Vermont tries a novel harm reduction approach: No more criminal penalties for buprenorphine possession
By: Kenneth A. Feder, PhD
As states consider investing dollars in evidence based interventions (Principle 2), like expanding access to methadone and buprenorphine, The Principles also encourage states to conduct a policy review. In many jurisdictions, state and local policies may block adoption of programs that work or hinder their effectiveness. Localities may not even be aware that some of these restrictive policies are in place as some of them may have been in existence for decades. Removing policies that promote punitive approaches to solving the opioid crisis may also be a method to ensure equity (Principle 4).
As part of its effort to address the ongoing drug overdose crisis, since 2021, Vermont has adopted a novel harm reduction law: eliminating all adult criminal penalties for possession of 224 mg or less of buprenorphine. Research on the first two years of this law by the Johns Hopkins Research and Evaluation arm of the Bloomberg Overdose Prevention Initiative suggests this new policy is a promising approach to reduce unnecessary criminal justice contact. It also holds potential for further positive downstream health benefits, but probably only if coupled with public health outreach.
Most people with opioid use disorder in the United States do not receive recommended treatment with medications like buprenorphine and methadone. There are many reasons for this treatment shortfall, including: stigma against the use of medications for substance use treatment, burdensome regulations that limit the number of providers who can prescribe and dispense medication, financial and other insurance barriers that limit patient access to these medications, and underutilization in licensed treatment programs and correction centers.
Whatever the reasons, this treatment shortfall likely contributes to a robust secondary market for buprenorphine, which is among the medications most frequently diverted from people without a prescription to people with a prescription. Indeed, past studies have shown most people who use buprenorphine that is not prescribed to them do so principally to prevent opioid withdrawal symptoms while avoiding more dangerous drugs, and that most would prefer to have their own prescription. Others show most adults taking buprenorphine as treatment for opioid use disorder had previously used buprenorphine obtained illicitly, suggesting use of non-prescribed buprenorphine may be a precursor to treatment. For all these reasons, the architects of buprenorphine decriminalization in Vermont argued decriminalization “corrects the error of criminalizing a person struggling with opioid addiction for possessing an effective means to treat it.”
Vermont is the first state in the country to eliminate criminal penalties for buprenorphine possession, so we wanted to understand the early impact of this law. To do so, we conducted surveys with 474 Vermont residents who had recently used opioid drugs and were recruited from a variety of service and community settings.
In our survey, we found that about three-quarters of respondents to our survey had taken buprenorphine that was not prescribed to them at least once in their lives. Participants described to us how they used non-prescribed buprenorphine to prevent the symptoms of withdrawal when they could not access formal treatment or experienced gaps in their care. For example, participants took non-prescribed buprenorphine after leaving inpatient programs, hospitals, or jails and discovering their appointments to obtain a buprenorphine prescription had been suddenly canceled.
Perhaps most important, participants also stated that taking buprenorphine that was not prescribed to them had a mostly positive impact on their lives: helping participants alleviate withdrawal, avoid overdose-causing drugs like fentanyl and heroin, hold down jobs, and improve the relationships with friends and family that opioid abuse had worsened.
Finally, there was also evidence that, before criminal penalties were eliminated in 2021, respondents to our survey had faced legal punishment related to their buprenorphine possession. One in five survey respondents had been arrested at least once while in possession of buprenorphine. One in ten had been punished for violating the terms of their parole or probation because of buprenorphine possession. Both punishments were more common among respondents to the survey who were not white.
In addition to our survey of people who use drugs, we also surveyed 117 Vermont clinicians who had prescribed buprenorphine in the past year. More than nine in ten supported eliminating criminal penalties for buprenorphine possession and almost none said they had changed their prescribing practices in response to the law.
Taken together, our research suggests that permanently eliminating penalties for buprenorphine possession could help reduce unnecessary and racially disparate criminal justice involvement for people who use drugs, and possibly facilitate a harm reduction strategy that people who use drugs in Vermont say has helped them avoid fentanyl. We found no evidence of adverse consequences of the law.
However, for buprenorphine decriminalization to achieve its full public health potential, it is important key constituents are actually aware of the law. Our study found that most people who use drugs were unaware that buprenorphine was decriminalized. Both in Vermont, and in other states that may be considering a similar approach, we hope public health agencies will partner with organizations that interact with and serve people who use drugs – including harm reduction programs, health care providers, social service agencies, and law enforcement officers – to disseminate information about the new law.
Dr. Feder is an Assistant Scientist in the Department of Mental Health at Johns Hopkins Bloomberg School of Public Health. This post is adapted from an article that previously appeared in VT Digger.