Under-treatment of Pain

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Chronicle Book Review: American Cartel

American Cartel: Inside the Battle to Bring Down the Opioid Industry, by Scott Higham and Sari Horwitz (2022, Twelve Press, 400 pp., $30.00 HB)

Phillip S. Smith, with contributions from David Borden

https://stopthedrugwar.org/files/americancartel.jpg
Pulitzer Prize-winning Washington Post investigative reporters Scott Higham and Sari Horwitz have been on the opioid beat for years, teaming up (with others) on the Post's "The Opioid Files" series, which was nominated for a Pulitzer in 2020. Now, with American Cartel, the pair provide a deeply-sourced account of how opioid manufacturers, distributors, and pharmacies waged an all-out campaign to fend off DEA efforts to stanch the flow of billions of opioid pain pills, and to evade any culpability, even as the overdose death toll mounted year by year.

The picture Higham and Horwitz paint of corporate and political malfeasance is damning. But the laser sharp focus with which they paint it, omits much of the context in which the opioid crisis has unfolded. And that context is also very important.

An article in yesterday's Guardian shows one of the reasons why. In much of the world, very few pain patients are able to access opioids at all. Much suffering results, sometimes leading to suicide attempts. Dr. MR Rajagopal, chair of Pallium India, told the Guardian, "Pain is not visible. It happens in hospital beds or patients' rooms and is not visible to the world. Addiction, on the other hand, is very visible in headlines which quote the US epidemic and overdose deaths. No one talks about the western European success over decades; all the news is about the opioid crisis in the USA. This means that when we try to have discussions, our work becomes harder because many minds are primed against opioids."

In other words, by speaking too solely to one side of an issue, one risks adversely impacting the other sides. Whether "opiophobia" is real or significant in the US is another question. Higham and Horwitz don't venture a view on this, at least not in American Cartel.

One entity that has warned about opiophobia (without using the term) is the US Centers for Disease Control. In a 2019 memo, CDC writes that a 2016 guidance the agency issued on prescribing opioids for chronic pain had seen "misapplication[s]" by some physicians that put patients at risk. The memo cites a New England Journal of Medicine commentary by the authors of the 2016 guidance. It warns against "hard limits" on opioid dosages or cutting patients off; abrupt tapering of prescriptions; applying the guidance to acute pain situations patients face in situations like active treatment for cancer or sickle cell anemia or post-operative care; and applying it to medication-assisted treatment prescriptions for addiction.

Technically the CDC memo addressed a period of a few years beginning in 2016. But the dynamics it describes are inherent risks in a situation where providers are charged with supplying a substance that's useful but also addictive and potentially deadly if misused, and for which they can be sanctioned professionally or even prosecuted and imprisoned if things go wrong or someone disagrees. Pharma-driven promotion of their new opioid products was a factor in driving up prescribing rates to where they reached. But a part of the increase was also the medical community reacting to a real problem of under-treatment or non-treatment of pain for some patients, a problem that coexists with over-prescribing to some other patients. That increase in turn came with a learning curve.

The authors also give short shrift to the impact of today's woes and inequalities in driving the so-called deaths of despair -- a concept coined by Princeton professors Anne Case and Angus Deaton -- alienation and anomie, helplessness and hopelessness afflicting many Americans who have been left behind in the modern economy, especially in the opioid use heartlands of the Midwest and Appalachia. The Midwest deindustrialized beginning in the 1970s, and both regions largely missed out on the tech boom of the '90s and '00s. Then came even more pain with the Great Recession, followed by COVID and more economic and social disruption. People there (and elsewhere) are dying not just of opioids, but of smoking, drinking, and suicide. Big Pharma is easily (and oh so deservingly) demonized, but the laser focus on the companies allows us not to have to look in the mirror about the pain our society produces.

That factors like these should play a role in the opioid crisis, though, doesn't exonerate Big Pharma. Rather, the misleading promotions of their products carried out by pharma, took an even greater toll due to the vulnerabilities those other factors had brought to the fore.

Meanwhile, the death toll continues to mount -- over 100,000 per year, and with a new record high every year. Prescription opioids still figure prominently in overdoses. But the greatest part of the problem by far is black-market fentanyl, used deliberately by some high tolerance heavy users of opioids, but primariy causing overdose as an adulterant in heroin, counterfeit prescription pills, and other street drugs, essentially a poisoning crisis. But as Higham and Horwitz note, that is part of a wave of opioid use that began with pharmaceutical companies such as Purdue Pharma taking Oxycontin onto the market in the late 1990s. The first decade of this century also saw other prescription opioids -- oxycodone, hydrocodone, Vicodin, Percocet, Opana, et al. -- hit the market.

