should be a lesson for other needle exchanges.”

“At least 100 people asked or expressed interest for services, especially treatment, but we couldn’t find evidence that a single patient actually got the treatment,” he said in the interview. “In essence we saw that there were a lot of missed opportunities to help people more.”

By supporting the toxic political agenda of Charleston’s mayor, Gupta’s audit of the harm reduction program ran up against the CDC’s own position on syringe service programs. “Nearly thirty years of research shows that comprehensive [syringe service programs] are safe, effective, and cost-saving, do not increase illegal drug use or crime, and play an important role in reducing the transmission of viral hepatitis, HIV and other infections,” according to the CDC’s website.

Instead of throwing the program under the bus, public health professionals in West Virginia think Gupta could have used his authoritative position to support health department workers in Charleston in trying to fight multiple viral outbreaks.

Dr. Gupta did not respond to Filter’s request for comment by publication time; this article will be updated if he responds.

As West Virginia’s top health official, Gupta issued a standing order for naloxone, which saved lives, and conducted a “social autopsy” of every overdose death in the state that revealed numerous missed opportunities to prevent overdoses from turning fatal. “We saw this was clearly a missed opportunity where we could have saved people,” Gupta told Politico Magazine. “So it’s critical that whenever these individuals do come into contact with one of the health systems, we take advantage of that opportunity and we do not let that slide.”

Yet with the Charleston program shut down, Pollini, who has a PhD and a master’s in public health from Johns Hopkins, says the situation on the ground today is dire. As Filter reported earlier in March, lawmakers are set on passing legislation that would cripple syringe programs across the state, which experts say will only make the HIV and hepatitis outbreaks even worse.

“What we have always been lacking in West Virginia is leadership on evidence-based interventions to prevent morbidity and mortality among people who use drugs––HIV, hepatitis C and overdose,” Pollini said. “We’ve never had leadership and we still don’t have it. That’s how we got here. And now we’re stuck with the repercussions of that.”

Pollini said that means of the four biggest HIV outbreaks in the US, West Virginia is home to two of them. “This is totally preventable,” she said.

“He put the political situation well ahead of the urgent health needs of the community … That’s not who I’d want to see in charge of ONDCP.”

In June 2018, Peter Davidson, an associate professor in the department of medicine at the University of California San Diego, wrote a response to the audit that highlighted the ways in which Dr. Gupta and his office failed to understand how successful syringe programs actually operate.

“Dr. Gupta was happy to put his name on an audit that justified shutting down an essential health service,” Davidson, who has studied harm reduction and the prevention of overdose and blood-borne virus transmission for over 20 years, told Filter. “He put the political situation well ahead of the urgent health needs of the community. His job should have been to help explain to the community why this program is in their best interest. He not only didn’t do that, he actively contributed to condemning the program.”

“That’s not who I’d want to see in charge of ONDCP,” Davidson added.  

Photograph by Kaytee Riek via Flickr/Creative Commons 2.0

The post Biden’s Likely “Drug Czar” Presided Over Destruction of WV Syringe Program  appeared first on Filter.

The initiative, whose motto was “Rethink the Drinking Age,” garnered coverage across mainstream media and racked up support among college students, administrators and more than 100 college presidents, from Duke to Dartmouth to Johns Hopkins.

“This [21] law has been an abysmal failure,” McCardell told 60 Minutes in a 2009 segment about the debate he ignited. “It hasn’t reduced or eliminated drinking. It has simply driven it underground, behind closed doors, into the most risky and least manageable of settings.”

Young people indeed regularly flout the drinking age law. Government surveys show that 2.2 million adolescents aged 12-17 drank alcohol in the past month, while 1.2 million report binge drinking in the past month.

If those figures seem high, they used to be much higher. Since the 21 law passed in the ‘80s, youth drinking has steadily declined in the US. But college drinking, especially binge drinking—defined as five or more drinks in two hours for men, or four for women—is a more stubborn curve to flatten.

It was binge drinking among college students aged 18, 19 and 20 that most concerned the Amethyst Initiative. McCardell and the college presidents believed that the law, by requiring secrecy around underage consumption, created an allure for alcohol. So they urged Congress to rethink the Uniform Minimum Drinking Age Act of 1984, which threatened states with millions of dollars in lost highway funding if they set the drinking age lower than 21 (Fox News later called this move “blackmail” against the states).

