Tag: prohibition

New Evidence From British Columbia Provides a Strong Case for Harm Reduction Strategies

A study published last month in the peer-reviewed journal Addiction by researchers at the British Columbia Centre for Disease Control and the British Columbia Centre on Substance Use found that harm reduction strategies were responsible for the province’s opioid-related overdose death rate being less than half of what it otherwise would have been between April 2016 and December 2017.

The researchers noted that 77 percent of opioid-related overdose deaths during that time frame involved illicit fentanyl. Vancouver has long been a major port of entry for fentanyl and fentanyl analogs, produced in China and other parts of East Asia, often using historic seaborn drug trade routes

During the 23 months ending December 2017 there were 2,177 overdose deaths in British Columbia, according to the British Columbia Centre for Disease Control. Using mathematical modeling methodology to estimate monthly overdose and overdose-death risk along with the impact of harm reduction interventions, the researchers concluded an estimated 3,030 overdose deaths were averted.

The three harm reduction strategies investigated were take-home naloxone kits, safe injection sites, and “opioid agonist therapy”— known in the U.S. as Medication Assisted Treatment (which includes methadone, buprenorphine, hydromorphone, and heroin assisted treatments in British Columbia). The researchers employed counterfactual simulations with the fitted mathematical model to estimate the number of deaths averted for each harm reduction strategy as well as the three strategies in combination. 

While the harm reduction strategies combined for more than 3000 deaths averted, the number of lives saved by each strategy taken in isolation broke down as follows: 

  • 1,580 (1,480-1,740) deaths averted by take-home naloxone
  • 230 (160-350) deaths averted by safe injection sites
  • 590 (510-720) deaths averted due to opioid-agonist therapy

All three interventions worked in synergy to greatly reduce the death rate, but the widespread distribution of naloxone saved the most lives. 

Michael Irvine, the study’s lead author, told Canadian Broadcasting Company reporters that in recent years the overdose crisis has been driven by a prevalence of fentanyl and fentanyl analogs. 

Among the developed nations, Canada has been one of the hardest hit by the overdose crisis on a per capita basis, with overdose deaths in Vancouver, BC approximating those of some of the worst-hit states in the U.S. as recently as 2017. This recent study gives us reason to conclude that, had British Columbia not embraced harm reduction strategies, the per capita overdose rate would have far-exceeded that of the U.S.

Canadian policymakers are being urged to curtail the prescription of opioids to patients in pain, despite the fact that more than three-quarters of overdose deaths involve fentanyl and, as in the U.S., the majority of overdose deaths involve multiple other drugs as well, including cocaine, heroin, benzodiazepines, and alcohol. This approach is driven by the failure to recognize there is no correlation between the number of prescriptions written for patients and the incidence of non-medical use of prescription opioids or prescription opioid use disorder. 

The Canadian government has also given in to pressure by the U.S. government to double down on its war on drugs. But in the U.S., researchers have learned that overdoses from the non-medical use of licit and illicit drugs has been on a steady exponential increase since the 1970s–the only variation being which particular drug is in vogue in any particular era–with no evidence of any slowing. It appears to be a result of sociocultural and psychosocial factors. There is no reason to believe things are much different in Canada.

Efforts to approach this problem by doubling down on supply-side interventions and the War on Drugs are doomed to fail—and will only cause more people to die. Fighting a war on drugs is like playing a game of “Whac-a-Mole.”

If the British Columbia experience should teach policymakers anything, it should be that harm reduction is the most effective way to end the overdose crisis. Ending prohibition would be the most consequential form of harm reduction.

Topics:

CDC Provisional Drug Death Numbers Show Slight Improvement. Credit Harm Reduction.

Provisional data released by the Centers for Disease Control and Prevention suggest the annual overdose death rate may be levelling off or even slightly declining. The data predict a drop in the death rate to 69,096 for the 12-month period ending November 2018, down from 72,300 predicted deaths for the 12-month period that ended November 2017. These provisional findings represent a 4.4 percent drop in the national overdose rate. 

