The fruits of their fight to survive ripened into the harm reduction principles and practices that structured New York City’s first syringe service programs, founded by grassroots social-movement champions, like ACT UP!

Nothing about us without us and Meet us where we are—such are the tenets of our movement.

But in recent years, the power of drug users and sex workers to collectively determine the institutional character of harm reduction has been eroded by an opportunistic public health establishment.

Activist-founded organizations—like my former employer, the Lower East Side Harm Reduction Center—have been absorbed by larger nonprofits that many in the movement consider to be closer to revenue-hungry businesses than people-centered groups accountable to those they serve.

The lurch away from the movement’s origins is well known to New York City peers—a class of essential harm reduction workers who use or used drugs, many of whom are currently or formerly unhoused and are survivors of the carceral state.

Our collective dismay was cemented when we learned around 2021 that a Bronx harm reduction provider—whose tax filings show its CEO’s salary leaped to nearly a half-million dollars that same fiscal year—had simply fired most of its peers. The grassroots contingent of harm reduction has faltered in making good on our movement’s radically democratic promise.

My commitment to genuinely building an infrastructure of care that actualized the ideals of the harm reduction movement is what animated the creation of the Re-Queering Harm Reduction (RQHR) Project. I had been requested by the Lighthouse Learning Collective—a queer and trans outgrowth of the National Harm Reduction Coalition and a group of which I am a member—to produce a report with recommendations on how our movement could better meet the needs of queer and trans people who use drugs and do sex work (QT-PWUD/SW).

RQHR has been guided by the principle that QT-PWUD/SW—and anyone, for that matter, struggling to survive in a country enriched by their slow death—are always already finding ways to care for themselves and each other despite insufficient support.

Some may (misleadingly, I believe) call this self-care. RQHR instead dubs it embedded care. Self-care, as a term, attempts to capture a non-professionalized quality, but in doing so it wrongly suggests that humans are capable of caring for themselves independently and individually.

Instead, care requires interdependence and collaboration. Embeddedness describes care that is provided through social relationships based on solidarity and kinship, whereas disembeddedness refers to commodified care sold on the market by the health care industry for the purpose of profit.

RQHR endeavors to illuminate the limits of the disemebedded care provided by the harm reduction industry—if they are not already apparent. The spirit of grassroots harm reduction demands a revitalization of embedded care, re-foregrounding it within the movement.

This article is an adapted excerpt from the Re-Queering Harm Reduction Project report, “Our Lives, Our Care.”

Images courtesy of Sessi Kuwabara Blanchard/Re-Queering Harm Reduction

The post Re-Queering Harm Reduction Means Reclaiming Its Grassroots Spirit appeared first on Filter.

Among his achievements, David is credited with developing the concept of chemsex—or the queer and trans culture of sexualized drug use, particularly involving crystal methamphetamine, GHB/GBL, mephedrone, and other so-called “party” drugs.

Always humble, David never shied away from acknowledging that the term he championed circulated in the community long before he entered the field of public health. Here we find one of the great qualities that made him so brilliant and effective: He was no stranger to the hustle. According to his professional website, he was living with HIV and doing sex work by the age of 19. Later on, he engaged in activities still even stigmatized in institutionalized harm reduction spaces, doing “high profile pimping in the early 90s, high profile drug dealing in the noughties,” as he wrote.

David’s persistence, despite the intersecting wars on drug users and sex economies and his participation in the oppressed communities that survive together, is absolutely to thank for his contribution of chemsex harm reduction, as a framework and practice, to queer and trans people who use drugs during sex.

He didn’t stop at providing a foundational framework for what’s become its own field of academic research. In addition to pioneering and implementing harm reduction-based interventions for people struggling with their chemsex participation, David is responsible for getting the world’s first chemsex support services off the ground, only to continue supporting the development of countless others around the world. 

If someone from the lay public were to know a face from the chemsex harm reduction field, it would likely be David. He is featured in numerous documentaries, including the well-known Vice UK “Chemsex” documentary, and the recent shorts series “hu.mans.” Or they may have stumbled upon what he called his “prolific” YouTube channel.

As a young trans woman who uses crystal meth in the context of New York City‘s chemsex scene (referred to locally as “parTying” or “party ’n’ play”), my connection with David has undoubtedly helped keep myself and my community safer. For one, the resources he developed on chemsex harm reduction were indispensable as I entered the scene.

Thanks to the Chemsex First Aid guide that he co-authored with fellow London chemsex harm reductionist Ignacio Labayen De Inza—and on which I previously reported for Filter—tips on responding to highly-stigmatized GHB/GBL overdoses and preventing psychosis and dental harms of crystal meth were already under my belt.

As I learned more about the advanced infrastructure David had developed in London, and saw the lack of it where I live, I had his wisdom and support to thank as I embarked on organizing harm-reduction mutual aid by and for trans women who use crystal meth. In our email correspondences, he was always humble about the need to expand chemsex supports to meaningfully include trans women, and constantly encouraging of my efforts to do so on my side of the Atlantic.

Queer and trans chemsexeurs can find him at any parTy where we take care of each other.

Something I always appreciated about David was his unflinching commitment to the queer community.  As the “chemsex” term proliferates, David has noted that some are attempting to apply it to the heterosexual/cisgender context—which he rightly called out as “appropriation” in an interview with me in 2021. “Gay sexual liberation has a unique history and flavor that includes bathhouses and Grindr and a particularly widespread availability of certain drugs that can enhance or medicate the sexual experience,” he said. “These cultural uniquenesses define the word chemsex.”

David has indelibly changed how queer and trans people use drugs, have sex and find support. While nothing can replace the loss felt by his absence, his presence is inextinguishable. Harm reductionists can find him at the international chemsex conferences indebted to his conceptual innovation. Most strongly, perhaps, queer and trans chemsexeurs can find him at any parTy where we take care of each other.

If you find yourself missing David, I encourage you to visit his professional website’s bio, a beautifully composed reflection on his life that almost reads like a pre-mortem obituary. Go read it; the love he has for himself, for other gay men and for the movement is palpable. Perhaps I should have just copied and pasted it.

Reading David’s reflection of his own life is cathartic, even for those of us who only knew him by way of email and the occasional call. It gives us insight into how he’d like to be remembered. And it seems like it’s rather clear.

“So I am an activist, and I don’t stop,” he wrote, in reference to raising awareness around and responding to the deaths of an average of two gay men in London every month from drug toxicity. “Join me. I insist.”

Screenshot of David Stuart giving a talk in 2016 via Youtube

The post David Stuart: An Inspirational Leader in Chemsex Harm Reduction appeared first on Filter.

In addition to narrowing the applicability of the criminal charge of intentional HIV transmission and reducing the penalty, the law—sponsored by State Senator Dallas Harris—entirely eliminates the statutory section providing criminal liability for simply doing sex work while living with HIV. No longer will sex workers—whether employed at licensed businesse or working illicitly—face felony charges that can carry a maximum sentence of 10 years and fine of $10,000.

“When people are no longer penalized for knowing their status, it encourages them to come forward, get tested and get treatment.”

The new law “fulfills the goal of reducing the harm to sex workers by allowing for people living with HIV to work and earn a living without the risk or fear of arrest or additional charges simply because they have HIV,” Chelsi N. Cheatom, program director of Trac-B Exchange, a syringe service program in Las Vegas, told Filter. “It also will hopefully encourage more people who engage in sex work to get tested and know their HIV status.”

