Toward Healthy Drug Policy in the United States - The Case of Safehouse

"Politics Versus Policy": Qualitative Insights on Stigma and Overdose Prevention Center Policymaking in the United States

BACKGROUND

Federal, state, and municipal governments in the United States have been reluctant to authorize overdose prevention centers (OPCs), which are evidence-based approaches for preventing overdose deaths and blood-borne pathogen transmission.

METHODS

From July 2022 to February 2023, we explored how stigma manifests in OPC policymaking by conducting in-depth interviews with 17 advocates, legislators, service providers, and researchers involved with OPC advocacy and policymaking in Rhode Island, California, Pennsylvania, and New York.

RESULTS

We found that although jurisdictions differed in their OPC policymaking experiences, stigma manifested throughout the process, from planning to authorization. Participants described OPCs as a tool for destigmatizing overdose and substance use, yet confronted institutionalized stigma and discriminatory attitudes toward people who use drugs (PWUD) and harm reduction from multiple sources (eg, politicians, media, and members of the public). Opposition toward OPCs and harm reduction approaches more broadly intersected with public discourse on crime, homelessness, and public disorder. Employed stigma-mitigation strategies included humanizing PWUD, publicizing the benefits of OPCs to the wider community, and strategically engaging media.

CONCLUSION

These findings illustrate the importance of understanding stigma at different stages of the policymaking process to better facilitate authorization and eventual implementation of OPCs in the United States.

"Make yourself un-NIMBY-able": stakeholder perspectives on strategies to mobilize public and political support for overdose prevention centers in the United States of America

BACKGROUND

Overdose prevention centers (OPCs), also known as supervised injection facilities and safe consumption sites, are evidenced-based interventions for preventing overdose deaths and drug-related morbidities. The pathways to legalizing OPCs in the USA have confronted multiple social, political, and legal obstacles. We conducted a multi-site, qualitative study to explore heterogeneities in these pathways in four jurisdictions, as well as to understand stakeholder perspectives on valuable strategies for galvanizing political and public support for OPCs.

METHODS

From July 2022 to February 2023, we conducted 17 semi-structured, in-depth interviews with OPC policymakers, service providers, advocates, and researchers from California, New York City, Philadelphia, and Rhode Island, where efforts have been undertaken to authorize OPCs. Using inductive thematic analysis, we identified and compared contextually relevant, salient approaches for increasing support for OPCs.

RESULTS

Participants described several strategies clustering around five distinct domains: (1) embedding OPC advocacy into broader overdose prevention coalitions to shape policy dialogs; (2) building rapport with a plurality of powerbrokers (e.g., lawmakers, health departments, law enforcement) who could amplify the impact of OPC advocacy; (3) emphasizing specific benefits of OPCs to different audiences in different contexts; (4) leveraging relationships with frontline workers (e.g., emergency medicine and substance use treatment providers) to challenge OPC opposition, including 'NIMBY-ism,' and misinformation; and (5) prioritizing transparency in OPC decision-making to foster public trust.

CONCLUSION

While tailored to the specific socio-political context of each locality, multiple OPC advocacy strategies have been deployed to cultivate support for OPCs in the USA. Advocacy strategies that are multi-pronged, leverage partnerships with stakeholders at multiple levels, and tailor communications to different audiences and settings could yield the greatest impact in increasing support for, and diffusing opposition to, future OPC implementation.

Supervised Inhalation Sites: Preventing Overdose and Reducing Health Inequities among People Who Use Drugs

Policy and research on the implementation of services for people who inhale drugs lag behind similar efforts for people who inject drugs, limiting access to adequate harm reduction resources for people who inhale drugs. This commentary considers why supervised inhalation sites (SIS) are needed, highlights operational characteristics of four existing services, and advocates for future SIS research. Our hope is to encourage the expansion of SIS worldwide for overdose prevention and reduction of health inequities. Given the limited literature regarding SIS, more extensive study of these programs is warranted to incorporate inhalation into the implementation of supervised consumption sites to provide fair opportunities for all people who use drugs to do so safely without fear of stigma and overdose.

Reflections from Rhode Island's Safe Consumption Sites Regulations Committee: A Lesson in Racial Equity

ABSTRACT

In July 2021, a statewide measure to create Harm Reduction Centers (also known as safe consumption sites [SCS]) was signed into law in Rhode Island. Convincing evidence shows that SCS can reduce premature death in the surrounding neighborhood. Although SCS have had success around the globe for approaching 40 years, implementing a harm reduction center of this kind in the United States requires consideration of this country's unique racial and geographic politics. In this manuscript, we describe a series of discussions at the Regulations Committee meetings in Rhode Island around the question of whether or not to mandate the presence of inhalation rooms. Through this vignette, we aim to convey how, at the highest level of government, citizens of Rhode Island were able to promote and prioritize racial equity.

Experiences with the Philadelphia police assisted diversion program: A qualitative study

BACKGROUND

The U.S. relies far too heavily on punitive criminal justice strategies to address problems that are better prevented and resolved through social and health services. The resulting harms are especially large and longstanding for people trapped in the failed War on Drugs. Philadelphia launched a Police Assisted Diversion (PAD) program to address the highest rates of poverty, incarceration, and fatal overdose among large cities in the U.S. PAD enables police officers to connect people with supportive services in many instances that would otherwise result in arrest or through outreach when no crime is suspected.

