Running head: H.B.

3256 POLICY ANALYSIS 1

Disease Control Pilot Program: H.B. 3256 Policy Analysis

Sherman P. Fricks

University of Houston-Clear Lake

November 29, 2017

H.B. 3256 POLICY ANALYSIS 2

Delineation and Overview of Policy Under Analysis

Introduction to Disease Control Pilot Program

Substance Use Disorder (SUD) is recognized by the American Psychiatric Association as

a psychological illness which manifests in an array of behaviors that, by definition, can

strengthen in severity and impact upon an individual, his or her family and friends, as well as the

community (American Psychiatric Association, 2013). The central characteristic of SUD is

continued thinking, obtainment, and use of a psychoactive drug despite the consequences and an

inability to stop (American Psychiatric Association, 2013). In America, this issue is primarily

addressed or covered up in four ways: religion, 12-step programs, treatment centers, and

imprisonment (Fillmore & Hohman, 2015; Mauer, 2016). Although success stories are found

from each, the crux of SUD and its web of harm, fail to fully be addressed (Lenton & Single,

1998; Newall, 2017).

An empirically proven trend, harm reduction, is slowly gaining acceptance in North

America among constituents, health care providers, and politicians (Clarke et al, 2016; Fillmore

& Hohman, 2015;). This model’s ideology is based around prioritizing the safety and health of

individual and their community, instead of aiming to eliminate drug use (Coleman, 2015; Harm

Reduction Coalition, 1998; Lenton & Single, 1998). Such route attributes versatility, with an

ability to be expressed in the form of: Educating those at risk of encountering an opioid overdose

on proper Naloxone application, empowering law enforcement the ability to publish results of

analysis of confiscated controlled substances for adulterants, or establishing needle exchange

programs (NEPs) which collect used syringes and exchange sterile syringes in return to prevent

expose to Human Immunodeficiency Virus (HIV) and Hepatitis C (HCV) by people who inject
H.B. 3256 POLICY ANALYSIS 3

drugs (PWID) (Clarke et al, 2016; Coleman, 2015; Gay Mens Health Crisis, 2009; Harm

Reduction Coalition, 1998).

To address the issue, H.B. 3256 was authored by Representative Toni Rose and proposed

on March 3, 2017 (HB 3256, 2017). The bills stated primary purpose is reduce infectious blood

to blood diseases, which are a cause of concern for PWIDs, as the sharing of syringes and other

IV consumption equipment is how these chronic illnesses can be transferred (Avert, 2017; Clarke

et al, 2016; Coleman, 2015). Due to the inherent illicit nature of the subject, rough estimates of

PWID are half a million to a million per year nationally (Lansky et al, 2014). HIV diagnoses

contributed to IV use is 55 in 100,000 people, while HCV is a staggering 43,000 per 100,000

(Lansky et al, 2014). A cause of concern is such diseases are virtually preventable in PWID, if

precautions are taken with every injection (Clarke, 2015; Harm Reduction Coalition, 1998;

Sawangjit, Khan, & Chaiyakunapruk, 2016).

Texas H.B. 3256

House Bill 3256 (H.B. 3256), proposes formally, in regions of Bexar, Dallas, Harris, and

Travis County, creating proof of concept programs which allows agencies to collect used

syringes and return, in equal amount, sterile syringes, for the purpose of reducing infectious

diseases. If the bill is enacted, the effective date is September 1st 2017. To clarify ambiguity, the

word disease refers to blood borne pathogens, such as HIV/AIDS, Hepatitis B (HBV), and HCV

(HB 3256, 2017).

Section 1 states the purpose of drafting H.B. 3256 came out of need due to the impact of

substance abuse has on Texas' citizens. Overall goals for this policy are to addresses prevention

through education, reducing disease rates through needle exchange programs, reduce intravenous

drug use, refer those infected or addicted to proper treatment, and reduce harm such as accidental
H.B. 3256 POLICY ANALYSIS 4

needle pricks. Acknowledging the multifaceted complexity of addiction, the legislature finds that

an effective approach comes in the form of integrating both community and faith organizations

together for an empathetic approach to those who have drug addiction and or disease. The

program's purpose, outlined in H.B. 3256, is to allow both agencies and hospitals legal authority

to exchange used intravenous equipment for new, sterile material. In addition to this service,

providers will have established relations with other agencies which provide treatment for drug

addiction, HIV/AIDS, hepatitis B & C, and general health care (HB 3256, 2017).
Section 2 makes changes to Government Code Sec. 531.0972. Health and human services

is alluded to being the commission to reside over the proposed pilot program for both hospitals

and agencies within the previously stated counties. This program falls under Health and Safety

Code, Chapter 81, Subchapter K, and reiterates the primary purpose, as an anonymous syringe

exchange (HB 3256, 2017).

In section 3 of HB 3256, Health and Safety Code, Chapter 81, is amended by adding

Subchapter K which states the regions with which the pilot program may be implemented. Sec.

