The drug treatment program in Baltimore, the Institutes for Behavior Resources, operated a DEA-licensed van and a backup van to dispense methadone to hundreds of patients for about 10 years, and then purchased new vans and used them for another 10 years before parking the vehicles and letting their licenses expire.
Two years ago, Behavior Resources leased one of those vans to another nonprofit program, the Behavioral Health Leadership Institute, which is using the vehicle to provide buprenorphine instead of methadone. Although the DEA also has authority over buprenorphine, it has not banned licensed prescribers of the medication from working out of a van.
Equipped with a bathroom and private counseling rooms, the van allows Behavioral Health Leadership to offer low-income residents drug screenings, addiction assessments, counseling and pre-paid prescriptions for buprenorphine.
Nowhere to Go
WILMINGTON, N.C. — Until the opioid epidemic began seeping into nearly every city and town in the country, the idea of a Main Street storefront offering free needles, alcohol wipes and small metal cookers for heroin users was unthinkable in a conservative Southern city like this one.
But these days, most of the roughly 100,000 residents of this historic port on the Cape Fear River are painfully aware that their community has a serious drug problem. Syringes carpet sections of public walkways, drug users congregate in vacant lots, and an increasing number of residents are attending the funerals of friends and family members who have died of an opioid overdose.
As a result, many police officers here fully support syringe exchanges, places where drug users can go to dispose of used needles, pick up fresh ones, get health exams, and maybe find out about treatment options. They say they’re willing to overlook the fact that possessing drug paraphernalia, including syringes, is an arrestable offense.
But even in North Carolina, where the state Sheriffs’ Association helped a grassroots harm reduction organization enact the most liberal syringe exchange law in the country in 2016, many cops still insist that giving free supplies to heroin users simply enables their drug use.
“Police officers are just like the rest of the public,” said Capt. Lars Paul of the Fayetteville Police Department. “Until I got educated on harm reduction, I questioned why we were giving drug users all kinds of free supplies too. It was just a matter of taking the time to talk to folks and learn about the public health benefits of syringe exchanges.”
Kendra Williams, a recovering addict who works part-time for the Wilmington syringe exchange, said some cops in the drug unit there still don’t take the law seriously. “They’ll take away ID cards proving they’re syringe exchange clients and tell them it doesn’t mean anything. If they want to arrest you, they’ll find a way.”
Last year, a poll in Ohio — among the nation’s hardest-hit states — found that half of adults in that state favor syringe exchange programs. Politicians are listening.
Nationwide, at least a dozen states legalized syringe exchanges in 2016 and 2017, said Daniel Raymond, policy director of the Harm Reduction Coalition, a New York-based national organization that advocates for syringe exchanges. And nearly all of the new laws were signed by Republican governors and approved by GOP-led legislatures, including in Ohio.
That’s not surprising, Raymond said. Many Republican leaders’ constituents — particularly middle-income white males — are among those who have suffered most in the opioid epidemic.
Even so, most of the lawmakers and governors who ultimately approved the laws resisted until they received endorsements from law enforcement groups, Raymond said. Otherwise, they would have risked appearing soft on crime.
A dozen states — Florida, Indiana, Kentucky, Louisiana, Montana, New Hampshire, North Carolina, North Dakota, Ohio, Tennessee, Utah and Virginia — enacted laws in 2016 and 2017 that protect the employees and clients of syringe exchanges from existing state drug paraphernalia laws that otherwise could be used to prosecute them for possessing a syringe, according to Raymond.
Five more Republican-led states, Alabama, Arizona, Georgia, Iowa and Missouri, are considering similar legislation this year, he said.
An Old Idea
Syringe exchanges, also known as needle exchanges, first came into being in the late 1980s in places such as New York City and San Francisco and in liberal states such as Massachusetts, Minnesota and Washington. Once it became clear that the HIV/AIDS epidemic was spreading through needle sharing among injection drug users, public health officials took up the cause.
But until recently, syringe exchanges were nonexistent in rural towns and cities in the rest of the country, except for informal underground efforts organized by advocates.
In North Carolina, syringe exchanges now are cropping up in office parks, pawn shops, church basements, fire stations, hotel parking lots and treatment centers throughout the state, and the state health department is tracking their progress. So far, 26 syringe exchanges have opened, and the coalition is working to open more.
“Until the law was enacted, people were afraid they’d be arrested if they came to pick up supplies,” said Robert Childs, director of the North Carolina Harm Reduction Coalition. “And we were afraid to advertise.”
