Tag: Fentanyl

Fentanyl as a WMD? The War on Opioids Reaches a New Level of Misinformation

“This is like declaring ‘ecstasy’ as a WMD,” an anonymous source from the Department of Defense counter-WMD community commented incredulously. This source was quoted by a Task and Purpose reporter investigating a Department of Homeland Security internal memo discussing designating the synthetic opioid fentanyl as a weapon of mass destruction. This is just the latest example of how misinformation and hysteria inform federal and state policy regarding the overdose crisis. 

Policy makers maintain their state of denial about the role of prohibition in the overdose crisis. Denial fosters vulnerability to misinformation and “alternative facts” to prop up falsely held views. Denial that the war on drugs is responsible for most of the death and destruction surrounding illicit drug use makes policymakers susceptible to claims about fentanyl that are not based in reality.

Misinformation about fentanyl leads to avoidable stress and overreaction among first responders. But misinformation about the causes of the opioid overdose crisis causes much more harm. 

Lawmakers and policy makers continue to believe the overdose crisis was caused by doctors too liberally prescribing pain pills. This ignores the government’s own data that shows there is no correlation between the number of pills prescribed and the incidence of nonmedical use or pain reliever use disorder. It ignores evidence that nonmedical drug use was on a steady exponential increase well before the doctors began prescribing more liberally, and is showing no signs of letting up. As I have written before, the main driver of the overdose crisis has always been prohibition. Policies that fail to recognize this and focus on reducing prescriptions only serve to drive nonmedical users to more dangerous drugs and make patients suffer in the process.

The WMD hypothesis probably derives from a lone instance in 2002 when fentanyl was pumped into a Moscow theater by Russian police to end a hostage crisis, resulting in nearly 200 deaths. The means by which it was aerosolized have never been made public. Much remains secret. American authorities believe a second disabling substance might have been mixed in with the fentanyl. And Russian doctors complained that delays in entering the building and the failure to have naloxone available contributed to the deaths. 

However, a 2017 position statement from the American College of Medical Toxicology states, “At the highest airborne concentration encountered by workers, an unprotected individual would require nearly 200 minutes of exposure to reach a dose of 100 mcg of fentanyl… evaporation of standing product into a gaseous phase is not a practical concern.” 

The urban myth that even minimal skin contact with fentanyl or an analog can cause a drug overdose has been difficult to eradicate. Because it not easily absorbed through the skin it took years of research before pharmaceutical companies finally devised a means to deliver fentanyl trans-dermally using a skin patch, now one of the most common ways it is prescribed in the outpatient setting. In its position paper, the ACMT also affirms that even extreme skin exposure to fentanyl “cannot rapidly deliver a high dose” of fentanyl.

Yet reports abound of first responders being rushed to emergency rooms after manifesting overdose symptoms upon exposure to fentanyl, only to be cleared and released upon evaluation. This may be attributable to the nocebo effectan exquisite example of the power of suggestion that has a neurochemical explanation. Guidelines on preventing occupational exposure from the Centers for Disease Control and Prevention and first responder alertsfrom the Drug Enforcement Administration that state, “Exposure to an amount equivalent to a few grains of sand can kill you,” only serve to enhance the nocebo effect and feed the hysteria.

The DEA states almost all of the fentanyl it seizes is “illicit fentanyl“—fentanyl and fentanyl analog powders made in clandestine labs in Asia and now in Mexico. It is often purchased on the “dark web” and shipped to the US in the mail. Fentanyl’s appearance in the underground drug trade is an excellent example of the “iron law of prohibition:” when alcohol or drugs are prohibited they will tend to get produced in more concentrated forms, because they take up less space and weight in transporting and reap more money when subdivided for sale. 

Licit fentanyl is an excellent drug, not usually produced in powdered form, and is used in many different clinical settings, not the least of which is in the operating room as an anesthetic adjunct. 

Illicit fentanyl is mainly used to enhance the strength of heroin and as an additive to cocaine (for “speedballing”). Drug dealers also use pill presses to press fentanyl into counterfeit prescription pain pills and sell them to unsuspecting drug users. 

The Drug Enforcement Administration recently moved several illicitly produced analogs of fentanyl to Schedule 1 (no known medical use), thus banning them.

This will do nothing to stop the fentanyl trade. The DEA already claims that almost all of the fentanyl seized is illicit fentanyl. Making it schedule 1 will not cause these labs to shut down or the cartels to stop their already lucrative trade. Dozens of fentanyl analogs have been developed and more are on the way. They are as easy to make in the lab as making meth from Sudafed or P2P. 

