Tackling Drug Abuse: Harm Reduction in the Midwest

JULY 2015

The Council of State Governments

CAPITOL RESEARCHHEALTH POLICY

THE COUNCIL OF STATE GOVERNMENTS

Creating and implementing effective risk-manage-ment strategies for injection drug users is a challenge around the world. Countless policies have been proposed and implemented with varying degrees of success.

The World Health Organization, also known as WHO, has developed a comprehensive program comprised of nine interventions designed to mitigate the risks associated with injection drug use,1 includ-ing needle exchange programs; opioid substitution therapy; prevention, diagnosis and treatment for diseases related to drug abuse, and public education campaigns for injection drug users and their sexual partners.

Some of these strategies have been implemented recently by Midwestern states.

Needle Exchange ProgramsNeedle exchanges allow injection drug users to turn in used needles for safe disposal and receive clean syringes, with the goal of preventing the spread of infectious diseases. States have two options to allow needle exchanges. The first is to permit needle exchanges explicitly by law. The second is to exempt syringes and injection equipment from laws pro-hibiting possession of drug paraphernalia, thereby removing possible criminal charges against those using programs developed by local governments and nonprofit organizations.

Illinois, Minnesota and Wisconsin have exempted syringes from their drug paraphernalia laws.2 Indiana allows communities to create needle exchanges, but only upon declaration of a medical emergency related to HIV or hepatitis outbreaks.

Needle exchange facilities are often used to distrib-ute other paraphernalia, such as tourniquets and alcohol swabs, which improve sanitation and inhibit the spread of infectious diseases such as HIV and viral hepatitis. These programs also are used as plat-forms for the provision of counseling and referral to rehabilitation services. Studies have found that injec-tion drug users who make use of needle exchanges are more likely to seek treatment.3

Congress has enacted a ban on federal funding for needle exchanges, meaning that all funding is pro-vided directly by the 16 states and local governments that permit needle exchange programs.

Overdose Prevention DrugsIllinois, Indiana, Michigan, Minnesota, Nebraska, North Dakota, Ohio, South Dakota and Wisconsin have increased the availability of the opioid antago-nist naloxone.4

• Naloxone is used to stop overdoses of drugs like heroin or morphine. It binds to opioid receptors in the brain, quickly reversing an overdose in progress.

• The drug is generally administered as an injection, but an intranasal form also has been used by emer-gency response personnel in some jurisdictions. 5

• Recently, more states have been making nalox-one accessible to emergency response personnel through third-party prescriptions.6

2 THE COUNCIL OF STATE GOVERNMENTS

• A study from the Centers for Disease Control and Prevention found that community-based naloxone distribution programs facilitated the reversal of more than 10,000 opioid overdoses between 1996 and 2010.7

Opioid Substitution TherapySuboxone is a medication used for the long-term treatment of opioid addiction, called opioid substi-tution therapy. The therapy works by replacing an illegal substance, such as heroin, with a longer-lasting but less euphoria-inducing drug, allowing the indi-vidual to avoid debilitating withdrawal symptoms.8

• Indiana, Iowa, Minnesota, North Dakota, Ohio, South Dakota and Wisconsin have added Sub-oxone to their Medicaid preferred drugs lists, although all but Minnesota and North Dakota require prior approval to be obtained by the prescribing doctor.

• Adding the Suboxone to the Medicaid preferred drugs list allows low-income injection drug users to more easily acquire prescriptions for the drug. Unlike methadone, patients may be prescribed home supplies of Suboxone, as it has a lower potential for abuse and is less dangerous in an overdose.9

Good Samaritan LawsIllinois, Minnesota, North Dakota and Wisconsin have implemented overdose immunity laws—or Good Samaritan laws—which protect individuals from arrest or prosecution for drug possession when they request emergency assistance on behalf of someone experiencing a drug overdose.

• Since New Mexico passed the first overdose immunity law in 2007, 25 states and the District of Columbia have followed suit.10

• Most statutes offer the use of reporting as a mitigating factor if prosecuted for drug-related offenses, but some give outright exemption from

Austin Coleman, Graduate Fellow, acoleman@csg.org

REFERENCES

“WHO, UNODC, UNAIDS technical guide for countries to set targets for universal access to HIV prevention, treatment and care

for injecting drug users – 2012 revision” (Jan. 2013), p. 10. http://www.who.int/hiv/pub/idu/targets_universal_access/en/.

2 Public Health Law Research, “Syringe Distribution Laws

SyringeD_Report.pdf.

3 Brooner, et al., “Drug Abuse Treatment Success Among Needle Exchange Participants,” Public Health Reports, 1998; vol.

133(supplement 1): 129-139. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1307735/.

4 Network for Public Health Law, “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good

Samaritan Laws” (May 2015). from https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf.

5 Goodman, J. David, “ ,” New York Times

will-carry-antidote-for-heroin-overdoses.html?_r=0&gwh=99E6FF89137DA9C083636D2D3771DA06&gwt=pay.

6 Network for Public Health Law, “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good

Samaritan Laws,” p. 3-11 (May 2015). https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf.

7 Centers for Disease Control and Prevention, “Community-Based Opioid Overdose Prevention Programs Providing Naloxone

— United States, 2010,” Morbidity and Mortality Weekly Report (Feb. 17, 2012). http://www.cdc.gov/mmwr/preview/

mmwrhtml/mm6106a1.htm.

