Lecture 12_Harm reduction & policy PDF

HARM REDUCTION & PUBLIC POLICY PSYC 3333: PSYCHOLOGY OF ADDICTION EMILIE LACROIX PUBLIC POLICY  Addictions treatments, Increasing target population effect individ...

HARM REDUCTION & PUBLIC POLICY PSYC 3333: PSYCHOLOGY OF ADDICTION EMILIE LACROIX PUBLIC POLICY  Addictions treatments, Increasing target population effect individualized interventions harm Increasing individual effort needed reduction strategies Screening & brief intervention, e.g. in primary care settings Goal: reduce use programmes Drug prevention in schools and mass media campaigns Goal: goal improve knowledge, change attitudes, prevent use Strang, J., Babor, T., Caulkins, J., Arrest traffickers & dealers, force Fischer, B., Foxcroft, D., & suppliers suppliers to operate inefficiently Humphreys, K. (2012). Drug policy goals: and the public good: evidence for Goal: keep prices high, reduce effective interventions. The availability availilability Lancet, 379(9810), 71-83.  - a decrease in overdose deaths - drug related arrests (going up or down). - how many people are being hosptialized - finding used needles in public spaces - the price of drugs individual user: - to what extent they have for level of functionsing, quality of life - ask about risky behaviours - hows thier mental health Evaluating drug policy: - How can we tell what works? What factors are typically considered? POLICY EVALUATION  Randomized controlled trials  Can be used to assess effectiveness of treatments, prevention approaches, and drug courts RCT’s are not always possible - they are expensive  Quasi-experimental studies  “Next best” type of evidence when randomization is not possible  Attempt to simulate characteristics of controlled experiments  Statistical analyses of the effects of policy interventions on health or other outcomes over time  Natural policy experiments  Observational studies to assess effect of policy interventions  Comparing the effects of different policies in different states/provinces  Comparing the effects of different policies in different countries  SUPPLY CONTROL  Goal: reduce access to drugs by interfering with supplier activity  Make drug so scarce that users cannot find it without great difficulty or expense Increase cost Reduce Increase law Increase of shipping & access and enforcement price of drug risk to seller use Strang, J., Babor, T., Caulkins, J., Fischer, B., Foxcroft, D., & Humphreys, K. (2012). Drug policy and the public good: evidence for effective interventions. The Lancet, 379(9810), 71-83.  EVIDENCE FOR SUPPLY CONTROL INTERVENTIONS Intervention Impact Comments Crop eradication Temporary market disruption No recordable downstream effect on markets, as production moves to other regions. Controls on precursor chemicals Temporary market disruption Cheap to initiate, costly to enforce. hard to work with every pharmacy New production materials emerge, production moves to other regions. Investigation and incarceration of key Little empirical evidence Possibly more cost-effective because figures in drug production/trafficking high-level sellers not as easily replaced. Imprisonment Some evidence, but has diminishing Expensive to manage prison system returns and rehabilitation. Strang, J., Babor, T., Caulkins, J., Fischer, B., Foxcroft, D., & Humphreys, K. (2012). Drug policy and the public good: evidence for effective interventions. The Lancet, 379(9810), 71-83.  CROP GROWTH INTERVENTIONS  Forcible eradication of coca has been part of supply-reduction strategy for decades  Burning, chemical herbicides, manual deracination  Massive infusion of US funds to support aerial spraying in the Andes  Plan Colombia (2000-2012): 128,000 hectares per year subjected to glysophate (Roundup) spraying  Ineffective and costly:  To eliminate a single hectare, 30 hectares must be sprayed  Cost: $80,000 per hectare eliminated  Market value of coca leaf: $400 per hectare  Negative health and environmental impacts, destroys food crops they are farmers and feeding families rural houshold strategies to form an income Strang, J., Babor, T., Caulkins, J., Fischer, B., Foxcroft, D., & Humphreys, K. (2012). Drug policy and the public good: evidence for effective interventions. The Lancet, 379(9810), 71-83.  “Policies, programmes and practices that aim primarily to reduce the adverse health, social and economic consequences of the use of legal and illegal psychoactive drugs without necessarily reducing drug consumption. Harm reduction benefits people who use drugs, their families and the community.” International Harm Reduction Association, 2010 9 HARM REDUCTION APPROACH (CHARPP FRAMEWORK) Recognize stigma and discrimination towards people who use drugs Involve people who use drugs in policy development and implementation Acknowledge that not all substance use is problematic Acknowledge need for evidence-informed policies and programs Recognize importance of preventing drug-related harm (not just use) Low-threshold to service provision Human rights dimensions (e.g. dignity, autonomy) Consider social determinants (e.g., SES and housing) that influence drug-related harm SUPERVISED INJECTION FACILITIES  Needle distribution & disposal service  Take-home naloxone kits  Overdose prevention site (supervised consumption)  Support groups a nusre or health care professional on site you aren’t allowed to smoke drugs or cook with a spoon - the nurse could breathe in the drug injection drug use only given clean gear to use drugs - they need to bring thier own stuff  SUPERVISED INJECTION FACILITIES  Vancouver: Insite  A place where people can inject drugs and connect to health care services  Provides a safe, sanitary environment and clean syringes  Does not provide illegal drugs to users Outcome: 35% reduction in overdose mortality in 500m surrounding the site Marshall, B. D., Milloy, M. J., Wood, E., Montaner, J. S., & Kerr, T. (2011). Reduction in overdose mortality after the opening of North America’s first medically supervised safer injecting facility: a retrospective population-based study. Lancet, 377(9775), 1429–1437.  EFFECTIVENESS OF SUPERVISED CONSUMPTION SITES Reduction in Overdose Deaths: INSITE in Vancouver saw a 35% decrease in fatal opioid overdoses within 500 meters of the facility (from 253.8 to 165.1 deaths per 100,000 person-years; p = 0.048), compared to a 9% reduction in the rest of the city. Simulation studies estimate up to 1004 overdoses were avoided over four years, including 453 life-threatening overdoses. Reduced Harmful Behaviors: Regular supervised use decreased syringe sharing (adjusted odds ratio [aOR] = 0.30) and syringe reuse if the odds were one that would mean there was no impact -.3 means odds are less than one third Public injection rates dropped in Vancouver, with homelessness significantly linked to public injection (aOR = 3.1) fewer people are injecting in public Improved Health Access: Facilitate referrals to addiction treatment centers (1.57 x more likely to access) and improved access to ancillary services (e.g., shelter and food). In a Danish study, increased treatment uptake for medical conditions (51.3% vs. 25.7%, p = 0.003). Magwood, O., Salvalaggio, G., Beder, M., Kendall, C., Kpade, V., Daghmach, W.,... & Pottie, K. (2020). The effectiveness of substance use interventions for homeless and vulnerably housed persons: a systematic review of systematic reviews on supervised consumption facilities, managed alcohol programs, and pharmacological agents for opioid use disorder. PloS one, 15(1), e0227298. MEDICAL TREATMENTS Opiate use disorder  OAT (opiate agonist therapy) includes Stimulant use disorder Buprenorphine/Naloxone (Suboxone), Methadone,  SRT (stimulant replacement therapy): Stimulant Sustained Release Morphine (Kadian) agonists such as Sustained Release  Buprenorphine (Sublocade) injections Dextroamphetamine (Dexedrine), Sustained Release Methylphenidate (Concerta), or dopamine  iOAT (injectable opiate agonist therapy) antagonists such as Aripiprazole (Abilify) provides liquid hydromorphone that participants self inject IV or SC three times per day, plus a long acting OAT medication to take for overnight Riverstone Recovery Centre – Fredericton, NB *not a safe injection site River Stone Recovery Centre is a non-judgmental, welcoming space providing trauma- informed treatment for substance use disorder, with a focus on opiate agonist therapy, stimulant replacement therapy and wraparound social supports. Medical/pharmaceutical care OAT (opiate agonist therapy) iOAT (intravenous OAT) SRT (stimulant replacement therapy) Wraparound services peer support intensive case management psychosocial programming Education students in healthcare, social work and related fields public healthcare workers Advocacy housing (esp. supported housing) access to