Pew Charitable Trusts

It’s been about 40 years since the majority of moms stayed home, and married dads in the 21st century spend twice as much time caring for their children as they did back then.

Yet when parents divorce or separate, custody arrangements are more likely to reflect life as it was in 1975, with the mother as the primary caretaker and the father working to help support a child he seldom sees.

As fathers become more vocal about what they see as inequities in custody cases — and as more research shows how important it is for fathers to be present in their children’s lives — states are considering changing their custody laws.

Five states — Colorado, Florida, Maryland, Massachusetts and Missouri — are looking at proposals that would require judges to presume that it’s best for children to split their time as evenly as possible between their two parents. Utah enacted a similar law last year.

State laws have historically directed judges to determine custody based on what is in a child’s best interest, looking at factors such as which arrangement would disturb his or her life the least and be safest. The proposals would instead require judges to presume it’s best that both parents be awarded a substantial amount of parenting time — often at least a third of the time — and, if they don’t award substantial time to both parents, to explain why it wouldn’t be in the child’s best interest to do so.

Fathers’ rights groups, such as the National Parents Organization, are pushing the proposals, arguing that they will give fathers a better chance at a fair ruling and pointing to new research that shows how joint custody may be better than sole custody for children’s health.

But only a fraction of custody cases actually are up to a judge to decide — in Washington state, for example, nine in 10 cases that go to court are settled — and the cases that judges do hear are more likely to be ones in which parents can’t communicate or cooperate to make decisions. In those high-conflict situations, some researchers have warned that joint custody may be harmful to a child’s well-being.

Laws that encourage shared parenting may sound “seductive” to state lawmakers, but they often force families into bad situations, said Maritza Karmely, a professor at Suffolk University Law School in Boston. Bar associations, judges and lawyers have come out against some of the proposals.

“A presumption is a pretty radical step,” Karmely said. “That assumes that shared parenting works for most families, and I think that is an enormous assumption.”

But Ned Holstein, founder of the National Parents Organization, said none of the proposals forces judges to do anything. They would still be able to use discretion and decide what’s in the best interest of the child.

Changing Families

There haven’t been sweeping changes to state laws on custody arrangements since 1970, when the Uniform Marriage and Divorce Act set the “best interest” standard.

But the dynamics of American families have changed significantly since then. The share of children under 18 living with both parents fell, from 85.2 percent in 1970 to 69.2 percent in 2015. And more fathers are living away from their children, up from 11 percent in 1960 to 27 percent in 2010, a recent Pew study found; the shift is likely due to more children being born to unmarried parents. (Pew also funds Stateline.) At the same time, the amount of time married fathers spend caring for their children has more than doubled, from 2.5 hours a week in 1965 to 7.3 hours in 2010, according to Pew findings.

And that may be a good thing. Research shows that children who spend more time with their fathers are more likely to succeed academically and less likely to be delinquent or have substance abuse issues.

They will also grow up to be healthier mentally and physically, said William Fabricius, an associate professor of developmental psychology at Arizona State University who has been studying fathers and divorce since 2000.

In a yet to be published 10-year study funded by the National Institutes of Health, he found that children who felt they mattered to their fathers were less likely to later have mental health problems such as depression or anxiety.

“There are attributes and benefits that both parents bring to the child,” said Missouri state Rep. Kathryn Swan, a Republican who has sponsored shared parenting bills the last two years.

The Missouri Bar last year opposed provisions in Swan’s bill that put limits on judges’ discretion when deciding child support arrangements in cases where equal parenting time is granted; and that required judicial education on shared parenting. This year’s bill no longer includes those provisions, but the group has not yet taken a position on it.

Some fathers, such as Troy Matson of Jacksonville, Florida, push for shared custody, only to get worn down by the time, the cost and the acrimony of their court battles. Matson’s daughter was just a few weeks old when he and his wife started divorce proceedings. He asked to have her half the time. After contentious court hearings, the couple settled; he now sees his 4-year-old daughter 30 percent of the time.

Matson, who now chairs Florida’s chapter of the National Parents Organization, helped push a Florida bill that would require judges to presume that approximately equal time sharing is best. The bill, which passed the Legislature last week, would also require judges, when they rule differently, to show that equal time sharing is not the best solution. If Republican Gov. Rick Scott signs the bill, Florida would have one of the strongest shared parenting laws in the nation.

“I grew up without my father,” Matson said. “When I was a kid, I told myself if I’m ever blessed with children, I would do everything I could to be as involved in their lives as possible.”

Case-By-Case

Along with Utah, the National Parents Organization lists seven states as having laws most supportive of shared parenting — Alaska, Arizona, Idaho, Iowa, Louisiana, Minnesota and South Dakota.

While many family law and child psychology specialists agree that shared parenting is best in situations in which both parents are interested, involved and capable, they have concerns about other situations.

Domestic violence awareness groups have opposed some of the proposals, arguing that a victim shouldn’t have to prove that it’s not in a child’s best interest to live half the time with an abusive ex-partner. And specialists in the field have come to different conclusions about whether separating infants from their mother would be best for the infant’s well-being.

Most agree that each case is unique. “It is hard to find fault with examining each case and each child individually, when deciding what works best for their family and them,” said Peter Salem, executive director of the Association of Family and Conciliation Courts, a national trade association for family law professionals.

Fathers’ rights groups are often the ones pushing for the laws, but it’s not about the parents, said Robert Langlois, a former family court judge in Massachusetts who is now a lawyer there. “It’s about the kids, and what is in their best interest, not in their parent’s best interest,” he said.

When approaching a case, a judge looks at what the situation has been, if that should change, and why, Langlois said. Other factors judges look at include how old the children are, where they go to school, and where the parents live.

