Topic: Health Care

Lessons for the Opioid Epidemic from Meth

As the nation remains fixated on the opioid epidemic, methamphetamine is making a resurgence. Meth is less expensive than heroin, and it is gaining users who fear opioid overdoses.

Meth is not new; it burst onto the scene in the early 1990, as the crack epidemic waned.  Synthesized from readily available chemicals, meth provided a cheaper, homemade alternative to other drugs. As use increased, legislators and law enforcement officials took note.

The first major legislation targeting meth was the 1996 Comprehensive Methamphetamine Control Act. Passed unanimously by the Senate and by 386-34 in the House, the legislation required that individuals buying and selling chemicals used in meth production register with the federal government, which sought to track such chemicals and reduce their supply to manufactures.

Despite this legislation, meth use – and fatal overdoses – increased. In response, Congress passed the Combat Methamphetamine Epidemic Act of 2005 (officially enacted in March 2006), which limited over-the-counter sales of ephedrine and pseudoephedrine, and required retailers to log customer purchase of such drugs. Simultaneously, federal and state authorities were instituting restrictions on pharmaceutical amphetamines including Ritalin and Adderall. And many states instituted prescription drug monitoring programs to reduce the availability of prescription amphetamines acquired legally and resold on the black market.

While well-intentioned, these policies may have induced users to substitute from expensive prescription drugs to cheap, readily available meth. And this switch had the usual impact of restrictions on access.

Overdose deaths related to methamphetamine initially declined after the crackdown on prescription access, but by 2016, the meth overdose rate had reached four times its level a decade ago. The likely explanation is that restrictions pushed users from prescription versions to black market meth, where uncertainty about purity generated increasing overdoses.

 Methamphetamine Overdose Death Rates

As the opioid crisis worsens and calls for supply restrictions increase, policymakers should consider how the same approach failed to halt – indeed exacerbated – the meth epidemic.

 

Research assistant Erin Partin contributed to this blogpost.

Right to Try and the FDA’s Proposed Ban on Kratom

In his State of the Union address, President Trump expressed support for a Right to Try law that would allow terminally-ill patients to test medicines not yet fully vetted by the FDA. This perspective recognizes the tradeoff between benefits and risks.

The administration is singing a different tune, however, regarding kratom, a medicinal herb grown in East Asia that might help Americans who suffer from chronic pain and do not wish to, or cannot, rely on opioids.

The FDA recently announced that it is considering a ban on kratom and is working to prevent shipments to the United States. This announcement comes on the heels of the DEA’s attempted ban in 2016, which caused a public and Congressional backlash, forcing the DEA to back down.

Kratom, which appears to target opioid receptors in the brain, is used by many chronic pain sufferers. The FDA correctly notes that existing evidence is not conclusive on kratom’s efficacy, but numerous studies and a wealth of anecdotal evidence suggest kratom relieves pain with modest risks.

Kratom is also used to reduce opioid addiction. The FDA also doubts about its effectiveness in this area, but again several studies support its value in easing withdrawal.

Doubts about effectiveness aside, the prima facie reasoning behind the FDA’s crackdown can be found in a press release from November 14, 2017, in which Commissioner Scott Gottlieb attributes 36 deaths to kratom. A recent study, however, found no evidence that kratom alone causes death.

And even if kratom can be dangerous, banning it violates the administration’s defense of Right to Try laws: potentially dangerous medicines are nevertheless valuable if their expected benefits exceed their risks.

Outlawing kratom, moreover, will mainly spawn a black market. This harms kratom consumers (by raising prices and diminishing quality control) and society generally (by generating violence and corruption, as occurs now for other banned substances).

The FDA may believe that kratom’s risks are so great that no rational person would ever accept them. But in a free society, individuals—not a government bureaucracy—decide what risks to take with their health.

The Trump White House is on the right track by supporting Right to Try. The administration should stick to this philosophy in its treatment of kratom.

Yet Another Study Points to The Potential of Cannabis for Reducing Opioid Use

The Minnesota Department of Health reported today that 42 percent of the more than 2,000 first-time medicinal marijuana users with intractable pain enrolled in its research study obtained significant pain relief. In announcing the results, the Minnesota Health Commissioner said, “We need additional and more rigorous study, but these results are clinically significant and promising for both pain treatment and reducing opioid dependence.”

The study found that 63 percent of the patients who were taking opioids for their chronic pain when they started taking cannabis were able to reduce or eliminate their opioid use after six months.  Some patients were also able to reduce their use of other pain medicines, as well as benzodiazepines.

This is not the first study to point to the potential of cannabis in reducing opioid use. A study reported in JAMA in 2014 by researchers looked at all 50 states from 1999-2010 and found opioid overdose rates approximately 25 percent lower in states with legalized medicinal marijuana during that time period. A RAND study published in the March 2018 Journal of Health Economics reveals similar findings. And researchers at the University of Michigan reported in 2016 64 percent of chronic pain patients were able to reduce their use of opioids. Researchers at the University of California at Berkeley reported last June that 97 percent of the chronic pain patients they studied were able to reduce their opioid use.

Opponents of cannabis, including Attorney General Sessions, believe it is a “gateway” drug to more potent and dangerous drugs. But this is not born out by the evidence. Since cannabis was legalized for recreational use in Colorado and Oregon, opioid overdose rates have actually come down, making a case that  cannabis is an “off-ramp,” not a “gateway.”