“When people are no longer penalized for knowing their status, it encourages them to come forward, get tested and get treatment,” said André C. Wade, the state director of Silver State Equality, a prominent supporter of the bill. While likely to encourages sex workers to feel safe enough to seek testing, the law simultaneously eliminates the mandatory HIV testing of arrested sex workers, restoring personal autonomy. “That’s good for all Nevadans.”

SB 275 emerged from the Governor’s Advisory Task Force on HIV Exposure Modernization—created by a 2019 law fought for by Nevada HIV Modernization Coalition, a grassroots group mostly led by women living with HIV. A report from the Task Force, together with recommendations by the governor and legislative counsel, informed the bill that Senator Harris would introduce in March 2021.

The new law puts to rest a statute that garnered challenges in the Nevada Supreme Court. In Glegola v. State (1994), the Justices rejected a sex worker’s request to vacate her convication and 15-year sentence for having agreed to engage in paid sex with an undercover cop while knowing her positive HIV status. The Justices paid no mind to the fact that no such sex even occured. In fact, researchers recently found that the circumstances in question in cases like Glegola “almost always” did not involve any sex, one of the few ways HIV can actually be transmitted, according to a May 2021 data brief submitted to the legislature by the Williams Institute at the University of California, Los Angeles.

The enactment of SB 275 appears to be a resounding win for both the Black Lives Matter and sex worker rights movements. The HIV criminalization laws are mostly enforced, in reality, against Black sex workers. More than half of all HIV-related charges and convictions—61 percent and 64 percent respectively—were related to the laws specifically targeting sex workers. Black defendants were involved in 66 percent of the sex-work HIV-criminalization charges and 61 percent of the convictions.(In the scheme of things, the number of Nevadans directly impacted by the law is quite small: 47 discrete individuals since 1995. There have been 80 separate arrests under the HIV-related laws.)

But it appears that an outright prohibition on the employment of HIV-positive sex workers at licensed businesses remains in place.

Law enforcement can no longer target sex workers for simply living with HIV. One police department stands out when it comes to enforcement of the law. A large majority (78 percent) of HIV-related charges originated with the Las Vegas Metropolitan Police Department (LVMPD), the Williams Institute brief found. LVMPD did not respond to Filter’s request for comment.

But it appears that an outright prohibition on the employment of HIV-positive sex workers at licensed businesses remains in place. SB 275 failed to make any amendments to the statute (NRS 441A.120) authorizing the regulatory ban (NAC 441A.800). Currently, anyone seeking regulated employment as a sex worker must undergo rigorous monthly HIV and sexually transmitted infection (STI) testing. If the results return as positive for HIV, or for syphilis, gonorrhea or chlamydia, “the person shall immediately cease and desist from employment as a sex worker,” the regulation states.

Banning people diagnosed with an STI is different from banning people living with HIV. The former cases are curable, while the latter, at present, is a lifetime condition as well as a constitutionally protected disability.

The regulation, presumably promulgated for the sake of reducing the chances of seroconversion, does not appear to account for the reality that HIV can become untransmittable when people adhere to treatment medications. The Board of Health, which devised the regulation, did not respond to Filter’s request for comment about any plans to amend the regulation regarding sex workers living with untransmittable HIV.

Although it didn’t address the ban head on, SB 275 planted the seeds that will make it “easier [for advocates and politicians] to go back and address that,” Catherine Hanssens, executive director and founder of the Center for HIV Law and Policy, which supported the bill, told Filter. The new law prohibits health authorities, like the Board of Health, from barring people living with HIV from accessing places of public accommodation or employment, like licensed sex worker businesses. It additionally provides that such a policy would constitute a violation of the Americans with Disabilities Act.

Nevada lawmakers could take action if the Board does not. “The continuation of this prohibition may be addressed by the next iteration of the Governor’s Advisory Task Force on HIV Exposure Modernization,” Wade told Filter. If so, it would follow in the procedural footsteps of SB 275.

Despite the continuation of certain policies discriminating against sex workers living with HIV, the enactment of SB 275 adds Nevada to a list of other Western states, like Colorado in 2016 and California in 2017, to have legislated the repeal of harsh penalties against the vulnerabalized community. 

Photograph of the bill signing courtesy of the Nevada HIV Modernization Coalition

The post Sex Workers No Longer Criminalized for Simply Living With HIV in Nevada appeared first on Filter.

A government watchdog has now found that law enforcement officials at the United States Department of Justice (DOJ) don’t even use or find useful the criminal charges provided by the law. Meanwhile, the prosecutors say it’s actually made their jobs harder.

On June 21, the Government Accountability Office (GAO) published a report on prosecutions pursuant to FOSTA (Allow States and Victims to Fight Online Sex Trafficking Act of 2017), as mandated by the law itself. In the law’s three years of existence, the DOJ has only brought a single criminal FOSTA case. It was in June 2020, when the DOJ indicted the operator of CityXGuide.com on charges of “promotion of prostitution and reckless disregard of sex trafficking,” as provided by Section 3 of of FOSTA and located in 18 US Code § 2421A.

While DOJ officials say FOSTA is “relatively new,” implying that it could be used more in the future, they also note that they simply already have other avenues to prosecute website operators, saying they’ve had “success” with racketeering and money laundering charges. DOJ’s career of prosecuting website operators for allegedly facilitating prostitution was kick-started in 2014 when it secured the conviction of MyRedBook.com’s operator on racketeering and money laundering charges. Since then, every one of 10 total cases—including the CityXGuide.com indictment—has involved one or both of those charges.

“There was no benefit and everyone said this would happen at the outset.”

In addition to the lack of FOSTA criminal cases brought, only one individual has sought civil damages as provided by the law, and in circumstances that were a far cry from lawmakers’ intentions for the bill. The plaintiff made claims under 29 other federal statutes and against a family, their lawyer and court officials—not the online platform operators FOSTA was designed to target. On March 22, 2021, a judge dismissed the case.

The apparent finding that FOSTA has so far offered little utility to law enforcement or victims is unsurprising for sex worker and anti-trafficking advocates who fought against the law. “There was no benefit and everyone said this would happen at the outset,” Kate D’Adamo, a member of the sex worker collective Hacking//Hustling and partner at Reframe Health and Justice, told Filter.

Despite the contents of the report, the GAO official behind it is not ready to affirm that FOSTA is of little use to law enforcement. “Such a conclusion may be premature given that the law has been around just 3 years,” Gretta Goodwin, director of justice and law enforcement Issues at GAO, told Filter. “It is correct that FOSTA didn’t create a wave of new federal prosecutions against online platforms.” Goodwin shared that GAO is not aware of any forthcoming cases by the DOJ that involve charges pursuant to FOSTA.

Goodwin notes that there are, in the eyes of law enforcement, potential benefits of FOSTA. Bringing harsher punishments is one reason DOJ officials say prosecutors could opt for charges pursuant to 18 US Code § 2421A. “Promotion of prostitution and reckless disregard of sex trafficking” carries a maximum penalty of 25 years, while money laundering and racketeering charges offer between five and 20 years, depending on the statute violated. Another reason for FOSTA’s use, GAO found, would be that it could increase the chances of securing a conviction.

GAO’s finding that the online sex market has radically transformed is old news.

Beyond not being an utilized asset for law enforcement, FOSTA has even proven to make investigations and prosecutions more difficult. FOSTA’s enactment on April 11, 2018, and the seizure of Backpage.com by federal authorities less than a week prior, “have led to the relocation of platforms overseas” and the “fragmentation of the market,” according to GAO—in effect creating a more decentralized and inconsistent sex market.

GAO’s finding that the online sex market has radically transformed is old news. Before FOSTA even became law, advocates were saying the market would simply rearrange itself in response. “When websites are shut down,” the anti-trafficking organization Freedom Network USA testified before Congress in 2017, “the sex trade is pushed underground.”