A bill proposed in Massachusetts would change the law to encourage shared parenting without requiring judges to presume equal time is best. Still, the change would require judges to provide reasoning when deciding a parent should not have significant time with a child.

“If you’re going to separate a child from one of his or her parents for most of their childhood, it’s only fair to say why,” said Holstein of the National Parents Organization, who lives in the state.

Outcomes

Proponents of shared parenting argue that current laws treat fathers unfairly. But gender bias in custody cases may be more perception than reality.

While mothers are custodial parents 82.5 percent of the time, it may just be because fathers aren’t asking for that job. A study in Massachusetts found that fathers who actively sought primary or joint custody obtained it more than 70 percent of the time.

In at least one state, specialists say recent changes to custody laws have made a difference. The Arizona Legislature passed a policy statement in 2011 in support of shared parenting and, in 2012, changed custody law to mirror the statement. This changed the culture of the court system, at least in Maricopa County, according to both Fabricius of the state university and Annette Burns, a lawyer there who specializes in family law.

The perceptions of parents have changed, too, Burns said. Now, both parents know they are likely to get a significant amount of time with their child.

Read original article – March 15, 2016
More Time for Dads? States Weigh Changes to Custody Laws

CAPRON, Va. — Walter Melvin Atkinson is a bit vague about how long he has been in the assisted living portion of the Deerfield Correctional Center and how long he has left on his sentence. He claims to not even remember the crime — pedophilia — that landed him here.

At 92, “Speedy,” as he is called ironically by fellow prisoners and guards, is frail enough to require a wheelchair to get around, and his inmate caregivers rushed to his side to grab from his shaking hand a coffee mug that seemed destined to spill all over his cot. A huge, bright orange star has been sewn on to the white blanket that covers the cot — an idea the unit manager, Kathy Walker, dreamed up to help Atkinson spot his own bed among the six rows of beds in the spotless unit.

Atkinson is representative of an ever deepening trend in state corrections systems, and an ever growing problem, too. According to Human Rights Watch, from 2007 to 2010, the increase in the elderly population, 65 and up, being sentenced to state and federal prison outpaced the increase in the total population by 94 to 1.

Nearly every state is seeing that upward tick in elderly state prisoners. In Virginia, for example, 822 state prisoners were 50 and over (corrections officials usually consider old age for prisoners to begin at 50 or 55) in 1990, about 4.5 percent of all inmates. By 2014, that number had grown to 7,202, or 20 percent of all inmates.

For state prisons, the consequence of that aging is money, more and more of it every year. Health care for aging prisoners costs far more than it does for younger ones, just as it does outside prison walls. Corrections departments across the country report that health care for older prisoners costs between four and eight times what it does for younger prisoners.

In 2013, nearly half the $58 million that Virginia spent on off-site prisoner health care went to the care of older prisoners, according to Trey Fuller, acting health services director in the state Department of Corrections. “Over time,” Fuller said, “we’ll need more and more money for that population because they will need more drugs, more specialist visits, more nursing hours, more everything.”

Many states have taken steps to reduce their prison populations by releasing nonviolent inmates or by diverting some offenders to community programs before sending them to prison. But corrections officials say those reforms alone will do little to decrease the population of older prisoners who are serving mandatory sentences or have committed violent crimes.

Several states have adopted programs such as early release for geriatric patients or “compassionate release” for the dying. But advocates for prisoners say the programs are often so cumbersome and restrictive that few older prisoners are able to take advantage of them.

Accommodating the Elderly

The graying of the U.S. prison population reflects the rising median age of Americans since 1970. But that broader trend doesn’t fully explain the sharp increase in older prisoners. For that, corrections officials point to two factors. One is a steady increase in the rate of older adults entering prison. The second, and more potent, factor is changes enacted in the get-tough-on-criminals 1990s that resulted in longer prison sentences.

“It was the push for mandatory sentences and three strikes you’re out,” said Linda Redford, who studies health issues related to aging prisoners and is the director of aging and geriatrics programs at the University of Kansas Medical Center. “So we’re seeing people who came to prison in their 30s and 40s and 50s in their 50s and 60s and 70s today.”

Virginia’s problem was compounded in 1995 when the General Assembly eliminated parole for any offender entering its prisons from then on.

To accommodate the growing number of older prisoners, most states have been adding or retrofitting facilities.

“Prisons weren’t designed for patients who are getting older,” said Owen Murray, chief physician for Correctional Managed Care, University of Texas Medical Branch, which overseas health care for most of that state’s prisons. “They were designed for people 18 to 55” and who were able to walk, Murray said. One in five Texas prisoners is older than 50.

States have had to install ramps and shower handles and make other physical modifications. Many prisons have had to create assisted living centers with full-time nursing staffs, as Deerfield has. In addition, at least 75 U.S. prisons, including Deerfield, provide hospice services for dying prisoners, according to the Vera Institute of Justice, a nonprofit that advocates for criminal justice reform.

In prison, services for the elderly are often stretched thin. The 57-bed assisted living unit at Deerfield is always full; there’s a waiting list to get in. The nearby 18-bed infirmary provides hospice services, but its beds are also needed for nonterminal acute care patients, such as inmates who have just had surgery and need special care while they recover.

As a result, Deerfield has tightened restrictions on which elderly patients can go to assisted living or hospice care. For example, it used to be that prisoners would be considered eligible for assisted living if they could not perform any one basic task such as bathing, dressing or walking, said Susan Wright, nurse manager of assisted living at Deerfield. Now, they must be unable to do two or three or them.

