Liberty from Opioids
A Plan for a New New York
Prepared for: Larry Sharpe for NY Governor 2018
Prepared by: Siobhan P. Lynch, Policy Director, Larry Sharpe for New York
May 21, 2018
Proposal number: DP-0001
To solve the problem of the Opioid Crisis by allowing more treatment options, medication assisted therapy, Overdose Protection Sites (OPS), reduction of penalties for possession, and comprehensive fact-based drug education
- Reduce deaths resulting from opioid overdose
- Reduce the impact of the opioid crisis on communities
- Reduce the opioid crisis’ negative economic impact on healthcare and law enforcement services provided by the state.
- Reduce the prison population by disrupting the steady flow of people arrested for problematic drug use- instead, offer effective, evidence-based treatment.
- Reduce the strain placed on the child welfare system and offer resources that enable better outcomes for everyone, especially families affected by the opioid crisis.
- Reduce the crime that accompanies opioid abuse.
- New York has a reputation for having some of the toughest and most complicated drug laws in America. Not only does the state classify common illicit substances, including heroin and cocaine, they also include the compounds to manufacture them. New York’s drug laws are incredibly complex and convoluted, in fact, there are half a dozen different felony classifications for drug possession alone. In particular, a law known as “constructive possession” may apply when drugs are found in a home owned by a person reasonably believed to be “in control” of that home- this law paves the way to criminal possession charges. (Mauer & King, 2007)
- “Every day, more than 115 people in the United States die after overdosing on opioids. The misuse of and addiction to opioids—including prescription pain relievers, heroin, and synthetic opioids such as fentanyl—is a serious national crisis that affects public health as well as social and economic welfare. The Centers for Disease Control and Prevention estimates that the total “economic burden” of prescription opioid misuse alone in the United States is $78.5 billion a year, including the costs of healthcare, lost productivity, addiction treatment, and criminal justice involvement.” (National Institute on Drug Abuse, 2018)
- 1 in 13 New Yorkers suffer from a substance abuse condition. An estimated 447,0000 people in New York State need treatment, but do not get it. Translation: statewide, over 1.8 Million New Yorkers, including 156,000 young people age 12-17, have a substance abuse condition. (Pugh, et al., 2013)
- Drug use is a major contributor to illness, injury, and death. In New York City, accidental drug overdose is the fourth leading cause of premature death among adults. More than 600 people die from drug overdoses each year— a rate that exceeds the number of homicides committed annually. People who use heroin face annual mortality rates six to 20 times higher than the rate expected among their peers who do not use drugs. In 2009, over 54,000 New York hospital discharges were related to drug abuse (Pugh, et al., 2013).
- A review of New York City hospitals found that two-thirds of the non-long term care Medicaid beneficiary population, a segment considered to be high-cost to the health care system, had a substance abuse condition. (Two-thirds to three-fourths also had a chronic health condition, almost half had more than one chronic health condition, two thirds had a mental illness, and approximately half had a mental health and substance abuse condition). High-cost Medicaid beneficiaries account for the majority of Medicaid spending, mostly due to hospitalizations and emergency department visits. The most costly 10 percent of recipients accounts for 57 percent of all Medicaid spending—an average of $20,000 per patient—and the top one percent account for 20 percent of spending with an average of $71,000 per patient. (Pugh, et al., 2013)
- 1/3rd, or 6.6 million, New Yorkers are on Medicaid (Faso, 2017)
- While drugs have destroyed many lives, it is clear that bad government policies have destroyed many more. A criminal record for someone found guilty of a minor drug offense can actually be a bigger threat to their overall well-being than occasional drug use. These unintended consequences over the past 50 years include mass incarceration as well as the creation of a massive international black market enterprise. (Kofi Annan, Forward. International Drug Policy Consortium, 2018)
