2020 Presidential Candidates: Policies for Addressing the Opioid Overdose Crisis.

This post is first in a series aimed at identifying and exploring some of the public health issues and policies under consideration by candidates in the 2020 Presidential Election.

The goal of this series is to provide a deeper look at the ways in which candidates may or may not be including a public health framework in their healthcare reform policies, and encourage candidates to thoughtfully and purposefully develop nuanced, evidence-based, impactful policies. We also hope to inform the public as they continue to evaluate each candidate’s efforts to articulate plans that address healthcare and public health challenges in the U.S. Our goal is not endorse a particular candidate or political party; rather, our goal, as always, is to research, analyze, inform, and equip people with the knowledge they need to be engaged and thoughtful members of their communities and this nation.

———————————————————————————————————————————————————

Each day, over 130 people die from opioid-related overdoses. This includes both prescription and illicit opioids. The National Institute on Drug Abuse attributes the opioid overdose crisis to unscrupulous pharmaceutical companies, who misled healthcare providers to believe opioid pain relievers were not addictive. Other researchers, while agreeing that increased drug supply was an important factor, argue that economic and social issues fueled the crisis, viewing the issue through the lens of a structural and social determinants of health framework.   

Public health experts and practitioners are increasingly pursuing support for and implementation of evidence-based harm reduction policies and programs to reduce harmful outcomes related to substance use disorders (SUD) and opioid use disorders (OUD). Our colleagues at the Health in Justice Action Lab (HIJAL) have identified a series of proven hard reduction programs. Below we offer a description for a few such programs and identify which of the 2020 Democratic Presidential Candidates support each program:

• Safe injection facilities

• Buprenorphine deregulation

• Increased access to SUD treatment in prisons and jails

• Decriminalization of opiates for personal use

Safe injection facilities

Safe injection facilities, also known as supervised consumption services (SCS), are legal facilities in which people can bring in and consume illicit drugs under the supervision of trained staff. The facilities provide clients with sterile injection supplies and a safe place to consume drugs, as staff members monitor for overdose and provide first aid as needed. Additionally, staff members are available to provide clients with referrals to drug treatment and other support programs. Although many studies have identified myriad public health benefits of safe injection sites, they remain controversial. Safe injection sites exist around the world, but due to legal issues (and specifically the Controlled Substance Act), not yet in the United States. However, that may be changing soon; a federal judge recently ruled that the Controlled Substance Act does not apply to Safehouse, a Philadelphia group seeking to open a safe injection facility

Candidates who have expressed support for safe injection facilities:

• Pete Buttigieg

• Bernie Sanders

• Elizabeth Warren

• Andrew Yang

Buprenorphine deregulation

Buprenorphine is an opioid partial agonist used in treating opioid use disorder (OUD). Under the Drug Addiction Treatment Act of 2000, prescribers must complete an approved training, attest to their referral capacity, and submit an application to SAMHSA in order to receive what is known as an “X-waiver.” As noted by Kevin Fiscella et al, “X-waivered prescribers face heightened scrutiny by federal and state law enforcement officials, including periodic audits that are intended to minimize diversion and misuse.” Fiscella articulates four reasons for deregulating buprenorphine:

“First, buprenorphine’s comparative safety undermines a critical rationale for regulation. Buprenorphine, regardless of prescribing intent, is safer than commonly prescribed full-opioid agonists.

Second, deregulation would improve access to buprenorphine during the opioid national emergency. Despite promotion and training initiatives by SAMHSA and legislation that has expanded patient limits and waivers to nurse practitioners and physician assistants, access to buprenorphine has not kept pace with the current epidemic, particularly in rural communities.

Third, buprenorphine regulation is premised on the faulty assumption that buprenorphine diversion is driven by a desire to “get high.” Yet, buprenorphine obtained illicitly is mostly used for self-medication to relieve withdrawal symptoms rather than for euphoria… This suggests that regulations constraining access to buprenorphine may paradoxically contribute to a market for illicit buprenorphine among those who seek treatment.

Lastly, deregulation could help integrate opioid disorder treatment into primary care. Regulations reinforce the stigma surrounding buprenorphine prescribers and patients who receive it while constraining access and discouraging patient engagement and retention in treatment.”