As they develop scenarios and contingency plans for weaponized fentanyl, policymakers refuse to see that the actual weapon of mass destruction is America’s endless war on drugs.

 

 

They Still Call It An “Opioid Epidemic.” Why’s That?

The Cleveland Plain Dealer recently reported that, while overdose deaths have come down slightly over the past year in the Cleveland metropolitan region, a new killer has emerged on the scene: cocaine mixed with fentanyl.

The Cuyahoga County Coroner’s Office informs the public that cocaine was involved in 45 percent of overdose deaths last year, the highest rate in ten years. It reports that cocaine is being found in combination with fentanyl with increasing frequency, and it is believed that many cocaine users are either unaware of the presence of fentanyl or, if they are, they are uncertain as to the amount that is present. The highly potent fentanyl (roughly 100 times more potent than morphine) causes them to asphyxiate and die.

This phenomenon was reported a year ago in Massachusetts and the New England region. According to the Drug Enforcement Administration, fentanyl has been supplanting heroin as the narcotic often combined with cocaine to affect “speedballing”—a dangerous technique designed to minimize the negative effects of the “come-down” after the rush from cocaine. 

The rise in cocaine-related overdose deaths is also associated with a change in the demographic mix of overdose victims. The Plain Dealer report states:

Historically in Cuyahoga County, opioid deaths have had the most severe impact among white people, and in suburban communities, Gilson said. Cocaine, on the other hand, has largely been linked to overdose deaths among African-Americans, and in urban communities…

“We’re starting to see a rise in fentanyl deaths among African-Americans, but we’re also seeing more cocaine in the fentanyl deaths among the white, suburban residents,” Gilson said. “Now, as those two interface, we start to see more deaths, period.”

One encouraging part of the Plain Dealer story is that the overall overdose rate in Cuyahoga County came down slightly in the past year. Credit has been given to the more liberal distribution of the overdose antidote naloxone as well as the distribution of fentanyl test strips. Originally approved by the FDA for urine drug testing, they are now being used “off-label” to test for the presence of fentanyl in a drug bought on the black market. Distributing naloxone and fentanyl test strips are two harm reduction strategies. 

A Canadian firm, BTNX, manufactures the test strips and has neither sought nor gained approval for their use in this context. The test strips work well for IV heroin users, who adjust their heroin dose or even discard the heroin according to the amount of fentanyl detected. Public health officials are concerned that it might be more difficult to use the test strips with cocaine, because the substance must be liquified in order to test it. In most cases, the heroin is already in liquid form because it is intended for injection.

Sadly, in many states with anti-paraphernalia laws, such as my home state of Arizona, fentanyl test strips are illegal for distribution because they are considered a form of drug paraphernalia. Last June the Maryland legislature removed fentanyl test strips from that state’s drug paraphernalia list.

As public health and law enforcement authorities more openly discuss the prevalence of cocaine, fentanyl, heroin, and methamphetamines in the overdose statistics, it is reasonable to ask why they and the media continue to refer to this as an “opioid epidemic” when it is obviously a “prohibition crisis.”

 

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From “Meth Crisis” to “Opioid Crisis” to “Fentanyl and Meth Crisis” to…

Today’s Wall Street Journal reports that, just as overdose deaths related to prescription pain relievers are showing signs of leveling off, officials worry that the surge in methamphetamine-related deaths is joining the surge in fentanyl-related deaths to fuel the total drug overdose rate. 

There were 1887 meth-related deaths reported in 2011. By 2017 more than 10,000 deaths were reported related to meth and other chemically-similar psychostimulants.

The Drug Enforcement Administration has seen a 118 percent increase in meth seizures by law enforcement between 2010 and 2017. The meth is cheap and abundant and flooding the US mainly from Mexico, according to the agency. The Mexican cartels have taken up the meth trade to compete with cocaine coming up from South America. 

The Journal article quotes a spokesman from the Phoenix office of the DEA as saying the meth is smuggled through tunnels, through ports of entry, and between ports of entry. 

As I wrote here, the meth trade became the domain of the Mexican cartels after the US cracked down on homegrown meth labs and made Sudafed (a decongestant converted to meth in those labs) more difficult to obtain. 

I pointed out elsewhere that waging a war on drugs is like playing a game of “Whac-a-mole.” The war should be drawn to a close and attention should turn to ameliorating the death and other harms that prohibition has wrought. 

In 2005 Congress acted to address the “Meth Crisis.” Shortly thereafter it turned its attention to the “Opioid Crisis.” Now it is dealing with a fentanyl crisis and a replay of the meth crisis. How many more will die or suffer needlessly before lawmakers wise up?