- The intranasal version of Naloxone revives 98% of overdose victims who receive it. This cuts the OD death rate by nearly 50% in regions with high levels of availability when compared to areas where the antidote was less accessible. (Szalavitz, 2014)
- Secondary costs within child protection services are also greatly affected by the opioid crisis. In Hennepin County, MN, the only place where researchers have taken a deeper dive into the relative costs of the opioid crisis, the budget for Child Services doubled. In fact, in a single year, reports of child abuse doubled and the county experienced a 70% increase in foster placements over a two year period. Within this case study, 9 out of 10 of those placed were children under the age of 5 who had a parent entrenched in drug abuse. Medical examiner costs also went up due to the increase in autopsies necessary for those who died from overdose. (Farmer, 2018)
- Fentanyl is increasingly in the illicit opioid supply making it hard to dose drugs accordingly. (Siemaszko, 2018)
- Drug crime went up two times in human history: once during alcohol prohibition, and again from 1970-1990 when drug prohibition and prosecution were put front and center in overall drug policy. Jeffrey Miron and Milton Friedman estimate that the amount of drug-related murders caused by prohibition exceeds 10,000 a year nationwide- this is the equivalent of more than three 9/11s every single year. (Hari, 2016)
- The war on drugs makes it almost impossible for drug users to get milder forms of their drug of choice which often pushes them inexorably toward harder drugs. (Hari, 2016)
- Contrary to some belief, there are people who use drugs responsibly- we only see the 10% that actually develop problems as a result of their use which is only the tip of the iceberg. While some of these individuals may struggle with substance abuse, they remain functional members of society. People should be given the tools to help themselves stay out of harm’s way. (Hari, 2016)
- The average cost for 1 full year of methadone maintenance treatment is approximately $4,700 per patient whereas 1 full year of imprisonment costs approximately $24,000 per prisoner. (National Institute for Drug Abuse)
- Every dollar invested in addiction treatment programs yields a return between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft. When savings related to healthcare are included the combined savings can exceed costs by a ratio of 12 to 1. (National Institute for Drug Abuse)
- As of 2016 (the last “Under Custody Report” available to the public) there are 6,780 people in prison for Drug Related offenses of which 48% (3,267) were related to charges stemming from possession (New York DOCCS, 2016)
- About half of all violent crimes are committed or associated with Alcohol or Drugs. (Wen, Hockenberry, & Cummings, 2014)
It is obvious that the opioid crisis not only affects the lives of those who are problematic drug users, but everyone around them, as well as the economic well-being of New York State.
We need to address the opioid crisis with a myriad of approaches, including reasonable access to treatment options and facilities for those who seek help. We must promote facilities designed for the safe consumption of drugs which creates gateways to evidence-based treatment. It is imperative that these resources also work to give avenues for treatment which address socio-economic issues, mental health, and criminal justice outcomes. We need to reduce or eliminate penalties for possession of drugs while simultaneously offering education oriented by factual information regarding drug use and abuse.
Recommendation: To work with private Drug Policy NGOs like Drug Policy Alliance, Students for Sensible Drug Policy, Families for Sensible Drug Policy on comprehensive fact-based Drug Education. in an effort to catch all types of drug users, including functional, responsible and problematic, education must target the entire population of New York- not just the 10% of users who experience major life disruptions as a result of their disease.
Recommendation: To allow the creation of Overdose Prevention Sites (referencing the Swiss Model and the Ithaca Plan) to allow for harm reduction, which will save lives, and ultimately reduce the burden on Medicaid (City of Ithaca, 2016)
Recommendation: Reduce penalties for the possession of any drug or substance of abuse. In lieu of the common modes of punishment, a referral to a class would be provided where the participant will learn of non-coercive treatment options available; an alternative to this option could include a referral to an OPS (Portuguese model). This decriminalization will depend upon enrollment and participation in the OPS program.