Candidates who have expressed support for buprenorphine deregulation:

• Michael Bloomberg

• Pete Buttigieg

• Amy Klobuchar

• Bernie Sanders

• Andrew Yang

Increased access to SUD treatment in prisons and jails

A federal report found that 58% of people in prison and 63% of people in jail suffer from drug use disorders (SUD) based on criteria from the Diagnostic and Statistical Manual of Mental Disorders. However, only 28% of people in prison who met this criteria and 22% of people in jail participated in any type of SUD treatment.

Candidates who have expressed support for increased access to SUD treatment in prisons and jails:

• Joe Biden

• Mike Bloomberg

• Pete Buttigieg

• Tulsi Gabbard

• Amy Klobuchar

• Bernie Sanders

• Elizabeth Warren

Decriminalization of opiates for personal use

Some advocates have proposed decriminalization as a measure to improve public health. The Drug Policy Alliance lists several benefits of decriminalization on their website:

 “Removing criminal penalties for drug possession and low-level sales would:

• Save money by reducing prison and especially jail costs and population size

• Free up law enforcement resources to be used in more appropriate ways

• Prioritize health and safety over punishment for people who use drugs

• Reduce the stigma associated with drug use so that problematic drug users are encouraged to come out of the shadows and seek treatment and other support

• Remove barriers to evidence-based harm reduction practices such as drug checking, heroin-assisted treatment, and medical marijuana.”

Candidates who have expressed support for decriminalization of opiates for personal use:

• Pete Buttigieg

• Andrew Yang

Philadelphia’s City Council could have fought opioids by placing limits on pharma reps

By Robert I. Field, Ph.D., J.D., M.P.H.

Does the over-prescribing of opioids lie at the heart of the addiction crisis? Some members of Philadelphia City Council along with many public health experts think so. The Philadelphia City Council recently considered a bill to limit the activities of pharmaceutical sales representatives, also known as detailers, who promote prescription drugs to physicians.

The bill would have required detailers to register with the city for a fee of up to $250, wear identification badges, refrain from giving even small gifts like free lunches to doctors and their staffs, and submit the sales materials they use to the city for review.

Philadelphia is fertile ground for selling pharmaceuticals. It is home to several major academic health systems and physician organizations, and the region contains the headquarters of numerous pharmaceutical and biotechnology companies. It also plays host to a large number of medical conventions that generate business for local restaurants and hotels. Opponents of the bill warned it would have encouraged convention sponsors to look elsewhere, driving away the industry, and the jobs and tax revenue that go with it.

In the end, opponents carried the day, and the bill was defeated by a vote of 9-5.

Would the bill have worked? Recent research suggests that it could have.

A study published in 2017 by researchers at UCLA and Carnegie Mellon examined the effects of limits on drug detailing at 19 academic medical centers around the country. It found that the restrictions resulted in fewer prescriptions for brand-name drugs that detailers promoted. The reduction in prescriptions was modest, but clear.

There is every reason to believe that the proposed limits in Philadelphia would have had a similar effect. And fewer patients receiving prescriptions for opioids could have led to fewer becoming addicted. For a plague as serious as opioid addition, even a small reduction in the number of new victims would prevent a tremendous amount of human suffering, not to mention medical and law enforcement costs that go with it.

With the bill’s defeat, Philadelphia’s risk of losing convention business has faded. At the same time, the opioid epidemic continues unabated. The City is left to wonder which threat is the greatest.

This blog post first appeared in the Health Cents blog on Philly.com.

_______________________

About the author: Robert I. Field is a member of the Inquirer’s Health Advisory Panel, and nationally known expert in health care regulation and its role in implementing public policy. He holds a joint appointment as professor of law at the School of Law and professor of health management and policy at the School of Public Health at Drexel University.

Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment [from American Journal of Preventive Medicine]

George Consortium member Rebecca L. Haffajee has a new article in the American Journal of Preventive Medicine focusing on some of the reasons why only 40% of people with opioid use disorder actually receive medication-assisted treatment. One major reason is that so few physicians are licensed to even prescribe buprenorphine (such as Suboxone). As the article details, numerous workplace barriers contribute to this lack of licensing, including insufficient training, lack of peer support, inadequate reimbursement, and regulatory hurdles. 

