PROVIDENCE – The new draft strategic plan of the Governor’s Task Force on Overdose Prevention and Intervention cites harm reduction development as a continuing strategy.

Dr. Nicole Alexander-Scott, the director of the R.I. Department of Health and co-chair of the Task Force, said that there is the intention to put some “teeth’ into harm reduction.

There has been some preliminary work underway: an ad hoc harm reduction group has met regularly since the beginning of the year, and the Task Force has formed a harm reduction committee that first met in May [both groups are open to public participation].

The Task Force has been very proactive in the introduction of conventional harm reduction strategies, in enhancing those strategies when indicated, and is open to innovative strategies, such as the required legislation to allow the distribution of fentanyl test strip kits.

We expect that the Task Force will continue to maintain Rhode Island’s national leadership in our response to the opioid accidental overdose death epidemic.

As part of that effort to move the conversation forward, RICARES has developed its second “Report to the Community” on Harm Reduction and Drug Policy.

The role of harm reduction
Harm reduction is an essential part of a comprehensive public health response to problematic substance use that complements prevention, treatment, and enforcement [efforts].

[We believe] a harm reduction philosophy should inform strategies directed at the whole population, as well as specific programs aimed at sub-populations of vulnerable [Rhode Islanders].

Harm reduction is pragmatic and focuses on keeping people safe and minimizing death, disease, and injury associated with higher risk behavior.

For our specific purpose, harm reduction refers to policies, programs, and practices that seek to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive substances.

A look at drug policy
Internationally, drug policy is focused on at least three primary areas: supply reduction, demand reduction and harm reduction. The “pillars” of those areas are: drug control policy, treatment policy, prevention policy and harm reduction policy.

In the U.S., supply reduction is primarily the responsibility of a complex law enforcement network that has spent hundreds of billions of dollars since the initiation of the War on Drugs in 1971 [even longer if we consider that drug prohibition in the U.S. started in 1914 with the passage of the Harrison Narcotics Act].

Law enforcement has been active. The U.S. “zero tolerance” policies have resulted in mass incarcerations. In 2013, the U.S. had 4.4 percent of the world’s population and 22 percent of the world’s prisoners.

That translates to 2.2 million persons in the wide range of U.S. prisons – of which 1 in 5 were imprisoned for a drug offense [possession, trafficking or other non-violent drug related crime].

In 2017, more than 1.6 million people were arrested for drug-law violations, and 85 percent of these arrests were for possession, not sales.

However, [the evidence suggests that] the zero tolerance policies have done little to reduce drug supply.

Epidemic levels
The new National Drug Threat Assessment from the U.S. Drug Enforcement Administration chillingly states: “The opioid threat has reached epidemic levels and shows no sign of abating. Meanwhile, the methamphetamine threat remains prevalent, the cocaine threat has rebounded, new psychoactive substances are still challenging, and the domestic marijuana situation continues to evolve.”

All of DEA’s field divisions reported that heroin is available in their areas of responsibility. Availability ranges from moderately available to highly available. DEA reporting continues to indicate that there is “ample supply” to meet the demand of heroin users.

The heroin user population in the U.S. continues to grow; results from national-level treatment data and statistical death data [also] indicates heroin availability is increasing.

Fentanyl
We all [have recognized] that fentanyl is the latest and most deadly threat. It now contaminates much of the illicit drug supply.

According to the DEA report, “Fentanyl’s availability is widespread and increasing. The annual percentage of fentanyl reported in death certificates reporting heroin, cocaine, psycho-stimulants, and semi-synthetic opioids has increased significantly since 2014.”

The use of both the open and dark web to obscure transactions and to distribute fentanyl directly to both users and independent drug trafficking organizations presents challenges for law enforcement and policy makers working to restrict the flow of fentanyl to the United States.

The zero tolerance policies have done little to reduce the harms associated with drug use.