D’Adamo attested to advocates’ foresight. “Before this bill passed, we knew this would cause a lot of disruption throughout industry, and for the most marginalized and most vulnerable to exploitation,” they said. “This really confirmed everything we were saying.”

As a result of the anticipated disruptions, law enforcement faces more challenges in policing online sex markets. Gathering “tips and evidence” to support investigations and prosecutions has become more difficult as a result of platforms relocating overseas and using more complex payment systems, DOJ officials told GAO. They also attributed the trouble developing their cases to sex market participants increasingly using a wider variety of sites to conduct transactions, including “social media, dating, hookup, and messaging/communication platforms.”

Ironically, the aftermath of FOSTA has, according to the report, seen increased use of certain online commercial sex websites, namely “hobby board and sugar dating platforms.”

Building the Case to Repeal FOSTA

So if federal prosecutions have gone relatively unaltered by FOSTA, what has it impacted?

The lives and livelihoods of sex workers, say activists and researchers.

A growing body of evidence shows that the new landscape produced by FOSTA has destabilized workers’ ability to practice self-defense, like by screening clients, and negotiating fair terms of work.

The consequences are alarming. According to a “participatory action-based, sex worker-led” research report published in 2020 by Hacking//Hustling, a majority of surveyed online-based sex workers (72.45 percent) reported “increased economic instability”, and one-third (33.8 percent) said they’ve experienced a rise in violence from clients. In a qualatative study of male sex workers in California published in 2019, researcher David Eichert found that some had trouble with finding platforms on which to advertise services, with clients increasingly disregarding workers’ boundaries, and with declining mental health.

The patchwork of small-scale studies has provided the public with evidence beyond anecdotes. The GAO report represents an effort by the federal government to evaluate the implications of FOSTA, albeit as it concerns law enforcement rather than the vulnerabilized population of sex workers actually being harmed by the legislation.

But others in Washington have demonstrated interest in building a rigorous picture of FOSTA’s effects. In 2019, Representative Ro Khanna and Senator Elizabeth Warren introduced the SAFE SEX Workers Study Act into their respective chambers. It would task the Department of Health and Human Services with “utiliz[ing] community-based nonprofits to conduct surveys and interviews of sex workers to collect information about (1) experiences of violence from clients; (2) interactions with law enforcement; (3) experiences with exploitation; and (4) the impact on housing stability and mental health, among other effects,” according to the bill’s summary.

The legislatively-proposed research, along with GAO’s report (likely to a lesser extent), could provide the evidence to support arguments for repealing FOSTA and ensuring that similar legislation does not become law in the future.

“Informed government policies begin,” reads the SAFE SEX Workers Study Act, “with seeking out relevant information to better guide our actions moving forward.”

Image of Backpage after it was seized in 2018 via Wikimedia Commons/Creative Commons 4.0

The post Federal Watchdog: FOSTA Isn’t Even Useful for Law Enforcement appeared first on Filter.

On June 15, the Drug Policy Alliance (DPA) held a press conference unveiling the Drug Policy Reform Act of 2021 (DPRA). It featured DPRA co-authors Representative Bush and Representative Bonnie Watson Coleman, together with DPA board member Dr. Mary Bassett and Neill Franklin, former executive director of the Law Enforcement Action Partnership.

The bill will eliminate criminal penalties for possession of any scheduled substance up to quantities to be determined by a novel commission. It additionally invests in substance use disorder treatment and harm reduction services, while, among other things, preventing people being refused employment, housing, federal benefits, and immigration status due to a criminal record for drug possession or personal drug use.

“Do we support a safe supply? Yes.”

During the press conference, DPA Executive Director Kassandra Frederique posed my question to the congresswomen: Do you support medical practitioners prescribing to patients their controlled substances of choice in order to encourage them to divest from the adulterated illicit supply, just as US doctors did in the late 1910s and early 1920s?

Rep. Bush gave a clear answer. “Do we support a safe supply? Yes,” she said. She also explained why DPRA does not provide for some form of safe supply policy. “Right now, our focus is to decriminalize.”

Her comment appears to be one of the first, if not the first, public endorsements by a US politician of a safe supply policy. It’s increasingly a priority for progressive drug-user activists in North America, driven by Canadian advocacy, like that of the Drug User Liberation Front. 

“We are enthused to have a congressional leader who is willing to support evidence-based, life-saving interventions like safe supply,” Queen Adeyusi, a policy manager at DPA’s Office of National Affairs, told Filter.

Rep. Watson Coleman offered promising, albeit inconclusive, thoughts on the safe supply question. Part of the “whole issue of […] personal use of substances,” she said, is “how you get them” and how consumers avoid “getting drugs that kill you as opposed to the right drug that you’re looking for.”

(Ensuring consumers have consistent easy access to pharmaceutical-grade drugs—instead of the unpredictable and adulterated illicit supply that’s driving fatal overdoses—has been shown in multiple studies to greatly reduce engagement with the unregulated supply.)

“To have it in the health care realm instead of the criminal realm is what we’re trying to accomplish,” said Rep. Watson Coleman.

“Everything that we’re talking about, we’re looking at it from an evidence-based standpoint,” said Rep. Bush. “So, making sure we are looking for guidance from people like Dr. Bassett and others.”

Rep. Watson Coleman suggested the question of safe supply policy could be one for the planned Commission on Substance Use, Health and Safety to consider, saying it “will be looking at issues of this nature and will be making recommendations to the Secretary of Health and Human Services.”

According to a summary of DPRA published by DPA, the Commission will provide “recommendations for preventing the prosecution of individuals possessing, distributing, or dispensing personal use quantities of each drug for the purpose of subsistence distribution.”

The biggest win for the North American safe supply movement thus far has, according to advocates’ critiques, been largely symbolic: British Columbia’s mostly-unimplemented prescribing guidelines to provide consumers with pharmaceutical alternatives to adulterated street drugs.

A strong grassroots movement for safe supply policy has yet to materialize in the United States, and advocacy organizations like DPA are still developing their strategy. “We do deep work internally and with movement before moving to introduce legislation,” said Adeyusi. “We are working on a safe supply strategy with others, that can include legislation, but we are not ready yet.”

It appears that Representative Bush may be a meaningful ally to such efforts when the time comes.

Photograph of Cori Bush as a congressional candidate speaking at an Expect Us rally in 2020, by Craig Currie/PhotoNews247 via Wikimedia Commons/Creative Commons 3.0

DPA previously provided a restricted grant to The Influence Foundation, which operates Filter, to support a Drug War Journalism Diversity Fellowship. LEAP was formerly the fiscal sponsor of The Influence Foundation.

The post Congresswoman Cori Bush Voices Groundbreaking Support for Safe Supply appeared first on Filter.

On May 21, former Food and Drug Administration (FDA) Commissioner Dr. Scott Gottlieb spread a baseless claim on social media with a call to criminalize kratom consumers and obstruct access for people with opioid use disorder (OUD).

“I’m convinced [kratom is] fueling the opioid addiction crisis,” Gottlieb posted on Twitter, followed by a call for the Biden Administration to finish the Drug Enforcement Administration’s (DEA) 2016 scheduling effort that failed in the face of consumer advocacy and public opposition. 

Dr. Gottlieb’s statement came in response to a series of tweets by both the official FDA account and that of the agency’s current acting commissioner, Dr. Janet Woodcock. They were announcing the seizure of over $1 million in kratom products in Florida by the US Marshals Service at the request of the FDA. 

Gottlieb’s claim is not evidence-based. But data on the risks and harms of kratom do exist.

