The Legal Landscape for Opioid Treatment Agreements.

Policy Points Opioid treatment agreements (OTAs) are controversial because of the lack of evidence that their use reduces opioid-related harms and the potential risks they pose of stigmatizing patients and undermining the clinician-patient relationship. Even so, their use is now required in most jurisdictions, and their use is influencing the outcomes of civil and criminal lawsuits. More research is needed to evaluate how OTAs are implemented given existing requirements. If additional research does not resolve the current level of uncertainty regarding OTA benefits, then policymakers in jurisdictions where they are required should consider eliminating OTA mandates or providing flexibility in the legal requirements to make room for clinicians and health care institutions to implement best practices. CONTEXT: Opioid treatment agreements (OTAs) are documents that clinicians present to patients when prescribing opioids that describe the risks of opioids and specify requirements that patients must meet to receive their medication. Notwithstanding a lack of evidence that OTAs effectively mitigate opioids' risks, professional organizations recommend that they be implemented, and jurisdictions increasingly require them. We sought to identify the jurisdictions that require OTAs, how OTAs might affect the outcomes of lawsuits that arise when things go wrong, and instances in which the law permits flexibility for clinicians and health care institutions to adopt best practices. METHODS: We surveyed the laws and regulations of all 50 states and the District of Columbia to identify which jurisdictions require the use of OTAs, the circumstances in which OTA use is mandatory, and the terms OTAs must include (if any). We also surveyed criminal and civil judicial decisions in which OTAs were discussed as evidence on which a court relied to make its decision to determine how OTA use influences litigation outcomes. FINDINGS: Results show that a slight majority (27) of jurisdictions now require OTAs. With one exception, the jurisdictions' requirements for OTA use are triggered at least in part by long-term prescribing. There is otherwise substantial variation and flexibility within OTA requirements. Results also show that even in jurisdictions where OTA use is not required by statute or regulation, OTA use can inform courts' reasoning in lawsuits involving patients or clinicians. Sometimes, but not always, OTA use legally protects clinicians from liability. CONCLUSIONS: Our results show that OTA use is entwined with legal obligations in various ways. Clinicians and health care institutions should identify ways for OTAs to enhance clinician-patient relationships and patient care within the bounds of relevant legal requirements and risks.

Police seizure of drugs without arrest among people who use drugs in Vancouver, Canada, before provincial 'decriminalization' of simple possession: a cohort study.

BACKGROUND: Several jurisdictions in Canada have recently considered decriminalizing possession of illicit drugs for personal use (henceforth, simple possession) as part of their responses to the ongoing drug toxicity/overdose crisis. In this context, we sought to examine an early implementation case of a de facto depenalization policy of simple possession offences in Vancouver, Canada, that was enacted in 2006. Specifically, we characterized experiences of people who use drugs (PWUD) whose drugs were discretionally seized by police without arrest. METHODS: Data were derived from three prospective cohorts of community-recruited PWUD in Vancouver over 16 months in 2019-2021. We conducted multivariable generalized estimating equations analyses to determine the prevalence of and factors associated with drug seizure. Sub-analyses used data collected in 2009-2012 and examined the trends over time. RESULTS: Among 995 participants who were interviewed in 2019-2021, 63 (6.3%) had their drugs seized by police at least once in the past 6 months. In multivariable analyses, factors significantly associated with drug seizure included: homelessness (adjusted odds ratio [AOR]: 1.98; 95% confidence interval [CI] 1.09-3.61), working in the unregulated drug market (AOR: 4.93; 95% CI 2.87-8.49), and naloxone administration (AOR: 2.15; 95% CI 1.23-3.76). In 2009-2012, 67.8% reported having obtained new drugs immediately after having their drugs seized by police. Odds of drug seizure were not significantly different between the two time periods (2019-2021 vs. 2009-2012) (AOR: 0.93; 95% CI: 0.64-1.35). CONCLUSIONS: Despite the depenalization policy, the Vancouver Police Department has continued to seize illicit drugs from PWUD, even in cases where no arrest occurred. This policing practice may create health and safety risks for PWUD as it forces PWUD to increase the engagement with the unregulated illicit drug market. Our findings support calls for abolishing this often-undocumented discretionary policing practice that may exacerbate ongoing health inequities and interfere with peer-based overdose prevention efforts.