81.502 defines the requirements of the proposed program being limited to only hospitals and

agencies, with the purpose of preventing infectious diseases. Required services to be provided

are stated as follows: The service is an anonymous exchange of used hypodermic needles for

clean needles. Agencies or hospitals may offer education and methods to prevent the spread of

diseases. Pilot programs may assist clients in obtaining both health and mental health care as

well as substance abuse treatment, and referral to disease testing agencies. An additional

requirement for the pilot program is registering with the county or hospital district to have

authority to distribute needles. Within this requirement is a clear disclosure that a reasonable fee

may be charged for registration, in order to cover law enforcement coordination and hospital

oversight. Subsection c states that agencies and hospitals may charge participants a fee for each
H.B. 3256 POLICY ANALYSIS 5

needle, yet restricting markup cost to 150% of purchase price. Subsection d states that hospital or

agency must report statistics of participants to the authorizing district including: effectiveness,

impact on reduction rates, and impact on injection drug use within the area (HB 3256, 2017).

Section 81.503 defines actual distribution of syringes to be limited to wholesalers and

those deemed authorized to resell product. Furthermore, specific guidelines to actual handling of

needles requires only those authorized by the organization, such as employees or volunteers to

handle both clean and used needles. The items given to participants must be in “safe kits”,

though a clear definition is not provided. Storage and disposal of syringes must abide by state

medical waste laws. Sec. 81.505 clearly states, by law, that organizations may receive gifts,

grants, or donations to fund their program. The proposed subchapter is to expire on September

1st, 2027. Section 4 reiterates Section 3, defining the ethics and medical purposes of the

exchange. Section 5 states that offenses committed under Sec. 481.125 before the bill’s effective

date are subject to law (HB 3256, 2017).

Historical and Social Analysis

An effective approach to analyze the proposed bill will be achieved by acknowledging

the intertwining of previous bills and how specific penal code has shaped H.B. 3256 (Popple &

Leighninger, 2010). The Texas Controlled Substance Act Sec. 481.125 subsection a defines drug

paraphernalia as any item which is intended or will be used for a controlled substance (Texas

Controlled Substance Act, 1993). At first glance, the definition seems appropriate in relation to

the current status of illicit narcotics, but in retrospection the wording sets up for the following

line which sets restrictions the disease pilot program outlined in Health and Human Services

Commission Sec. 531.0972 (Health and Human Services Commission, 2007). Subsection b goes
H.B. 3256 POLICY ANALYSIS 6

on to classify distribution of drug paraphernalia as intentionally giving or intending to give drug

paraphernalia (Texas Controlled Substance Act, 1993).

In 2007 the Texas Senate passed S.B. 10, which was a bill similar to H.B. 3256 allowing

for a disease control pilot program in Bexar County, but did not make an amendment to Texas

Controlled Substance Act Sec. 481.125 (Health and Human Services Commission, 2007).

Implications of the oversight meant that even though a pilot program is able to have oversight

from Health and Human Services, the legal authority to dispense syringes to clients, employees

and volunteers were technically breaking penal code Sec. 481.125, and as of present, no current

program exists (Health and Human Services Commission, 2007). H.B. 3256 learned from the

mistakes of S.B. 10, and proposed amendments to Texas Controlled Substance Act Sec. 481.125

by excluding drug paraphernalia penalties for approved pilot programs (HB 3256, 2017).

Projected legislation aligns with meeting a client where they are at (National Association

of Social Workers, 2008), upholds social work values of self-determination and autonomy, holds

a neutral stance on substance use by removing distribution of drug paraphernalia penalties, and is

similar to what other countries have implemented (HB 3256, 2017; National Association of

Social Workers, 2008; Vakharia & Little, 2016). Dr. Peter Lurie gave testimony to the Texas

House of Representatives and the Senate in which he gave a professional opinion while

providing evidence suggesting NEPs save lives and reduce fiscal costs (Lurie, 2007). Although

America is lacking enough domestic data to justify a nationalized program, Western Europe has

had enormous success with reducing HIV and HCV rates, as compared to Eastern Europe which

has similar PWID rates, but less NEPs (Gay Mens Health Crisis, 2009). Canada dominates the

continent with only roughly 5% of individuals reporting non-sterile equipment with their last use

(Avert, 2017; Newall, 2017). Statistics within the USA are difficult to obtain due to the illicit
H.B. 3256 POLICY ANALYSIS 7

nature, but recent years show a 25% jump in organizations which offer access to clean supplies,

bringing the number to 244 in 2014 (Avert, 2017; Clarke et al., 2016).

In regards to goals, H.B. 3256 explicitly states the objectives are to: reduce transmission

rates of diseases contracted through sharing of syringes, and refer willing clients to appropriate

resources for substance abuse and disease testing (HB 3256, 2017). Because the bill requires

registration of pilot programs, overseeing agencies may require maintaining and reporting

statistics of effectiveness, reduction rates of transmission and acquirement, and how the program

has impacted IV drug use on the community served (HB 3256, 2017). The bill has potential to

serve as creating infrastructure within the community for future harm reduction measures, as

well as providing proof of efficacy for other states to base their programs off of, although the

legislation does not state this purpose (Clarke et al, 2016). Overall, the bill meets the standards

other NEPs have set (Harm Reduction Coalition, 1998).