Worse Health

People sent to prison are generally less healthy than the general population, having abused drugs and alcohol or neglected their health for many years. Prisoners have much higher ratesof cardiac disease, high blood pressure, hepatitis C, diabetes and other chronic diseases than the general population. That is why corrections officials consider that old age comes much sooner for prisoners.

“The norm in prisons is to use 55-and-older as the metric associated with older prisoners primarily because the consensus is that our population is 10 years ahead, clinically,” of people on the outside, Murray said.

Prison is a particularly treacherous place to get old. Getting to a top bunk is difficult for many aging prisoners, as is climbing stairs. Hearing loss, dementia and general frailty can make it difficult to comprehend or obey rules. And being infirm in an institution full of young predators can make older prisoners vulnerable. “If there’s an old lion or gazelle,” said Phillip Wheatley, one of the prisoner caregivers who tends to Atkinson, “the young ones are going to take advantage.”

When aging prisoners do reach the end of their sentences, corrections officials often have a hard time placing them, even if they look beyond their state. “Private nursing homes don’t want to take elderly offenders who were murderers or sex offenders,” said Virginia’s Fuller. He is currently keeping a wheelchair-bound former prisoner in a hotel, where a nurse visits daily, “because we couldn’t find a home for him,” he said.

Atkinson seems likely to present a similar problem. He was sentenced to 27 years in 1990 for pedophilia, paroled in 2005, and taken back into custody in 2008 for entering a school in violation of his parole. Thanks to credit he earned for good behavior, Atkinson could be released later this year, but his criminal record will likely make it difficult to find an outside assisted living facility or nursing home willing to take him.

Varying Approaches

Dealing with an aging prison population isn’t so complicated, said Texas’ Murray. “Either you figure out ways to get them out of the prison system and on to Medicare, or you choose to take a firm line that those patients have to do their time and you need to fund those facilities and care services that are necessary.”

So far most states have opted for the second approach, which means continuing to add services for an elderly population, including a special dementia unit for prisoners in New York state and housing units just for the elderly at Ohio’s Hocking Correctional Facility.

In 2012, Connecticut contracted with a private nursing home in Rocky Hill to care for elderly and infirm inmates granted parole. But even there, the state is locked in a battle with the federal government over whether the facility qualifies for Medicare or Medicaid reimbursement.

Several states have a mechanism they could use to shed some older prisoners. Louisiana, Ohio and Virginia have “geriatric conditional release” laws that make old age grounds for consideration for an early release. In Virginia, prisoners are automatically considered for release if they are 60 and have served 13 years or if they are 65 and have served five years.

Last year, 505 eligible prisoners were considered for geriatric release, according to Karen Brown, chairwoman of the state’s Parole Board. Only 3 percent were granted release, she said, adding that many of those who were denied had committed violent crimes.

Decisions about aging prisoners and the risk they would pose to the outside world should better reflect their medical conditions, said Brie Williams, an associate professor of geriatric medicine at the University of California, San Francisco, who studies aging in prison. “Health care professionals and criminal justice administrators should be coming together … to evaluate people for release,” she said. “We need to develop different approaches to their parole that are informed by their medical state.”

Virginia, like most other states, also permits the governor to grant clemency to prisoners certified by doctors to have less than 90 days left to live because of terminal illness. Last year,two Virginia prisoners received such clemencies.

Studies have found that older ex-offenders are less likely than younger ones to commit additional crimes after their release. But politicians and the public don’t seem willing to release former murderers, rapists and sex offenders, even though they are decades removed from their crimes and physically incapable of repeating them, said Liz Gaynes, president of the Osborne Association, a nonprofit that works on behalf of ex-offenders.

“It comes down to they did a bad thing and they should be punished,” she said. “Endlessly.”

States will be forced to pay more and more for that attitude, Gaynes said. “What to do about this is going to be the challenge for prisons in the next 20 years.”

Read original article – March 17, 2016
Elderly Inmates Burden State Prisons

They’re poor, more likely to be sexually abused, end up in foster care, drop out of school, become homeless. They’re often the prey of traffickers.

American Indian and Native Alaskan girls are a small fraction of the population, but they are over-represented in the juvenile justice system, whether they are living on or off the reservation.

Native American girls have the highest rates of incarceration of any ethnic group. They are nearly five times more likely than white girls to be confined to a juvenile detention facility, according to the U.S. Office of Juvenile Justice and Delinquency Prevention.

There are programs on tribal lands that work with Native girls who have been caught up in the system, using federal funds. But American Indian girls often find themselves without state or local social service programs tailored to their cultural backgrounds and experiences, which are distinct from other girls living in or on the edge of poverty.

“As Indian people, our greatest hope is our children. And our kids are really at risk,” said Carla Fredericks, director of the American Indian Law Clinic at the University of Colorado Law School in Boulder. “The only way we can help these girls is if we do it cooperatively, with the states, federal government and within our own communities.”

A rare example of that kind of collaboration is the Minnesota Indian Women’s Resource Center in Minneapolis. In Minnesota, American Indian girls have 18 times the incarceration rates of white girls. They are often disconnected from family who themselves may be battling addiction and mental health problems. Native girls who are extremely poor and lack stable housing often get involved with gangs and drug and sex trafficking, said Patina Park, the center’s executive director.

The center’s programming seeks to combat those trends using a combination of state, federal and private funds to create culturally specific programs, including case management, support groups, housing and mental health services for American Indian women and girls and their families. The center also has youth-specific programming for girls ages 11 to 21, many of whom have been sexually assaulted, involved in sex trafficking or are at high risk.

The idea is to keep girls in school, off drugs and alcohol and focused on a future with a career, rather than turning to crime to make ends meet. The program, which is run with the help of the Fond du Lac Band of Lake Superior Chippewa, provides Native girls who’ve been cut off from their cultural heritage with a sense of community and purpose, Park said. Less than a quarter of American Indians live on tribal lands.

