Tag: Overdose

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.”

 

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Libertarians and Harm Reduction

Last week we held a day-long conference at the Cato Institute devoted to exploring the strategy known as “harm reduction” to address the rising rate of drug overdose deaths and the spread of infectious diseases, such as hepatitis and HIV.  

In my remarks at the beginning and at the conclusion of the conference, I pointed out that the harms afflicting the drug-using community and their intimate contacts are the direct result of drug prohibition. Cato’s Jeffrey Miron emphasized that point in a key presentation and discussed the success Portugal has had in reducing overdose deaths, HIV, hepatitis, and the heroin addiction rate after it decriminalized all drugs in 2001.

While I stated that the ultimate act of harm reduction would be to end the War on Drugs, I argued that, as a start, the goal of drug policy must shift from one that is focused on prohibiting and punishing the consumption of certain unapproved substances to one that is focused on reducing the disease transmission and deaths that come from drug prohibition. Rather than continue to pour huge amounts of resources into putting people in cages for buying, selling, or placing certain unapproved substances into their bodies, those resources would be put to better use reducing the harms our current policies inflict on people. Harm reduction is realistic. It recognizes there will never be a drug-free society and therefore seeks to make nonmedical use of licit and illicit drugs in the black market less dangerous.

Harm reduction strategies include:

  • Needle-exchange programs and safe (aka supervised) injection facilities 
  • Medication Assisted Treatment with drugs like methadone, buprenorphine, and sometimes hydromorphone (dilaudid) and heroin—so those with addiction or dependency can avoid the horrors of withdrawal (and the use of dirty needles) while stabilizing their lives, then gradually taper off the drug on which they are dependent.
  • Making the overdose antidote naloxone as well as fentanyl test strips more readily available. 
  • Decriminalizing cannabis, which has demonstrated potential in the treatment of pain as well as in the management of withdrawal and possibly even as Medication Assisted Treatment.

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?

 

For Those Who Are Serious About Increasing Access to MAT for Opioid Use Disorder…

The synthetic opioid methadone, developed in Germany in the 1930s for the treatment of severe pain, has been employed for the Medication Assisted Treatment (MAT) of heroin addiction and opioid use disorder since the 1960s. In the US, methadone clinics are tightly regulated by the Drug Enforcement Administration and the Substance Abuse and Mental Health Services Administration. 

Patients receiving methadone to treat their addiction must ingest it under the observation and supervision of clinic staff, who keep it in a lock box. Eventually, patients are permitted to take a few doses home with them for use over the weekend, and only after a lengthy course are some patients allowed to take home doses for themselves for “maintenance” purposes.

Individual states add additional layers of regulation. West Virginia has had a statewide moratorium on new methadone clinics since 2007. Georgia, Indiana, Louisiana, Mississippi, and Wyoming have onerous restrictions and caps on their growth. Ohio recently lifted its moratorium on privately-owned methadone clinics. 

All of this makes it very difficult for health care practitioners who wish to treat patients with substance abuse disorder to do so using methadone. Despite these obstacles, the DEA reports it approved 254 new methadone clinics between 2014 and 2018 in response to the opioid overdose crisis. But the demand for methadone clinics far exceeds the supply. And it is unrealistic to expect people seeking treatment who live in rural areas or in states where methadone clinics are few and far between to drive long distances to and from the nearest clinic to take their daily dose. 

Contrast this with MAT using buprenorphine (Suboxone). This partial opioid agonist was approved by the Food and Drug Administration for MAT in 2002 and was combined with the overdose antidote naloxone into its abuse-deterrent formulation, Suboxone, in 2010. Under the Drug Addiction and Treatment Act (DATA) passed in 2000, doctors were permitted to prescribe buprenorphine on an ambulatory basis after taking an 8-hour course and meeting other requirements administered by SAMHSA. There are strict limits on the number of patients a practitioner may treat, and nurse practitioners and physician assistants need to obtain a waiver in order to prescribe Suboxone.  Congress passed the SUPPORT for Patients and Communities Act last October, raising the quota on the number of patients a doctor can treat while expanding the role of nurse practitioners and physician assistants. These regulations still deter many practitioners from providing MAT to their patients. SAMHSA reports that as of this date only 8 percent of practitioners have sought certification for buprenorphine treatment. Yet as onerous as these regulations may be, they are not nearly as onerous as those that govern methadone treatment.

Will US Drug Policymakers Blow It Again—This Time With Benzodiazepines?

In a recent column, Maia Szalavitz reports on the rise in overdose deaths related to benzodiazepines (a class of tranquilizers including Xanax, Valium, and Ativan). According to a recent study in JAMA, the number benzodiazepine prescriptions doubled in the US  from 2003 to 2015. And benzodiazepines are found in the bloodstream of almost a third of all opioid overdose victims—a nearly ten-fold increase since the beginning of this century. Szalavitz reminds us that the US is not the only developed country with an overdose problem from the nonmedical use of prescription drugs: Scotland has been contending with this problem for years, and the city of Dundee has been dubbed the “drug death capital of Europe.” 