Fatal drug overdoses killed 72,000 Americans in 2017, according to a preliminary estimation from the Centers for Disease Control and Prevention. This figure marks a 10 percent increase from 2016.

[In the first six months of 2018, fentanyl-related overdose deaths in Rhode Island accounted for more than 70 percent of the 157 overdose deaths, according to data from the R.I. Department of Health.]

The assertion and expectation that even multiple agencies and billions of dollars can significantly decrease supply has proven to be false and unrealistic. The tide has not stopped rising.

Demand reduction
In the U.S., demand reduction is primarily the responsibility of a complex treatment and prevention network that has spent at least hundreds of millions of dollars in the past decades.

The demand for drugs continues to far exceed the demand for treatment and for community-based prevention services. Only about one in four people [28.6 percent] with opioid use disorder received specialty treatment for illicit drug use last year.

Only about 12.2 percent of adults who need treatment for any substance use disorder receive treatment, and 40 percent of people who know they have an alcohol or drug problem state that they do not want to stop using.

In Rhode Island, “substance abuse (sic) prevention services” are only funded through a federal block grant. The primary focus is on the prevention of tobacco and marijuana use. State funding for prevention was discontinued a few years ago. Legislation to reinstate some state funding for prevention was introduced last session but the bill did not move forward.

Harm reduction policies
In the U.S., harm reduction policy has not historically been a focus of drug policy.

However, Rhode Island policy makers now accept the notion that the addiction epidemic should be considered a public health issue rather than exclusively a criminal justice issue. Barriers remain for public health strategies that include some harm reduction strategies, especially for marginalized and stigmatized groups.

Even a demonstrated [evidence-based] strategy such as syringe exchange programs for reducing the spread of HIV/AIDS and Hepatitis C among IV drug users continues to meet resistance in many states and communities.

More on drug policy
The examination and modification of drug policies has been an international harm reduction strategy in many other countries as part of their public health response to the drug addiction epidemic (e.g., most of Europe, Australia, Canada).

They recognize that the most effective harm reduction strategy is some alternative to the prohibition policies that was the international norm in 1990. They recognize that far more harm is done to many more individuals as the result of prohibitionist polices than the drugs themselves.

It is difficult to imagine a more harmful effect on us all than the 47-year ‘War on Drugs.’ The United Nations Special Rapporteur on the Right to Health stated: “Punitive drug control regimes increase the harms associated with drug use by directing resources toward inappropriate methods and misguided solutions, while neglecting evidence-based approaches.”

The primary purpose of our nation’s long-standing policy of criminalization is not clear to us. Our impression is that the primary purpose of criminalization, and certainly its effect, is to stigmatize drug use and people who take drugs: if criminalization is to deter people, it must stigmatize. And that stigma, of course, is a barrier to getting people into treatment, a barrier to making treatment more effective, and a barrier to expanding harm reduction. It is basically a barrier to everything we need to do to end the crisis.

In search of a coherent policy
We do not believe that our national drug policy is a coherent policy. From state to state and region to region, the local social, cultural, political and legal contexts are not similar or stable. Policies at different levels are incongruent; they can be implemented differently in different contexts, and practice can differ from policy. This is clearly illustrated in the present Wild West of national marijuana policy.

Our national drug policy remains rooted in the 1970s. That was the time of measures such as mandatory sentencing, the expansion of the Federal drug control agencies, and the scheduling of marijuana as a Schedule 1 substance.

The present policy does not adequately address: the continuing introduction of novel psychoactive substances, cultural shifts, attitudinal shifts, globalization, the aging population of people who use drugs, and changes in the supply and purchasing methods.

A closer look at a new supply and purchasing method is illustrative of the new challenges for the old drug policy.

Systematic illicit drug transactions on the darknet (AKA the dark web) can proceed without any face-to-face meetings, and identities and locations remain anonymous.

The features offered on darknet market sites are similar to those provided by sellers of the wide range of consumer products on the Internet.