 

The Unrecognized Lesson of “Meth Crisis 2.0”

On February 21, Charles Fain Lehman wrote an important column in the Wall Street Journal alerting the public to the alarming rise in methamphetamine-related deaths in recent years. This has been occurring under our noses while the press and lawmakers focus their attention on overdoses related to opioids. 

He correctly tells readers that the recrudescent meth crisis, which I like to call “Meth Crisis 2.0: The Mexican Connection,” came about after lawmakers addressed “Meth Crisis 1.0” in 2005 with the Combat Methamphetamine Epidemic Act. That Act made it much harder for allergy sufferers to get the effective decongestant Sudafed by restricting its sales and making it “behind-the-counter” (in Oregon and Mississippi it was made prescription-only) and conducting a military-like crackdown on homegrown meth labs that had organically sprung up in neighborhoods across the country. Lehman then describes how the Mexican cartels quickly stepped in to fill the void and now supply meth users at record levels.

The US pressured Mexico into restricting domestic Sudafed sales, but the cartels quickly shifted to phenyl-2-propanone (“P2P”) to make their meth.

As I read his column, I kept thinking “he is about to explain that this is an example of why prohibition never works—it just drives the prohibited activity underground and makes it more dangerous.” 

Unfortunately, rather than indicting prohibition, he calls for toughening border security and surveillance and beefing up law enforcement, as if somehow doing the same thing we have been doing for the last 50 years, only harder, will make a difference.

To his credit, Lehman gives a nod to harm reduction, specifically to distributing test strips so meth users can screen their meth for fentanyl (an additive seen with increasing frequency) and supporting Medication Assisted Treatment. 

As my Letter to the Editor in today’s journal points out, Lehman came oh so close to making the right policy recommendations, but then disappointed. I’m glad he’s onboard with the idea of harm reduction. But the harms will continue to generate in ever greater numbers until prohibition ends.

Latest Numbers From Massachusetts Provide More Evidence That Prohibition Is The True Killer

The Massachusetts Department of Public Health reported today on the opioid-related overdose rate in the commonwealth for 2017. The good news is the overdose death rate decreased by 8 percent from 2016 to 2017. 

But a closer look at the numbers reveals that overdoses from prescription opioids were found in around 20 percent of “opioid deaths with specific drugs present.” (See figure 4, page 3 of the report.)

A startling 83 percent had fentanyl present in their drug screens, 43 percent had heroin, and 41 percent had cocaine. The report stated that the fentanyl was “most likely illicitly produced and sold, not prescription fentanyl.”

The 20 percent of deaths in which prescription opioids were found in the screen does not break things down any further, but judging by the estimated 68 percent of opioid-related deaths that feature multiple drugs on board (such as benzodiazepines, fentanyl, heroin, cocaine, methamphetamines, alcohol), we can safely assume that the overdose rate due exclusively to prescription painkillers is significantly lower than 20 percent.

Meanwhile, policymakers stay fixated on pressuring doctors to prescribe fewer and lower doses of opioids for their patients in pain, and state attorneys general set their sights on suing opioid manufacturers, completely ignoring the fact that the overdose crisis has primarily been about nonmedical users accessing drugs in the dangerous black market. Prohibition is the real killer.

Today’s Drug Abusers Did Not Derive From Yesterday’s Patients

We learned last week that the 2017 drug overdose numbers reported by the US Centers for Disease Control and Prevention clearly show most opioid-related deaths are due to illicit fentanyl and heroin, while deaths due to prescription opioids have stabilized, continuing a steady trend for the past several years. I’ve encouraged using the term “Fentanyl Crisis” rather than “Opioid Crisis” to describe the situation, because it more accurately points to its cause—nonmedical users accessing drugs in the dangerous black market fueled by drug prohibition—hoping this will redirect attention and lead to reforms that are more likely to succeed. But the media and policymakers remain unshakably committed to the idea that the overdose crisis is the product of greedy pharmaceutical companies manipulating gullible and poorly-trained doctors into over-prescribing opioids for patients in pain and ensnaring them in the nightmare of addiction.

As a result, most of the focus has been on pressing health care practitioners to decrease their prescribing, imposing guidelines and ceilings on daily dosages that may be prescribed, and creating surveillance boards to enforce these parameters. These guidelines are not evidence-based, as Food and Drug Administration Commissioner Scott Gottlieb seems to realize, and have led to the abrupt tapering of chronic pain patients off of their medication, making many suffer desperately. An open letter by distinguished pain management experts appeared last week in the journal Pain Medicine criticizing current policies for lacking a basis in scientific evidence and generating a “large-scale humanitarian issue.” 