Unlike the US, where fentanyl was found in 40 percent of overdose deaths in 2017, the main ingredients of Scotland’s overdoses are benzodiazepines, involved in more than half the drug deaths in Scotland. Like the US, most of Scotland’s overdose deaths involve multiple drugs, including heroin, cocaine, fentanyl, and alcohol.

US policy focused on decreasing opioid prescribing (high dose opioid prescriptions are down 58 percent in the US since 2008). Likewise, Scottish policy emphasized and succeeded in reducing benzodiazepine prescribing. In both cases, the goal was to reduce the amount of the drug available for diversion to the black market for nonmedical users. And in both cases, the efficient black market filled the vacuum with illicit and more dangerous substitutes.

Illicit benzodiazepines like phenazepam (originally developed in the USSR in the 1970s) and etizolam are much more potent and dangerous. Many are made in local clandestine labs and pressed into counterfeit Xanax or Valium pills.

Benzodiazepine overdoses are manifested by the victims growing stuporous, lapsing into a coma, hypoventilating from respiratory depression, developing bluish fingernails from decreased oxygenation and, ultimately, dying. Benzodiazepine withdrawal can last much longer than opioid withdrawal, sometimes taking months or years, often featuring seizures, and is much more likely to result in death. The potentially lethal consequences of acute withdrawal make Medication Assisted Treatment of benzodiazepine dependency or addiction essential.

It seems the Scots sowed the same (failed) supply-side policies towards benzodiazepine overdoses that the US did towards opioid overdoses. And they reaped the same results. Szalavitz explains:

“People who once had access to drugs that were of known dosage and purity suddenly did not. Drug dealers stepped in to meet the demand, and the global supply chain of illegally-manufactured pharmaceuticals provided the products users wanted.”wareness of the growing role of benzodiazepines in the US overdose crisis, US policymakers should learn from Scotland’s mistakes in addressing nonmedical benzodiazepine use so as not to repeat them. But that requires them to recognize that Scotland was merely emulating US policy towards opioids.

The growing role played by benzodiazepines in US drug overdose deaths is gaining more attention. US policymakers should learn from and avoid the mistakes Scotland made in dealing with nonmedical benzodiazepine use. That means recognizing that Scotland was emulating US policy toward nonmedical opioid use. 

(Maia Szalavitz will be a featured speaker at the Cato Institute day-long conference on harm reduction on March 21.) 

Add Hepatitis C to the List of Unintended Consequences of Abuse-Deterrent Opioids

One year ago Cato published my policy analysis, “Abuse-Deterrent Opioids and the Law of Unintended Consequences,” which provided strong evidence that reformulating opioids, so that they could not be crushed for snorting or dissolved for injecting by nonmedical users, only served to drive nonmedical users to more dangerous, readily available, and cheaper heroin provided by the efficient black market. 

The evidence included a RAND study that found “a substantial share of the dramatic increase in heroin deaths since 2010 can be attributed to the reformulation of OxyContin” which replaced regular OxyContin in 2010. It also included a study from researchers at Notre Dame and Boston Universities that found:

When we combine heroin and opioid deaths together, we find no evidence that total heroin and opioid deaths fell at all after the reformulation—there appears to have been one-for-one substitution of heroin deaths for opioid deaths.

Now comes a new RAND study that finds the abuse-deterrent reformulation of OxyContin led to an increase in cases of hepatitis C from IV drug use. As nonmedical users switched from OxyContin to injectable heroin, more became exposed to hepatitis C, transmitted by needle sharing.

The study compared states with above-median misuse rates of OxyContin to states with below-median misuse rates before and after the drug’s reformulation—from 2004 to 2015. Prior to the reformulation there was almost no difference in hepatitis C infection rates between the states. After the reformulation, states with above-median misuse rates saw a 222 percent increase in hepatitis C infections, while the below-median states saw a 75 percent increase during the same period. 

Add hepatitis C to the list of unintended consequences from abuse-deterrent reformulation of opioids.

Despite mounting evidence that abuse-deterrent reformulation of opioids has done nothing to reduce overdoses but may in fact be adding to them, the Food and Drug Administration continues to encourage pharmaceutical manufacturers to bring more abuse-deterrent formulations to market. As was the case with OxyContin, reformulation often results in extension of existing patents, reducing competition from generics and allowing patent holders to charge and profit more from their product. So opioid manufacturers are answering the FDA’s call for more abuse-deterrent reformulations.

Now that we have strong evidence that abuse-deterrent formulations spread disease as well as death, perhaps the FDA will reconsider this ill-advised policy.

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