South Dakota challenged the constitutionality of the drinking age law in the 1987 Supreme Court case South Dakota v Dole, but the court upheld the federal mandate—21 to drink has remained the law of the land ever since.  

An Age-Old Argument

“Debates about drinking are as old as time,” Joy Getnick, a historian who wrote her doctoral thesis on “The Drinking Age Debates,” told Filter. “It’s not a modern issue. Some of the first drinking laws dating back to the 1600s were about unaccompanied minors in saloons.” From a historian’s perch, Getnick says the question at the heart of the argument is whether laws can, or even should, govern private behaviors.

Americans have long debated when to drink, what to drink, where to drink and how to drink. So McCardell’s campaign to lower the drinking age tapped into a volatile history. After the repeal of Prohibition in 1933, most states set the legal age to drink at 21. Those foundations began to shake in 1971 after the passing of the 26th Amendment, which lowered the voting age from 21 to 18. Several states then lowered the drinking age.

The term “blood borders” was popularized to describe deadly crashes involving young people crossing state lines to drink where it was legal.

Young men being shipped across the world to fight in Vietnam also loosened up attitudes to alcohol. A popular refrain of the time captures the rebellious mood: If I’m old enough to vote and I’m old enough to die in combat, I’m old enough to have a beer. It does sound convincing, until one asks whether 18  is also too young to be shipped off to war.

Some lowered drinking ages in the ‘70s created conflict between neighboring states that had different laws. The term “blood borders” was popularized to describe deadly crashes involving young people crossing state lines to drink where it was legal. Research began to show a national spike in fatal car crashes among drunk and underage drivers.

Soon, drunk driving was a hot-button issue and Mothers Against Drunk Driving mobilized support for raising the drinking age. Since its inception in the ‘70s, MADD has helped put more than 1,000 new drinking laws on the books across the country, ranging from harsher penalties for drunk driving to sobriety checkpoints.

MADD played a part in pressuring President Ronald “Government-Is-the-Problem” Reagan to sign the 1984 Uniform Minimum Drinking Age Act into law, even though it ran counter to his states’ rights stance. Since then, no state has been willing to gamble its highway funding on lowering the drinking age.

McCardell personally believed the drinking age should be lowered to 18, in line with most of the world. He emphasized that he didn’t just want to change the law, which he deemed unenforceable, but hoped to refashion the national drinking culture, especially on college campuses. Instead of using the blunt instrument of criminalization to control behavior, he advocated for a massive education campaign to teach young people how to avoid negative consequences like alcohol poisoning and dissuade them from drunk driving.

He thought the way college kids learned to drink was dangerous, and that the 21 law was part of the problem. Aside from the forbidden-fruit aspect, he also said the law prevented open and honest dialogue about drinking—the illegality forced adults to take a “Just Say No” approach and deny the reality that young people are already drinking.

Caleb, who preferred to only use his first name because he belongs to an anonymous recovery support group, told Filter that the only education about drugs and alcohol he received in high school was from DARE officers who spoke to his science class. Before Caleb graduated from high school in 2009, college partying loomed large in his mind and he wanted experience drinking before he got there. So one weekend, when his parents were out of town for his brother’s soccer tournament, Caleb set out to learn his limits.

The 21 law ultimately did not deter him from drinking, but it did prevent reality-based education.

“I ended up getting black-out drunk at my parents’ house,” he said. The 21 law ultimately did not deter him from drinking, but it did prevent reality-based education about alcohol and how to drink it without harming himself or others.

Caleb continued to struggle with his drinking in college, until he found support through therapy and LGBTQ-friendly mutual-aid support groups. He’s not sure whether the law is a major determinant in youth drinking either way, but he does believe better education is sorely needed. “Since it’s illegal, they can’t tell you how to drink. You have to figure it out for yourself and sometimes that doesn’t go well.” Today, he’s studying to get his PhD in public health and focuses his research on substance use.

The kind of excessive, unsupervised drinking Caleb engaged in throughout college was what most alarmed McCardell and many of his supporters—some of whom were parents who lost their kids due to college drinking escapades that turned deadly. But after gaining some traction and sparking a national debate, the Amethyst Initiative slowly fizzled out, and the drinking age debate fell out of the news cycle.