For complete article with footnotes, please see:  https://www.sciencedirect.com/science/article/pii/S0749379718300746

---

Introduction

Opioid misuse and overdose continue to escalate, contributing to the growing population with opioid use disorders (OUDs) in need of treatment. The opioid-related overdose death rate increased from 6.1 to 16.3 deaths per 100,000 people from 1999 to 2015, totaling 33,091 deaths in the U.S. in 2015. Rates of opioid-related substance use treatment admissions have followed a similar trajectory. Despite recent abatements in prescription opioid dispensing and use,4 prescribing contributes heavily to those who are misusing opioids.  Moreover, overdoses and infectious diseases resulting from opioid injection drug use continue to climb, and are increasingly attributed to heroin and potent synthetic opioids, such as fentanyl.

Meeting the clinical criteria for an OUD—or a “problematic pattern of opioid use leading to clinically significant impairments or distress,”—increases a person’s risk of early death (typically from overdose, trauma, suicide, or infectious disease transmission) by a factor of 20.The prevalence of OUDs has increased significantly over time, from approximately 1.5 million in 2003 to more than 2.3 million in 2015. Despite the risks of untreated OUD, the gap between OUD prevalence and evidence-based medication-assisted treatment (MAT) capacity was close to 1 million in 2012.

Buprenorphine, one of three medications used as part of MAT, has high potential to address the persistent OUD treatment gap. Buprenorphine is approved for use in non-specialty outpatient settings, has demonstrated effectiveness at promoting abstinence and reducing opioid-related overdoses, and is cost effective. However, according to the Substance Abuse and Mental Health Services Administration (SAMHSA), less than 4% of licensed physicians were approved to prescribe buprenorphine in 2017. In 2016, overall 47% of counties—and 72% of rural counties—lacked a buprenorphine-waivered physician.26 Although buprenorphine capacity has increased since 2002—when it was first approved for OUD treatment in office-based settings—the treatment gap has not significantly narrowed because of the increasing population with OUDs. Moreover, many buprenorphine-approved prescribers treat far fewer than the number of patients allowed by regulations.17; 27 ;  28 Estimates range, but suggest that only 20%–40% of people with OUDs are receiving MAT.

Despite some recent policy successes in expanding buprenorphine treatment insurance coverage, funding, and provider capacity, significant provider and policy barriers remain and must be addressed to capitalize on this promising treatment at a time of dire public health need. This article provides a brief history of MAT and the factors contributing to buprenorphine’s promise. It then outlines persistent provider workforce barriers to buprenorphine provision in the U.S. and policy recommendations to address them.

The rest of the article (including footnotes) is available here: Policy Pathways to Address Provider Workforce Barriers to Buprenorphine Treatment

It's Time for Uncomfortable Solutions to the Opioid Epidemic [from The Fix]

We are thrilled to present some work from brand new George Consortium member Abraham Gutman! This piece from The Fix discusses the fact that we need to get creative, and uncomfortable, in addressing the opioid crisis. Be sure to follow Av's great Twitter feed at @abgutman.

__________________________

The results of the War on Drugs: an America that is the most incarcerated nation in the world, a sharp decrease in the price of heroin, and a new Jim Crow for Black communities.

Not every problem has a solution that we are comfortable with. The opioid epidemic and the overdose crisis are two examples of such problems. There has been a lot of work by states and cities to tackle the epidemic and mitigate harm. Laws limiting opioid prescriptions have been enacted (controversially), DEA regulations on who can administer treatment were laxed, Prescription Drug Monitoring Programs were founded, and states of emergency were declared.

“The United States has seen a vigorous legislative response to the opioid epidemic,” writes Scott Burris, the Director of the Center for Public Health Law Research at Temple University, in a recent article, “but legislators are running out of easy targets as the most popular ideas are adopted in all the states.

With no more low-hanging fruits left on the tree, and with the epidemic still raging, it is time to confront the solutions that we are less comfortable with. Philadelphia found itself in the middle of this conversation after city officials announced that they would encourage private organizations to operate comprehensive-user engagement sites, commonly known as safe-consumption sites.

While Philadelphia is the first city in which officials gave their blessing to open a safe-consumption site, other cities—including Denver, Seattle, and New York—are currently considering opening such sites. Two weeks after Philadelphia’s announcement, San-Francisco announced that the city is expecting to be the first city with a site coming July 1st of this year.

Safe-consumption sites are a harm reduction measure that has been shown to enhance access to primary health care for people who use drugs, reduce overdose mortality, and reduce transmission of disease such as HIV/AIDS. The evidence further suggests that the sites reduce the level of public consumption of drugs and dropped syringes without causing an increase in drug use, drug trafficking or crime in the vicinity of the site. Last summer the American Medical Association voted to support the development of pilot safe consumption facilities.