METHODS

We conducted semi-structured interviews with 30 clients, 15 police officers, and 12 other personnel involved with the program. Data were gathered in 2019 and 2020 and analyzed using standard qualitative methods.

RESULTS

PAD represents a new less-punitive model for responding to illegal purchasing of drugs, possession of drugs, prostitution, and retail theft in Philadelphia. Clients reported mostly positive experiences with the program, identifying the primary benefits as avoided arrest and relational support from affiliated service providers. Police officers expressed support for the program in principle but skepticism about its effects in practice, questioning the quality of available services. Program personnel and police officers described multi-sectoral collaboration as essential to addressing frequent and diverse logistical challenges, including overly restrictive eligibility criteria, mistrust between police and service providers, and coordination across different neighborhoods. Finally, all three groups suggested that people can only benefit from service linkages when they are ready to engage and that inadequate access to resources like housing limits program effectiveness.

CONCLUSIONS

The PAD program is a promising public health intervention for diverting people away from punishment and towards services to address unmet social and health needs. But increasing investments in training and in other supportive services is essential to sustainable and transformational change.

Legacies of the war on drugs: Next of kin of persons who died of opioid overdose and harm reduction interventions in Philadelphia

BACKGROUND

Between the years 2017-2019 in Philadelphia, more than 70% of all deaths from opioid overdose occurred in a private residence. To learn more about home-based opioid use and overdose, researchers conducted qualitative interviews with next of kin of overdose victims to learn their perceptions about the decedent's drug use and their opinions about city-led harm reduction efforts, specifically naloxone administration and collaborative efforts to open an overdose prevention site.

METHODS

In 2019, researchers conducted 35 qualitative interviews with next of kin of persons who died of opioid overdose in Philadelphia in 2017. Data were coded and analyzed using NVivo software.

RESULTS

Data reveal that while persons who use drugs may benefit from enhanced harm reduction interventions that target their family members and caregivers including naloxone education and public health messaging about overdose prevention, these efforts may be up against other realities that Philadelphia families navigate-in particular structural inequalities exacerbated by decades of "War on Drugs" policies.

CONCLUSION

Existing health disparities and structural barriers to care increase vulnerability to overdose and highlight the urgency to collaborate with impacted families and communities to design relevant harm reduction interventions. Without efforts to redress the consequences of war on drug policies, however, harm reduction interventions will not reach their full potential.

Impact of an unsanctioned safe consumption site on criminal activity, 2010-2019

BACKGROUND

Health and social impacts of safe consumption sites (SCS) are well described in multiple countries. One argument used by those opposed to SCS in the US is that findings from other countries are not relevant to the US context. We examined whether an unsanctioned SCS operating in the US affected local crime rates.

METHODS

Controlled interrupted time series (ITS) analysis of police incident reports for five years before and five years after SCS opening, comparing one intervention and two control areas in one city.

RESULTS

Narcotic/drug incidents declined across the pre- and post-intervention periods in the intervention area and remained constant in both control areas, preventing an ITS analysis but suggesting no negative impact. On average, incident reports relating to assault, burglary, larceny theft, and robbery in the post-intervention period steadily decreased at a similar rate within both the Intervention area and Control area 1. However the change in rate of decline post-intervention was statistically significantly greater in the Intervention area compared to Control area 1 (difference in slope -0.007 SDs, 95 % CI: -0.013, -0.002; p = 0.01). The Intervention area had a statistically significant decline in crime over the post-intervention period compared to Control area 2 (difference in slope -0.023 SDs, 95 % CI: -0.03, -0.01; p < 0.001).

CONCLUSIONS

Documented criminal activity decreased rather than increased in the area around an unsanctioned SCS located in the US in the five years following SCS opening.

The impact of patient characteristics on enzalutamide pharmacokinetics and how this relates to treatment toxicity and efficacy in metastatic prostate cancer patients

Purpose

The aim of the study is to investigate the influence of patient characteristics, age and body mass index (BMI), on pharmacokinetics of enzalutamide, and to study the relationships between drug exposure and enzalutamide efficacy and toxicity, in mCRPC patients.

Methods

Data were collected in a longitudinal cohort study (ANDROPS) and a prospective observational study (ILUMINATE), both in mCRPC patients treated with enzalutamide. To investigate the influence of age and BMI on exposure, enzalutamide and N-desmethylenzalutamide levels were compared by ANOVA. To investigate the relation of exposure versus time to progression (TTP), the sum plasma levels were divided into quartiles and compared by Kaplan–Meier analysis. To assess the relation of exposure with fatigue, plasma levels in patients experiencing fatigue vs. no fatigue were compared by and independent t test.

Results

Data of 68 mCRPC patients were included for analysis. Plasma levels were not different for age or BMI. No difference in TTP between both studies was observed (383 days (95% CI 287–859), and 567 days (95% CI 351–NR), p = 0.36). Kaplan–Meier analysis of quartiles of sum levels showed no difference for TTP. Fatigue was reported by 22 patients, no difference in sum plasma levels was observed between patients with and without fatigue.

Conclusions

We observed that age and BMI did not influence systemic exposure in patients treated with enzalutamide. No relation of exposure with efficacy or fatigue was observed. Further research using enzalutamide at a lower dose is needed to understand the relation of enzalutamide exposure and fatigue.