Higham and Horwitz are fond of tossing around astounding numbers of pills produced by manufacturers or sold by certain pharmacies, such as Mallinckrodt producing 3.5 billion 30 milligram hydrocodone pills in one year, and critics could protest that those numbers need context, too. A prescription for a medication doesn't just have a number of pills to take. It specifies how large a dosage there is inside each pill. A smaller number of pills that each contain a higher dose might mean more than a larger number that each contain a smaller dose. And a higher dose prescription sometimes reflects a patient's tolerance to opioids built up through past medical (or non-medical) use. Maybe West Virginia didn't really need 81 million pain pills during a five-year span. But maybe it did. Without more information, it's just not clear what these numbers mean.

They do provide some context, though, for example by comparing pain pill sales across all drug stores in a region and pointing out anomalies not easily explainable by, say, differing rates of cancer or other serious illness. And they demonstrate that plenty of businesses -- from Big Pharma to the drug store chains and individual pharmacies -- were either in it for the money or at best screwed up, both through detailed analysis and telling anecdote. For example, there was the guileless Florida pharmacist who explains to investigators that she fills pain pill prescriptions all day long, but always keeps a certain number of pills on reserve "for my real pain patients."

When the DEA cracked down first on Wild West internet sales of opioids and then on the "pill mills," medical practices with perfunctory examinations and huge numbers of opioid prescriptions whose entire business model seemed to be writing opioid prescriptions, it succeeded in reducing access to those drugs. But the people using opioids didn't stop; they went to black market drugs, fueling first a resurgence in heroin use and now an opioid crisis driven by fentanyl.

A key figure in the tale is Joe Rannazzisi, who as head of DEA's Office of Diversion Control from 2006 to 2015 oversaw the agency's endless effort to ensure that prescribed opioids are only prescribed for legitimate medical purposes and not leaking into the black market. We are inclined to think of the DEA as a prohibitionist agency, but in this case, it is acting as a regulatory agency. And what Higham and Horwitz uncover is a case of regulatory capture -- when the industry being regulated manages to set the terms under which it is regulated, for its own benefit, not that of the public.

Rannazzisi and his team of DEA lawyers spent years going after opioid manufacturers, distributors, and pharmacy chains who were repeatedly (administratively) busted for failing to do due diligence about just who was buying their products. The companies would pay huge fines, promise not to do it again, and then continue to pump massive amounts of opioids through the supply chain.

The companies mobilized against Rannazzissi and his campaign, forming industry front groups, undertaking lobbying efforts, hiring legions of high-priced law firms, and crafting legislation that would rein in what they saw as an out-of-control agency. As Higham and Horwitz document in great detail, it worked.

Sponsored by Rep. Tom Marino (R-PA) and Sen. Marsha Blackburn (R-TN), both of whom received substantial contributions from the industry, but written by industry lobbyists, the nicely named Ensuring Patient Access and Effective Drug Enforcement Act removed from the DEA tools that Ranizzisi had been using to try to force drug distributors to monitor and report suspicious orders, such as the 1.2 million oxycodone tablets one distributor bought from Mallinckrodt in one day, only to order another 1.2 million the next day.

The bill passed, only to be drastically revised amidst scandal after an earlier Post report on the opioid bill derailed then-President Trump's effort to name Marino drug czar. But Higham and Horwitz also detail rot inside the DEA, where the industry managed to get to high-ranking officials who sidelined Rannazzisi, forcing him into retirement and forcing many of his team members into bureaucratic Siberia. It's an ugly little story of money and power, the sort that is all too common in Washington.

If the first part of American Cartel reads like a detective novel, the second part is more like a legal thriller, It covers the massive wave of civil lawsuits filed against the drug companies, and it is not particularly edifying reading. You see hundreds of high-powered attorneys from the country's top litigating firms -- including dozens of former DEA attorneys working now working for the industry they regulated -- facing off against armies of lawyers for the thousands of states, cities, and counties. You see massive settlements from the companies and massive damages wrested from companies that went to court and lost. While it is unclear just how the moneys won or negotiated by the various plaintiffs is actually being used to help people who suffered from the opioid crisis, what is clear is that it has been a bonanza for the legal profession, with winnings -- excuse me, earnings -- by attorneys reaching well over a billion dollars.