The debate about safe-consumption sites is mostly not about the evidence that supports the efficacy of the practice but about whether it is the right path to take. One opponent in Philadelphia wrote, “we don’t need to enable drug addiction. We need to keep kids off drugs in the first place. We need to help addicts who want to stop using.”

The truth is: we don’t know how keep kids off drugs in the first place. Furthermore, medication assisted treatment, the gold standard treatment for opioid use disorder, is heavily regulated on the state and federal level leading to barriers in access.

America spent billions of dollars in an attempt to convince the nation’s youth to “just say no” to drugs. The phrase that was first used by First Lady Nancy Reagan to respond to an elementary school girl in Oakland in 1982 became a national and international campaign, and a myth. Telling kids to “just say no” doesn’t work. In fact, it might have the exact opposite effect.

If we can’t make kids say no, maybe we can prevent anyone from offering them drug in the first place. This was the logic of Donald Trump in his first State of the Union when he declared that “we must get much tougher on drug dealers and pushers” and that “open borders have allowed drugs” to enter the country. In a recent speech in New Hampshire, Trump doubled down on this line of thinking and called for the death penalty for some dealers.

Getting tough on drugs is in no way a new idea, in fact it is almost 100 years old. America conducted a horrifying policy experiment to see if this idea works. This experiment, known as the War on Drugs, was conducted with communities of color as the subjects. The results are an America that is the most incarcerated nation in the world, a sharp decrease in the price of heroin with virtually no change in the number of high school seniors using illicit drugs, and a new Jim Crow for Black communities. Renewed calls to get tough on crime are either driven by blindness to the realities of the War on Drugs, racism, or a combination of both.

Tightening the border is not doing much to prevent drug abuse either. While Trump believes that a wall will prevent drugs from entering the US, most drugs that cross the southern border do so through legal entry ports to the U.S., according to the Drug Enforcement Administration. In fact, some argue that the tightened border security gave rise to proliferation of Fentanyl, a deadly synthetic opioid much stronger than heroin, because drug traffickers can make profits from very small volumes. Executing drug dealers as a means to reduce the supply of illicit drugs is dehumanizing and racist, unconstitutional, and won't work.

If we can’t completely stop illicit drug use, we can at least provide easily accessible treatment. When it comes to opioid use disorder we even have effective treatment to offer: medication-assisted treatment using methadone, buprenorphine, and naltrexone. But access to medication-assisted treatment is far from sufficient to meet the growing need, with some in rural areas having no providers within a 350 mile radius. Investing in treatment is extremely important, however stigma and regulatory barriers from federal law and DEA regulations make increasing access very difficult.

The fight over increasing access to medication assisted treatment is a worthy and necessary fight that we should engage in with full force. That said, we need to be realistic about how long it will take to change established laws, regulations, and hearts and minds. Meanwhile people who use drugs are actively dying from overdose, suffering from injection related wounds, and contracting bloodborne diseases such as Hepatitis B and C and HIV/AIDS.

Safe-consumption sites are in no way a silver bullet that will defeat the opioid epidemic. They are a strong tool that should be utilized to end the overdose crisis. More than 64,000 Americans died in 2016 from drug overdose. Not taking action on evidence-based practices because the solution doesn't feel intuitive should not be an option.

Some still view safe-consumption sites as “enabling” drug use (even though that is not supported by the evidence). “If the current epidemic can teach us anything, it’s that drug use is soaring unassisted,” writes Dr. Sarah Wakeman, the Medical Director of the Substance Use Disorder Initiative at Mass General Hospital. “The time has come to think instead about how we can enable people to stay alive.”

The effort to end the opioid epidemic is a marathon and not a sprint. As a society our goal must be to ensure that as many people who are currently using drugs cross the finish line with us - alive and with the least irreversible damage. The next steps to do that might go against many of our gut instincts but at the end of the day we must trust the evidence and embrace harm reduction measures.

___________________________

The original article can be found here. 

Q&A: Holding Drugmakers Accountable for Opioid Crisis

Recently, George Consortium member and University of Michigan professor Rebecca Haffajee gave an interview to the Associated Press, addressing issues around opioid companies and litigation:

“Q: Why didn’t early lawsuits filed against opioid drugmakers have much success?