Since 1977, the White Buffalo Calf Woman Society on the Rosebud Reservation has been working with American Indian women and girls to address issues of sexual assault and domestic violence. Many Native juvenile girls are also victims of sexual abuse and family violence. But there are no such programs at the state and local level. Targeted programming coupled with more federal and state funding could make a huge difference in other cities and states with significant American Indian populations, Park said. “You could really change the disparity within the Native community fairly quickly and dramatically.”

Few Programs for Girls

Juvenile justice advocates who work with delinquent girls say they face challenges that boys don’t, and there aren’t enough programs that meet their needs. For example, girls are more than four times as likely as boys to have been physically or sexually abused, according to the National Women’s Law Center.

Delinquent girls are more likely than other girls to end up in the adult criminal justice system and are more likely to be dependent on social safety nets, according to Nona Jones of thePACE Center for Girls in Florida. They also are more likely to have children who end up in child protective services and the juvenile justice system. Girls who spend time in juvenile detention facilities are nearly five times more likely to die before age 29.

American Indian girls who collide with the juvenile justice system are particularly vulnerable, say legal advocates such as Terri Yellowhammer, an attorney with the Indian Child Welfare Law Center in Minneapolis who represents Native youth. Native girls are 40 percent more likely than white girls to be referred to a juvenile court for delinquency; 50 percent more likely to be detained; and 20 percent more likely to be adjudicated, according to the Office of Juvenile Justice. They are also more likely to face harsher sentences for the same offenses, said Joshua Rovner of The Sentencing Project.

American Indian girls in Wyoming have the highest rates of commitment to juvenile facilities (1,302 per 100,000), followed by Iowa (860), South Dakota (656), Oregon (568) and North Dakota (535).

In general, juvenile offender boys greatly outnumber girls, and that is true for Native boys, as well. But the disparities between American Indian boys and white boys aren’t quite as great.

Many Native girls are geographically segregated and isolated, particularly if they’re living in urban areas away from their communities, advocates say. They’re more likely than white girls to be arrested for crimes that are only crimes because they are underage, so-called status offenses, such as drinking alcohol or running away from home. They’re also more likely to be arrested for family disputes, Yellowhammer said.

And once they are arrested, they get tangled in a web of state, local and tribal jurisdictions, said Erik Stegman, executive director of the Native American Youth Center at the Aspen Institute in Washington, D.C. Law enforcement in Indian Country is uneven and exceedingly complicated, which hurts Native girls who run into trouble, he said.

According to the Tribal Court Clearinghouse, a database project of the Tribal Law and Policy Institute, tribal communities don’t have adequate funding to train law enforcement personnel and fund social service programs to combat juvenile delinquency.

Another complicating factor: Some tribes prosecute crimes and others do not, depending on tribal resources and capacity. As a result, Native girls often are prosecuted in the federal system, which doesn’t have a juvenile division. And if girls are arrested in the state system, the state usually doesn’t have to notify their tribes.

“We don’t have a system that’s nuanced enough to fit Native girls,” Yellowhammer said.

Stegman of the Native American Youth Center agreed: “When a young girl is traumatized, what she needs is a variety of interventions at the community level. Unfortunately, children end up bearing the brunt of a very haphazard criminal justice system.”

A Legacy of Trauma

American Indians today face a legacy of inherited trauma, legal experts say. Beginning in the second half of the 19th century, Indian children were shipped off to boarding schools far from their tribal communities and culture, in accordance with federal assimilation policies. Families were fractured.

The Indian Child Welfare Act of 1978 sought to right that situation, making it a priority to find homes for displaced American Indian children within their own tribe. In theory, the law is supposed to provide rights for families and tribes. But in practice, the law creates an extra layer of bureaucracy; with no one agency taking ownership of a child’s case, leaving children to languish in the system, said Sue Mangold, executive director of the Juvenile Law Center.

Children that grew up without parents become parents who don’t know how to raise children, juvenile advocates say.

In 2013, the American Indian and Alaska Native population was 5.2 million, about 2 percent of the U.S. population. The median age was 31, compared to 38 in the general population. And 29 percent of American Indians-Alaska Natives were poor, a higher rate than any other ethnic group.

American Indians ages 16 to 24 have the highest dropout rates in the country, more than twice the national rate, 15 to 7 percent. One in five Native girls become mothers before age 20.

American Indian women have the highest rates of rape in the country, more than twice that of other ethnic groups. The vast majority of the perpetrators are non-Indian men, according toAmnesty International.

All these factors create a climate where juvenile delinquency can flourish, child advocates say.

Violent crime rates among Native Americans are twice that of the country as a whole, and tribal communities experience high rates of domestic violence, child abuse and neglect, alcohol addiction and gang involvement, according to the Tribal Court Clearinghouse. Native children are over- represented in child protective services. And while the violent juvenile crime rate for U.S. teens has declined, it has increased for teens in tribal communities, according to the Clearinghouse.

A 2013 report by the Indian Law and Order Commission found that American Indian children suffer post-traumatic stress disorder at the same rates of veterans returning from combat duty in Afghanistan and Iraq.

“It’s like these kids are living in a war zone,” said Sarah Deer, co-director of the Indian Law Program at the Mitchell Hamline School of Law in St. Paul, Minnesota, and a 2014 winner of a MacArthur Fellowship, also known as a genius grant.

‘Blood Memory’

Working with Native girls who’ve ended up in the juvenile justice system in Minnesota has its challenges. Particularly girls who were lured into prostitution and peddling drugs by older men whom they believe to be their boyfriends and with whom they have developed intense, unhealthy emotional connections. Breaking those bonds is difficult, Park said.