There is pharmacological data in non-human animals suggesting that 7-hydroxymitragynine, an alkaloid present in only very low concentrations in commercial kratom products (0.01 to 0.04 percent of leaf content), has “high abuse potential”—while the far more common alkaloid mitragynine does not. And there are epidemiological reports by the Centers for Disease Control and Prevention showing that only 0.56 percent of opioid-involved overdose deaths from July 2016 to June 2017 involved kratom (in combination with other drugs).

There are case reports of withdrawal symptoms after stopping kratom. And while there also some reports of people developing mental health complications after starting kratom, it cannot be accurately said to fuel the overdose crisis.

A spokesperson for American Enterprise Institute, the organization with which Gottlieb is currently affiliated as a resident fellow, did not respond to Filter’s request for comment. Neither did an FDA spokesperson. 

In his seemingly bad-faith claim against kratom, Gottlieb targets one of the few tools yet to be criminalized.

The unprecedented opioid-involved overdose crisis is well-studied. And experts agree on what’s really “fueling” it: the adulteration of unregulated drug supplies in a society that criminalizes not only drugs but drug-checking technology, safe consumption sites and other lifesaving, empowering resources like syringe service programs.

In his seemingly bad-faith claim against kratom, Gottlieb targets one of the few tools yet to be criminalized. Dr. Oliver Grundmann, a pharmacy professor and kratom researcher, told Filter that research has shown the plant to be “very beneficial” for people looking to manage their opioid consumption. He described kratom as being used for harm reduction among people with OUD because of its ability to manage opioid withdrawal symptoms—an observation verified in multiple studies of mice. 

“There is definitely a therapeutic potential that can be derived from kratom,” Grundmann said. “But it has to be [manufactured and made available] in a well-controlled setting.” He recognized both the potential benefits and harms of kratom’s alkaloids, advocating a balanced policy that would ensure consumers access to a “safe, regulated product.”

That does not appear to be the goal of past nor present FDA leadership. Having spent his time as Commissioner inaccurately branding mitragynine as an “opioid” (without recognizing its partial-agonist status and weak ability to bind to receptors) and being openly hostile toward its harm reduction potential, Gottlieb seems to envision a reboot of the DEA’s scheduling attempt. And Dr. Woodcock endorsed raids on suppliers her May 21 tweet: “FDA will continue to take action against kratom-containing dietary supplements.” The agency has been pursuing kratom seizures since at least 2012. 

Without the force of the Controlled Substances Act behind them, such seizures have been legally authorized through the addition of certain kratom products to FDA’s Import Alerts as “adulterated dietary supplements.” Ironically, the adulterant specified is kratom itself. 

Despite the stated positions of the former and current FDA commissioners, other federal health leaders have not followed suit.  

In a 2018 letter by a leader of Health and Human Services—the FDA’s parent agency—to the DEA, HHS withdrew its support for designating kratom’s alkaloids as Schedule I controlled substances. One reason was the insufficient evidence to meet its statutory condition that kratom has a “high potential for abuse.” In order to meet that requirement, the FDA must have “inadequate information to provide reasonable assurance that such [new dietary] ingredient does not present a significant or unreasonable risk of illness or injury.”

“There is a significant risk of immediate adverse public health consequences for potentially millions of users if kratom or its components are included in Schedule I,” wrote HHS Secretary for Health Brett Giroir. He also referenced a study that showed mitragynine, the common kratom alkaloid compound, “does not have abuse potential and actually reduced morphine intake.”  

In fact, Giroir issued a specific warning: that “kratom users switching to highly lethal opioids” as a result of a Schedule I placement would risk “thousands of deaths from overdoses.” Gottlieb and current FDA leadership appear to be ignoring this warning.

Photograph via National Institute on Drug Abuse

The post Ex-FDA Head Falsely Claims Kratom Is “Fueling” the Overdose Crisis  appeared first on Filter.

Fortunately for opioid use disorder (OUD) patients in a country whose federal government has sought to chill opioid prescribing for pain patients, the defense did not hold up. On May 20, US Attorney’s Office for the District of Massachusetts (USAMA) announced a settlement had been reached with the defendant, New England Orthopedic Surgeons (NEOS).

According to the settlement agreement, NEOS violated the Americans with Disability Act (ADA) by imposing “eligibility criteria that screened out individuals with disabilities”—in this case, OUD patients—“on the basis of their disability.”

In addition to violating patients’ civil rights, the agreement states that NEOS failed to comply with the mandatory procedures of Baystate Medical Center, the hospital in which it operates. Surgeons there were required to maintain patients already taking prescribed buprenorphine on their medication before, during and after surgery. According to the agreement, this was never implemented by NEOS.

Instead, NEOS turned away two Suboxone patients seeking full-joint replacements because the “surgeons were not comfortable with the post-operative pain management protocol needed.”

NEOS did not respond to Filter’s requests for comment. USAMA’s spokesperson declined to comment.

“The Americans With Disabilities Act protects healthcare access for people under medical treatment for Opioid Use Disorder,” said Acting US Attorney Nathaniel R. Mendell in a press release. “Health care providers must comply with the ADA, even when doing so is inconvenient or makes them uncomfortable.”

“That the provider claimed that they couldn’t adequately provide pain treatment to a person receiving buprenorphine doesn’t really make any difference from a legal standpoint.”

NSEO’s defense appears to be novel. “It is the first where the defendant tried to justify its practices due to alleged concerns about pain management,” Sally Friedman, the lawyer and legal advocacy director of Legal Action Center, an organization defending the rights of people with substance use disorders (SUD), told Filter. The reason for this may be simple: It’s not a smart strategy. 

“The fact that the provider claimed that they couldn’t adequately provide pain treatment to a person receiving buprenorphine doesn’t really make any difference from a legal standpoint,” Corey Davis, lawyer and director of the Harm Reduction Legal Project, told Filter. “They were discriminating against that person because of their disability.”

NEOS has agreed to maintain and make available to USAMA a log of any patient prescribed medication for opioid use disorder (MOUD) who is receiving or seeking full-joint replacement and has been denied any care. It also agreed to notify USAMA of any complaints made by any MOUD patient alleging a denial of care on the basis of their medication; to draft a non-discrimination policy; to pay each victim $15,000; and to train staff and contractors on MOUD and disability discrimination.

“The settlement sends a strong signal that health care providers may not deny care based on assumptions and stereotypes about people receiving MOUD—even where pain management is concerned,” said Friedman.

Although the determinations of the settlement are “not legally binding on other entities,” in contrast to some courts’ decisions, Friedman said they’re still an asset. “Advocates can point to [the settlement], and courts can take note that the US Department of Justice views this type of conduct as illegal.”

USAMA has enforced the ADA on behalf of OUD patients many times before. The NEOS lawsuit was its fifth since 2018. Three were with distinct skilled nursing facilities in May 2018, September 2019 and December 2020. The fourth was with Massachusetts General Hospital—a top-ranked facility with a robust package of SUD services—in August 2020.

Radio announcement by USAMA describing disability rights protections for OUD patients

USAMA’s track record on advocating for OUD patients sets it apart from other Offices of US Attorney, most of which “do not appear to be focusing on these cases,” Davis said. “Hopefully, the continued pursuit of providers who discriminate in this way will convince other US Attorney’s offices to pursue similar violations in their districts.” 

Although USAMA has enforced disability rights protections for OUD patients, the Office has also participated in the country’s widespread efforts to block access to pharmaceutical opioids for people who need them, including pain patients. 

