Blueprint Short Version

EXECUTIVE SUMMARY In order to reduce drug-related harm in Los Angeles, there is a need to take specific action in a number of key areas. Persons who are injection drug users (IDU’s) are particularly vulnerable to a number of health risks, most especially HIV/AIDS and Hepatitis C. They are also a large portion of persons incarcerated in California jails and prisons and due their enfranchised state face a number of barriers accessing mental health and social services. While Needle Exchange Programs (NEP’s) provide key services for IDU’s, there are too few of them in the Los Angeles area and their work is often highly misunderstood. There is a need to conduct a wide-spread media and education program to enlighten the public. There is also a need to conduct culturally appropriate education programs to reach IDU’s across a broad range of communities. California jails and prisons need to update their protocols on Hepatitis C testing and treatment. Mental health and social services need to review the protocol of providing only abstinencebased services and the RFA’s related to the release of funds provided by SB767 should be immediately distributed. In addition, there must be a greater awareness of overdose-related issues – in particular, the general public requires education on the principle that drug users’ lives are worth saving. HARM REDUCTION: A FRAMEWORK FOR IDU HEALTH Harm reduction is a set of practical strategies that reduce negative consequences of drug use, incorporating a spectrum of strategies from safer use, to managed use to abstinence. Harm reduction strategies meet drug users "where they're at," addressing conditions of use along with the use itself. Because harm reduction demands that interventions and policies designed to serve drug users reflect specific individual and community needs, there is no universal definition of or formula for implementing harm reduction. Harm reduction accepts for better and for worse that licit and illicit drug use is part of our world and chooses to work to minimize its harmful effects rather than simply ignore or condemn them. It understands drug use as a complex, multi-faceted phenomenon that encompasses a continuum of behaviors from severe abuse to total abstinence, and acknowledges that some ways of using drugs are clearly safer than others. It also establishes quality of individual and community life and well-being--not necessarily cessation of all drug use as the criteria for successful interventions and policies. Harm reduction philosophy calls for the non-judgmental, non-coercive provision of services and resources to people who use drugs and the communities in which they live in order to assist them in reducing attendant harm and ensures that drug users and those with a history of drug use routinely have a real voice in the creation of programs and policies designed to serve them. It is a philosophy that affirms drugs users themselves as the primary agents of reducing the harms of their drug use, and seeks to empower users to share information and support each other in strategies which meet their actual conditions of use. Finally, it recognizes that the realities of poverty, class, racism, social isolation, past trauma, sex-based discrimination and other social inequalities affect both people's vulnerability to and capacity for effectively dealing with drug-related harm but does not attempt to minimize or ignore the real and tragic harm associated with licit and illicit drug use. THE NEED FOR HARM REDUCTION IN LOS ANGELES Persons who are injection drug users (IDU’s) continue to face a high number of health risks – Hepatitis, HIV, STD’s, Tuberculosis and death from overdose. As of 2005, injection drug use was the second leading 1 | Page Blueprint for Harm Reduction Coalition Ilanna S Mandel, 2008

cause for HIV transmission and the leading cause of Hepatitis infection in California.1 There is also a particularly strong link between injection drug use and women and people of color. Among adult/adolescent women in California, injection drug use-related risk factors account for 37% of cumulative AIDS cases. Forty-six percent of AIDS cases among African American women and 55% of AIDS cases among Native American women are associated with injection drug use, compared to 40% of AIDS cases among White women. HIV/AIDS LA is disproportionately affected by the HIV/AIDS epidemic.” Los Angeles County, with 45,241 cumulative reported AIDS cases has the second highest number of AIDS cases in the nation, exceeded only by the City of New York. Furthermore, the City of Los Angeles accounts for 25,696, or 56%, of all AIDS cases ever reported in the County, despite the fact that it accounts for only 40% of the County population”2. According to a 2006 report published by AIDS Project LA, persons who are injection drug users are the second highest group of persons contracting HIV/AIDS in LA at 7%, with a cumulative number of 3,463 persons. There is a great need to prevent or at least reduce the prevalence the HIV/AIDS among IDU’s. BARRIERS Persons who are IDU’s are often disenfranchised, socially isolated and poor. Society’s continued negativity towards drug use creates a strong stigma on the use of drugs. The spread of HIV/AIDS among IDU’s needs to be addressed among a large group of culturally diverse communities and individuals who are often difficult to reach. HEPATITIS C Injection drug use is the highest risk factor for contracting the Hepatitis C virus. Nationally, their rates of infection vary between 72% and 89%3. It is imperative that injection drug users understand the connection between sharing drug paraphernalia and the risk of becoming infected with Hepatitis C. A March 2006 report by a group known as The HCV Advocate www.hcvadvocate.org reported that persons who are injection drug users are the persons who are most at risk for contracting HCV. However, one of the greatest areas of risk for IDU’s is the fact that they often face incarceration rather than treatment. “Hepatitis C (HCV) in prisons is a public health crisis tied to current drug policy’s emphasis on the mass incarceration of drug users”4. A 2005 report5 on Hepatitis C infection in California prisons stated that “… HCV infection is pervasive among the California prison population, including prisoners who are nonIDUs and women with high-risk sexual behavior. These results should promote consideration of routine HCV antibody screening and behavioral interventions among incarcerated men and women”. The report also states that the risk of HCV infection rises with the number of years a person is incarcerated (p. 181). 1

California Department of Health Services, Office of AIDS, Fact Sheet 2005.