8 Lobmaier and Waal, “The Pharmacological Treatment of Opioid Addiction—A Clinical Perspective,” European Journal of

pharmacological_treatment_of_opioid_addiction--a_clinical_perspective/links/541ab99c0cf25ebee988bc80.pdf.

9 US Food and Drug Administration, “Subutex and Suboxone Questions and Answers” (June 13, 2014). http://www.fda.gov/

Drugs/DrugSafety/PostmarketDrugSafetyInformationforPatientsandProviders/ucm191523.htm.

10 Network for Public Health Law, “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good

Samaritan Laws” (May 2015), p. 2. https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf.

11 Ibid, p. 55-60.

12 National Conference of State Legislatures, “Drug Overdose Immunity ‘Good Samaritan’ Laws” (Feb. 19, 2015). from http://

www.ncsl.org/research/civil-and-criminal-justice/drug-overdose-immunity-good-samaritan-laws.aspx.

13 Centers for Disease Control and Prevention, “State HIV Laws” (June 4, 2015). http://www.cdc.gov/hiv/policies/law/states/

index.html.

14 World Health Organization HIV/AIDS Program, “Guidance on Prevention of Viral Hepatitis B and C Among People Who Inject

Drugs,” (July 2012), p. 15. http://apps.who.int/iris/bitstream/10665/75357/1/9789241504041_eng.pdf?ua=1.

15 Centers for Disease Control and Prevention, “HIV and Viral Hepatitis” (March 2014), p. 1. http://www.cdc.gov/hiv/pdf/

library_factsheets_HIV_and_viral_Hepatitis.pdf.

16 National Conference of State Legislatures, “Hepatitis C: Overview” (March 6, 2015). http://www.ncsl.org/research/health/

hepatitis-c-overview.aspx.

prosecution for possession of paraphernalia or controlled substances.11

• Seventeen of the 26 statutes mandate that indi-viduals claiming Good Samaritan defense or immunity must be acting in good faith.

• The immunity associated with overdose Good Samaritan laws generally does not apply to more serious offenses like trafficking or manufacturing controlled substances.

• Some of these laws also provide immunity for bystanders who use naloxone to reverse the effects of an overdose.12

Infectious Disease TestingTesting and reporting diagnoses of infectious diseases associated with injection drug use has become a standard element of harm reduction policies, as has HIV counseling.

• Illinois, Indiana, Iowa, Michigan, Minnesota, Nebraska, North Dakota, Ohio and Wisconsin maintain some HIV screening laws, and all 11 Mid- western states require reporting of HIV diagnoses by laboratories.13

• The Midwestern 11 states have implemented laws related to confidentiality and counseling for HIV patients, which protect confidentiality for individuals being tested and provide post-test counseling for those who test positive for HIV.

• The WHO estimates 72 percent of people who inject drugs in the United States are infected with hepatitis C.14

• The CDC estimates that 80 percent of injection drug users who are HIV positive also are infected with some form of hepatitis.15

• Only one state, New York, has implemented a law that facilitates testing for hepatitis C. This statute allows physicians and nurse practitioners to issue non-patient-specific standing orders for hepatitis C tests.16

3THE COUNCIL OF STATE GOVERNMENTS

StateSyringe

Paraphernalia Exemption1

Naloxone Access2 Good Samaritan Laws3

Hepatitis-C Screening4

State HIV Screening and

Counseling5

Suboxone on Medicaid Preferred

Drugs List6

Illinois Yes Yes Yes No Yes No

Indiana No Yes No No Yes Yes**

Iowa No No No No Yes Yes**

Kansas No No No No No No

Michigan No Yes No No Yes No

Minnesota Yes Yes Yes No Yes Yes

Nebraska No Yes7 No No Yes No

North Dakota No Yes Yes8 No Yes Yes*

Ohio No Yes No No Yes Yes**

South Dakota No Yes9 No No No Yes**

Wisconsin Yes Yes Yes No Yes Yes**

CURRENTLY IMPLEMENTED HARM REDUCTION MEASURES IN THE MIDWEST REGION

Data Source: 1 LawAtlas Policy Surveillance Portal (2015, April). Syringe Distribution Laws. Retrieved June 26, 2015, from http://lawatlas.org/files/upload/20150421_SyringeD_Report.pdf. 2 Network for Public Health Law (2015, April). Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws. Retrieved June 26, 2015, from https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf. 3 Network for Public Health Law (2015, April). Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws. Retrieved June 26, 2015, from https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf. 4National Conference of State Legislatures (2015, March). Hepatitis C Biology Basics. Retrieved June 26, 2015, from http://www.ncsl.org/research/health/hepatitis-c-overview.aspx. 5 Centers for Disease Control and Prevention (June 2015). State HIV Laws. Retrieved June 26, 2015, from http://www.cdc.gov/hiv/policies/law/states/index.html. 6 CSG Research of State Medicaid Preferred Drug Lists.7 Legiscan (2015, May). Nebraska Legislature Bill 390. Retrieved June 26, 2015, from https://legiscan.com/NE/bill/LB390/2015. 8 Open States (2015, April). SB 2070 - North Dakota Senate Bill. Retrieved June 26, 2015, from http://openstates.org/nd/bills/64/SB2070/. 9 South Dakota Legislative Research Council (2015, Feb.). Senate Bill 14. Retrieved June 26, 2015 from http://legis.sd.gov/Legislative_Session/Bills/Bill.aspx?Bill=14&Session=2015.

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