North Carolina’s law made it simple for a syringe exchange to open its doors, he said. For underground groups already supplying drug users with sterile supplies, it simply meant registering with the state health department and providing a plan to ensure the privacy of clients. For new groups, it meant finding funding and a base of operations, even if it was a private vehicle in a parking lot.
A Rural Problem
Unlike the AIDS epidemic of the 1980s and previous drug epidemics, which were spawned and largely defeated in urban areas, this opioid epidemic is ensnaring people who live in far-flung small cities and rural communities. In addition to mounting overdose deaths, these rural communities are experiencing unprecedented surges in hepatitis C infections and increasing threats of HIV/AIDS outbreaks.
Despite nearly 200 people testing positive for HIV in Scott County in 2015, Indiana’s then-Gov. Mike Pence, a Republican, was reluctant to allow a syringe exchange, because of his moral opposition to drug use. But among those whom Pence sought for counsel, according to The New York Times, was the local sheriff, who told him: “I believe the only thing we can do … is to get clean needles out there.” Pence declared a public health emergency and allowed a syringe exchange to open to curb further infections.
That exchange has since closed because of lack of support.
Even so, Pence’s emergency declaration marked a turning point for other Republican governors, said Gary Tennis, president and CEO of the National Association of Model State Drug Laws, a research group supported by the federal government. It made it easier for conservative politicians to support syringe exchanges.
But if states want to attack their long-term drug problem, Tennis said, it will be essential to nurture grassroots coalitions like North Carolina’s and build political will, particularly with law enforcement. Without that local support, standing up and maintaining syringe exchanges in affected communities will be impossible, he said.
According to Paul LaKosky, executive director of the North American Syringe Exchange Network, which helps fledgling groups launch syringe exchanges, that’s already starting to happen in dozens of places, including Native American tribal lands and small rural communities across the country.
Nationwide, LaKosky said, the list of syringe exchanges, both official and unofficial, has grown by about 15 percent a year for the past three years, with the fastest growth in Kentucky, North Carolina and Ohio.
“We’re seeing the greatest growth in rural areas, where there’s been an historic lack of access to health services of any kind,” LaKosky said. “The opioid epidemic is shining a light on those places.”
West Virginia, which has by far the highest opioid overdose death rate in the country, has not yet enacted legislation to authorize syringe exchanges. But a proposed opioid response plan released by the state health department in January lists harm reduction, including syringe exchanges, as a top priority.
Even without statutory authorization, at least 10 West Virginia municipalities have started exchanges, including eight with affiliations to county health departments.
In Charleston, the state’s new director of the Office of Drug Control Policy, Dr. Michael Brumage, said the police department there fervently supports the city’s syringe exchange. But just a few miles outside of the city, he said, the attitude among police officers is very different.
Dr. Michael Kilkenny, who as Cabell-Huntington public health chief runs a syringe exchange an hour’s drive away in Huntington, said the lack of state authorization makes him nervous.
The city’s drug control director when the exchange opened in 2015, Jim Johnson, said he also worried whether the police department would continue to support it without a state law. “All you’d have to do was stick a policeman outside the office on Monday and you’d have to close the doors on Tuesday.”
In Philadelphia, which has also been hit hard by the epidemic, Scott Burris, director of Temple Law School’s Center for Public Health Law Research, said Kilkenny’s concerns are warranted. To be effective, he said, syringe exchange laws must affirm that distributing syringes is a legitimate public health function that should be funded with public money. At the same time, any new laws must remove syringes from the definition of illegal drug paraphernalia, so that anyone can possess one without fear of prosecution.
“Authorizing exchanges to distribute syringes still leaves drug users vulnerable to arrest, which means fewer will come,” he said.
DENVER — Long before tourists started converging here to sample freshly legalized marijuana in the form of gummy bears and chocolate brownies, thousands of Coloradans were cultivating the medicinal plants for their own consumption and to share with ailing friends.
“We think it can easily be done in a way that addresses concerns like Colorado’s large medical grows,” said Karen O’Keefe, the group’s director of state policy. “Since adults can brew their own beer in every state, we think people should be able to grow their own marijuana.”
A wave of new state fetal homicide laws recognizing a fetus "of any gestational age" as a person and potential crime victim has abortion rights advocates worried the statutes could undermine a woman's right to end her pregnancy.
This year, Alabama, Alaska, Oklahoma, South Carolina and West Virginia passed new fetal homicide statutes making it a separate offense to kill a fetus when a pregnant woman is murdered or assaulted. All five new laws apply to fetuses starting at conception.