There is no one reason why McCardell and the college presidents failed, although a public feud with grieving mothers is an unenviable position for any campaign. In a press release, MADD criticized the Amethyst Initiative as “misguided” and scolded the college presidents for “deliberately misleading… the public on the effectiveness of the 21 law.” Perhaps states just want their highway funding. Maybe the mountain of favorable public health research for the 21 law was too high a hurdle. Raising the drinking age is widely accepted to have caused a reduction in traffic fatalities, although this has sometimes been contested.

“Since the drinking age was raised, the percentage of people under the age of 21 who engage in binge drinking has been more than cut in half,” Ralph Hingson, the director of the National Institute of Alcohol Abuse and Alcoholism’s division of epidemiology and prevention, told Filter. “Alcohol-related traffic deaths are also down 80 percent.”

In 2009, while the Amethyst Initiative was still gaining steam, public health researchers revisited the evidence of the 21 law and declared “case closed” for the drinking age debate. According to the researchers, science definitively proves the 21 law has been good for society and improved youth drinking on a host of outcomes.

The Case Isn’t Closed

The case may be closed among researchers who study traffic safety and public health. But other scholars and experts believe there is ample reason to keep the drinking age debate open, and continually question any law that restricts the rights and liberties afforded to adults in the US. 

Across most of America, the age of majority—the age at which one is considered an adult—is 18.

Historians, criminal justice scholars and harm reductionists are among those who raise thorny questions and criticisms about the 21 minimum. “Large-scale policies like the [minimum legal drinking age] are not to be set in stone; they instead should constantly mature as a result of developing research and the evolving needs and demands of society,” a group of scholars at Temple University’s Department of Criminal Justice wrote in response to their colleagues’  bold assessment that the “case is closed” on the debate.

The Temple researchers quibble with the methods used to show that the 21 law itself is responsible for fewer traffic fatalities. The variables in play are endless: better roads, safer cars, ubiquitous seat-belt wearing, medical and surgical advancements, ride-sharing apps and cell phones—all developments that have radically changed driving safety since the ‘80s. Then there are questions like, what time of day was the crash? What was the weather? How experienced was the driver? That’s a lot to control for.

“Have all extra-legal methods of reducing the harms been exhausted before employing criminal sanctions?”

Focusing the lens on proving this one law led to overwhelmingly positive outcomes is too narrow, argue the Temple scholars, who are instead interested in the moral and philosophical questions surrounding such a sweeping policy.

For starters, are criminal penalties the best line of attack to achieve a safer and healthier society? “Have all extra-legal methods of reducing the harms been exhausted before employing criminal sanctions?” they ask. “These laws are positioned to punish young people who merely imbibe alcohol and do not cause any further damage to themselves or others.”

Instead of applying criminal penalties, leaving “blemishes” on young people’s record that may impact their future, the Temple group aims to reframe the debate. What if, they wonder, instead of criminal laws, the government and rest of society emphasized non-punitive strategies like harm reduction, higher taxes, breathalyzers in cars, sobriety checkpoints and—like McCardell argued for—scientifically validated health education for young people? With all these in place instead of the 21 law, what would the outcomes look like?

Research shows that one of the best ways to curb alcohol consumption is not through tough laws, but by raising prices through higher taxes. Higher prices are especially effective among younger people who are more sensitive to price fluctuations. And although such measures have been criticized for penalizing poorer people, recent research has disputed this (indeed, richer people generally drink more). “We know of no other preventive intervention to reduce drinking that has the numbers of studies and consistency of effects seen in the literature on alcohol [of] taxes and prices,” the Temple scholars quote from the literature.

A variety of perspectives criticize the 21 law. On ideological grounds, some despise the means by which the law came to be, arguing that it undermines federalism and that drinking age should be up to the states. Some who question the law don’t doubt that it has led to positive public health benefits, and even acknowledge that harm may result from lowering the age, but say it should be done on principle.

Yet an essential question remains: Can a healthier and safer society be built without relying on punitive laws, criminal sanctions and restricting rights? 