They weren't all in it for the money, though. Some, like West Virginia attorney Paul Farrell, whose state was one of the epicenters of the pain pill epidemic, were sickened by the toll of addiction they saw all around them. Not willing to settle for the pittance the town and county he represented would receive under a massive settlement agreed to by most of the suing entities, he gambled on going it alone against the drug distributors. As this book went to print in April, he was still waiting for a decision. Earlier this month, he lost, with a federal judge ruling that drug distributors were not responsible for the area's opioid crisis.

The litigation goes on, and the dying goes on. Sometimes the drug companies settle, sometimes they lose and have to pay even more. But sometimes they win.

The profit-driven wave of opioids that engulfed the country in the last couple of decades is not an anomaly. The pharmaceutical companies have a historical pattern of creating and marketing drugs that later wreak havoc. That's what they did with amphetamines, that's what they did with barbiturates, that's what they did with benzodiazepines. It's almost enough to make one wonder if profit-driven capitalist enterprises should be in charge of the nation's drug supply.

Read Higham and Horwitz's book. But read Case and Deaton's too. And when you see the next "pill mill" story, don't assume that it is, or isn't, what it seems.

CA Bill to Make Growing 7 Pot Plants a Felony Is Pulled, Biden Signs Meth Emergency Bill, More... (3/15/22)

Mexico is sending more trips to fight cartel violence in the state of Jalisco, the head of the WHO speaks out about unneccessary suffering due to lack of access to pain medication around the world, and more.

WHO Director General Tedros Adhanom Ghebreyesus raises the alarm on the global lack of access to pain medications. (CC)
Marijuana Policy

California Bill to Make Growing Seven Pot Plants a Felony is Pulled. A bill that would have re-felonized the cultivation of more than six marijuana plants, Assembly Bill 1725, is dead for the year. Bill sponsor Assemblyman Thurston Smith (R-Apple Valley) pulled the bill from consideration by the Assembly Public Safety Committee on Tuesday, signaling a lack of support in the committee.

Methamphetamine

President Biden Signs Bill Declaring Methamphetamine an Emerging Drug Threat.  President Biden on Monday signed into law S. 854, the Methamphetamine Response Act of 2021, which designates methamphetamine as an emerging drug threat and requires the Office of National Drug Control Policy to develop, implement, and make public a national response plan that is specific to methamphetamine. The Senate version of the bill was sponsored by Sens. Dianne Feinstein (D-CA) and Charles Grassley (R-IA), while the House version was sponsored by Reps. Scott Peters (D-CA), John Curtis (R-UT), Diana Harshbarger (R-TN), Cindy Axne (D-IA), and Josh Harder (D-CA).

International

World Health Organization Director General Uses Commission on Narcotic Drugs Vienna Meeting to Raise Alarm on Global Lack of Access to Pain Medications. At the 65th meeting of the Commission on Narcotic Drugs (CND) in Vienna, World Health Organization (WHO) Director General Tedros Adhanom Ghebreyesus raised the alarm on the global lack of access to pain medications. In his speech, entitled "Ensuring access to medicines for patients – a global concern," Ghebreyeus said, "Around the world, millions of people rely on medicines based on controlled substances. They rely on them either to manage life, or to manage the end of life. These controlled medicines are critical for treating patients with severe COVID-19 disease. They are also essential for pain management in cancer, surgical care and palliative care, and for the management of drug use, neurological and mental health disorders. And yet millions of other people suffer needlessly, because for them, these essential medicines are out of reach." 

Ghebreysus pointed out that in low- and middle-income countries, "97% of the need for immediate-release morphine, an essential medicine for the management of pain and palliative care, is unmet." He cited several factors for the "appalling lack of access" to pain medications, including "a lack of national policies that facilitate access to controlled medicines, unstable supply chains, and limited production and regulatory capacity." He also cited supply chain breakdowns.

He did not address the role of the global drug prohibition regime in leading to restricted access to such drugs, but he did say that "WHO is proud to join the United Nations Commission on Narcotic Drugs, the United Nations Office on Drugs and Crime, and the International Narcotics Control Board to call for international cooperation to increase access to controlled substances for medical and scientific purposes."