A: The earlier lawsuits were typically brought by individuals and were vulnerable to a number of defenses from the manufacturers. The companies could argue that individuals misused the prescription drugs or prescribers weren’t providing adequate medical advice about the products. Companies also argued that they were marketing and selling their products in accordance with Food and Drug Administration rules for these FDA-approved products.

Many of those cases were dismissed. Sometimes the individuals bringing the suits simply ran out of resources to pay for the litigation.

Q: Why are these newer lawsuits different?

A: Governments are bringing these more recent lawsuits, and they are alleging harms to their overall social systems that (acknowledge) misuse was happening, but regardless, are trying to hold companies accountable.

The idea is that these companies must have known, based on their own records and information, that the mass selling and distribution of opioids had gone beyond their appropriate medical use. The defense that people misused these drugs doesn’t hold as much weight in these cases.

Q: People have compared this litigation to the lawsuits against Big Tobacco in the 1990s that resulted in a nearly $250 billion financial settlement for state governments. What are some of the differences?

A: Part of the idea with tobacco was to get this product off the market altogether. With opioids we don’t want that. We want to be limiting the amount of opioids prescribed and misuse, but we recognize these are FDA-approved products that have a medical use and can be appropriate and effective, particularly for acute pain. The idea here is to try and thread the needle and allow appropriate use, but rid the market of inappropriate use.

Q: Beyond a financial settlement, many government officials say they want to change how this industry does business. Is that likely to happen?

A: That certainly can be a byproduct of the litigation, changing marketing practices and behavior. If it’s a penalty that’s big enough, it could have a deterrent effect.

Some of the recent settlements we’ve seen with drug distributors and manufacturers have required that they report certain information or refrain from certain conduct going forward.”

The PORTAL Literature Scan for March

Every month, our friends at the Program on Regulation, Therapeutics, and Law (PORTAL) - part of a collaboration between Harvard Medical School and Brigham & Women’s Hospital - publish a great list of the best and most interesting studies, policy analyses, and editorials about regulation, therapeutics, and law. Below, we're featuring one in particular co-authored by George Consortium member Lainie Rutkow. You can find the rest of this month's list here:  https://www.portalresearch.org/literature-scan.html

Impact of Florida's prescription drug monitoring program and pill mill law on high-risk patients: A comparative interrupted time series analysis.    
Chang HY, Murimi I, Faul M, Rutkow L, Alexander GC.  
Pharmacoepidemiol Drug Saf. 2018 Feb 28. [Epub ahead of print] 
Compared with Georgia, Florida's prescription drug monitoring program and pill mill law were associated with large relative reductions in prescription opioid utilization among high-risk patients... Read More

 

"Benefits, Limitations, and Value of Abuse-Deterrent Opioids" in JAMA Internal Medicine

Two members of our team - Dr. Gregory Curfman and Professor Leo Beletsky - and friend of PHLW Ameet Sarpatwari have an important new piece out in JAMA Internal Medicine entitled "Benefits, Limitations, and Value of Abuse Deterrent Opioids."  "Abuse deterrent opioids" are formulations of the drugs meant to be tamper-resistant, "intended to make manipulation more difficult or to make abuse of the manipulated product less attractive or less rewarding." Looking at the Institute for Clinical and Economic Review report on Abuse-Deterrent Formulations of Opioids: Effectiveness and Value and adding independent analysis, the authors found that the selective use of abuse deterrent opioids may mitigate opioid abuse and diversion. However, the use may also promote switching to more dangerous opioids (like heroin). Finally, they found no evidence that abuse deterrent opioid use reduces overdose deaths. 

Read the entire article here.

Briefly: Some Interesting Public Health Law Moves in Massachusetts

As you enjoy a very nutritious helping or two of Thanksgiving dinner this week, here's some interesting happenings in Massachusetts public health law for you to chew on (haaa).  

By Elisabeth J. Ryan

This week, the Commonwealth of Massachusetts became the first state in the nation to ensure that most health insurance plans cover birth control without cost-sharing to patients.  Technically, this provision already exists federally in the still-good-law Affordable Care Act.  However, in October, the federal government issued rules to roll back that requirement by allowing any employer to avoid such coverage by invoking religious or moral objections to contraception. The Massachusetts law still contains religious exceptions, including for churches and "qualified church-controlled organizations" as employers; it also does not cover any employers who insure themselves and are thus subject solely to federal, rather than state, regulations.  This law was intended as a direct rebuke to Trump and his Cabinet; the fact that it was drafted, passed, and signed within a matter of weeks is actually quite a remarkable feat for the Massachusetts state government.  Both the health insurance industry and the reproductive rights community supported the bill and helped to negotiate the resulting language.  In addition to the birth control access without cost-sharing, the bill also expands coverage by allowing a one-year supply of birth control pills, by increasing the types of birth control covered, and by covering the so-called “morning after” pill without a prescription. 