The International Outlier

A minimum age of 21 is out of step with most of the world. Most provinces in Canada, for example, have a minimum of 19; Alberta, Quebec and Manitoba are set at 18 years. In Mexico, the minimum age is also 18, as it is in Australia and most of Western Europe. Iraq and Sri Lanka are among a handful of other countries where the law is 21.

So how does the US stack up against other countries on youth drinking outcomes? And have other countries found ways to improve them without raising the legal age?

Conventional wisdom among many Americans is that drinking in Europe is normalized from a young age, and therefore creates a safer, less problematic drinking culture. “It’s a myth,” said Hingson of the NIAAA. “It’s simply not true. Compare Europe to the rest of the world, and they have the highest per capita alcohol consumption, and the highest proportion of people who meet alcohol dependence.”

According to the World Health Organization, European adolescents do report higher levels of drinking and binge drinking than Americans. In fact, nearly every European country reports higher levels of drinking than the US.

Still, whole-population drinking levels don’t necessarily reflect drinking harms. A 2001 Harvard study comparing Canadian students to American students found that more Canadian students drink overall, but that American students who do drink wind up drinking much more than their Canadian counterparts. There are perhaps trade-offs that come with either a higher or a lower age.

“I was pretty shocked when I saw how American college kids drink.”

And when you ask people from inside or outside the States about US drinking culture, the high-risk college party experience inevitably comes up as stereotypically American.

“I was pretty shocked when I saw how American college kids drink,” Peter Davidson, an adjunct professor of medicine at UC San Diego, told Filter. Davidson, who has published numerous peer-reviewed articles on drug use and harm reduction, arrived in the US in his 20s, as an exchange student from rural Australia where the drinking age is 18.

“Me and my peers started drinking around 15 or 16 years old,” Davidson said. “If a kid was puking on the front lawn, adults were around to provide guidance and keep things reasonably sane.” Davidson and his friends tended to drink at their parents’ homes, and did so without the kind of hiding and secrecy found among underage drinkers in the US.

By the time Davidson arrived in the States for college, he had gotten the “dumb, silly” drinking out of his system, and credits early exposure for that. “When the US kids left home and there were no adults or supervision around, they were drinking the way me and my friends were drinking back in high school. The drinking behavior being modeled by their peers seemed pretty negative to me.”

How does Australian drinking among young people compare to American drinking? The latest Australian surveys show more people aged 12-17 are abstaining from alcohol than previously. In 2013, 72 percent of 12 to 17-year-olds abstained from drinking. By 2016, the percentage who report abstaining rose to 82 percent, according to government surveys. That’s a high amount of abstention among people one year away from legally drinking—and not attributable, clearly, to an age limit.

It’s difficult to find one-to-one comparisons between countries, but in the US, 7 percent of 8th-graders, 20 percent of 10th-graders and 33 percent of 12th-graders report having drunk in the past month.

With a drinking age of 18, Australia has better alcohol-related health outcomes.

According to the World Health Organization, Australia reports 10 percent more “heavy episodic” drinking among 15 to 19-year-olds than the US. But America has more fatal car crashes, more liver cirohosis, more cancer caused by alcohol, and more alcohol use disorders than Australia. WHO also gives each country a “years of lost life score” due to alcohol: Australia scores a 2 and the United States a 3. With a drinking age of 18, Australia has better alcohol-related health outcomes. It’s interesting to reflect on the cultural contrasts that might account for this.

“The route Australia took with underage drinking was not to teach kids that drinking is bad and not to do it, but rather to work out how to consume alcohol in a way that leaves you with a positive and not a negative, regretful experience,” Davidson said. “There’s a subtle harm reduction approach in schools. It’s less about ‘saying no’ and more about how to negotiate drinking around your peers.”

For instance, if a friend is drinking much more than you are, how do you avoid succumbing to social pressure to join them? Education about these sticky situations can help teens to do what they want to do, not what they think is expected of them.

Like the US, Australia had a horrific drunk driving problem. Davidson described an aggressive campaign by the Australian government to mitigate it. “When I grew up drunk driving was very common, people even thought that driving drunk made them better drivers. But today, drunk driving is viewed as ridiculous and frowned upon, especially by young people. Drunk driving laws got a bit harsher, but we still didn’t change the drinking age.” 