USAMA has sent cautionary letters to medical providers warning them about their opioid prescribing practices in order to “stem the flow of opioids to the public,” former US Attorney Andrew Lelling said in November 2018.

Additionally, USAMA has prosecuted multiple prison staff members for trying to provide unprescribed Suboxone (a branded combination of buprenorphine and naloxone) to incarcerated OUD patients. It even prosecuted a nurse taking prescribed Suboxone for sharing just five of her own doses with two people involuntarily confined at a civil commitment program for SUD patients. 

“There does seem to be a tension between the DOJ’s pursuit of cases of discrimination against people receiving buprenorphine and methadone for OUD,” said Davis. “And the well-documented fact that some pharmacies refuse to dispense buprenorphine because of (mostly unfounded) fears that doing so may result in investigation by the DEA (which is part of the DOJ).”

Photograph via National Institutes of Health

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I’m so sorry to tell you, but the state law is changing, and your dose was seven times higher than the dose Oklohoma law is going to [permit], Stewart recalled him saying. I have to have your doses reduced by November.

Over the next five months, her dosage was dropped by hundreds of units, measured in morphine milligram equivalents (MME). The consequence: “My health deteriorated so bad,” she said. She developed chest pain “because my heart was not handling the extra pain,” and her blood pressure soared. To address the additional pain caused by the rapid reduction of the single opioid medication, she says she was prescribed five non-opioid drugs and had to see a gastroenterologist due to the cocktail’s damage to her digestive system.

Additionally, her mental health declined. She was unable to provide for her family members the way she’d like. “I basically laid in bed and cried.”

The new law’s language seems to have spooked her doctor.

No state law required her doctor to forcibly taper her dosage. But then-Governor Mary Fallin had just signed into law Oklahoma Senate Bill 1446, which imposed new opioid prescribing regulations aimed at discouraging this form of treatment for pain.

Fear, in Stewart’s opinion, drove her doctor’s decision. “It had enough big scary words that all the doctors thought that meant they had to reduce every dose under a certain point and try to get as many patients off of pain management as possible.”

The bill made prescribing more than 100 MME legally risky for practitioners. Stewart had been on nearly seven times that. The statute only granted greater leniency for patients in “active treatment for cancer,” not former cancer patients like herself. Her pain treatment was working for her, but the new law’s language seems to have spooked her doctor.

What happened to Stewart is an increasingly common experience among chronic pain patients across the United States.

No formal legal structure incentivizes those registered with the Drug Enforcement Administration (DEA) to handle controlled substances—prescribers, pharmacists and suppliers—to ensure that the people who need opioids can access them. Governments of all scales consider opioids more of a liability than an asset. And in a health care system where profit outweighs people, it’s no wonder that registrants have abandoned pain patients.

Tamera Lynn Stewart

Prescribing Plummeted After CDC Guideline

Tamera Lynn Stewart, who quickly blossomed into a pain patient advocate, wanted to get to the bottom of her physician’s decision.

After seeking explanations from regulators, law enforcement and lawmakers about why prescribers were working in fear, she was led to the Centers for Disease Control and Prevention. In March 2016, the federal health agency published a “voluntary” and “not prescriptive” Guideline for primary care physicians treating chronic pain patients (except those receiving active cancer treatment, palliative care and end-of-life care).

The Guideline stated that clinicians “should avoid increasing dosage to ≥90 MME/day or carefully justify a decision to titrate dosage to ≥90 MME/day.” Yet nowhere in the document are prescribers told to stop prescribing opioids. Quite the contrary: “Clinicians should consider the circumstances and unique needs of each patient when providing care.”

Despite the Guideline’s language, opioid prescribing plummeted in its wake. It had already been declining since 2012, but that only accelerated in the months after publication, according to a 2018 study.

“The messaging that has resulted … inappropriately suggests opioid prescriptions above certain day or dose limits are outside appropriate medical practice.”

“Most states have enacted laws that put arbitrary limits on what a physician or other health care professional can prescribe to a patient in pain,” Dr. Patrice A. Harris, the American Medical Association’s immediate past president and chair of its Opioids Task Force, told Filter. “As a result, a physician who prescribes above those limits may believe that he or she is breaking the law. Related to that is the messaging that has resulted from the … guideline that inappropriately suggests opioid prescriptions above certain day or dose limits are outside appropriate medical practice.”

Civil rights attorney Kate Nicholson, who recently founded the National Pain Advocacy Center, notes the way specific recommended numbers—like “avoid increasing dosage to” more than 90 MME per day—were mistaken for commandments. “The problem that occurred was the provisions were fairly concrete. [They] had numbers in them that were then seized by the federal and state legislators, by the healthcare system,” Nicholson told Filter.

In response to the outpouring of testimony and data indicating patient abandonment informed by the CDC’s 2016 Guidelines, the CDC then denounced forced tapers, among other erroneous interpretations, in a 2019 New England Journal of Medicine article. It explicitly stated: “the guideline does not support stopping opioid use abruptly.”

Yet even after that, advocates say things haven’t gotten better. “I’m surprised we haven’t had a trickle-down of the clarifications by CDC among policy makers and with pain patients. I haven’t seen any improvement for people on the ground,” said Nicholson. But for Stewart, it’s no surprise. “Everybody thought those 2019 clarifications were just virtue signalling. Nobody took them seriously,” she said.

Law Enforcement’s Chilling Effect

In the fall of 2018, Stewart walked into an Oklahoma State Board of Medical Licensure and Supervision meeting as part of her quest to get answers about her forced taper. The members, she recalled, “said they felt bad for me, and that it was basically the drug cops doing it, not them.” (The Medical Board did not respond to Filter’s request for comment.)

It was Oklahoma’s attorney general who pioneered the use of lawsuits seeking billions of dollars from Pharma corporations for their  misleading marketing of opioids. More than 2,000 lawsuits by other prosecutors have also been pursued, yielding spectacular results—like Purdue Pharma pleading guilty to criminal charges in October 2020.

The DEA has been increasingly conducting criminal and regulatory investigations and bringing lawsuits.

The fear of law enforcement in chilling prescriptions cannot be overstated. For over a decade, the DEA and attorneys general have ramped up investigations of practitioners, pharmacists and distributors. It’s no wonder that those in the prescribed opioid supply chain have exercised an abundance of caution to the detriment of chronic pain patients.

Since 2006, the DEA has been increasingly conducting criminal and regulatory investigations and bringing lawsuits against distributors and pharmacies. Practitioners working in the field of pain medicine are most commonly targeted for criminal sanction, according to a 2020 study.

Advocates have warned of how law enforcement actions are affecting those working to care for chronic pain patients. “Even when medical providers understood that the Guideline was voluntary, they believed they risked punishment or unwanted attention from law enforcement agencies or state medical boards if they maintained patients at high doses,” Human Rights Watch found in a 2019 report.

Asked to comment on the DEA’s role in obstructing chronic pain patients’ access to treatment, a spokesperson told Filter: “DEA exists to enforce the drug laws of the United States and does not interfere with the practice of medicine. As long as doctors are operating within the normal course of professional practice, can show legitimate medical need for the medications they prescribe, and are not otherwise in violation of the Controlled Substances Act, they would not be subject to law enforcement action.”

But a federal government watchdog has confirmed how fear of legal scrutiny has driven health industry practices that make it harder for patients to access their medically-necessary opioids.

The Government Accountability Office (GAO) found in a 2015 investigation that more than half of 62 distributors surveyed were placing stricter thresholds on opioid orders from practitioners and pharmacies, attributing these actions mostly to the DEA.  Fifty-two out of 84 individual pharmacies and 18 of 29 chain pharmacy corporate offices said that the stricter thresholds limited their ability to supply drugs to those with a legitimate need.