- Establish and maintain contact between the drug abusing population and the social-service and health-care network, within which low-threshold facilities (LTFs – OPS and Needle Exchanges) are often the First point of access because of the care and social assistance they offer;
- Reduce risky behaviours that may lead to the transmission of infectious diseases, particularly HIV/AIDS
- Reduce the incidence of fatal overdose and, therefore, the mortality rate in this population
- Reduce problems of public order by doing away with open drug scenes, drug use in public places, recovering used syringes, and the impact of drug problems on residential areas (apartment buildings) (Zobel & Dubois-Arber , 2004)
At the same time, the available data does not indicate any specific detrimental effect on:
- The number of drug users and the frequency with which they use drugs- these figures are falling in both cases;
- Entry into and retention within treatment programs because the majority of OPS users are already undergoing treatment. The proportion of those in treatment is growing and this subject is also addressed within the facilities. The users assert that OPS does not have any major influence on their course of treatment
- All of these observations relate to the overall level of public health and do not indicate that OPS may not produce negative consequences in certain individual cases. However, on the basis of current studies, it would appear that the overall effect of OPS on drug-related problems is positive.” (Zobel & Dubois-Arber , 2004)
Recommendation: For those already involved in the criminal justice system options for non-traditional treatment options beyond the 12 steps should be readily available. This includes programs like SMARTRecovery which will allow this disease to be addressed as a health condition permitting relapses to be therapeutically treated as opposed to imprisonment and probation.
People who have encountered family problems arising from their drug use be given ample opportunities to keep their families together through the use of private outpatient programs that provide counseling and treatment aimed at building and maintaining such relationships.
Recommendation: For those with housing or family issues, referrals to private programs which help find housing and have family based counseling should be available. Public housing bans regarding drug convictions should be lifted.
Recommendation: Increase access to Naloxone nasal spray to Over the Counter.
Recommendation: Allow drug reagent testing at venues that tend to have higher amounts of drug use associated.
Recommendation: Release all non-violent drug offenders to probation or treatment and pardon them after.
Costs for Treatment vs. Cost of Incarceration
There are about 33,664 individuals in prison for violent crimes. About half of them are associated with drug-related offenses or crimes committed while under the influence (Wen, Hockenberry, & Cummings, 2014), there are 6780 in for non-violent drug crimes. Although they have already been convicted, it is in our best interest to release these prisoners and offer them treatment. Treatment costs are 1/12th of what it actually costs to house an inmate (NIDA, 2018), therefore, at an average of $21,000 per inmate a year, treatment, including Medication assisted therapies, will cost about $1,750 per year, a savings of $19,250 per inmate. This results in for those prisoners, approximately $130.5m in savings.
If there had been prevention and harm reduction, it is possible that savings could have been closer to $454m/yr
With harm reduction, prevention, and education systems in play, we could see results like this come about within roughly 10 years. These glowing statistics must also call attention to a 50% reduction in the prison population; this is similar to a drop is being seen in the Netherlands following radical changes to their drug policies. (Weller, 2017)
Costs to Medicaid System
Even if we use the most conservative estimates, harm reduction, overdose prevention, and education could reduce medicaid spending by $3.2B. Considering 2/3rds of 57% of the Medicaid budget is potentially drug emergency related, this could potentially results in upwards of $23B a year in savings if all drug users are medically supervised. This is most likely somewhere around the $11B mark (assuming 50% compliance). However, we’ll go with an estimate of around $4B in savings, meaning we could potentially wipe out New York’s budget deficit in just Medicaid system burden alone. Even if the conservative estimate is true, of $3.2B, it gives us a huge start in resolving New York’s budget Deficit.