Poverty shapes their lives in ways that makes it hard for them to see a way out, she said. To make ends meet, they often rely on “working long weekends,” heading out to the oil fields along the North Dakota border, “man camps” where men have cash and an appetite for paid sex. It’s tough trying to break them out of the cycle. “Sex is a tool for surviving,” she said.

But at the Indian Women’s Resource Center, they try. Young girls receive mental health services and education counseling. And elder women teach them about their cultural roots, learning about Indian medicine, ceremony, praying the traditional way and honoring their ancestors.

As Park sees it, these girls connect with the “blood memory” of their ancient heritage and heal from their past traumas.

“It gives them hope,” Park said. “It helps them see they can be more than their parents, who are struggling with drug addiction and homelessness. It’s hard to see yourself as more when you don’t see that around you.”

Read original article – March 04, 2016
American Indian Girls Often Fall Through the Cracks

A bustling economy. Record-low unemployment. A ballooning heroin problem.

That’s how Mayor Svante Myrick describes Ithaca, New York, where he hopes to open the nation’s first safe injection facility — a place where heroin users could shoot their illegal drugs under medical supervision and without fear of arrest.

His proposal, part of a plan to address drug abuse in the 31,000-person college town in central New York, is not a novel idea. Safe injection sites, which also connect clients to treatment programs and offer emergency care to reverse overdoses, exist in 27 cities in other parts of the world. Some have been around for decades.

But no safe havens for injecting illegal drugs exist in the United States, which is experiencing an epidemic of opioid addiction and a rising tide of overdose deaths. Some lawmakers in California and Maryland want to change that and make legal what addiction specialists say is already going on at many clinics or needle-exchange programs across the country.

Proponents of the sites say they reduce the risk of dying from heroin use because addicts are drawn out from alleys, public restrooms and run-down buildings and into supervised settings where they can be quickly treated for overdose symptoms. Once there, access to clean needles reduces an addict’s exposure to infections, as well as diseases like hepatitis C and AIDS. And, supporters say, drug users are more likely to pursue addiction treatment once they develop trusting relationships with clinic staffers.

Other lawmakers, however, warn that supervised heroin shooting galleries run contrary to state and federal drug laws and would encourage illegal drug abuse.

In New York’s Tompkins County, a jurisdiction of just over 100,000 people that includes Ithaca, at least 14 deaths were drug-related in 2014, up from six in 2010. An addiction treatment center there reported that more than a quarter of its admissions in 2014 were for opioids, second only to alcohol.

“We’re not the capital of heroin in America or even in New York state,” Myrick said. “But we’re losing people.”

Studies of safe injection sites, largely in Canada and Australia, have found that they help reduce overdoses and don’t increase drug use or trafficking in the communities where they’re located.

Sites in the United States could violate the federal Controlled Substances Act, which prohibits possession of drugs such as heroin or cocaine or operating a place where people use them. But Congress could change the law or the U.S. Justice Department could make exceptions for the sites, said Leo Beletsky, a law and health sciences professor at Northeastern University.

Most state laws mirror the federal act and would also need to be amended to allow injection sites to operate legally, he said. Though if states begin legalizing them, the federal government could choose not to prosecute people who run and use them — just as the Justice Department has decided not to enforce federal laws for possessing, processing or selling marijuana in states that have legalized it.

“Do you try to solve these [legal] problems first? Or do you proceed with what you know is needed, the innovation that is needed in, really, a time of national crisis?” Beletsky said.

Advocates would rather establish the injection sites through legislative action, but creating the sites through executive orders issued by mayors or county executives could create quicker access to care, he said.

Even with the approval of the district attorney in Tompkins County, Gwen Wilkinson, Myrick is not interested in opening a site in Ithaca without permission from the New York Legislature and Democratic Gov. Andrew Cuomo.

“Our hope is once this is put in place, we’ll be ready for the next epidemic,” he said.

Legislative Effort

Maryland state Del. Dan Morhaim, an emergency room physician, wants to create safe injection sites in his state, saying supervised injection would help break the cycle of drug use by exposing addicts to counseling and making them less prone to drawing others into the habit of drug use.

Morhaim’s proposal received little opposition during a recent legislative hearing, and officials at the University of Maryland School of Medicine said they would “seriously consider” establishing a pilot program to evaluate the concept if the legislation passes.

“If all our polices were doing great, we’d be talking about how addiction rates are down and streets are safer,” said Morhaim, a Democrat.

Opioid deaths in Maryland increased by 76 percent between 2010 and 2014, to nearly 900. And according to the American Society of Addiction Medicine, drug overdoses are the leading cause of accidental death in the United States. In 2014, heroin contributed to about 10,600 deaths nationwide.

But proposals like Morhaim’s and Myrick’s are not without opposition.

Steve Schuh, a Republican county executive from Anne Arundel County, Maryland, called Morhaim’s bill one of the most “irresponsible” that the General Assembly has ever considered.

Providing those in the throes of addiction a place and the tools to use heroin is “careless, reckless, and unconscionable” and tantamount to making the state an accomplice to murder, he said in a letter to the chairman of the health committee, which held a hearing on the bill this week.

New York state Assemblyman Edward Ra, a Republican, opposes Myrick’s Ithaca plan because he said it would stand in the way of cooperation between local, state and federal law enforcement. The state should instead focus on treating more heroin addicts, Ra said.

“I object to the idea that this drug can be used safely. It’s a drug that kills people.”