One distributor, the GAO noted, “reported it refuses to distribute large volumes of controlled substances to prescribers or pharmacies that specialize in pain management, even if it has no evidence that the prescribers or pharmacies are engaged in diversion.” Because of the DEA’s threat to hold distributors responsible for “diversion” at the prescriber and pharmacist level, the distributor explained that “supplying a large volume of controlled substances to customers with a pain management practice creates too great a risk of being the target of a DEA enforcement action.”

The DEA’s lack of clarity about the definition of a “suspicious order” meant that some “distributors elected to arbitrarily set thresholds for the amount of controlled substances pharmacies could order,” as the GAO summarized in its report.

The vagueness has had a trickle-down effect. One pharmacy told the GAO that “DEA has clearly stated that it is not calling for distributor cutoffs (i.e., thresholds), but their distributors have communicated that these changes are made because of fear of DEA enforcement actions, which has led many pharmacies to refuse to fill legitimate prescriptions.”

The GAO recommended that the DEA offer suppliers guidance on suspicious order monitoring and reporting—something the DEA has since failed to do. In November 2020, the agency published a proposed rule updating requirements, but it’s unclear how it will impact suppliers’ business practices.

The DEA’s method for measuring “success” included simply tracking the number of investigations conducted and the number of sanctions imposed.

Even with that potential clarification, the damage to how pharmacies operate has been done. In one of the highest-profile cases, Walmart, the fifth largest pharmacy chain in the country, installed in 2018 a block on “suspicious” prescribers and a seven-day, 50 MME-per-day limit on initial opioid prescriptions for acute issues. That came after the Department of Justice considered criminally indicting the world’s largest company for filling “suspicious” prescriptions.

A 2019 letter to the DoJ from an attorney representing Walmart demonstrates that the company’s “aggressive policy,” supposedly modeled on the 2016 CDC guidelines, was made to reassure investigators that they were doing their part, even if it meant “significant blowback” from state Boards of Pharmacy. According to the letter, three states sent letters warning that the policies were impermissible. In December 2020, DoJ sued Walmart anyway.

Despite the resources poured into these investigations, there’s no evidence supporting their effectiveness at stopping diversion—an activity criminalized on the premise that using unprescribed pharmaceuticals is undesirable, despite their being far safer than the unpredictable illicit opioid supply driving fatalities. In 2011, in response to the agency’s escalating enforcement actions, the GAO found the DEA did not have a system in place to accurately measure any impact on diversion. The DEA’s method for measuring “success” included simply tracking the number of investigations conducted and the number of sanctions imposed, among other things.

In a letter responding to the watchdog’s findings, Joseph Rannazzisi, the head of DEA’s Diversion Control office, made two things clear: 1) the “vast majority of registrant inspections do not uncover serious violations of the [Controlled Substances Act]” and 2) “it is impossible” to measure whether anti-diversion efforts are actually working. Instead, he wrote, “the specter of increased scheduled regulatory investigations” has a “deterrent effect that cannot be measured by raw data.”

In other words, the DEA had a hunch that scaring people with policing would make a difference.

Years before the escalating prosecutions, Dr. Scott Fishman, now the director of Center for Advancing Pain Relief at University of California, Davis, outlined the impact of the kind of fear mongering that Rannazzisi later championed.

“It seems that all you may need to change physician behavior is to simply advance intimidating policy statements or even initiate a few physician investigations that begin with a visit from DEA field agents dressed in flak jackets who carry weapons,” Dr. Fishman wrote in 2006. “Physician fear of regulatory scrutiny may not always be based on real threats, but they lead to real changes in prescribing behaviors that can substantially impair the treatment of patients in pain.”

Prescription Drug Monitoring Programs

When Stewart sought answers from the Oklahoma Medical Board, they clarified that “the law doesn’t say they have to take me off of it,” she recounted, and that she should therefore just “find a new doctor.”

But it’s not that simple. Although Stewart says she eventually was able to get her dosage increased after her cardiologist and gastro-enterologist sent a letter to her pain management doctor urging the reversal, a wave of reports from chronic pain patients say that practitioners willing to prescribe the dosage they need are increasingly scarce.

In large part, the stonewalling has been facilitated by prescription drug monitoring programs (PDMP)—state-run databases, the use of which is available to and, as of October 2021, required of practitioners and pharmacists to track controlled substance prescriptions. If Missouri approves a bill to start a PDMP, all 50 states will have one. PDMP data are monitored by law enforcement for investigations of both “pill mills” and “doctor shoppers.”

“That data is context-free … You can’t assume or conclude anything about it.”

The information provided by PDMPs is limited: drug, dose days and units, prescriber and pharmacist, usually. It does not account for why a patient may be prescribed multiple or high-dosage opioid prescriptions from one or more practitioners. “That data is context-free,” said Dr. Terri Lewis, a clinical educator who researches PDMPs. “It doesn’t really lend itself to analytics: You can’t assume or conclude anything about it,” such as whether the personal is “doctor-shopping,” “because that’s not what you’re collecting.”

Amid a climate of fear cultivated by law enforcement, practitioners have denied care to patients simply on the results of a PDMP search, which offer no resources or referrals to those suspected of having an opioid use disorder.

“PDMP surveillance provokes prescribers to cut loose chronic pain and other complex patients for whom opioids and other suspect controlled substances are indicated,” Jennifer Oliva, a law professor and director of the Center for Health & Pharmaceutical Law at Seton Hall University, told Filter. “Prescribers engage in such behavior to avoid DEA investigation and professional licensing board scrutiny. Research further teaches that prescription surveillance puts patient lives at risk by incentivizing opioid patients to opt out of the health-care delivery system to avoid law enforcement surveillance and possible prosecution.”

This abandonment of care for chronic pain patients has led to devastating outcomes: an alarming number of suicides and fatal overdoses, according to a 2020 study. Numerous anecdotal reports of patients taking their own lives have proliferated online—a major reason for the CDC’s 2019 clarification. For those seeking to treat their pain when medical professionals won’t, the more-accessible criminalized market exposes them to an unpredictable supply, often cut with highly potent opioids like fentanyl, and with other depressants that drive up overdose risk.

Practitioners’ problematic conceptions or perceptions can play a role in whether they abandon a chronic pain patient after querying a PDMP. One faulty assumption promoted by regulators is that a higher dosage means greater risk of an overdose. Although there is a risk relationship between dosage and overdose, the assumption that dosage predicts overdose misunderstands when overdoses actually occur among prescribed patients—as three physician-advocates explained in a 2018 letter to the Center for Medicaid and Medicare after the agency proposed negatively rating the performance of physicians by the number of high-dosage prescriptions written. As they found through examining a number of studies, it’s patients on lower doses (under 90 MME) who most frequently end up fatally overdosing, not those on the higher doses targeted by laws and regulations.

Stigma against and misconceptions about people living with substance use disorders (SUD) also influence practitioner decision-making. “I don’t want heroin addicts in my waiting room,” Dr. Eric Schnakenberg, a New York family medicine doctor, previously told Filter in explaining why he uses PDMPs. Physical dependence (experiencing withdrawal when a substance is removed) is not the same as SUD, defined as continuing to consume drugs despite negative consequences. Yet that distinction can be lost on practitioners making clinical determinations merely off of PDMP-reported dose days and units.

Racism and Bias

Other subjective factors have been shown to play a role in PDMP-influenced decision-making. A 2016 study found that a patient’s perceived honesty and intent played a role in discharging them from care. The researchers flagged for further study the need “to examine clinician interpretation of apparent patient dishonesty and to determine the appropriate level of influence of this factor in formulating prescribing decisions.”