It’s the Culture, Not the Age

“History aptly proves that youth drinking behavior will not change until American alcohol culture changes,” Getnick wrote in her “Drinking Age Debates” thesis.

Like McCardell and the college presidents a decade ago, Getnick came away from her research on youth drinking believing that the drinking age law is too high. The law legally prevents important conversations from happening.

“From a technical standpoint, you can’t help people learn safe behaviors if you prohibit the behavior entirely,” she said. “Students are drinking well before they’re 21. We should focus on harm reduction, on preventing problematic behaviors versus focusing on a numerical age. Non-abstinence education is significantly more effective than abstinence.”

It sometimes feels like everyone is arguing over the wrong questions.

If US drinking laws curtail the rights of, and criminalize, 18 to 20-year-olds and those who supply alcohol to them without conferring a clear public health benefit, that matters. But when re-examining America’s drinking age debate, it sometimes feels like everyone is arguing over the wrong questions.

Focusing exclusively on one short age-window, the debate so often ignores the decades of life after one turns 21. By all accounts, America’s youth today drink less than before. They’re also driving less and having less sex. And despite the spread of legalization, youth marijuana use is not increasing. Teen culture is not shaped by laws, and is always in flux. For a host of reasons, today’s youth appear to be extra risk-averse—increases in youth nicotine vaping, when set against declines in smoking, plausibly reflect this too.

Many may call these trends a public health success, while others question whether young people are merely prolonging the markers of adulthood—driving, drinking, sex, drug experimentation—into later and later years.

All these 18-year-olds will graduate into adulthood some day. And if they drink the way older adults drink now, they could well face unnecessary harms. The number of alcohol-related deaths has substantially increased over the years—albeit the net health impact of whole-population drinking is far from settled. A recent study found the number of alcohol-related deaths per year doubled from 35,914 to 72,558 between 1999 and 2017.

Death rates were highest not among teenagers or underage drinkers, but among mostly men between ages 45-74. Meanwhile, the largest increase in deaths during this time period occurred among legal drinkers aged 25-34. Officially recorded alcohol-related deaths outnumber even those related to opioids—experts might debate the validity of the figures, including categorization of the many deaths that involve opioids in combination with alcohol—yet neither news coverage nor public health emergency declarations reflect this complexity.

Given where alcohol harms are centered today, the drinking age debate, while far from irrelevant, does not feel like the highest priority amid a harmful drinking culture. While adults are busy trying to control youth drinking, they’ve too often lost control of their own.

Adapted image via CDC/Public Domain

R Street Institute supported the production of this piece through a restricted grant to The Influence Foundation. Filter’s editorial independence policy applies.

The post 21 to Drink? The Debate Around America’s Outlier Status  appeared first on Filter.

These are the questions that Sarah Ziegenhorn, the 30-year-old executive director of the Iowa Harm Reduction Coalition and a medical student at the University of Iowa, had in mind when she and her team organized the fourth annual Iowa Harm Reduction Summit. It took place October 3-5 in Iowa City in the name of Andy Beeler, who died in his home from an accidental heroin overdose in March. Beeler was a program coordinator at the Iowa Harm Reduction Coalition, beloved by the participants to whom he dedicated his life. 

Far from an abstraction, the questions raised by Ziegenhorn were present throughout the weekend. Deaths involving synthetic opioids like illicit fentanyl tripled from 2011 to 2017, while those involving heroin quadrupled from 2012 to 2017, according to the Centers for Disease Control and Prevention. In 2017, stimulants like methamphetamine contributed to 28 percent of the 342 overdose deaths in Iowa, according to Iowa’s Department of Public Health. A mix of heroin, illicit fentanyl and meth is contributing to an upswing in morbidity and mortality across the plains of Iowa and the Midwest at large.

A much-anticipated Saturday night presidential candidate forum was postponed after Senator Bernie Sanders—who was slated to wax on health care, drug policy and criminal justice reform—had a heart attack. “Due to Senator Sanders’ illness, we are postponing tomorrow evening’s kick-off candidate forum,” Ziegenhorn wrote in an email to panelists and speakers from out of town. “Because many of you arranged travel plans to Iowa around this event, we are throwing a party instead.”