Current policy has brought high-dose prescriptions down 41 percent between 2010 and 2016, another 16.1 percent in 2017, and another 12 percent this year. Yet overdose deaths continue to mount year after year, up another 9.6 percent in 2017.

One might expect the obvious prevalence of heroin and illicit fentanyl among overdose deaths would make policymakers reconsider the relationship between opioid prescribing, nonmedical use, and overdose deaths. The data certainly support viewing the overdose crisis as an unintended consequence of drug prohibition: nonmedical users preferred to use diverted prescription opioids and, as supplies became tougher to come by in recent years, the efficient black market responded by filling the void with cheaper and more dangerous heroin and fentanyl.

No Let Up On The Bad News About Overdose Deaths

The National Center for Health Statistics (NCHS) just issued Data Brief Number 329, entitled “Drug Overdose Deaths in the United States, 1999-2017.” Drug overdose deaths reached a new record high, exceeding 70,000 deaths in 2017, a 9.6 percent increase over 2016. That figure includes all drug overdoses, including those due to cocaine, methamphetamines, and benzodiazepines. The actual breakdown according to drug category will be reported in mid-December. However, estimates are opioid-related deaths will account for roughly 49,000 of the total overdose deaths. 

The big takeaways, quoting the report:

- The rate of drug overdose deaths involving synthetic opioids other than methadone, which include drugs such as fentanyl, fentanyl analogs, and tramadol, increased from 0.3 per 100,000 in 1999 to 1.0 in 2013, 1.8 in 2014, 3.1 in 2015, 6.2 in 2016, and 9.0 in 2017.The rate increased on average by 8% per year from 1999 through 2013 and by 71% per year from 2013 through 2017.

-The rate of drug overdose deaths involving heroin increased from 0.7 in 1999 to 1.0 in 2008 to 4.9 in 2016. The rate in 2017 was the same as in 2016 (4.9).

-The rate of drug overdose deaths involving natural and semisynthetic opioids, which include drugs such as oxycodone and hydrocodone, increased from 1.0 in 1999 to 4.4 in 2016. The rate in 2017 was the same as in 2016 (4.4).

-The rate of drug overdose deaths involving methadone increased from 0.3 in 1999 to 1.8 in 2006, then declined to 1.0 in 2016. The rate in 2017 was the same as in 2016 (1.0).

Despite the fact that overdose deaths from prescription opioids—and even heroin—have stabilized, the overdose rate continues to climb due to the surge in fentanyl deaths. 

This has happened despite policies in place aimed at curtailing doctors from prescribing opioids to their patients in pain. Prescription surveillance boards and government-mandated prescribing limits have pushed prescribing down dramatically. High-dose prescriptions were down 41 percent between 2010 and 2016, another 16.1 percent in 2017, and another 12 percent this year.

Policies aimed at curbing prescribing are based on the false narrative that the overdose crisis is primarily the result of greedy drug makers manipulating gullible doctors into overtreating patients in pain and hooking them on drugs. But as I have written in the past, , the overdose crisis has always been primarily the result of non-medical users accessing drugs in the dangerous black market that results from prohibition. As the supply of prescription opioids diverted to the underground gets harder to come by, the efficient black market fills the void with other, more dangerous drugs. Lately, the synthetic opioid fentanyl has emerged as the number one killer.

In a New York Times report on the matter today, Josh Katz and Margot Sanger-Katz hint that policymakers are aiming at the wrong target by stating, “Recent federal public policy responses to the opioid epidemic have focused on opioid prescriptions. But several public health researchers say that the rise of fentanyls requires different tools. Opioid prescriptions have been falling, even as the death rates from overdoses are rising.”

Prescription opioids are not the cause of the overdose death crisis. Neither is fentanyl, despite the fact that it is now the primary driver of the rising death rate. The ultimate cause of the drug overdose crisis is prohibition. US policymakers should drop the false narrative and face reality, like Portuguese health authorities did 17 years ago.

Portugal, in 2001, recognized that prohibition was driving the death rate. At the time it had the highest overdose rate in Western Europe. It decriminalized all drugs and redirected efforts towards treatment and harm reduction. Portugal saw its population of heroin addicts drop 75 percent, and now has the lowest overdose rate in Europe. It has been so successful that Norway is about to take the same route.

At a minimum, policymakers in the U.S. should turn to harm reduction. They should expand syringe exchange and supervised injection facilities, lighten the regulatory burden on health care practitioners wishing to treat addicts with medication-assisted treatments such as methadoneand buprenorphine, and reschedule the overdose antidote naloxone to a truly over-the-counter drug.

Unless this happens, we should expect more discouraging news from the NCHS in the years ahead.

 

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