Matt Curtis, policy and program director at Voices of Community Activists & Leaders (Vocal), a nonprofit that offers counseling, hepatitis screening, syringe exchanges and other services to drug users in New York City, said it would be easier to establish injection sites locally than at the state level. A campaign for injection sites in New York City already has the support of at least one city councilman.

“We’re not quite there,” Curtis said. “We are still in the stage of getting people familiar with the idea.”

Already Happening

Although no sanctioned injection sites exist, advocates for them say informal sites exist at needle exchanges around the country where addicts can already get clean syringes and substance abuse counseling.

Organizations that operate exchange programs say they do not condone drug use and injection is still prohibited on-site. But because people use bathrooms at the exchanges to shoot up after receiving new needles, the organizations have taken steps to make those spaces safer.

In the past, staff at some exchanges tried to discourage drug use by installing black lights so users couldn’t find their veins and timing how long each person spent in the bathroom. But these practices led to overdoses as drug users rushed to take large amounts of heroin before being detected by staff members.

“That is terrible public health practice and you’re basically saying, ‘Go out and use it in the street,’ ” said Curtis of Vocal, which runs a facility in Brooklyn.

Now, many exchanges have installed syringe disposal boxes, put intercoms in the bathrooms and installed emergency locks so staff members can get into a bathroom to help if someone becomes unresponsive.

Vocal made similar renovations to its facility in 2014, not because very many people were using drugs in the bathroom, Curtis said, but because the changes make the site safer for clients and staff.

Reducing Harm

Supervised injection sites are part of a “harm reduction strategy” to reduce the negative effects of drug abuse through public health initiatives. The harm reduction theory stresses the rights of drug users and acknowledges that abstaining from drug use is not the only measure of improving the quality of life of an addict.

The Boston Health Care for the Homeless Program is applying this theory in its new Supportive Place for Observation and Treatment Center. The center prohibits drug use and won’t offer needle exchange. But users can come there after they inject to wait out their high under medical supervision and there is an exchange close by, said Jessie Gaeta, the group’s chief medical officer.

As many as a handful of clients overdose at the main Health Care for the Homeless site each week and Gaeta said she thinks the rate of overdoses in the Boston area is increasing because people are taking heroin that is combined with other drugs like benzodiazepines, which also have a sedative effect.

“Dead people don’t recover,” Gaeta said. “Our hope is to make it less dangerous for the people who are currently using, who are not seeking treatment or not able to access treatment. I like to think we’re enabling people to live.”

Read original story -March 11, 2016
Are State-Sanctioned Heroin Shooting Galleries a Good Idea?

BALTIMORE — A crowd quickly gathers here on one of West Baltimore’s many drug-infested street corners. But it isn’t heroin they’re seeking. It’s a heroin antidote known as naloxone, or Narcan.

Two city health department workers are holding up slim salmon-colored boxes and explaining that the medication inside can be used to stop someone from dying of a heroin overdose. Most onlookers nod solemnly in recognition. They’ve heard about the drug. They want to know more.

Nationwide, more than 150,000 people received naloxone kits from community outreach programs like Baltimore’s between 1996 and 2014, and more than 26,000 overdoses were reversed using those kits, according to a recent survey funded by the U.S. Centers for Disease Control and Prevention.

In addition, police, emergency medical technicians and emergency room physicians have used the drug to save tens of thousands of lives. Baltimore police officers started carrying the kits last year.

But as the opioid epidemic seeps into nearly every small town and suburb across the country, state, local and federal officials are trying to make the life-saving prescription drug available everywhere, particularly at local pharmacies.

To accomplish that, New Mexico last week became the 29th state to adopt a law that allows doctors and other prescribers to write a naloxone prescription known as a standing order, enabling local pharmacists to distribute the overdose rescue drug to anyone who asks for it.

Maryland adopted a similar measure in October. The day after it took effect, Baltimore’s health commissioner, Dr. Leana Wen, wrote a standing order for the entire city, allowing anyone who completed a simple naloxone training — like the demonstration offered on the West Baltimore corner last week — to walk into a pharmacy, show a certificate of completion, and walk out with a kit.

“I like to say I became the prescriber-in-chief,” Wen said.

New Mexico’s new law updates a 15-year-old law that allowed lay people to administer naloxone. In addition to allowing standing orders, the new measure allows people without a medical license to distribute naloxone kits in their communities, a legal provision found only in Maryland and 12 other states. This exception allows jails, treatment centers, homeless shelters and others to hand out the drug. Even the local PTA could offer it.

“It needs to be in everyone’s first-aid kit and medicine cabinet,” Wen said.

A Nationwide Movement

Forty-two states have enacted laws to make naloxone available beyond hospitals. New Mexico, which has had one of the highest drug overdose rates in the country for more than two decades, was the first to act with its 2001 law.

After more than a decade, Massachusetts in 2012 became the second state to enact a law. Most other states adopted so-called rescue drug measures in 2014 and 2015 after the opioid epidemic began making headlines.

This year, “States are going back and expanding or tweaking their laws,” said Amber Widgery, who tracks these and other drug related laws at the National Conference of State Legislatures.

Thirty states also have adopted so-called good Samaritan measures, which give limited legal immunity to a bystander or friend who calls 911 to report an overdose. Those laws also need to be expanded, said Corey Davis, an attorney who tracks the laws for the Network for Public Health Law.

In Maryland, for example, the law only protects overdose bystanders from being arrested, charged or prosecuted for possession of a controlled substance or use of drug paraphernalia. It does not protect them against arrests for open warrants or probation and parole violations, which are common among heroin and opioid addicts. As a result, residents of West Baltimore or other communities where drug use is prevalent may be unwilling to call 911.

