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Thesis advisor: Marius Stan / This thesis explores America's Opioid addiction crisis through a philosophical lens, arguing for a need to adopt a national mandatory rehabilitative approach for the sake of maintaining our country's cultural ethos grounded in freedom and the subsequent capacity to flourish as a human being. It proceeds in four chapters: the development of our cultural ethos through an analysis of John Locke and J.S. Mill, the history of the opioid addiction crisis and development of the two dominant addiction theories, America's current measures to tackling the crisis, and the proposal of a new approach that recovers addicts' freedom and ability to flourish. The work concludes by arguing for the importance of using philosophical principles and interpretations to guide problem solving and tackling current crises. / Thesis (BA) — Boston College, 2023. / Submitted to: Boston College. College of Arts and Sciences. / Discipline: Departmental Honors. / Discipline: Philosophy.

New drug epidemics often unleash punitive campaigns to end them- highlighted by the 1980’s drug wars. However, the opioid crisis has been met with public-health driven policies, like clean needle programs and community-based substance abuse therapy. This thesis asks why policy responses to the opioid crisis are so different than those of the War on Drugs. First, as the cost of the drug war became clearer, policy makers across the political spectrum became less inclined to wage a new punitive war against opioids, especially as public-health responses proved to be more effective while also less costly. Second, the demographics of those addicted to opioids is different than those who were addicted to crack cocaine. The brunt of War on Drugs policies was felt by those in the lowest socioeconomic brackets and perpetuated poverty in low-income communities. Today’s softer approaches have been informed by a greater percentage of middle- to upper-class individuals affected by the opioid crisis. Third, as opioids have legitimate medical purposes, they are harder to demonize or ban, rendering it more difficult to declare total war against them. Further, the influence opioid manufacturers have has made policy makers less inclined to declare war, taking supply-side action. Public-health driven policies and policies that minimize supply-side action against pharmaceutical opioid manufacturers are duplicate representations of the United States’ departure from War on Drug tactics. As long as the “medical model” of health care, which emphasizes drugs, medical treatment, and surgery is ingrained in society and the economy, these patterns will continue.

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INTRODUCTION: Drug overdose death is now the leading cause of mortality among homeless adults in Boston, with opioids implicated in a majority of those deaths. Harm reduction interventions help minimize the risks associated with substance use, and are critical in supporting individuals with substance use disorder. Medical monitoring programs are an effective harm reduction strategy that work to prevent fatal drug overdoses and keep people safe while still actively using. METHODS: Visit data from the Supportive Place for Observation and Treatment (SPOT) was compiled and analyzed. The two measures of interest were the count of referrals to substance use disorder treatment and the count of visits prior to the first referral to treatment. Chi-square tests of independence, odds ratios, and binary logistic regression models were used to describe the association between factors of interest and referrals to substance use disorder treatment. RESULTS: Gender and age did not show any significant association to a connection to treatment. Overdose history (Adjusted Odds Ratio 6.59), reported stimulant use (AOR 2.59), and documented health or harm reduction education (AOR 5.14) were all associated with increased odds of being referred to substance use disorder treatment. Heavy sedation (AOR 0.55) was associated with decreased odds of a treatment referral.When examining factors associated with rapid connection to treatment, male gender (OR 1.87) was associated with increased odds, while overdose history (AOR 0.42) was associated with decreased odds. DISCUSSION: The two most impactful factors associated with increased odds of connecting to substance use disorder treatment were reported overdose history and documented education. Both of these factors suggests that a strength of SPOT is its ability to form and maintain meaningful connections with participants. One way that SPOT could improve referral outcomes would be to increase its ability to engage participants, such as through the recruitment of more harm reduction specialists or peer recovery coaches.

Abstract available through the Annals of Behavioral Medicine.