The Spatial-Temporal Pattern of Policing Following a Drug Policy Reform: Triangulating Self-Reported Arrests With Official Crime Statistics.

BACKGROUND: In 2009, Mexico enacted a drug policy reform (Narcomenudeo) designed to divert persons possessing small amounts of illicit drugs to treatment rather than incarceration. To assess reform impact, this study examines the spatial-temporal trends of drug-related policing in Tijuana, Mexico post-enactment. METHOD: Location of self-reported arrests (N = 1,160) among a prospective, community-recruited cohort of people who inject drugs (PWID) in Tijuana (N = 552) was mapped across city neighborhoods. Official police reports detailing drug-related arrests was triangulated with PWID self-reported arrests. Exploratory spatial data analysis examined the distribution of arrests and spatial association between both datasets across three successive years, 2011-2013. RESULTS: In 2011, over half of PWID reported being detained but not officially charged with a criminal offense; in 2013, 90% of arrests led to criminal charges. Official drug-related arrests increased by 67.8% (p <.01) from 2011 to 2013 despite overall arrest rates remaining stable throughout Tijuana. For each successive year, we identified a high degree of spatial association between the location of self-reported and official arrests (p <.05). CONCLUSION: Two independent data sources suggest that intensity of drug law enforcement had risen in Tijuana despite the promulgation of a public health-oriented drug policy reform. The highest concentrations of arrests were in areas traditionally characterized by higher rates of drug crime. High correlation between self-reported and official arrest data underscores opportunities for future research on the role of policing as a structural determinant of public health.

[Unsupervised data mining for prescription and medication regularity for treatment of cervical vertigo].

Vertebral artery type cervical spondylosis is a common type of cervical spondylosis, also known as cervical vertigo. In recent years, with the increase of people's life pace and the number of office staff, the incidence rate has been rising year by year, with a trend of younger age. Because traditional Chinese medicine has unique advantages in treating cervical vertigo, it is necessary to study the regularity of the Chinese medicine for cervical vertigo. But at present, the research is mainly based on the statistics for frequency and proportion of herbs. In addition, in the process of diagnosis and treatment of Chinese medicine, personal experience also caused differences in prescription compatibility and drug dosage, which makes difficult guarantee for the safety and effectiveness of drug treatment. So, this paper is based on literatures about the traditional Chinese medicine in treatment of cervical vertigo in the past 5 years, by using association rules algorithm, complex system entropy clustering and other non supervised data mining methods. Analysis was made for the use of various drugs in the frequency, the association rules, the core drug combination and the new prescriptions. The traditional Chinese medicine inheritance support system(TCMISS) was utilized to analyze 154 drugs from the 101 prescriptions, determine the use frequency of drugs, analyze the characteristics and the compatibility of core drugs, and dig out 14 core drug combinations and 7 new prescription combinations. The prescription and medication regularities illustrates the drugs for treatment of cervical vertigo, including those for flating liver and suppressing yang, invigorating the circulation of blood to remove blood stasis, reducing water and permeating dampness, increasing qi and activating blood, and nourishing the liver and kidney mainly. Treatment rules are nourishing liver and kidney, invigorating the circulation of blood stasis Tongqiao, reducing phlegm and dampness, flating liver and suppressing yan, dredging collaterals, supplementing qi and nourishing blood. This study aims to summarize frequently used single herbs for vertebral artery type cervical spondylosis, combinations of frequently used herbs and dosage of frequently used herbs with significant efficacy, define the current prescription and medication regularities for treating cervical vertigo and give guidances for clinical mediation.

National and regional trends in seizures of shrooms (psilocybin) in the United States, 2017-2022.