Many Iowans directly impacted by chaotic drug use and inhumane policies drove hours.

Grim statistics and the big heart of America’s leading socialist giving out did not diminish the spirited, vulnerable tone of the weekend. Hundreds of people showed up with all the urgency that Ziegenhorn’s questions express.

At many harm reduction conferences, people tend to fly in from the usual hubs: New York, Chicago, Los Angeles, Seattle and the Bay Area. While these harm reduction hotspots were well represented in Iowa, sharing decades of wisdom and up-and-coming programs, the substance of the Summit was distinctly Midwestern. Many Iowans directly impacted by chaotic drug use and inhumane policies drove hours to hear about how to expand services that save lives, and learn about innovative strategies to mitigate harms to people who use drugs and sex workers.

Drug User Organizing in a Red State

Topics ranged from “Eliminating Hepatitis C in Iowa: Building Financial Sustainability for Payers and Providers” to “Drug User Organizing.” In the latter meeting, led by activists Jess Tilley and Louise Vincent, nearly 40 people who identified themselves as drug users sat in a circle and engaged with the difficult task of how to organize in their communities and fight to be treated with dignity by medical, legal and other institutions.

Christopher Abert, former executive director of the Indiana Recovery Alliance and founder of Southwest Recovery Alliance, told Filter how inspiring this had felt. “So many people identified as using drugs,” he said. “I’ve never seen anything like that before.” Indeed, they were mostly strangers to one another, but Abert felt a unique vulnerability and openness.

Tilley, who smiles with her eyes and frequently calls herself “jaded,” shared with the group how safe she felt there, and then got down to the business of people who use drugs engaging in direct action against punitive drug laws. Tilley and Vincent used their Reframe the Blame campaign, which targets cruel and misplaced drug-induced homicide laws, as an example of how people can make their voices heard.

In the rural Hawkeye State, is harm reduction really being embraced?

Having flown in from Chicago, where harm reduction groups like the Chicago Recovery Alliance have a 25-year history, I had a question on my mind beyond those Ziegenhorn raised.

In the rural Hawkeye State⁠—which President Trump carried by the largest margin of any Republican candidate since Ronald Reagan in 1980, and where conservatives maintain a trifecta of control over the House, Senate and Governor’s office⁠—are harm reduction services, like naloxone and syringe distribution, fentanyl test strips and support for sex workers, really being embraced?

The answer, I learned, is an unsatisfying yes and no. But groups like the Iowa Harm Reduction Coalition are moving the needle. Part of this involves building bridges with critical institutions at the University and the state’s criminal-legal system. Except for the police chief. 

Me: Hello, I would like to invite you to attend a conference on the overdose crisis & drug policy.

100 speakers from around the world: you bet.

Bernie Sanders: I’ll be there.

1000 guests: deal.

Local police chief: you’re a criminal, no thanks.

— Sarah Ziegenhorn (@sarah_ziggy) September 30, 2019

A Troubled Relationship With Religion

An exchange during one of the weekend’s most moving workshops illustrated the moral and political complexity of providing harm reduction services in deep-red political terrain and within conservative institutions.

Early Saturday morning, Blyth Barnow, of Faith in Public Life, had delivered what was by all accounts a fiery sermon on bridging the gap between harm reduction and the Christian church.

“As a community organizer, I knew that better understanding the language and values of Christianity could be a powerful tool when attempting to make change somewhere like Ohio,” Barnow said with the force of a preacher. “But perhaps most importantly, I wanted to learn how to bury my friends with dignity, because nobody else ever had.”

The pastor at the funeral condemned him to Hell for his sins.

When Barnow’s ex-boyfriend died from an overdose 15 years ago, she was livid in the aftermath.

“I lost one of my first loves to an accidental overdose on heroin and crack,” she said. “He came from a family of evangelical Christians, and at his funeral all his friends who had been caring for him sat in the back of the church while his family, who I trust loved him in some way, but who also kicked him out and called him an abomination, got to sit up front.”

The pastor at the funeral condemned him to Hell for his sins.

“In theory it would be easy to say ‘fuck the church’ and walk away,” said Barnow. “It is harder to admit that that day, the pastor reaffirmed what many of us already felt—that we were worthless, we were broken, we were dirty, and that we ought to be ashamed of ourselves. I sat in a row of about 10 of my friends that day, and almost all of them are dead or locked up now.”