This dissertation presents three chapters of contemporary research in environmental and development economics. Each chapter echoes a common theme, in that achievement of regional goals constitute 'Wicked Problems' and that the approaches that parties may take to address these specific regional goals may have complex interactions with other regional goals. Decision-making, cost analysis, and multipurpose efficacy of the approaches that regional parties may take to achieve goals are evaluated in environmental and development contexts and implications for program analysis and policy design are discussed. The first chapter of this dissertation seeks to understand how regulated parties, i.e. Municipal Separate Storm Sewer Systems (MS4s), choose from the strategies at their disposal to achieve compliance with their Chesapeake Bay Total Maximum Daily Load (TMDL) obligations. To address declining Chesapeake Bay water quality, the United States Environmental Protection Agency (EPA) set extensive nutrient and sediment reduction goals under the 2010 Chesapeake Bay TMDL. Virginia has responded by passing along explicit nutrient and sediment reduction requirements to its MS4s, which can choose from a variety of urban stormwater, land use change, source control, and restoration practices to achieve reductions toward these requirements. MS4s in Virginia have also been granted flexibility to achieve reduction requirements through purchase of nutrient and sediment credits toward requirements through trade. In spite of the cost-savings that these credits provide, MS4s' interest in trading for these credits has been low. MS4s instead generally engage in onsite nutrient and sediment reduction themselves, in spite of the high costs of doing so. In response to low interest in trade, case analysis of MS4s' Bay TMDL compliance behavior and semi-structured interviews are conducted to better understand the role of trade in compliance strategy and the reasons for its non-use. Findings reveal that the Virginia MS4s studied typically choose to implement onsite urban stormwater practices, source control practices, and restoration practices in order to generate long-lasting local benefits, like erosion control, flood risk reduction, and progress toward local TMDL obligations, alongside reductions toward the Bay TMDL. MS4s refrain from term credit purchases out of concern over future availability and refrain from perpetual credit purchases because they have been able to use funding sources to achieve reductions from long-lasting onsite practices at similar per-pound costs, while also receiving local benefits. Implications are that supply-side efforts to support trade markets may not generate the level of activity expected, given that would-be buyers have generally limited interest in trade as a compliance strategy. The second chapter studies the degree to which the practices used to meet local TMDL water quality obligations contribute to Bay TMDL compliance for the Loudoun County MS4. Linear programming is used to estimate the minimal cost of achieving Bay compliance in addition to local obligations through representative nutrient and sediment reduction strategies. The model estimates that Loudoun County MS4 faces substantial costs just to meet local water quality goals ($11 million/yr). Since many of the actions taken to meet local water quality goals also generate pollutant reductions to the Chesapeake Bay, adding Bay TMDL obligations adds 0.2%, 3%, and 32.9% to these costs, depending on the water quality trading used to reach Bay TMDL compliance. Findings shed additional light on Chapter 1's goal of investigating the role of trade by explaining low interest in trade as stemming from heavy local water quality needs. Implications are that the burden imposed by the Bay TMDL may not be as high as generally thought. The third chapter shifts focus to the Opioid Crisis to evaluate the efficacy of Syringe Exchange Programs, best known for their efforts to prevent bloodborne illness transmission, at achieving their secondary intervention goal of preventing opioid overdose. While research has established that Syringe Exchange Programs, or SEPs, are effective at preventing bloodborne illness, little focus has been given to their ability to prevent fatal overdose, which they aim to do by engaging in intervention practices like naloxone and fentanyl test strip distribution. In response for need for understanding of Syringe Exchange Programming's impact on overdose, fixed effects analysis is used to empirically study the impact of county-level SEP in North Carolina following the state's 2016 SEP legalization. Need-based programming complicates analysis and likely biases findings of the impact of SEP on overdose upward. Regardless, findings consistently fail to find that SEP has a significant effect on fatal overdose from four categories of opioids, which should reduce concerns in recent literature that they may increase overdose death. Implications are that, since SEPs have a richly documented history of saving lives through the prevention of bloodborne illness and do not appear to increase overdose, contrary to findings in other work, policy makers should continue to incorporate SEP into their portfolio of strategies used to address the Opioid Crisis. / Doctor of Philosophy / This dissertation presents three chapters of contemporary research in environmental and development economics. Each chapter echoes a common theme, in that achievement of regional goals constitute 'Wicked Problems' and that the approaches that parties may take to address these specific regional goals may have complex interactions with other regional goals. Decision-making, cost analysis, and multipurpose efficacy of the approaches that regional parties may take to achieve goals are evaluated in environmental and development contexts and implications for program analysis and policy design are discussed. The first chapter of this dissertation seeks to understand how regulated parties, i.e. Municipal Separate Storm Sewer Systems (MS4s), choose from the strategies at their disposal to achieve compliance with their Chesapeake Bay Total Maximum Daily Load (TMDL) obligations. To address declining Chesapeake Bay water quality, the United States Environmental Protection Agency (EPA) set extensive nutrient and sediment reduction goals under the 2010 Chesapeake Bay TMDL. Virginia has responded by passing along explicit nutrient and sediment reduction requirements to its MS4s, which can choose from a variety of urban stormwater, land use change, source control, and restoration practices to achieve reductions toward these requirements. MS4s in Virginia have also been granted flexibility to achieve reduction requirements through purchase of nutrient and sediment credits toward requirements through trade. In spite of the cost-savings that these credits provide, MS4s' interest in trading for these credits has been low. MS4s instead generally engage in onsite nutrient and sediment reduction themselves, in spite of the high costs of doing so. In response to low interest in trade, case analysis of MS4s' Bay TMDL compliance behavior and semi-structured interviews are conducted to better understand the role of trade in compliance strategy and the reasons for its non-use. Findings reveal that the Virginia MS4s studied typically choose to implement onsite urban stormwater practices, source control practices, and restoration practices in order to generate long-lasting local benefits, like erosion control, flood risk reduction, and progress toward local TMDL obligations, alongside reductions toward the Bay TMDL. MS4s refrain from term credit purchases out of concern over future availability and refrain from perpetual credit purchases because they have been able to use funding sources to achieve reductions from long-lasting onsite practices at similar per-pound costs, while also receiving local benefits. Implications are that supply-side efforts to support trade markets may not generate the level of activity expected, given that would-be buyers have generally limited interest in trade as a compliance strategy. The second chapter studies the degree to which the practices used to meet local TMDL water quality obligations contribute to Bay TMDL compliance for the Loudoun County MS4. Linear programming is used to estimate the minimal cost of achieving Bay compliance in addition to local obligations through representative nutrient and sediment reduction strategies. The model estimates that Loudoun County MS4 faces substantial costs just to meet local water quality goals ($11 million/yr). Since many of the actions taken to meet local water quality goals also generate pollutant reductions to the Chesapeake Bay, adding Bay TMDL obligations adds 0.2%, 3%, and 32.9% to these costs, depending on the water quality trading used to reach Bay TMDL compliance. Findings shed additional light on Chapter 1's goal of investigating the role of trade by explaining low interest in trade as stemming from heavy local water quality needs. Implications are that the burden imposed by the Bay TMDL may not be as high as generally thought. The third chapter shifts focus to the Opioid Crisis to evaluate the efficacy of Syringe Exchange Programs, best known for their efforts to prevent bloodborne illness transmission, at achieving their secondary intervention goal of preventing opioid overdose. While research has established that Syringe Exchange Programs, or SEPs, are effective at preventing bloodborne illness, little focus has been given to their ability to prevent fatal overdose, which they aim to do by engaging in intervention practices like naloxone and fentanyl test strip distribution. In response for need for understanding of Syringe Exchange Programming's impact on overdose, fixed effects analysis is used to empirically study the impact of county-level SEP in North Carolina following the state's 2016 SEP legalization. Need-based programming complicates analysis and likely biases findings of the impact of SEP on overdose upward. Regardless, findings consistently fail to find that SEP has a significant effect on fatal overdose from four categories of opioids, which should reduce concerns in recent literature that they may increase overdose death. Implications are that, since SEPs have a richly documented history of saving lives through the prevention of bloodborne illness and do not appear to increase overdose, contrary to findings in other work, policy makers should continue to incorporate SEP into their portfolio of strategies used to address the Opioid Crisis.