BACKGROUND: Psilocybin, the principle psychoactive component in "shrooms", is regaining acceptance in therapeutic settings, leading to media coverage of medical benefits associated with use. Possession is also becoming increasingly decriminalized throughout the United States. There is a lack of data on prevalence of shroom use, but trends in law enforcement seizure data can provide one indicator of shroom availability in US communities. We determined whether seizures of shrooms have shifted between 2017 and 2022. METHODS: This study examined national and regional trends in counts and total weight of shroom seizures reported to High Intensity Drug Trafficking Areas in the US between 2017 and 2022 (N=4526). RESULTS: There were 402 seizures in 2017 compared to 1396 in 2022 with the plurality occurring in the Midwest (36.0%), followed by the West (33.5%). Between 2017 Quarter 1 (Q1) and 2022 Quarter 4 (Q4), the number of seizures increased by 368.9% (AQPC=7.0; 95 CI: 5.9-8.1) and there were significant increases in all four regions. In terms of weight, 226.0kg was seized in 2017 vs. 844.0kg in 2022, and the greatest total weight in seizures was in the West (1864.2kg, 42.6%), followed by the South (1831.9kg, 41.8%). Between 2017 Q1 and 2022 Q4, the total weight seized in the US increased by 2749.7% (AQPC=6.2, 95% CI: 0.3-12.4) and there were significant increases in all four regions. CONCLUSIONS: Seizures of shrooms have increased, suggesting that availability may be escalating; thus, increases in prevention efforts and harm reduction education are warranted.

National Drug Laws, Policies, and Programs in India: A Narrative Review.

Background: Drug use is a major public health issue in India. Significant changes in the approach toward drug use have happened in the last few decades. Despite this, no systematic attempt has been made to document the same in the scientific literature. This narrative review attempts to discuss the major drug laws, policies, and national programs of the Government of India (GoI). Methods: A thorough search was conducted to look for policies, programs, acts, and notifications related to substance use/drug use on various websites of different ministries of the GoI. Acts, programs, and policies addressing substance use were identified. Results: Various drug laws, programs, and acts from the GoI provide a multipronged approach to curbing the procurement of drug use along with its prevention and cure. The Ministry of Social Justice and Empowerment (MoSJE) is the nodal ministry for drug demand reduction. The enactment of the Narcotic Drugs and Psychotropic Substances (NDPS) Act 1985 and Policy 2012 and the implementation of India's Drug De-Addiction Program (DDAP) are important landmarks in this journey. Conclusion: The GoI initiatives for reducing the mental health burden in this country in general and substance use disorders (SUDs), in particular, are immense. The acts/statutes/laws/notifications are all interlinked. Stakeholders in mental health, public health, and policy-making need to upgrade themselves with the relevant statutes to curb the menace of drug use.

Distinguishing personal use of drugs from drug supply: Approaches and challenges.

The ability to fairly and justly distinguish between drug possession for personal use and drug possession for supply is a central feature of drug laws across the globe. Whether such distinctions pertain to decriminalisation of simple possession, or to the penalties associated with drug offences, such differentiation remains a core problem for policymakers. In this commentary, taking 91 different jurisdictions into consideration, we identify five different approaches to distinguishing personal use from supply: four of these involved quantification of an amount of drug (whether in weight or number of doses). The other approach relied on case-by-case judgement. Drawing upon survey data of drug use from nine countries, we provide an example of how the quantity bears little resemblance to drug use patterns, and does not take heterogeneity of drug use into account. While the non-quantified approach can lead to discriminatory and racialised policing, all of the quantification approaches also pose problems, largely concerned with arbitrary amounts. There appears to be no perfect way to differentiate possession for personal use from intentions to supply. This commentary opens up a number of important policy-relevant research questions given this central feature of drug policy design.

What is substance use about? Assumptions in New York's drug policies and the perceptions of African Americans who are low-income and using drugs.

The current article uses intersectionality and standpoint theories to examine the social impact of solely relying on Eurocentric worldviews when developing drug policies that affect low-income African American communities. It is argued that low-income African Americans share a unique cultural and historical background that must be taken into account in the development and implementation of policies and interventions that effect this population. Analysis of longitudinal qualitative data will compare the assumptions informing New York's Rockefeller Drug Laws with the worldviews of drug using and low-income African Americans in New York City, New York, while examining the impact of these policies in participants' lived experiences.

Effects of a voter initiative on disparities in punishment severity for drug offenses across California counties.