She continued, “In our society, clergy are granted authority and power. His words had the power to turn our self-criticism into a truth. It created so much harm. And I truly believe that hearing that message from a pulpit was part of what cost my friends their life and their freedom. When left unchecked, toxic theology kills people. Which is why we need to get and stay in the mix.”

Ever since she graduated from seminary, Barnow and others, like Rev. M Barclay and Erica Poellot, director of faith and community partnerships at the Harm Reduction Coalition, have been pushing religious communities to embrace harm reduction. Connecting biblical concepts like resurrection to lifesaving drugs like naloxone, the overdose antidote, Barnow has organized church services called “Naloxone Saves,” at which naloxone kits are blessed on the altar.

“It was harm reduction that taught me that resurrection is possible,” Barnow told the room. “Harm reductionists are some of the most powerful ministers I know, whether they want to claim that title or not.”

After Rev. M, Barnow and Poellot took turns speaking, Ziegenhorn shared how local church communities in Iowa shut the Iowa Harm Reduction Coalition out, refusing to give them space to store syringes and naloxone. Ziegenhorn said her team sent emails to local churches about the faith and harm reduction workshop, and in terms of those local churches, “nobody fucking showed up!”

Barnow, Poellot and Rev. Meg Wagner, of the Episcopal Diocese of Iowa, shared Ziegenhorn’s frustration and told her to not give up. It will take time and patience, they said, to engage with traditionally conservative institutions about harm reduction concepts.

They’re simply fighting so that they and their loved ones, year-by-year, can suffer a little less.

But with powerful synthetic fentanyl analogues taking over the heroin market, spreading across the Midwest from the East Coast, time is an unaffordable luxury.

The Iowa Harm Reduction Summit was instituted four years ago as a series of talks and panels to teach medical students how to better care for people who use drugs in their community. Today, the coalition constitutes Iowa’s largest free naloxone distribution program and provider of opioid overdose prevention education, and the Summit attracted hundreds of people.

Beeler, who was 30 when he died, was Ziegenhorn’s partner. A generation of people from all kinds of backgrounds and professions has grown up in a world of unfathomable grief. Yet even if harm reduction concepts are not being embraced by conservative legislators in red states (nor even by liberal politicians in big cities), this generation is fighting to create a world where people don’t have to grow up losing so many loved ones.

Hundreds of attendees at this year’s Summit were among those who have suffered. They’re simply fighting so that they and their loved ones, year-by-year, can suffer a little less.

All photographs by Zachary Siegel.

The post The Struggle of Death, Hope and Harm Reduction in the Midwest appeared first on Filter.

“Florida Man” stories, stripped of all context, are ubiquitous across digital media. Take Esquire, which has a running tally of “The 90 Wildest Florida Man Headlines of 2019 (So Far),” accompanied by the subtitle, “Whatever insanity is happening in your state, Florida has done it with an alligator and possibly some amphetamines.” Florida Man is everywhere.

After listening to a recent episode of Citations Needed—a popular podcast hosted by media critics Adam Johnson and Nima Shirazi—that critically examined what lies beneath the media’s obsession with the proverbial Florida Man, well, these viral stories are not so funny anymore.

At the top of the show, Shirazi asks, “What are we really mocking when we mock ‘Florida Man’?” Johnson goes on to say, “We want to talk about what we believe is the anti-poor, mental health-shaming subtext that animates much of the viral Florida Man meme; how that, and a broader culture of weird crime stories and mugshot-shaming serve as little more than a socially acceptable way of mocking the marginalized and indigent.” Florida in particular, notes Johnson, “is notorious for having some of the harshest systems in place for those on the margins of society.”

The ubiquity of the Florida Man represents much more than a vulgar SEO-hack.

To test the ubiquity of the Florida Man trope, I searched for it on the very morning I wrote this piece. Lo and behold, the first hit was a piece from Cleveland.com, which purports to cover Northeast Ohio, with the headline, “Florida Man: Driving Drunk on Riding Lawnmower, Crashing into Police Car.” The fine folks of Northeast Ohio would no doubt be shamefully ill-informed without knowing that a supposedly drunk man on a lawnmower in Florida allegedly crashed into a cop car.