services  IOAT… “is the one thing that helps” “literally saved my life” “has taken one of the biggest, most stressful things off my plate so I can get other things done” “makes you feel like you're important, like you're not just a patient but somebody that they care about” “has given me stability” BEHAVIOUR CHANGES -- BEFORE BEHAVIOUR CHANGES -- AFTER 65% REPORT IMPROVED PHYSICAL HEALTH sleeping able to walking and better exercise biking every day gaining remembering fewer weight to take blood abscesses pressure meds 65% REPORT IMPROVED MENTAL HEALTH iOAT seems to HUGE no longer spend make dealing I feel more improvement in all day in bed with mental health positive, optimistic mental health "being devoured possible with depression” much better seeing therapist attitude; feeling now – my mind feel a lot less mind is a little better mentally can handle anger on iOAT clearer therapy now ECONOMIC IMPACT hospitalization emergency department before/after iOAT ambulance incarceration encounters with criminal ECONOMIC justice system IMPACT METHADONE MAINTENANCE PROGRAMS  Methadone: a drug used to help control the withdrawal symptoms from opiates  Prescription covered by NB drug plan (though Buprenorphine/Suboxone is not)  11 programs funded by Horizon Health Network  St. Joseph’s Health Centre in Sant-John offers “low-threshold” methadone maintenance  No mandatory patient counselling, urine tests, or punishment for using other drugs  1-year retention rate 95%, higher than any other clinic in the country and double the rate of other clinics  Cost effective: about $5,000/year, compared to $45,000 in health and legal costs for untreated opiate addiction Canadian Harm Reduction Policy Project (CHARPP): New Brunswick Policy Analysis Case Report (2017) https://www.cbc.ca/news/canada/new-brunswick/n-b-methadone-clinic-boasts-highest-retention-rate-1.1284841 https://www.cbc.ca/news/canada/new-brunswick/n-b-methadone-clinic-boasts-highest-retention-rate-1.1284841  Methadone and buprenorphine treatment reduce all-cause mortality. Methadone treatment cuts risk of death by about two thirds. Buprenorphine cuts risk of death in half. Magwood et al., 2020  Methadone and buprenorphine treatment reduce overdose mortality. Magwood et al., 2020 EVEN WITH WRAPAROUND SERVICES, IOAT ISN’T ENOUGH… Only 1/3 of iOAT participants have stable housing. Focus on basic survival is paramount. Primary needs: shelter, food, addiction supports, and access to physical and mental health care. Many need stable housing with intensive supports before they can try treatment. NOT HOUSING PEOPLE IS EXPENSIVE DRUG TREATMENT COURTS Integrate therapeutic interventions & administration of justice. Goals:  Divert from incarceration  Enter and remain in treatment  Abstinence from illegal drugs  Improve wellbeing, housing, life skills, employment and education DRUG TREATMENT COURT: PROCESS 1. Offender submits application soon after arrest 2. Crown attorney screens against eligibility criteria (e.g., non-violent offenders and criminal behaviour that is a result of illicit drug dependency, guilty plea to criminal charges, etc.) 3. Admission process: interview by treatment personnel, presentation of case to drug treatment course. If rejected, return to regular court process. 4. Program participation: must plead guilty, make regular court appearances, attend treatment, random urine drug testing  Integrated team of probation officers, addiction counsellors, physicians, health care workers, and an employment assistance worker 5. Program completion if:  Period of abstinence (e.g. three consecutive months) recitivism - doing more crimes  Secure employment, training, or volunteering huge reduction in recitivism in drug treatment courts  Live in stable, approved housing  No new offences why would it be challenging to set this up? - there needs to be funding 6. Graduation ceremony, sentenced to non-custodial sentence for original crime - you need a whole team of people CULTURAL CONSIDERATIONS PAPER  Paper grades will be released this afternoon  If you have questions about your grade, please email the TA, Brittany: [email protected]  Meetings upon request  Before contacting Brittany, please review:  “Lecture 7_Cultural Considerations paper & Quiz Review”  AND the rubric posted on D2L (These documents may hold the answers to your questions) CANADIAN CANNABIS LEGISLATION HISTORY OF CANNABIS POLICY IN