Purpose of Review: The purpose of this review is to address infection with HIV and hepatitis C in the Appalachian region of the USA and the driving forces underlying this epidemic. We seek to discuss epidemiology of disease and the possible interventions to reduce incidence and burden of disease in this resource-limited area. Recent Findings: The rise of the opioid crisis has fueled a rise in new hepatitis C infection, and a rise in new HIV infection is expected to follow. Injection drug use has directly contributed to the epidemic and continues to remain a risk factor. Men who have sex with men remains a significant risk factor for HIV acquisition as well. Summary: Progress has been made in the battle against HIV and, to a lesser extent, hepatitis C, but much more can be done. Limited data on co-infection with HIV/HCV are currently available for this at-risk region, but it is clear that Appalachia is highly vulnerable to co-infection outbreaks. A multipronged approach that includes advances in assessment of co-infection and education for both patients and clinicians can help to recognize, manage, and ideally prevent these illnesses.

This project utilized an interdisciplinary approach to explore what harm and harm reduction meant during intersecting public health emergencies, the opioid crisis and the coronavirus pandemic. Using thematic and historical analysis, I analyzed interviews with frontline workers, news coverage, and municipal government documents to understand how people conceptualized the opioid crisis during coronavirus (and vice versa). On the whole, I found that harm reduction was a central aspect of the efforts against the opioid crisis in Hamilton. However, there were discrepancies in how it was practiced and understood. Generally, harm reduction was presented in municipal government documents as a medical intervention that involved, for example, the provision of new needles and naloxone kits to prevent disease and death. Such a practice was indeed important to address the unique harms at the intersection of COVID and the opioid crisis. However, to frontline workers and activists, harm reduction was a much broader term: it included services that were crucial to daily life, such as food and washrooms; the right to safe housing; and broader social and structural interventions, such as the decriminalization of opioid use. The context of the coronavirus pandemic, which exposed people who use opioids to unique harms, exacerbated the disparity between these definitions: harm reduction was simultaneously presented as a narrow, medical practice and a broad, political intervention. / Thesis / Master of Arts (MA)