I watched the daily virality occur in real time. Hours later, the lawnmower incident had filtered all the way “up” to Fox News, appearing under the “crime” tab. Exactly why is this news?

No journalist or editor seriously thinks this is news, of course. Rather, it’s a cheap and glib way for financially hollowed-out local news outlets to draw clicks and eyeballs at the expense of another human being who is likely suffering from poverty, mental illness, or addiction—possibly all three at once.

To show how cruel this trend truly is, Citations Needed even created a clever Chrome plugin that replaces the text “Florida Man” with “Man Likely Suffering From Mental Illness or Drug Addiction” on your browser.

The ubiquity of the Florida Man represents much more than a vulgar SEO-hack for outlets like the increasingly deranged Fox News and even supposedly woke new media like Buzzfeed. Beneath the goofy headlines is the distressed state in which sick and poor people living in Florida exist.

Florida is a hotbed of far-right government that strips desperate people from accessing health care, bars black and formerly incarcerated people from voting, and of course, drug tests some people receiving government benefits.

Back in 2012, only 108 of the 4,086 people on benefits who took a drug test tested positive, creating a net loss of $45,780 for the state. Fiscal conservatives who are otherwise hellbent on cutting government waste doesn’t seem to care. “The cruelty is the point,” as the saying goes.

Early on in “Episode 75: The Trouble with ‘Florida Man’,” Shirazi paints a grim picture of where Florida ranks on a series of health outcomes, injecting important context that’s entirely absent in the viral Florida Man articles. “Florida is in the midst of a major mental health crisis while having virtually no social safety net,” Shirazi says. “Florida ranks 49th out 50 among states for [spending on] mental health programs; 41st in support for those affected by drug addiction; and No. 3 for percentage of the population who are homeless.” In lieu of actually treating these issues with health care, the police step in to arrest and harass.

“Jails and prisons are the asylums of the new millennium,” says Michelle Bruder, an organizer with the Orlando Chapter of Democratic Socialists of America, and soon to be a statewide organizer for Florida DSA. Bruder was interviewed by Johnson and Shirazi for the Florida Man segment, and explained how unstably housed people in Florida are criminalized. The segment reveals that roughly 80 percent of prosecutions in Miami Beach target homeless people.

“We devote $718,000 million a year to mental health programs, but $1 billion a year into jails and prisons for mentally ill inmates,” Bruder says. “What little support mentally ill Floridians are getting is involved in their incarceration.”

Florida is also a hotspot for the national opioid-involved overdose crisis. In 2017, 3,425 Floridians died from opioid–involved overdoses, at a rate of 16.3 deaths per 100,000 people, which is higher than the national rate of 14.6 deaths per 100,000 persons, according to the National Institute on Drug Abuse. Putting these figures into context, in 1999 fewer than 500 people in Florida died from opioid overdoses; the past two decades have seen an increase of over 500 percent.

Yet while the state struggles with this horrific and soaring death toll, the media still sees fit to laugh at the expense of the opioid-addicted Florida Man: “Florida Man thought he was stealing opioids but instead got laxatives,” reads a headline from USA Today.

Johnson and Shirazi identify Florida’s expansive “Sunshine Laws” as the main culprit.

Florida’s mental health and overdose crises are not necessarily unique among states that refused to expand Medicaid coverage. So what explains all the “crime” stories coming out of Florida?

Johnson and Shirazi identify Florida’s expansive “Sunshine Laws” as the main culprit. “While ostensibly designed to make the government more transparent, they have instead created a conveyor-belt of searchable crimes that lazy journalists can cherry-pick for salacious clicks,” Shirazi says.

If there’s any bright spot, it’s knowing that Florida does have organizers like Bruder, who are working to empower communities and upend the circumstances that create the viral Florida Man content in the first place.

After listening to Shirazi, Johnson, and Bruder describe the hellish environment that Florida has become for people suffering from mental health issues, addiction and poverty, it is much easier to resist giving a click to viral Florida Man stories. We should all try harder not to take the bait.

Photo by Cleo Vermij on Unsplash

The post If You Care About Health Justice, Stop Clicking on “Florida Man” Stories appeared first on Filter.