Topic: Health Care

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.

Fed Chair High on Banking Reform for Cannabis Industry

Advocates of marijuana legalization, and owners of cannabis-oriented companies, received a positive boost this week when Jerome Powell, the Federal Reserve Chair, testified to Congress that providing clarity to banks dealing with the cannabis industry would be desirable:

“I think it would be great to have clarity,” Powell said from Capitol Hill. “It puts financial institutions in a very difficult place and puts the supervisors in a difficult place, too. It would be nice to have clarity on that supervisory relationship.” (CNBC)

Powell’s testimony comes as a new draft of the Secure And Fair Enforcement Banking Act of 2019 (SAFE Act) is circulating. The legislation would expand dispensary and other cannabis company access to formal banking – allowing a shift away from cash-based operation – and protect investors and bankers from the current potential legal consequences of providing financial services to the cannabis industry.

Expanding these legal protections will not only allow banks and investors to participate in a rapidly growing market; it might also increase pressure on the federal government to legalize – or at least de-schedule – marijuana.

 

Research assistant Erin Partin co-authored this blog post.

Safe Injection Sites Are Good; Legalization Would Be Even Better

Along with several major US cities—including New York, Philadelphia, Seattle, and San Francisco—Massachusetts is considering approval of “safe consumption sites” for drug users. The Massachusetts Harm Reduction Commission called for:

“pilot sites where people can consume illegal drugs in hygienic surroundings with trained staff who can revive those who overdose.”

Establishing safe injection sites is undoubtedly a useful step in stemming opioid overdoses.  These sites expand individual freedom, and substantial evidence indicates that supervised injection sites reduce overdose death and infection rates while not increasing drug use or crime. Despite this, the federal government remains staunchly opposed to such sites, at the cost of human lives.

Safe injection sites are only necessary because of drug prohibition. If opioids were legal, quality control would be vastly better and accidental overdoses would be rare.  Also, without FDA restrictions that make Naloxone available only via prescription (Naloxone is a drug that reverses overdoses), users could protect themselves against overdoses, reducing or obviating the need for safe injection sites.

Thus safe injection sites are good. But we should not lose site of the broader goal of full legal access to all drugs.


Research assistant Erin Partin co-authored this blog post.

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.) 

Early Results From Canada’s Recreational Cannabis Legalization

Statistics Canada released the National Cannabis Survey results for the fourth quarter of 2018 yesterday. Despite comedic predictions that Canada will become “the stoner living in America’s attic” after it legalized cannabis for recreational use, the early results suggest nothing much has changed. The survey found: 

“About 4.6 million or 15% of Canadians aged 15 and older reported using cannabis in the last three months. That was a similar percentage to what was reported before legalization. In addition, nearly one in five Canadians think they will use cannabis in the next three months.”

Survey respondents stated that quality and safety were the primary factors influencing their decision as to where to purchase the cannabis, with price and accessibility secondary factors. Slightly over half the respondents stated they used cannabis for medical as opposed to recreational purposes. The overwhelming majority of documented medical users were daily users. A large majority of medical users preferred methods other than smoking as their means of consumption.

Recreational marijuana legalization took effect only recently, in October 2018, so this report represents an early snap shot. But based upon what we have seen so far, those who fear that Canada’s economy will collapse as it transformed into a nation of non-working stoners can “mellow out.”

Pages