Costs in Life
In Switzerland, where they have instituted SCS/OPS, they have seen a reduction in mortality related to heroin and other opioid use of about 50% (Reuter & Schnoz, 2009)
There has also has been a reduction in drug-related infectious diseases from 35% to 9% among catalogued drug users in Vancouver, BC; a reduction of ambulatory responses from 27 per month to only 9; and the prevention of an estimate of 6 to 57 HIV infections within the targeted population which encompasses about 35 blocks around the OPS site. This may include unmeasured benefits from needle exchange programs. (Ng, Sutherland, & Kolber, 2017)
Farmer, L. (2018). How One County Put a Number on the Opioid Crisis. Retrieved from http://www.governing.com/week-in-finance/gov-finance-roundup-opioid-crisis-child-protection-costs.html
Faso, J., Congressmember. (2017, July 21). One in three New Yorkers is on Medicaid. Retrieved from http://www.politifact.com/new-york/statements/2017/jul/21/john-faso/one-three-people-new-york-are-medicaid/
Hari, J. (2016). Chasing the scream: The first and last days of the war on drugs. London: Bloomsbury Publishing.
International Drug Policy Consortium. (2018). IDPC DRUG POLICY GUIDE. Retrieved from http://fileserver.idpc.net/library/IDPC-drug-policy-guide_3-edition_FINAL.pdf
Mauer, M., & King, R. S. (2007). Uneven Justice: State Rates of Incarceration by Race and Ethnicity. Retrieved from http://www.sentencingproject.org/wp-content/uploads/2016/01/Uneven-Justice-State-Rates-of-Incarceration-by-Race-and-Ethnicity.pdf
Moreira, M., Hugues, B., Zobel, F., & Storti, C. C. (2011). Drug policy profiles: Portugal. Luxembourg: Publications Office.
National Institute on Drug Abuse. (n.d.). Is drug addiction treatment worth its cost? Retrieved from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/frequently-asked-questions/drug-addiction-treatment-worth-its-cost
National Institute on Drug Abuse. (2018, March 06). Opioid Overdose Crisis. Retrieved from https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis
New York DOCCS. (2016, January 1). DOCCS Under Custody Report 2016.
Ng, J., Sutherland, C., MD CCFP DipABAM, & Kolber, M. R., MD CCFP MSc. (2017). Does evidence support supervised injection sites? Can Fam Physician,63(11), 866th ser.
Pugh, T., MHS, Netherland, J., PhD, Finkelstein, R., ScD, Frederique, K., MSW, Meeks, S., MS, & Sayegh, G. (2013, April). Blueprint for a Public Health and Safety Approach to Drug Policy. Retrieved from http://www.drugpolicy.org/sites/default/files/3371_DPA_NYAM_Report_FINAL_for_WEB April 19 2013.pdf
Reuter, P., & Schnoz, D. (2009). Assessing Drug Problems and Policies in Switzerland, 1998-2007. Swiss Federal Office of Public Health.
Siemaszko, C. (2018, May 1). Fentanyl figures in most fatal drug overdoses in U.S., researchers say. Retrieved from https://www.nbcnews.com/storyline/americas-heroin-epidemic/fentanyl-figures-most-fatal-drug-overdoses-u-s-researchers-say-n870481
Szalavitz, M. (2014, April 04). FDA Approval of Overdose Antidote Leaves Lives on the Table. Retrieved from http://time.com/49784/viewpoint-fda-approval-of-overdose-antidote-leaves-lives-on-the-table/
Weller, C (2017, May 31), Dutch prisons are closing because the country is so safe, Retrieved from https://www.independent.co.uk/news/world/europe/dutch-prisons-are-closing-because-the-country-is-so-safe-a7765521.html
Wen, H., Hockenberry, J., & Cummings, J. (2014). The Effect of Substance Use Disorder Treatment Use on Crime: Evidence from Public Insurance Expansions and Health Insurance Parity Mandates. doi:10.3386/w20537
Zobel, F., & Dubois-Arber, F. (2004). SHORT APPRAISAL OF THE ROLE AND USEFULNESS OF DRUG CONSUMPTION FACILITIES (DCF) IN THE REDUCTION OF DRUG-RELATED PROBLEMS IN SWITZERLAND. Swiss Federal Office of Public Health. doi:10.1.1.190.3214