In addition to state and local actions, initiatives at the federal level are picking up. Last week, the U.S. Senate passed a comprehensive opioid addiction and overdose prevention bill that would expand the use of naloxone, and the U.S. Department of Health and Human Services announced additional funding for naloxone and other drug treatment services.

A ‘Miracle’ Drug

The majority of opioid overdose victims die from lack of oxygen one to three hours after they have taken a drug, leaving a substantial amount of time for someone to intervene and administer naloxone or call for help.

Naloxone, approved by the U.S. Food and Drug Administration in 1971 in injectable form and widely used as a nasal spray, is a relatively cheap generic drug that has been proven safe and effective at reversing the deadly lung suppression that can cause a fatal overdose. Once the drug is administered, most victims instantly begin breathing again; they also experience nausea and other withdrawal symptoms.

But until the late 1990s, naloxone was only used, intravenously, in hospital emergency departments and operating rooms. Even emergency medical personnel and other first responders did not use it initially.

In 1996, a community group in Chicago that provided clean needles and other assistance to drug addicts began handing out naloxone as a nasal spray as well. Later, similar pilot programs began cropping up in places like San Francisco and New York.

When people began coming back and reporting that they had saved a life with naloxone and wanted another kit, researchers took notice. Eventually, these and other programs handing out naloxone caught the attention of federal and state officials, said Daniel Raymond, policy director for the Harm Reduction Coalition, which advocates for the greater availability of naloxone and other health care services for drug addicts.

In 2006, Massachusetts began using naloxone in public health and social service centers. Along with New Mexico, it funded statewide distribution of the life-saving medication in communities with large numbers of known drug addicts.

But in other parts of the country, naloxone initiatives were limited and mainly local. Then in 2012, the FDA, along with the National Institutes of Health and the CDC, convened a meeting with state and local officials to discuss ways to expand availability of the drug nationwide. Initially, some objected to making naloxone widely available, arguing that it would simply enable more drug addicts to continue shooting up.

Now that more Americans are dying of heroin and prescription painkiller overdoses than from homicides — roughly 28,000 people in 2014 — that argument rarely comes up. Politicians from both parties vigorously support the use of naloxone. Along with increased access to treatment and safer opioid prescribing, expanding the use of naloxone is among the Obama administration’s top three weapons against the epidemic.

Baltimore’s commitment to naloxone began when the health commissioner, Wen, took office, in January 2015. Since then, the department has distributed nearly 6,000 kits to city residents. In addition, the department launched an online training site, dontdie.org, last month. Wen said she plans to work with local pharmacy chains to make it easier for people to walk in, get trained, and leave with naloxone.

More Work Needed

In February, the pharmacy chain Walgreens announced it had used state standing order authority to make naloxone available without a prescription across New York and would do the same in Indiana and Ohio. Pharmacy chain CVS made a similar commitment in Ohio.

But advocates for greater use of the overdose reversal drug worry that most local drugstores won’t stock the drug or supply it on demand. They also fear that pharmacists won’t allow people to use their insurance plans to pay for it.

According to Davis, the public health law researcher, insurance companies are on board with covering the drug. But, because people with naloxone prescriptions won’t be using the drug on themselves, many pharmacists appear to be worried they won’t get reimbursed for, essentially, a third-party prescription, the claims for which are traditionally rejected by insurance companies.

Baltimore has negotiated a $1 copay with the state Medicaid agency and private insurance companies have generally agreed to cover it, Wen said.

Even in Massachusetts, where standing orders have been allowed for years, not all pharmacies stock the medication and not all pharmacists know about it, according to Dr. Alexander Walley, medical director for the state health department.

“We have the legal pathways but not the implementation experience, yet, to make it as successful as policymakers had hoped,” he said. “We’re in the steep part of the learning curve right now.”

From their folding card table in West Baltimore last week, Daryl Mack and Darryl Burrell handed out 15 naloxone kits in less than a half-hour.

After witnessing friends, family members and strangers die on these streets from overdoses, most onlookers seemed eager to try to prevent at least one fatality.

Speaking one-by-one to each person who wanted a kit, Mack emptied the contents of a box onto the table and quickly demonstrated how to assemble and activate the tiny nasal atomizer used to squirt naloxone into an overdose victim’s nostrils.

You’re not going to harm someone who’s unconscious by giving them naloxone, he told them. And you can’t give them too much. But first, try to make sure they’re not just sleeping or passed out from alcohol, Mack said. Rub your knuckles up and down their chest bone to try to wake them up. If that doesn’t work, they need help, he said.

Maryland is the only state that requires anyone using naloxone to complete a brief training, Davis said. Several people who approached the table already knew the drill and were there to get refills. They also got a copy of Wen’s standing order so they could pick up additional kits at their local drugstore if needed.

One passerby heard the word “heroin” and waved the health workers away, saying, “I don’t have nothing to do with that stuff.” But when Mack explained that he could save someone’s life, the elderly man stopped and signed up.

Read original article – March 16, 2016
Building a Ground Army to Fight Heroin Deaths

This year, as Americans select the next president, the entire U.S. House of Representatives and a third of the Senate, as well as an array of state and local officials, many voters will cast ballots on a generation of electronic voting machines that is nearing extinction.

Most of the machines, adopted by local governments after “hanging chads” left the 2000 presidential election in the balance for weeks, are at least a decade old. And they create a perilous situation: an equipment breakdown on Election Day could mean long lines, potentially leaving some people unable to vote.

But replacing the old machines with newer models is costly. The latest computerized machines typically cost between $2,500 and $3,000 each, and election boards should budget for one machine per 250 to 300 registered voters, according to the National Conference of State Legislatures (NCSL).

