Tag: Opioids

The War on Meth Is Back. Big Time

Today’s Seattle Times reports on the surge in methamphetamine-related deaths, noting there are more meth-related deaths than at the height of the last “meth wave” in the early 2000s. 

The era of the American meth lab is over a decade gone, yet pure, cheap meth is back and bigger than ever in Western Washington. When Seattle residents point to needles proliferating on sidewalks, they usually say heroin’s to blame; however, a bigger proportion of those needles in recent years is actually from people injecting meth, according to King County syringe exchange surveys.

Death rates in King County have increased four-fold between 2005 and 2017. As I have written here, this is a nationwide phenomenon. In 2005 Congress passed the Combat Methamphetamine Epidemic Act, which moved behind-the-counter the effective decongestant pseudoephedrine (Sudafed), often converted into meth by local meth labs, and limited the amount one can purchase per month. Law enforcement led an all-out assault, often with S.W.A.T. teams, on local meth labs. The Seattle Times report states that the 2005 crackdown dramatically reduced the number of “mom and pop” meth labs in the state of Washington. But this only created an opening for Mexican drug cartels.

Since 2011, there have been just 212 meth-lab sites reported statewide, according to the state Department of Ecology. But drug cartels south of the American border stepped in to fill demand, making more and more meth in “superlabs” in Mexico and shipping it, along with heroin and fentanyl, up Interstate 5 — hidden away in tires, paint cans and hidden compartments in semi-trucks — according to Keith Weis, special agent in charge of the Drug Enforcement Administration’s Pacific Northwest division.

Shilo Jama, a harm reduction activist in King County, told the Seattle Times that for the last several years harm reduction sites have been treating more stimulant users than opioid users. 

I pointed out in a recent blog post, “The overdose crisis is the byproduct of psycho-sociocultural trends seen among many developed countries intersecting with the dangerous world of drug prohibition—where the content and dose of the substance being sold is never reliable, and where users take otherwise avoidable risks.” 

The War on Drugs is like a game of “Whac-a-mole.” We’ve gone from meth crisis to opioid crisis and now a meth plus fentanyl crisis. If the goal of public policy is to reduce the deaths and disease that result from underground drug use, the solution is to end the war, as Portugal decided to do in 2001, and switch the focus to harm reduction.

Topics:

An Encouraging Sign for Harm Reduction Advocates

A New Hampshire high school student who is remarkably knowledgeable about the various harm reduction strategies that are underused to address the overdose crisis engaged Senator Cory Booker (D-NJ) in a discussion of the subject during a campaign stop in Littleton, NH. The video of the exchange is here.

Senator Booker, who is seeking the Democratic nomination for President in 2020, is a former mayor of Newark, NJ, a city with major drug overdose problems. He had a sophisticated conversation with the student and agreed with her on the need for safe syringe programs. At about 1:50 into the video Booker was asked if he would support needle exchange programs and safe injection sites. He responded that as mayor of Newark he established the needle exchange program in that city and “fully supports” establishing safe injection sites.

As I detail in my Policy Analysis on harm reduction, both needle exchange programs and safe injection sites have been shown for decades to reduce the spread of HIV and hepatitis, reduce overdoses, and increase the number of addicts obtaining rehab. 

While needle exchange programs are legal in the US, and are even promoted by the Surgeon General, the Centers for Disease Control and Prevention, and the American Medical Association, many states have anti-paraphernalia laws that inhibit their creation.

Safe injection sites exist in over 120 cities in Europe, Canada, and Australia, and have been in use for over 30 years. One even operates in the US clandestinely, because federal law prohibits safe injection sites in this country. Several cities are attempting to establish safe injection sites in the US, including Seattle, San Francisco, Boston, and New York. In Philadelphia, a nonprofit that includes former Pennsylvania Governor Edward Rendell on its board is attempting to establish a “Safehouse” in that city, funded entirely with private money, but is being thwarted by the Department of Justice.

While the Senator seemed to wrongly accept the mistaken narrative that the opioid manufacturers are to blame for much of the problem, it is gratifying to learn that Senator Booker has an appreciation for harm reduction in general, and needle exchange and safe injection sites in particular. And, to his credit, he has also expressed enlightened views regarding cannabis legalization

As more members of Congress join the growing ranks of mayors of major US cities in endorsing safe syringe programs, momentum will hopefully build for states to remove any remaining obstacles to needle exchange programs and for Congress to remove the federal obstacles to safe injection sites.