Among the 37 states with laws making death of a fetus a separate crime, language giving legal status to a fetus at the earliest stages of pregnancy is proliferating. While often enacted in response to a high-profile crime such as the 2002 Modesto, Calif., murder of Laci Peterson and her unborn child, these laws are increasingly being drawn into the abortion debate.
States are using cookie-cutter language in fetal homicide laws, assigning legal rights to fetuses "at any gestational age," said Sondra Goldschein, state strategies director for the American Civil Liberties Union's Reproductive Freedom Project. A 2004 federal law -- the "Unborn Victims of Violence Act" -- takes the same approach.
Georgia and Nebraska amended existing laws to specify that a fetus of any gestational age is considered a person and a potential victim, according to the Guttmacher Institute, an abortion rights research group. The previous law in Georgia included only viable fetuses, and in Nebraska, no gestational age was specified.
Among states that are part of this trend, Arizona passed a feticide law defining a fetus at any stage of development as a potential crime victim in 2005, and similar statutes were enacted in Kentucky and Mississippi in 2004 and in Colorado and Texas in 2003.
While fetal homicide statutes have been on some state law books since the early 1970s, many did not stipulate when a fetus became a person and potential crime victim, leaving courts to decide whether the death of an early-term fetus constituted a separate crime in maternal murder cases.
Abortion rights advocates argue the new laws are part of a legal strategy to establish that life begins at conception. "It's the elevation of the status of the fetus that is going to erode the right to access abortion," Goldschein said.
Anti-abortion groups promote the laws, saying fetuses should be recognized as living human beings. But there is disagreement about whether the laws are part of a legal strategy to chip away at abortion rights.
"In as many areas as we can, we want to put on the books that the embryo is a person. That sets the stage for a jurist to acknowledge that human beings at any stage of development deserve protection -- even protection that would trump a woman's interest in terminating a pregnancy," Samuel B. Casey, Executive Director of the Christian Legal Society was quoted saying in a 2003 Los Angeles Times article.
But Denise Burke, vice president of the anti-abortion advocacy group Americans United for Life, said the "laws specifically exclude abortion from coverage. They have nothing to do with the woman's decision as to her pregnancy. These [laws] involve cases where women have chosen to have their children and to carry their children to term, and no one else has a right to end that pregnancy against their will."
The link between state fetal homicide laws and the abortion debate has been made in the past.
In a 1984 presidential election debate, Ronald Reagan cited the California feticide law -- passed in the early 1970s -- as support for regarding abortion as murder, asking: "Isn't it strange that that same woman could have taken the life of her unborn child and it was abortion, not murder, but if somebody else does it, that's murder?"
The new fetal homicide laws are among the most prevalent state legislation related to the abortion issue in recent years, according to Kathryn Prael of NARAL Pro-Choice America. In 2005, state lawmakers proposed more of these bills than bills directly restricting abortion, she said.
Though fetal homicide laws have faced legal challenges on the grounds they conflict with Roe v. Wade, the 1973 U.S. Supreme Court ruling legalizing abortion, none has been struck down.
The ACLU, NARAL and other abortion rights groups oppose laws that make fetal death a separate crime, but support stiffer penalties for those convicted of murdering or assaulting pregnant women. According to Goldschein, murder is the No. 1 cause of death in pregnant women.
"If lawmakers really wanted to stop violence against women, they could do other things like putting money into anti-domestic-violence programs and looking at why this is such a problem," she said. "It's no coincidence that the lawmakers introducing feticide bills are the same ones pushing anti-abortion bills," she added.
Still, those in favor of fetal homicide laws say tougher penalties are not enough.
"Most people who murder two people are going to get a longer prison term than those who have murdered one. It sends a strong message to the families, to society and to the offenders that there were two lives lost here," Burke said.
Several states have multiple feticide laws for manslaughter, first- and second-degree murder and recently states have passed laws protecting the fetus in vehicular murder while under the influence of drugs or alcohol.
In all, 37 states have one or more fetal homicide laws, with 24 states defining a fetus as a person and a separate homicide victim. In Maine and 12 other states, the laws apply stiffer punishments for murdering a pregnant woman, but do not make the death of the fetus a separate crime.
While most fetal homicide laws in the last three years have given legal rights to fetuses starting at conception, two states have taken the opposite approach.
Illinois Gov. Rod Blagojevich (D) signed a feticide law last year that specifically stated legal rights were not conferred on a fetus, and Maryland Gov. Robert Ehrlich (R) signed a law that made clear "fetal personhood" was not established. Both laws make the death of only viable fetuses a second homicide in maternal murder cases.