CANADA  Early 1900s: “Reefer Madness”  A cult classic of comically bad cinema  Alarmist views on the dangers of marijuana addiction  1923: Cannabis added to Canadian drug control schedule, becomes a controlled substance, but little enforcement https://www.youtube.com/watch?v=zhQlcMHhF3w HISTORY OF CANNABIS POLICY IN CANADA  1960s: cannabis use increases in Canada  1970s: arrests for cannabis possession increase from 1,500 (1969) to 65,000 ten years later 2017: LEGALIZATION BILLS INTRODUCED  C-45  Legal framework for legalization & regulation of production, distribution, sale, possession, importation and exportation of cannabis in Canada  C-46  Introduced new provisions related to police ability to screen drivers for drug impairment driving under the imfluence of cannabis is still dangerous they drive a little slower harder to test than alcohol www.Statscan.gc.ca www.Statscan.gc.ca www.Statscan.gc.ca BEFORE & AFTER LEGALIZATION  CANNABIS POSSESSION ARREST RATES BIASED APPLICATION OF DRUG POLICY: CANNABIS pre collected data that exists Owusu-Bempah, A., & Luscombe, A. (2021). Race, cannabis and the Canadian war on drugs: An examination of cannabis arrest data by race in five cities. International Journal of Drug Policy, 91, 102937.  DISPROPORTIONALITY SCORES BY RACE Disproportionality score >1.0 indicates the group is over- represented in arrests BIASED APPLICATION OF DRUG POLICY: CANNABIS disproportinality refers to the degree of over representation of the races in the data Owusu-Bempah, A., & Luscombe, A. (2021). Race, cannabis and the Canadian war on drugs: An examination of cannabis arrest data by race in five cities. International Journal of Drug Policy, 91, 102937.  GENDERED INCARCERATION FOR DRUG OFFENCES 80 77 68.4 68.2 68 59.4 57 53.9 49 45 33.5 33 25.1 24.8 23.8 16.8 14.3 17 17 12 A R G E NT I N A A US T R A LI A BR AZ I L C O LO M BI A E CU A D O R LA T V I A M EX I CO P ER U U S A ( F E D E R A L) U S A ( S T A T E S ) Proportion (%) imprisoned for drug offences overall Proportion (%) of women imprisoned for drug offences convicted for bring drug into jail for family memeber not for own use they don’t have inofrmation that you can exchange you don’t have much leverage - havae a sentence reduced and often women don’t have that information 92% convicted for non-violent offences Csete, J., Kamarulzaman, A., Kazatchkine, M., Altice, F., Balicki, M., Buxton, J.,... & Beyrer, C. (2016). Public health and international drug policy. The Lancet, 387(10026), 1427-1480.  LEGALIZATION ≠ END OF BIASED ENFORCEMENT who profits from the cannabis industry - 84% are white people, women are only 14% Racial disparities may remain or even worsen following legalization. In Colorado, following legalization…  White people experienced 51% decrease in cannabis arrests, compared with 33% for Latinx and 25% for Black people  Among 10-17 year-olds: arrest rate for White youth fell by nearly 10%, while rate for Latinx and Black youth increased by 20% and 50%, respectively Owusu-Bempah, A., & Luscombe, A. (2021). Race, cannabis and the Canadian war on drugs: An examination of cannabis arrest data by race in five cities. International Journal of Drug Policy, 91, 102937. effeecgive public health messaging: clarity and simplicity: - use clear, concise language free of jargon - focus on one key message at a time Credibility and trustworthiness: - cite reliable sources and evidence - engage trusted messangers, including community leaders and healthcare professionals. relevance and cultural sensitivity: - tailer messages to the target audience’s values, beleifs, and culutral context - ensure inclusivity by addressing diverse experiences and avoiding stigmas *****SHE IS UPLOADING MORE SLIDES GO LOOK AT THEM HARM NEGATIVE ADVERTISING can result in dismiss REDUCTION GUIDELINES FOR INDIVIDUALS WHO USE DRUGS ALCOHOL  Pace and plan  Set limits  Drink slowly  1:1 ratio  Only buy what you plan to drink  Eat before and while drinking  Consider individual factors (BAC) CANNABIS  Small amount to test strength  Vaporize  Use pipes that are glass, stainless steel, or brass  Lower THC content  Don’t mix with tobacco  Take time if using edibles  Consider risk for psychosis INJECTION DRUG USE  Use new sterile equipment  Rotate site of injection  Use veins in hands or arms  Safe disposal  Do not share  Regularly test for infectious disease  Have a naloxone kit  Avoid using alone