The drug overdose death numbers include deaths due to natural and semi-synthetic opioids, synthetic opioids other than methadone (fentanyl and its analogs), methadone, methamphetamines and other stimulants, cocaine, and benzodiazepines. For example, opioid-related deaths accounted for 47,600 of the 70,237 overdose deaths reported by the CDC for the year 2017. The final report for the year 2018 should be available in December of this year.

The possible slowing or decrease of the overdose rate is likely due to the fact that many state policymakers have begun to recognize the wisdom of harm reduction, a realistic acceptance of the fact that there will never be a “drug-free” society, that seeks to reduce the risks associated with non-medical use of licit and illicit drugs. As I have written here, harm reduction has long been an approach employed by health care professionals in modern and developed societies. 

The provisional report from the CDC shows the most dramatic improvements in states that have expanded the availability of the opioid overdose antidote naloxone, allowed for the expansion of needle exchange programs, and increased the licensing of Medication Assisted Treatment (e.g., methadone, buprenorphine) programs. In fact, the greatest improvement was seen in Ohio, which has aggressively promoted these harm reduction measures. Ohio had been an epicenter of opioid-related overdose deaths. The provisional numbers for the year ending November 2018 show a 23.3 percent decrease in overdose deaths. The states that have made the most progress are those that have increased the focus on harm reduction strategies.

Despite these encouraging signs, the overdose rate continues to and is likely to remain high. As researchers at the University of Pittsburgh have discovered, overdoses related to the non-medical use of licit and illicit drugs have been on a steady, exponential increase since the 1970s. The only changes that have occurred over that time period pertain to which drugs came in and out of vogue for non-medical users. 

Despite policymakers obsession with doctors prescribing pain medication to their patients, the government data show no correlation between the number of prescriptions and non-medical use or substance use disorder. In recent years deaths from fentanyl and heroin have come to represent the majority of fatalities reported by the CDC with cocaine, methamphetamines, and other stimulants showing a recent surge as well. And benzodiazepine-related deaths are also on the rise.

The driving force behind these deaths has always been drug prohibition. Ending the endless and unwinnable war on drugs would be the greatest exercise of harm reduction.

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:

The Coming “Stimulant Crisis?”

Earlier this month the Centers for Disease Control and Prevention, in the Morbidity and Mortality Weekly Report (MMWR), reported that from 2015-2016 deaths from cocaine and psychostimulants (such as methamphetamine, Ritalin, dextroamphetamine) increased 52.4 percent and 33.3 percent respectively. In 2017, the CDC reported a total overdose rate of 70,237, and cocaine was involved in 19.8 percent of those deaths while other psychostimulants were involved in 14.7 percent. Opioids, primarily synthetic (fentanyl and fentanyl analogs), were found in 72.7 percent of the cocaine deaths and 50.4 percent of the other psychostimulant deaths. The report mentioned that provisional 2018 data indicate deaths involving cocaine and other psychostimulants are continuing to increase.

As I have written here and here, deaths related to cocaine, methamphetamine, and other psychostimulants have been on the rise for several years now, despite legislation in 2005 that was supposed to address the problem, and recently fentanyl has replaced heroin as the drug with which they are combined to make a “speedball”—a mixture aimed at reducing the negative “come-down” effects after the rush from the stimulant.

The most important sentence in the CDC report was this: “Increases in stimulant-involved deaths are part of a growing polysubstance landscape.” This should be viewed in the context of a recent study from the University of Pittsburgh that concluded:

The U.S. drug overdose epidemic has been inexorably tracking along an exponential growth curve since at least 1979. Although there have been transient periods of minor acceleration or deceleration, the overall drug overdose mortality rate has regularly returned to the exponential growth curve. This historical pattern of predictable growth for at least 38 years suggests that the current opioid epidemic may be a more recent manifestation of an ongoing longer-term process. This process may continue along this path for several more years into the future…Indeed, it is possible that a future overdose epidemic may be driven by a new or obscure drug that is not among the leading causes of drug overdose death today. Understanding the forces that are holding multiple sub epidemics together onto a smooth exponential trajectory may be important in revealing, and effectively dealing with, the root causes of the epidemic.

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 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.

Pages