2

HIV and AIDS in Los Angeles: 21st Century Challenges and Approaches, A Report to the Mayor and City Council of Los Angeles Prepared by the Mayor’s AIDS Leadership Council, December 2003. 3 See “Chronic Viral Hepatitis in the United States” at: http://www.hepnet.com/hepc/aasld00/terrault.html 4 “Hepatitis C In Prisons: Evolving Toward Decency Through Adequate Medical Care And Public Health Reform”, By Andrew Brunsden. 5 See: “Hepatitis C Virus Infection among Prisoners in the California State Correctional System” at: http://www.journals.uchicago.edu/CID/journal/issues/v41n2/35610/35610.web.pdf

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It goes on to state that HCV is likely to be the most prevalent bloodborne infection in American prisons and surpassing HIV/AIDS as the most significant health risk (p. 183). BARRIERS One of the greatest barriers to the diagnosis and treatment of Hepatitis C among injection drug users is that people who have contracted the virus are often unaware of this fact until many years after they become infected. Persons can go for years without displaying any symptoms. Many injection drug users do not have health insurance and even if they know they are positive for the virus, they may not know how to access treatment. Persons who are co-infected with HIV also have a much better chance of receiving comprehensive services as the treatments and services for HIV/AIDS are far more advanced and more widely available. INCARCERATION ISSUES Many inmates enter jail or prison and are unaware they are positive for Hepatitis C. As there is no testing in correctional institutions, many inmates are actually spreading or contracting Hepatitis C without even realizing it. Many inmates who are IDU’s enter prison and may not be HIV or Hepatitis C positive, but a high percentage are when they leave. The statistics on HIV/AIDS in the nation’s prisons were last published by the Bureau of Justice Statistics in 2002. According to this report, at the time, California had the fifth highest rate of prison inmates who were HIV positive in the nation. At that time, 1, 181 prison inmates were identified as HIV positive. BARRIERS Inmates are not allowed access to clean syringes because using drugs is illegal. This remains the case even though it is widely recognized that inmates do somehow manage to obtain drugs. This leads to a dangerous situation whereby inmates share syringes. It also leads to the further spread of HIV/AIDS and Hepatitis C and further endangers the health of IDU’s6. The power to enable change is in the hands of the Department of Corrections and the Sheriff’s Office. NEEDLE EXCHANGE PROGRAMS Scientific research has demonstrated that syringe exchange programs (NEPs) are effective in reducing blood-borne disease transmission and do not increase drug use or crime rates. In 2007, NEP’s sponsored by the City of Los Angeles removed nearly 1.4 million used, potentially lethal syringes from the streets. The NEP’s serve app. 12,00 persons per year. The City spends about $42 per client per year to run its syringe exchange program, but one syringe-infected AIDS patient would require upwards of $25,200 per year in public health expenditures7.

6

“Focusing HCV care on prison populations is a public health strategy that draws not only from humanitarian arguments regarding prisoners’ individual rights to medical treatment, but that also appeals to instrumental utilitarian reasoning that help for prison inmates means improvement to community health generally”; Ibid. 7

See: www.lacityaids.org, “Facts About Syringe Exchange Programs In Los Angeles”

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BARRIERS There is a great deal of misunderstanding about what NEP’s do, how they function and a lack of knowledge about the broad range of services they provide. They continue to operate almost as an “underground” project rather than as an integral part of public health which is what they deserve to be. If there were fewer misperceptions about them, they would likely attract more IDU’s and provide services to an even broader number of people. SOLUTION: The HIV Planning and Prevention Committee has the ability to assist the NEP’s in raising their profile and help educate the community at large about what they do and its importance to public health. They can also work together with the NEP’s to advocate for long term funding which is essential to the expansion of their services. The power to enact these changes is with the HIV Prevention and Planning Committee, the LA County Board of Supervisors, the Department of Health and the Needle Exchange Programs in LA. ACCESS TO MENTAL HEALTH AND SOCIAL SERVICES IDU’s typically experience numerous barriers to accessing services. Many live in extreme poverty and are often homeless as well. They often lack the information on which services can be most helpful and how to access them. BARRIERS Many services are based on the principle of abstinence as opposed to a harm reduction philosophy. In addition, many services have not trained their staff to work with persons who are injection drug users and thus the knowledge and experience to work with them respectfully and appropriately is missing. SOLUTION: Mental health and social services must review their protocols for providing treatment to persons who are injection drug users. The primary focus here should be to remove the barrier that persons must cease all drug use before they can enter treatment. The power to enact change is with the Department of Social Services, Department of Alcohol and Drug Programs – Division of Treatment Services, CARE – California Access to Recovery Effort OVERDOSE PREVENTION It is a fact that deaths from drug overdose are entirely preventable. People continue to die unnecessarily from drug overdose. In March 2006, a summit on OD prevention identified that deaths in California from an overdose are up 73% since 1990. In LA County, deaths from drug overdose are a leading cause of premature deaths. The primary issue at this time is the need to make the applications available in order for community based organizations to begin distributing Naloxone. This money was made available when the Governor signed Bill SB767 but the applications are still being held up. BARRIERS 4 | Page Blueprint for Harm Reduction Coalition Ilanna S Mandel, 2008

The harm reduction philosophy has not yet been embraced as a ‘mainstream’ principle or philosophy and most drug and alcohol (or substance abuse) programs continue to follow an abstinence based philosophy and 12 step model. The notion of persons who are drug users as persons worth saving is not a concept that has reached the public consciousness. SOLUTION: Community groups (OD Prevention Task Force, Harm Reduction Collaborative, Drug Policy Alliance) must pressure the Department of Health must release the RFA’s to allow CBO’s to apply for and receive funds from the $100,000 allocated for Naloxone distribution. The power to move this funding into the next stage is with the Department of Health and the County Board of Supervisors. There is also a great need to generate greater awareness among the public at large that the lives of drug users are worth savings. The Department of Health could work with the County Board of Supervisors and the OD Prevention Task Force to create a public awareness campaign about the importance of health services for everyone.

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