Economic Analysis

A surprise within H.B. 3256 was the lack of emphasis on the positive economic impact

disease control pilot programs would have on the counties, as on a fiscal note, HIV infection

reduces life expectancy on average 15 years, which equates to loss of productivity (Nguyen,

Weir, Jarlais, Pinkerton, & Holtgrave, 2015). The programs have been proven in other parts of

the world to be an effective route to reducing transmission rates (Harm Reduction Coalition,

1998; Nguyen, et al, 2015). Speaking specifically on HIV, one prevention of transmission is

around $375,000 saved in treatment cost alone, with total treatment costs for PWID infections in

the United States costing about $1 billion (Nguyen, et al, 2015). When assessing the Legislative

Budget Board’s analysis, they reported having no impact expected, which goes against what
H.B. 3256 POLICY ANALYSIS 8

evidence shows (Nguyen, et al, 2015; Texas Legislative Budget Board, 2017). From a pure

financial aspect, NEPs have a positive, saving impact as compared to being a financial burden

(Nguyen, et al, 2015).

Political Analysis, Evaluation and Reform

Sadly, a frightful national trend is those who are in power use their theological beliefs as

basis to not implement empirically proven harm reduction measures (Davis & Rosenberg, 2013;

Lopez, 2017). A specific example comes from Larwence, Indiana where County Commissioner

Rodney Fish cites the Bible leading his decision to block a local NEP initiative, despite empirical

evidence suggesting his jurisdiction would benefit (Lopez, 2017). Similar stances are shared

across the country, though more heavily in the south (Davis & Rosenberg, 2013; Temple

University, 2008). Evidence supporting this claim is found by assessing state syringe statutes and

regulations (Temple University, 2008). East and West coast states have more lenient policy for

purchasing over the counter while southern states either highly limit or completely restrict

purchase of sterile syringes (Temple University, 2008).

Despite personal beliefs, a prevailing consensus in America is IV drug consumption does

pose numerous hazards, both to the end user and his or her community (Clarke et al., 2016; &

Davis & Rosenberg, 2013). The intersectional consequences individuals with SUD face, such as

higher incarceration rates (Hart, 2014; Mauer, 2016), impacts this population along with

pathogenic diseases like HCV and HIV are conceivably corrigible (Clarke et al., 2016). While

implementing NEPs have successful reduced transmission rates in European countries (Avert,

2017), domestic application is met with resistance due to a systemic moralist view on drug use,
H.B. 3256 POLICY ANALYSIS 9

and fearing such programs promote IV drug use (Clarke et al., 2016; Davis & Rosenberg, 2013;

Lopez, 2017; McLean, 2012).

Unfortunately, H.B. 3256 failed to make it out of the house committee (H.B. 3256, 2017).

The major implication is that failure of this bill prevents amending Texas Controlled Substance

Act Sec. 481.125, which in turn forces the already approved pilot program from being

implemented (H.B. 3256, 2017; Health and Human Services Commission, 2007; Texas

Controlled Substance Act, 1993). In retrospection, the main purpose of the bill is to have disease

control pilot programs, therefore a better approach might be taking the amendment and attaching

it onto a bill which is more likely to pass, and instead the next opportunity lies in 2019.
H.B. 3256 POLICY ANALYSIS 10

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders

(5th ed.). Arlington, VA: American Psychiatric Publishing

Avert. (2017, June 13). Needle and syringe programmes (NSPs) for HIV prevention. Retrieved

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programmes

Clarke, K., Harris, D., Zweifler, J. A., Lasher, M., Mortimer, R. B., & Hughes, S. (2016). The

significance of harm reduction as a social and health care intervention for injecting drug

users: An exploratory study of a needle exchange program in Fresno, California. Social

Work in Public Health, 31(5), 398-407. doi:10.1080/19371918.2015.1137522

Clarke, K. (2015). The case of a needle exchange policy debate in Fresno, California. Critical

Social Policy, 36(2), 289-306. doi:10.1177/0261018315608726

Coleman, A. (2015). Needle Exchange Programs. The Council of State Governments.

Fillmore, S., & Hohman, M. (2015). Traditional, alternative, and harm reduction approaches:

What do social work students think? Journal of Social Work Practice in the Addictions,

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Harm Reduction Coalition. (1998). Getting off right: A safety manual for injection drug users.

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Health and Human Services Commission of 1991, Sec. 531.0972, 80th Texas Legislature.

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H. B. 3256, Texas 85th Regular Legislative Session. (2017).

H.B. 3256 POLICY ANALYSIS 11

Lansky, A., Finlayson, T., Johnson, C., Holtzman, D., Wejnert, C., Mitsch, A., Crepaz, N. (2014).

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Lopez, G. (2017, October 20). An Indiana county just halted a lifesaving needle exchange

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politics/2017/10/20/16507902/indiana-lawrence-county-needle-exchange

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exchange-programs-texas

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H.B. 3256 POLICY ANALYSIS 12

Nguyen, T. Q., Weir, B. W., Jarlais, D. C., Pinkerton, S. D., & Holtgrave, D. R. (2014). Syringe

exchange in the United States: A national level economic evaluation of hypothetical

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archives. Austin, TX