They include feedback systems that allow customers to rate sellers and review products, special offers or discounts, and different payment systems that allow for dispute resolution. Products ordered on the darknet are usually delivered by traditional postal services.

A recent study looked at one single marketplace on the darknet. It sold $94 million of drugs in the study period, September 2015 through August 2016. Cocaine, cannabis, heroin and ecstasy comprised 64 percent of sales. The majority of users were male, in their early to mid-20s, the drug-use history ranged from 18 months to 25 years, and [many were] in professional employment or tertiary education.

An added concern is the estimate from the National Cyber-Forensics and Training Alliance that there are between 100-150 fentanyl vendors currently operating on the dark web.

The reach of the darknet market
These markets are easily accessible for users and they are very difficult for law enforcement agencies to shut down. The darknet markets first expanded significantly in 2011, and we can anticipate that they will continue to increase their market share. The study showed that it is actually a safer and more reliable way to buy drugs.

The feedback systems serve as a self-regulative mechanism and increase market transparency and probably consumer safety. The study’s laboratory tests showed that the samples matched the advertised substance on line with very high consistency, and were of high purity.

Due to the high availability, buyers didn’t need to hoard drugs and this may have helped them to moderate drug use.

There is clearly reduced market-related violence compared to face-to-face buying. Ironically, an unintended consequence of this new supply and purchasing method is that it may have a harm reduction component.

A recent study concluded that liberalizing drug policy increases the propensity of people who take illegal drugs to utilize health services. The main reason for that increase is the reduced fear of criminal sanctions. One of the goals of our harm reduction efforts is an increase in health service engagement by people who use drugs.

Harm reduction polices more cost effective
Harm reduction policies tend to be more cost effective than conventional criminal justice approaches.

Drug policy liberalization is neither a new nor a radical notion. In 2015, the Secretary General of the United Nations called on countries to “consider alternatives to criminalization and incarceration of people who use drugs and focus criminal justice efforts to those involved in supply.”

Some recent events suggest that we may be approaching an inflection point regarding significant drug policy change.

Since 2014, five states [California, Connecticut, Utah, Alaska, and Oklahoma] have reclassified all drug possession from a felony to a misdemeanor.

The bipartisan First Step Act may be re-introduced this year in Congress. It allows judges to sidestep or shorten mandatory minimum sentences for nonviolent drug offenders, and would extend a reduction in the sentencing disparity between crack and powder cocaine.

Policy tensions in Rhode Island
We are all aware of the present tension in our state between a movement toward drug policy liberalization, the resistance toward that movement, and the desire of some to move backwards.

Perhaps we need to recognize that the decades of reiterated argument about the counterproductive nature of the present policy, the argument that our drug policies have never been race-neutral, the argument that racial and socioeconomic bias informs the criminal justice system, the assertion that addiction is a disease, etc., do not seem to have gained sufficient traction with the general public and therefore not with policy makers.

Those arguments have not been accepted as compelling enough to develop a consensus to alter drug policy. Perhaps we need to change that narrative.

• We know that, in Rhode Island for sure, the incidence of opioid overdose deaths out into the suburban and rural towns has been a catalyst for the extraordinary level of response by policymakers.

• We know that changes in national policies often begin at the local/state level.

• We can continue to act. For example, in Rhode Island, opioid overdoses declined last year because people in prison have access to effective treatment.

• We see that harm reduction strategies are a crucial component of the effort to address the drug overdose epidemic, from which few families or friends of victims have been exempted.

We suggest that we frame drug policy changes as a viable and effective harm reduction strategy – a strategy that focuses on reduction of the harms related to drug use rather than on simply reducing drug use, a strategy that is a viable and effective way to save lives.

And, a strategy that will reduce the individual, family, and the community cost of the opioid overdose epidemic.

Ian Knowles is a frequent contributor to ConvergenceRI. He is the program director for the Rhode Island Communities for Addiction Recovery.