If anything, cannabis may have potential benefits as a substitute for opioids in the management of pain. And if the federal prohibition of cannabis is lifted then research can be more easily done, and we can find out if cannabis has a role to play in medication-assisted treatment for opioid addiction. If politicians in Washington want to do something constructive to address the opioid overdose problem, then lifting the federal ban and allowing states to go their own way would be a positive move.

Topics:

Politicians Cannot Stop Punishing Patients for the Unintended Consequences of Drug Prohibition

It seems no amount of evidence can make political leaders disabuse themselves of the misguided notion that the nation’s opioid overdose crisis is caused by doctors getting patients hooked on prescription opioids. A group of eight senators unveiled the CARA(Comprehensive Addiction and Recovery Act) 2.0 Act on February 27, targeting the opioid crisis. It would impose a 3-day limit on all opioid prescribing for patients in acute and outpatient postoperative pain.

But the movement to restrict prescriptions is not evidence-based, as prominent experts have pointed out. The politicians base their proposal on the 2016 opioid guidelines put out by the Centers for Disease Control and Prevention. The guidelines stated:

When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed.

The guidelines pointed out that the above recommendations were based on “Type 4” evidence:

Type 4 evidence indicates that one has very little confidence in the effect estimate, and the true effect is likely to be substantially different from the estimate of the effect.

It further described Type 4 evidence as being based upon “clinical experience and observations, observational studies with important limitations, or randomized clinical trials with several major limitations.”

Topics:

Hospital Didn’t Accommodate Flu-Shot Objectors On Staff, Must Pay $89,000

I’ve got the story at Overlawyered

The Equal Employment Opportunity Commission has announced that Mission Hospital in Asheville, N.C. will pay $89,000 for failing to accommodate employees “who declined flu vaccinations based on their religious beliefs.” [EEOC press release] Mission had in fact agreed to exempt employees from the flu shot based on religious objections, but required that they declare their intention ahead of time. And that turned out to be not accommodating enough, since not requiring that extent of advance notice would not in the EEOC’s view have posed an undue hardship on the employer — hence the expensive lesson….

Under the elastic “undue hardship” standard, employers may face much uncertainty as to how much disruption of their business they must put up with in the name of accommodation. The flu-shot example suggests that risks to co-workers, customers, and the general public might sometimes enter the calculus as well — an expensive guessing game at best.

More about obligations of religious accommodation under federal law, including the elastic way they tend to shrink or expand these days based on the ideological uses to which they are put, at the link. Here, however, I’d like to make a different point. Libertarians take a lot of flak because some of our number criticize mandatory government vaccination as an infringement of principles of voluntary association (though many other self-described libertarians do not in fact take this view). But in the case of Mission Hospital – a private, not-for-profit institution – principles of voluntary association lead directly to the view that the hospital should be free to require such measures of its workforce, whether to avoid risks of direct contagion, to set a good example when urging patients to vaccinate, or from other rationales. Yet here the federal government deploys its full force to prevent private and voluntary social mechanisms from being brought to bear to get a potentially high-risk group to undergo vaccination. 

Flu season is not over and this year’s strain has proved particularly deadly, by the way, so please consider protecting your family and loved ones if you have not already. Details here and here

Are Mass Shootings Becoming More Frequent?

Terrible mass shootings like the one at a Parkland, Florida high school are so shocking that it is easy to get the impression that mass shootings are increasingly common.  The number of deaths from mass shootings has been unusually high since 2007, because of five horrific incidents – Las Vegas (58), the Orlando nightclub (49), Virginia Tech (32), Sandy Hook (27), and the Texas First Baptist Church (26).  Statisticians would never try to fabricate a trend from such a small sample, even though the untrained eye may want to.

Last November, however, a Wall Street Journal essay by Ari Schulman claimed,

It isn’t your imagination: Mass shootings are getting deadlier and more frequent. A recent FBI report on “active shooters” from 2000 to 2015 found that the number of incidents more than doubled from the first to the second half of the period. Four of the five deadliest shootings in American history happened in the past five years, and 2017 already far exceeds any previous year for the number of casualties.

That FBI report “identified 160 active shooter incidents that occurred in the United States between 2000 and 2013,” with 486 people killed. The authors literally drew a straight line between just one incident in 2000 (after many in 1999) and 13 incidents in 2013, and called that a “rising trend.”

Marijuana Research Catch 22

George Hodgin’s mission seemed simple: manufacture uncontaminated, chemically consistent cannabis for use in scientific research on marijuana’s medical effects, all while complying with federal regulations surrounding the production of a drug still classified by the Drug Enforcement Administration (DEA) as highly dangerous. Despite new rules the DEA promulgated eighteen months ago, with the stated goal of allowing expanded cultivation of marijuana for scientific research, George Hodgin is still in administrative limbo. 

Hodgin, a former Navy SEAL, approached us recently for advice after encountering numerous regulatory roadblocks.  We have no special knowledge or ability in that direction; but perhaps publicizing his endeavors will nudge public opinion (and regulators) in the right direction. 

Expanding research access to high-quality marijuana is important. The Marijuana Policy Project estimates that roughly 2.5 million patients use medical marijuana – just in states with legal medical marijuana programs. This number is likely an underestimate, as it does not account for individuals obtaining marijuana for medical use through non-medical channels. Marijuana’s illegality at the federal level prevents the collection of much needed data that could help drive future research.

Veterans represent a particularly important category of medical marijuana users. Although Veterans Health Administration physicians are prohibited by federal law from recommending medical marijuana, new guidelines issued in December 2017 revise existing standards to encourage doctors and patients to discuss the use of medical marijuana without fear of recrimination.