Whose pain can be trusted is shaped by racist stereotypes. “Black Americans are seen as drug seekers and not as a patient who wants to remedy their pain,” said Dr. Tamara Baker, a psychiatry professor and an expert on racial disparities in pain management, referencing the broad literature demonstrating that Black pain is taken less seriously than others’.

The racist idea that Black people experience less pain dates back to chattel slavery, and appears to be alive and well. In a systematic review of 20 years of data, researchers found that Black patients were 29 percent less likely than whites to receive treatment with opioids for similar painful conditions. Another racist idea, that Black people are seeking drugs unnecessarily, also seems to be illustrated by the numbers. Black patients seeking emergency medical attention for issues not readily verifiable, like abdominal or back pain, were far less likely to be administered or prescribed opioids compared to their white counterparts, a 2016 study found.

“We’re not believed when we say we are in pain, generally thought to be lying or overestimating our pain and written off as disingenuous.”

Advocates for patients living with sickle cell disease—an inherited disorder most common among Black people and which can involve recurring episodes of acute pain as well as chronic pain—say that the confluence of racism and opioid prescribing crackdown has harmed their health.

“SCD patients are often undertreated, treated as drug seekers and many times ignored when they say they’re in pain,” said Jemela Williams, an SCD advocate and a Black woman herself living with the condition. Doctors and nurses often believe SCD patients are more likely to become “addicted” than other patient populations, resulting in reported reluctance to administer high dosages. Black SCD patients have reported that they had more difficulty accessing their needed dosage due to prescribing restrictions, stigma and racist bias after the 2016 CDC guidelines.

“A lot of the reasons we face these barriers has a lot to do with race,” Williams told Filter. “We’re not believed when we say we are in pain, generally thought to be lying or overestimating our pain and written off as disingenuous if we’re not acting the way that that medical professional thinks we should be if we are hurting.”

At first glance an increasingly-utilized artificial intelligence program—NarxCheck, a proprietary algorithm that produces a risk score (NarxScore) based on PDMP data—bears the promise of avoiding messy human bias. But Lewis and her colleagues are concerned its use will further disrupt chronic pain patients’ access. Forty-three jurisdictions  and companies, like Walmart, have adopted NarxCheck, even though the Food and Drug Administration has not evaluated it and nor has it been subjected to peer review.

Originally patented in 2011, the algorithm is largely based on the decontextualized data points visible to PDMP users and already vulnerable to erroneous human assumptions–––MME, number of providers and pharmacies, potentiating drugs, and number of overlapping prescription days, according to a paper by Appriss, the company bearing the rights to NarxCheck. It also includes data points that Oliva, who studies PDMPs’ discriminatory consequences, warns could exacerbate racial and gender disparities in pain treatment.

“NarxCare has begun to incorporate information from non-prescribing data sets—such as criminal and sexual trauma history—into its risk generating algorithms that are sure to disparately impact particular patient populations who have a long history of discriminatory treatment in the pain management setting,” she said.

The validity of NarxCheck is questionable, for Lewis, because of the data from which it was built.

NarxCheck stakes the threshold of risk at 90 MME per day, meaning those exceeding it will be predicted to be more likely to overdose. And it produces a numerical score, from 000 to 999, that Lewis says could inappropriately replace clinical judgement, as PDMPs have in some cases.

Additionally, the validity of NarxCheck is questionable, for Lewis, because of the data from which it was built: a sample of opioid-prescribed patients from Ohio’s PDMP who fatally overdosed and were suspected of “opioid misuse.” This begs the question of whether it is generalizable to people who do not have a problematic relationship with opioids, such as many chronic pain patients.

“Here’s the problem: If you’re sick and have been using your medicine for a while, you’re going to be flagged,” Lewis said. And there’s emerging evidence to back that up. Northeastern University researchers developed a machine learning model using data similar to NarxCheck to predict opioid use disorder among patients prescribed opioids. Their model targeted patients living with “complex chronic pain conditions and other burdensome comorbidities,” despite such patients not being likely to enjoy benefits from reduced prescribing, consequentially suggesting that the ways in which comparable risk-scoring algorithms have been constructed may be biased.

Through her advocacy work, Nicholson has heard anecdotes about NarxCheck’s misidentification of chronic pain patients. “We’ve seen a patient with a bad NarxScore because they have multiple doctors. They take that as doctor shopping, but there are lots of innocent reasons, and the problem is they overreach,” said Nicholson. “These algorithms assign them scores that can lead to turning them away.”

Appriss did not respond to Filter’s request for comment.

Taking together all the factors chilling opioid prescribing, Lewis believes we’re missing the point: empowering people to keep themselves safe, instead of making paternalistic judgements.

“We know a lot of people use street drugs properly, and they manage their risk very well,” she pointed out. “But patients’ individual risk management strategies, like taking their medicine with others if opioid naive [or] having naloxone on hand, won’t show up [in PDMPs or NarxScores] because it’s not counted!”

“Death by a Thousand Paper Cuts”

Once the horse is out of the barn, you can’t put it back.

That’s what sitting Oklahoma State Senator Rob Standridge allegedly told Tamera Lynn Stewart when she asked why he kept pursuing stricter opioid prescribing laws even as chronic pain patients suffered as a result. She had come to give him an obituary of a patient who had taken their own life. Senator Standridge did not respond to Filter’s request for comment.

It’s been two years since the CDC denounced misapplications of its Guideline—yet legislators continue to take the agency’s 2016 recommendations as orders to be codified.

There surely are numerous reasons why politicians continue passing laws at odds with a growing public health consensus. For one, the flawed narrative of overprescribing as a driver of the overdose crisis has “been on non-stop” in our media and culture, said Kate Nicholson. She also thinks “It’s a good narrative for politicians,” namely that they’re protecting vulnerable patients from predatory corporations.

And then, of course, there are the lobbyists. One such anti-opioid group is Physicians for Responsible Opioid Prescribing (PROP), whose VP for federal affairs, Dr. Andrew Kolodny, was a star witness in the Oklahoma lawsuit against Johnson & Johnson and has testified before Congress on the so-called “opioid crisis.” Publicly, PROP has remained steadfast in supporting the CDC’s 2016 Guideline. Most recently, the group confronted the head of the American Medical Association for urging “governors and state legislators to take action [to] remove …. arbitrary dose, quantity and refill restrictions on controlled substances.” In a February 2021 letter, PROP alleged that AMA’s recommendation is “simply a repeat of the pharmaceutical industry’s playbook that led to an epidemic of opioid use disorder,” instead of one informed by chronic pain patients’ lived experiences and empirical evidence.

With waves of new anti-opioid bills being drafted, Stewart and her advocate colleagues have their work cut out.

Despite the misinformation that remains on Capitol Hill and at state capitols across the country, some progress is being made. For example, Kate Nicholson and a slew of other advocates successfully had removed from CARA 3.0, prior to its introduction in March 2021, a section that would have installed a three-day limit on initial opioid prescriptions for acute pain across the country.

Back in Oklahoma, Stewart helped get Senate Bill 57 passed through both houses of the state legislature, though final approval of amendments and the governor’s signature are still pending. Nevertheless, when Filter spoke with her, she was excited: Patients receiving aftercare for cancer would be eligible for exemption from the 2018 law that sparked her forced taper. The bill also prohibits the misinterpretation of the law establishing the state’s PDMP to mean that it “require[s] a practitioner to limit or forcibly taper a patient on opioid therapy.”

With waves of new anti-opioid bills and the new CDC guidelines currently being drafted, Stewart and her advocate colleagues have their work cut out for them.