BACKGROUND: The jurisdiction where an offense is prosecuted significantly affects the severity of punishment for drug possession, creating geographic disparities in exposure to a social determinant of health. In California, felony conviction rates after drug possession arrests have historically varied enormously between counties. California Proposition 47 (Prop-47), passed in 2014, reduced drug possession offenses previously classified as felonies or wobblers (offenses for which prosecutors have discretion to file felony or misdemeanor charges) to misdemeanors. This study examines whether geographic variation in felony convictions after drug possession arrests was reduced, and whether effects were offset by changes in felony convictions for other offenses not addressed by Prop-47. METHODS: Arrests made after the implementation of Prop-47 were propensity score matched to similar arrests prior to Prop-47 to account for compositional changes in arrests. This approach compares the outcomes of individuals likely to be arrested with or without the reclassification of drug offenses. We used mixed models to estimate the change in county variance in the probability of felony conviction. RESULTS: The probability of a felony conviction among those arrested for Prop-47 drug offenses declined by 14 percentage points (95% CI: -0.16, -0.12), from 0.20 (95% CI: 0.18, 0.23) to 0.06 (95% CI: 0.06, 0.07). Counties with higher felony conviction probabilities pre-Prop-47 declined most, reducing cross-county variance. For those arrested for drug offenses unaffected by Prop-47, the probability of felony conviction declined by 7 percentage points (95% CI: -0.08, -0.05), from 0.34 (95% CI: 0.31, 0.37) to 0.27 (0.25, 0.29). Declines in both groups were driven by fewer felony convictions for Prop-47 drug offenses, with no increases in felony convictions for concurrent offenses. CONCLUSION: Reducing offense classifications for drug possession reduced previously large differences in the probability of felony convictions for people arrested for drug offenses in different counties.

"It's about bloody time": Perceptions of people who use drugs regarding drug law reform.

BACKGROUND: In Australia and elsewhere, the impacts of drug prohibition have sparked a critical dialogue about the state of current drug laws. While a range of 'experts' have offered their opinion and participation in these deliberations, the voices of the affected community have largely been excluded. This study aimed to gather the opinions and preferences of people who use drugs about the current or alternative models of drug laws, in addition to how they think drug laws could be changed Author Conflict of Interest Declaration. METHODS: In March 2018, four focus groups (n = 37) were conducted with people who were in receipt of social welfare services in Sydney, Australia, where participants were encouraged to share their views about the current drug laws, drug law reform options, and important messages to politicians. Several themes were identified through a thematic analysis. RESULTS: Models of drug law reform were often understood and expressed in language and constructs different to those commonly used by researchers. Opinions were diverse and there was no consensus on a preferred model, although discussions flowed around decriminalisation, legalisation, and a medical/prescription model; the latter being the preferred approach. Participants shared pessimistic views of the drug laws ever changing, and argued that public opinion would need to adjust for reform to succeed. Furthermore, they argued that the views of the affected community are vital to any drug law reform campaign. CONCLUSIONS: Participants affinity towards a medical/prescription approach to drug regulation was an unexpected finding. This study serves as an important example of the opinions and experiential knowledge of the affected community and this knowledge could be solicited alongside other forms of 'expertise' in drug law reform campaigns.

When People You Love Are The Unintended Consequences Of Opioid Policy.

After the release of federal guidelines to curb opioid misuse, a patient is unable to obtain effective pain treatment and dies from complications.

Assessing the concordance between illicit drug laws on the books and drug law enforcement: Comparison of three states on the continuum from "decriminalised" to "punitive".

BACKGROUND: Variations in drug laws, as well as variations in enforcement practice, exist across jurisdictions. This study explored the feasibility of categorising drug laws "on the books" in terms of their punitiveness, and the extent of their concordance with "laws in practice" in a cross-national comparison. METHODS: "Law on the books", classified with respect to both cannabis and other drug offences in the Czech Republic, NSW (AU) and Florida (USA) were analysed in order to establish an ordinal relationship between the three states. Indicators to assess the "laws in practice" covered both police (arrests) and court (sentencing) activity between 2002 and 2013. Parametric and non-parametric tests of equality of means, tests of stationarity and correlation analysis were used to examine the concordance between the ordinal categorisation of "laws on the books" and "laws in practice", as well as trends over time. RESULTS: The Czech Republic had the most lenient drug laws; Florida had the most punitive and NSW was in-between. Examining the indicators of "laws in practice", we found that the population adjusted number of individuals sentenced to prison ranked across the three states was concordant with categorisation of "laws on the books", but the average sentence length and percentage of court cases sentenced to prison were not. Also, the de jure decriminalisation of drug possession in the Czech Republic yielded a far greater share of administrative offenses than the de facto decriminalisation of cannabis use / possession in NSW. Finally, the mean value of most "laws in practice" indicators changed significantly over time although the "laws on the books" didn't change. CONCLUSIONS: While some indicators of "laws in practice" were concordant with the ordinal categorisation of drug laws, several indicators of "laws in practice" appeared to operate independently from the drug laws as stated. This has significant implications for drug policy analysis and means that research should not assume they are interchangeable and should consider each separately when designing research.