Massachusetts also took a significant step toward criminal justice reform recently when both branches of the legislature passed comprehensive bills addressing issues like repealing mandatory minimum sentences for drug crimes and considering 18-year-olds juveniles rather than adults.  While now in reconciliation talks, one provision that went mostly unnoticed in both bills would require prisons and jails to offer approved substance use disorder medication to inmates.  Currently, the only medication-based treatment available to inmates is Vivitrol, a monthly shot that “blocks” opioid receptors in the brain.  And even that shot (provided for free from a drug company accused of questionable tactics), is given to inmates only immediately pre-release.  Though a recent study suggests that Vivitrol is an effective treatment for opioid use disorder, the corrections system currently prohibits use of established medications like buprenorphine (Suboxone) and methadone, even for inmates who have valid prescriptions upon incarceration.  Corrections officials object to changing that status quo, claiming that such medications are simply contraband that would “caus[e] people to be assaulted. It’s causing people to have hits put on them.”  Yet knowingly withholding effective treatment from inmates in a state with one of the highest opioid-related death rates in the country because unauthorized use of medicine could cause security issues not only ignores the public health implications, but it assumes a controlled medical approach to such treatment would fail without actually trying it. The Commonwealth’s neighbors in Rhode Island instituted medication-assisted therapy in their correctional institutions last year and, at least anecdotally, have actually seen a reduction in contraband. 

"Graham-Cassidy" Provides Zero Funding to Address the "Opioid Crisis"

By Elisabeth J. Ryan

One of the few positive provisions of the summer’s Senate “health care” bills was the inclusion of funding to states to “support substance use disorder treatment and recovery support services.”  With more than 30,000 people dying from heroin and painkiller overdoses in the United States every year, sufficient funding to address and effectively treat this issue is crucial.  Yet the latest Republican version of the “health care” bill has omitted this funding entirely.

The original Better Care Reconciliation Act included a $2B fund to distribute grants to states for fighting the “opioid crisis” and other substance use disorder issues; the “Cruz amendment” version significantly increased that amount to nearly $45B over nine years.  While even that amount would likely not have been sufficient to cover needs, the increase was hailed as a key provision aimed specifically at some Republican Senators still wavering in their support.  Yet the latest iteration – “Graham-Cassidy” – includes absolutely no such funding.  This glaring omission has received little attention, but it contributes to the bill’s overall potential to actually harm public health.  The bill would also make alarming cuts to Medicaid (which is one of the top insurers for substance use disorder services) and would also allow states to waive the current requirements that insurance companies not only cover substance use disorder treatment but also that they cover it without charging people higher premiums.  One analysis estimates that a person with "drug dependence" could face a premium surcharge of $20,000 per year.  

Without any funding added to the bill to offset those potentially devastating losses, treatment for substance use disorder will become either financially or practically impossible for the millions of people who may need it.  This lack of adequate, evidence-based, available treatment already constitutes a public health crisis - Congress may be poised to make it even worse.  

Briefly: Massachusetts Governor Proposes New Crime of Manslaughter for 'Drug Dealers'

By Elisabeth J. Ryan

Massachusetts Governor Charlie Baker filed legislation yesterday which would, among other things, create a new crime of manslaughter for drug dealers if a person dies from using their drugs.  Specifically, anyone who "manufactures, distributes, or dispenses" any controlled substance would be "strictly liable" if "a death...results from the injection, inhalation, or ingestion of that substance."  The punishment would be a mandatory minimum of 5 years to a maximum of life in state prison.  

The Governor presented this proposal as a new way to fight the opioid epidemic, saying, “[W]e should ensure that those who cause our citizens the most harm by illegally selling drugs that kill people are held accountable for their actions.”  The law, however, doesn’t apply to just opioids; it covers all controlled substances except marijuana. 

Similar laws and prosecutions in Canada and other states have faced significant backlash.