Stewart has a phrase for both how chronic pain patients have been harmed by the opioid prescribing crackdown, and the amount of work needed to undo that harm: “death by a thousand paper cuts.’’ 

Top photograph by Preslava Glushkova on Unsplash. Other photograph courtesy of Tamera Lynn Stewart.

R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter.

The post How Fear, Misinformation, Stigma Have Devastated US Pain Patients appeared first on Filter.

On April 7, two public health agencies—the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA)—announced that certain federal funding can now be used to purchase FTS.

The strips are simple drug-checking tools that promote the bodily autonomy of people who use drugs. They inform people of the presence of fentanyl, the potent synthetic opioid that’s come to be nearly ubiquitous in the street supply of heroin, and increasingly in other drugs including cocaine, meth and pills marked as Xanax. 

In particular, grantees of CDC’s Overdose Data to Action and SAMHSA’s State Opioid Response programs are subject to the policy change. The former is primarily concerned with surveilling overdose trends, while the latter—recently found to squander funds—mostly addresses substance use disorders. 

Although the Biden Administration has said harm reduction is one of its priorities, as Filter first reported, the policy change seems to have been brewing before he took office in January. The CDC endorsed drug checking as an overdose prevention strategy on December 17, 2020, in the lame duck period of Trump’s presidency. The former head of SAMHSA during that administration was opposed to FTS.

Changes on the Ground

The longstanding ban, similar to the ongoing one criminalizing syringes, has forced syringe service programs (SSP) to secure other funding, rely on donations or go without FTS. “Until now, we have not been able to purchase fentanyl test strips using federal funds,” the Alliance LES Harm Reduction Center, an SSP in New York City, said in a statement shared with Filter.

“Our supply has been bolstered with fentanyl test strips generously donated by volunteers, however a limited supply means that we often are forced to ration or limit the amount of test strips that we can give out. This is certainly not ideal with a potentially life-saving tool that gives people who use drugs information that they can use to stay safe.” 

The policy change will likely allow Alliance LES and other SSP to step up their own drug-checking services. “The ability to purchase test strips with federal funds will improve our supply, and means that people can test multiple batches and substances,” the organization added. “Fentanyl is out there in the opioid supply, and it is being found in other substances, so the ability to test for it shouldn’t be limited.​”

For years, grassroots harm reductionists have been distributing FTS without governmental support. One such activist is Tino Fuentes, who resigned in 2016 from his position at a nonprofit SSP in New York City to pursue an independent effort to provide FTS to people who use as well as people who supply drugs—the latter of which he said would have been difficult if he had stayed in his organizational role. 

“I believe in asking for forgiveness, instead of permission. That’s the best way I’ve found,” Fuentes told Filter in 2019. “I’m going to do what I have to do. If I get caught and I go before a judge, I’ll say, ‘People are dying.’”

Preventable Deaths

The new funding will be no silver bullet for ending preventable overdoses. Instead, it appears to be a small policy step toward embracing evidence-based harm reduction policies—after years of rising fentanyl-involved death tolls.

FTS are still criminalized as drug paraphernalia in many parts of the US. Some jurisdictions, however, have exempted the strips, including Maryland, Rhode Island, North Carolina and the District of Columbia. The Delaware state legislature may soon follow suit.

Supply-side crackdowns on the unregulated drug economy appear to have driven the introduction of fentanyl analogs as an adulterant into heroin and pressed-pill supplies. Research has shown how efforts by law enforcement to reduce the drug supply have incentivized suppliers to shrink the volume of product by introducing higher-potency substances. 

One potential vision for addressing the structural issues driving fentanyl-involved overdoses include drug-possession decriminalization and a safe supply, as North American harm reductionists and drug-user activists have been demanding. Canada is considering a promising model, while the state of Oregon approved decriminalization at the ballot box last November. The Seattle Supreme Court also struck down the state’s felony drug possession law as unconstitutional. Some Canadian provincial governments have medicalized safe supply programs, while grassroots advocates call for a “community-led compassion club” model.

Photograph by Kastalia Medrano

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On March 30, the Home Office, which oversees national criminal justice affairs, announced that GHB will be reclassified from a Class C substance to Class B—making people found to be in possession vulnerable to up to five years in prison, rather than two. Supply and production punishments remain unchanged. Additionally, the department will advocate for legislation that creates a licensing system for the industrial use of GBL and BDO, two GHB precursors. All three chemicals are often referred to collectively as “G.”

The crackdown appears to be a response to a moral panic stoked by media outlets, like Buzzfeed UK, over a so-called “chemsex crimewave.” On January 6, 2020, Home Secretary Priti Patel called on the Advisory Council on the Misuse of Drugs (ACMD) to investigate whether G ought to be reclassified. She cited something that had happened earlier that day: A man named Reynard Sinaga had been sentenced to 30 years-to-life for serially raping queer men, many of whom are believed to have been unconsensually dosed with G. Patel also justified her request by citing Stephen Port and Gerald Motovu, two men who had committed murders facilitated by G.

Patel claims she’s trying to keep people safe. “I will do everything in my power to protect people from harm, which is why I am tightening restrictions around these dangerous substances,” she said in a statement making the announcement. “These changes will make the drugs harder to access and introduce tougher penalties for possession.”

Patel did not explain how the classic drug-war policies—harsher punishments and supply restrictions—will help stop rape. As the vast body of academic research on drug markets has demonstrated, supply-side crackdowns just makes conditions riskier for consumers who tend, invariably, to find what they’re looking for; this is otherwise known as the Iron Law of Prohibition.

More than two decades before Patel’s crackdown, a rape crisis counselor in the United States had known the punitive approach was misguided. “We must deal with the act and not deal with the vehicle specifically that is being used,”  Denise Snyder of the DC Rape Crisis Center told US Congressmembers in March 1998. The lawmakers were consideringd legislation, eventually enacted, to criminalize what a moral panic had branded as a “date-rape drug” due, in part, to misinformation about the deaths of two teenage girls. Snyder continued: “if we focus on specific drugs, I am afraid that what we are going to do is two years down the road find ourselves in the same place that we are in now.”

Patel’s approach will also likely disproportionately impact queer people. In the ACMD’s November 2020 report recommending the enhanced punishment, an unspecified number of advisors opposed the reclassification, in part on the grounds that there will be “unintended impacts of reclassification on those using these compounds—particularly those from the LGBT community and those using these compounds in the Chemsex context specifically.” They added that “These already vulnerable groups could be disproportionately impacted by any changes to the criminal justice system.”

London-based harm reductionist Ignacio Labayen de Inza, director of the organization Controlling Chemsex, is worried about the harm the policy change will have on people in the chemsex community.

“I felt very sad: Do they really believe that everyone who has G at home is a rapist?” he wrote to Filter. “Can’t they see that if the police arrives to a house where there is G, it can be [there] for many different reasons, including someone suffering from GHB dependency, and he needs that drug to function otherwise he will suffer from terrible withdrawal symptoms? So that person, who is already going through lots of difficulties … now he is going to be under more pressure?”

Instead of the harsher penalties for drugs, de Inza says that there needs to be more information and support for people who have been sexually assaulted or are struggling with their chemsex participation. He also believes that the “punishment has to be for the rapist.”

In a March 30 letter to the ACMD chair, Patel acknowledged that their report had made recommendations regarding “improved data, toxicology, prevention, treatment, and training of staff in health and social care.” She stated that Home Office “officials are in discussion with other government departments and agencies to develop a detailed response to these recommendations and I will reply further in due course.” 

Photograph of GHB containers by Filter

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