The Dangerous Drugs Act Amendment in Jamaica: Reviewing goals, implementation, and challenges.

BACKGROUND: After decades of internal discussion, the Government of Jamaica recently amended its laws to create a regulated and licensed cannabis industry for medical and scientific purposes. The new law also decriminalizes personal possession and use of cannabis; allows cannabis to be used by individuals for religious, medical, scientific and therapeutic purposes; and permits home cultivation of up to five plants. METHODS: We first describe the statutory changes under the Dangerous Drugs (Amendment) Act of 2015 and compare it with other jurisdictions. We provide an analytical framework for understanding how the DDA Amendment affects key populations and achieves its stated goals, drawing on publicly available information and unstructured interviews with non-governmental stakeholders in Jamaica. RESULTS: The Amendment's primary goals are to deliver economic impact and reduce criminal justice costs. A relaxed policy of enforcement toward possession and use seems to have occurred even before the law's passage; after the law's passage, enforcement remains limited. To access medical cannabis under the DDA residents must receive authorization from a certified health professional in Jamaica; tourists may self-declare their medical need; and Rastafarians may grow and exchange non-commercially for religious purposes. CONCLUSION: Internally, many see "ganja" as an industry sorely needed to drive economic growth in Jamaica. Indeed, the potential impacts could be large, especially if Jamaica draws additional tourism or creates a viable export industry. A growing cannabis-related tourism industry seems more realistic. We maintain that policymakers and observers should proceed in an orderly fashion, continuing to identify and resolve remaining uncertainties, initiate new types of data collection, and make decisions based on realistic assessments of potentials for economic impact.

"No meio do fogo cruzado": reflexões sobre os impactos da violência armada na Atenção Primária em Saúde no município do Rio de Janeiro / "In the middle of the crossfire": considerations about the armed violence impacts in Primary Health Care in the city of Rio de Janeiro

Resumo O artigo aborda os impactos da violência armada, a partir da Atenção Primária em Saúde, em um bairro do município do Rio de Janeiro, Brasil. Trata-se de estudo qualitativo exploratório desenvolvido em dois serviços com o objetivo de identificar os principais tipos de violência, seus impactos e as estratégias utilizadas para enfrentamento do fenômeno. A produção de informações incluiu coleta de dados nos registros dos serviços, realização de entrevistas semi-estruturadas, grupos focais e seminário de devolutiva. A violência armada, dentre todas as expressões de violência, foi identificada como uma das maiores preocupações de profissionais de saúde e usuários dos serviços, em função de sua intensa ocorrência e gravidade de suas consequências sob a saúde. Destaca-se seu impacto nas estratégias de enfrentamento à violência e a dificuldade em visibilizar o fenômeno. Considera-se que esse tipo de violência, predominante nos territórios negros da cidade, é legitimada pelo racismo estrutural, sendo a política pública de segurança - baseada no ideário de guerra às drogas e no enfrentamento bélico com grupos armados que atuam no comércio varejista de drogas ilícitas - expressões do racismo de estado e da necropolítica.

Abstract The paper addresses the impacts of armed violence, based on Primary Health Care, in a neighborhood in the city of Rio de Janeiro, Brazil. This is a qualitative exploratory study developed in two services aiming to identify the main types of violence, their impacts and the strategies used to cope with the phenomenon. The production of information included data collection in the service records, conducting semi-structured interviews, focus groups and feedback seminar. Armed violence, among all expressions of violence, was identified as one of the major concerns of healthcare professionals and users of services, due to its intense occurrence and the severity of its consequences on health. Its impact on strategies to cope with the violence and the difficulty in making the phenomenon visible are highlighted. It is considered that this type of violence, prevalent in the black territories of the city, is legitimized by structural racism, being the public security policy - based on the ideal of war on drugs and on the military confrontation with armed groups that operate in the retail trade of illicit drugs - expressions of state racism and necropolitics.