That high cost is just one reason the computerized machines, which record ballots via a touch-screen, push-button or dial mechanism, have been falling out of favor with cash-strapped local governments. Some elections officials and lawmakers also worry the machines could be hacked and lead to voter fraud.

Some states are already turning to other approaches. This year Maryland voters will cast paper ballots that can be scanned by machines. Optical scanners that read paper ballots cost up to $5,000, but only one is needed per polling location, making them a cheaper approach than computerized voting machines. In Virginia, officials have ditched most of their voting machines in favor a similar system, and legislation before the General Assembly would get rid of all voting machines in the state by 2018.

In New Hampshire, a proposal would create a municipal grant program to support local governments that want to change their election procedures, and lawmakers in Ohio put a provision in the state budget to save money by eliminating certain special elections.

About 25 percent of voters will use electronic voting systems this year, said Pamela Smith, president of Verified Voting, a nonprofit focused on ballot accuracy. That’s down from 30 to 40 percent when the machines were more popular.

In most states, those machines are at least 10 years old, an age at which most reach the end of their life span, according to a report from the Brennan Center for Justice. Nearly every state is using machines that are no longer manufactured.

Jurisdictions have to “make sure they have good emergency provisions in place,” Smith said. “If you have a good paper ballot and scanner system in place as your voting system, even if your scanner breaks down, voters can still vote.”

Cost of Voting

State and local governments first began to buy computer voting machines in the early 2000s under the federal Help America Vote Act. Some states still have HAVA money on hand, but additional federal help is not expected and many governments have trouble paying for new election equipment — typically from a combination of state and local coffers.

Election funding often butts against the need to pay for more in-demand priorities like schools and roads, said Colorado Secretary of State Wayne Williams, a Republican.

“You can’t wait for it to break to fix it,” he said. “You can wait for a road to have issues to fix it, but if you wait to do that in an election, it’s too late.”

Across the country, officials in at least 31 states want to purchase new voting machines within five years, but at least 22 of them don’t know where the money will come from, according to the Brennan Center report.

The Center estimates the total national cost of replacing existing machines could exceed $1 billion. The country’s largest jurisdiction, Los Angeles County, has allocated $70 million to design and develop its own voting system for the 5 million registered voters who live there. County officials are pursuing a system that will allow voters to cast ballots on a touch-screen device that would issue a printed ballot that they would place in a ballot box to be counted.

But other county and local governments will have to get by with existing equipment because many states have cut their election budgets in recent years. In 2014, Virginia lawmakers stripped $28 million from the state budget that was intended to pay for new voting machines.

In Utah, Republican Rep. Brad Daw is pushing legislation that would replace the state’s aging computer-based machines. His proposal would set up a selection committee to recommend voting equipment and help counties pay for the machines if they choose to use the state-selected brand.

Daw, who is also a software engineer, said he’s never been a fan of the state’s computer voting machines — they require a lot of equipment and their operating systems are easy to hack, he said.

Opponents of the machines also say they create long lines as voters have a hard time figuring out how to use them; they are prone to crashes as the software ages; and they are vulnerable to attack. A 2014 analysis of Virginia’s computerized voting machines found that hackers could access the wireless networks the machines ran on to view or change votes.

A system by which voters mark paper ballots that are scanned by machine could be a better option, Daw said.

“Marking a piece of paper is pretty old school,” he said. “But marking a piece of paper and putting it through a scanner” is just as efficient.

As the computer models fade out, most jurisdictions are replacing them with the scanner systems, which are more affordable and were recommended by experts following the 2000 presidential election. But, the high-tech (for the time) computer systems were more attractive, Smith said, because “nobody wanted to be the next Florida.”

Voting by Mail

To save on election costs, a few states have turned to voting by mail.

Oregon, Washington and Colorado require that all elections be conducted by mailed ballots, though many others permit localities to conduct mail-in special elections. California, Hawaiiand Oklahoma are also considering mail-in systems.

In Oregon, the first state to adopt a mail-in process, in 2000, all eligible voters are mailed a ballot, which can be mailed back to the election board, completed in person at a county clerk’s office or placed in a public drop box. People with disabilities are able to vote on machines at a clerk’s office.

The ballots are examined by election board workers who verify voters’ signatures and then pass them through scanners that tabulate results.

Phil Keisling, Oregon’s former secretary of state who is credited with pioneering the vote-by-mail program, said it not only saves money — an estimated $3 million per election cycle in Oregon — by reducing the number of polling places and machines required to hold an election, but also increases turnout.

A 2015 analysis from The Pew Charitable Trusts shows more people are voting by mail. In 2012, 19 percent of U.S. ballots were cast by mail, up from 10 percent in 2000 (Pew also funds Stateline).

During the 2012 presidential election, 64.2 percent of voters cast ballots in Oregon, compared with a national voter turnout of 58.6 percent.

In the last four general elections, 40 percent of Oregon voters returned their ballots by mail and roughly 56 percent returned them via public drop boxes, said Jim Williams, elections director for the Oregon secretary of state. The remaining ballots were cast by walk-in voters.

Last year, San Mateo County, California, held its first mail-in special election, garnering a nearly 30 percent voter turnout, almost five percentage points higher than a similar electiontwo years earlier. Only 2.5 percent of ballots were cast at a precinct or voting center in the 2015 election, down from 24 percent in 2013.

While Oregon has had success as the first state to move to a mail-in system, few others are interested, Keisling said.

Some states are resistant to mail-in ballots simply because they buck tradition, said Wendy Underhill of NCSL.

“Cost is one consideration,” Underhill said. “But it is by no means the only consideration. [Mail-in voting] does change the feel of Election Day. That’s not a small consideration.”

Read original article – March 02, 2016
Aging Voting Machines Cost Local, State Governments