Latest Opioid “Sting” Again Illustrates The Power of Prohibition to Corrupt

The front page of today’s Wall Street Journal reports on a federal sting operation that led to the arrest of 31 doctors, 7 pharmacists, 8 nurses, and other health care professionals including dentists for distributing more than 32 million prescription opioid pills to patients in five Appalachian region states. 

Federal prosecutors described doctors handing out pre-signed blank prescriptions in exchange for cash. In some instances, doctors provided prescriptions in return for sexual favors. One Alabama doctor allegedly recruited prostitutes to become patients and let them use drugs at his house. Dentists performed unnecessary teeth extractions on cooperative patients so they can have a legal excuse to prescribe them the opioid pills they desired. Some doctors knowingly sold prescriptions to nonmedical drug users and then billed Medicare and Medicaid for the evaluations and tests they performed as a cover.

Brian Benczkowski of the Department of Justice told reporters, “When medical professionals behave like drug dealers, the Department of Justice is going to treat them like drug dealers.” 

Mr. Benczkowski is right to consider these professionals “drug dealers.” This is just the latest and most graphic example of how prohibition fuels the so-called opioid crisis. In 2017 the DOJ arrested 412 doctors, pharmacists, and others for engaging in similar schemes in Florida. 

As I have written here, drug prohibition creates lucrative black market opportunities for people willing to sell drugs illegally. Prescription pain pills sell for a much higher price on the black market than they do legally at the pharmacy. The lure of easy money tempts corrupt doctors, dentists, nurse practitioners, and pharmacists to leverage their degrees to nefarious ends, especially because they can use the third party payment system to “double-dip:” they get paid by drug dealer middlemen for churning out and filling prescriptions which then get sold on the black market, and at the same time get reimbursed for their “services” by Medicare, Medicaid, and insurance companies.

Prohibition brings out the worst in people. It provides the corrupt and the corruptible with irresistible money-making opportunities. 

Meanwhile, desperate chronic pain patients, already the civilian casualties in the government’s war on opioids, are justified in their concern that politicians will react to the latest news with further crackdowns on opioid prescribing while more doctors will abruptly taper their chronic pain patients or abandon treating pain altogether out of fear they might risk being the next target of law enforcement wrath.

If lawmakers, policymakers, and the press want to know where to place the blame for the ugly facts revealed by this latest sting operation the answer is obvious: blame prohibition.

 

 

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.

 

 

The AG’s Position on Marijuana Legalization a Welcome Contrast to That of His Predecessor

Lost in all of the media frenzy over the Mueller Report, redactions, and alleged improprieties within the Department of Justice and FBI, was Attorney General William Barr telling the Senate Appropriations Committee yesterday that he favors a more federalist approach to marijuana laws.

In response to a question from Senator Lisa Murkowski (R-AK), Barr said that allowing the states to set their own marijuana policy and removing the federal government from the matter would be an improvement over the present situation, which he called an “intolerable” conflict between state and federal laws. Senator Murkowski is a sponsor of the Strengthening the Tenth Amendment Through Entrusting States (STATES) Act, which would give immunity from federal action against business and people engaged in the manufacture, sale, purchase, or consumption of marijuana in states where it has been legalized. President Trump has signaled in the past that he would sign the bill if it was passed and sent to his desk.

Unfortunately, Barr still opposes federal legalization, but his approach to the issue is a stark and welcome contrast to that of his predecessor Jeff Sessions, and would amount to de facto federal decriminalization—at least in the states that have decided to legalize marijuana. 

It also signals a realization that the march toward state-by-state legalization continues to gather momentum. It may be just a matter of a few years before federal decriminalization of marijuana becomes a reality and, as is the case with alcohol, it will be a matter left up to each of the states and the District of Columbia.

Decriminalization should be a welcome change for all who are concerned with the growing rate of opioid-related overdose deaths. There is growing evidence that marijuana reduces the need for opioids to relieve pain and numerous studies have shown lower opioid-related overdose death rates in states where access to marijuana is legal. Furthermore, marijuana has great potential as a harm reduction strategy. At the recent conference on harm reduction held at the Cato Institute, Dr. Adrianne Wilson-Poe, a nationally recognized cannabis clinical researcher at Washington University School of Medicine, gave a detailed and enlightening presentation on the potential role for cannabis in Medication Assisted Treatment (MAT) as well as opioid withdrawal management. You can see that presentation here. Dr. Wilson-Poe was also interviewed on a Cato Daily Podcast here.

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.”

 

Topics:

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?

 

Pages