Mexico Sends Another 500 Troops to Jalisco Amidst Cartel Violence. The Secretariat of National Defense has ordered 500 more troops to the Guadalajara metropolitan area to combat rising violence as rival drug trafficking organizations battle for control in Jalisco and neighboring Michoacan. The soldiers are part of the Joint Task Force Mexico, which can quickly be deployed anywhere in the country. There were already nearly 12,000 soldiers and National Guard members deployed to Jalisco, where the Jalisco New Generation Cartel is clashing with local cartelitos, such as Los Viagras. Local residents in Jalisco and Michoacan blame the Jalisco cartel for much of the violence. Last month, troops deployed for the first time in months in a township dominated by the Jalisco cartel, breaking up a civilian blockade of an army base in Aguilla that had endured for months. The military accuses the locals of supporting the cartel, but the locals say they were blockading the army base because the soldiers refused to come out and confront the cartels. 

CDC Prepares New Opioid Prescribing Guidelines, OH Senate Won't Take Up Legalization Voter Init, More... (2/10/22)

The South Carolina Senate approves a medica marijuana bill, a new Rand study tracks opioid prescribing declines, and more.

Opioid pain prescribing practices are in the news. (Creative Commons)
Marijuana Policy

Ohio GOP Senate Leader Says He Will Not Bring Marijuana Legalization Initiative to a Vote. State Senate President Matt Huffman (R-Lima) says he will not bring the Coalition to Regulate Marijuana Like Alcohol's marijuana legalization initiative to a vote in the Senate. Under Ohio law, petitioners who collect the requisite number of valid voter signatures for a ballot initiative then place the proposal before the legislature, which has four months to act on it. If the legislature refuses to act on the proposal or rejects it, petitioners can undertake a second round of signature gathering and, if successful, present the issue to directly to the voters.

"I don't want anybody to misunderstand my position," Huffman said. "I'm not going to bring it to the Senate floor. And if that means people want to go put it on the ballot, have at it." While the Coalition has yet to comment on Huffman's remarks, it has previously indicated it will indeed proceed to that second round of signature gathering. They will need to come up with 132,887 valid voter signatures to make the November ballot.

Medical Marijuana

South Carolina Senate Approves Medical Marijuana Bill. After the debate on medical marijuana made it to the Senate floor last week, the Senate on Wednesday approved the South Carolina Compassionate Care Act (Senate Bill 150). The bill gets a final vote in the Senate Thursday, before heading to the House, where its fate is unclear. Whether House Speaker Jay Lucas (R) will let the bill move in his chamber remains uncertain. And Gov. Henry McMaster (R) remains noncommittal on whether he would sign the bill, saying "that would depend on a lot of things."

Opioids

Opioid Prescribing Declines, but Cuts Are Not Uniform Across Locations, Age Groups, or Type of Prescriber. The volume of prescription opioids dispensed from retail pharmacies declined by 21% from 2008 to 2018, but the decline was not uniform across geographic areas, among types of patients, or by type of prescriber, according to a new RAND Corporation study. The study, published by the Annals of Internal Medicine, is the first to examine the decline in opioid prescriptions filled at retail pharmacies based on both volume and potency of the drugs dispensed.

The study found that over the study period, per capita MME (morphine milligram equivalents) volume declined the most in metropolitan counties (more than 22%) and in counties with higher rates of fatal opioid overdoses (a 35% decline). Substantial variation existed both within and across states. In some states, MME volume per capita increased in multiple counties. In many other states, there were both counties with increases and others with substantial decreases. Counties that experienced substantial decreases in per capita MME often were adjacent to counties with per capita increases.

Most clinical specialties recorded declines in the MME volume per practicing clinician. The greatest decrease in MME volume per practicing clinician was among adult primary care physicians (40% decline) and pain specialists (15% decline) -- the clinicians with the highest MME volume per clinician in 2008 -- 2009. The greatest percentage decrease was among emergency physicians (71% decline) -- clinicians who are likely prescribing opioids predominantly to patients experiencing acute pain in acute care settings.

"These results suggest the effects of clinician and policymaker efforts to reduce opioid prescribing have affected populations differently," Stein said. "Future efforts to enhance clinically appropriate opioid prescribing may need to be more clinically nuanced and targeted for specific populations."

CDC Proposes New, Slightly Looser Opioid Prescribing Guidelines. The Centers for Disease Control and Prevention (CDC) on Thursday released new draft guidelines for prescribing opioids for pain relief. The new guidelines remove previously recommended ceilings on doses for chronic pain patients, leaving it instead for doctors to use their own best judgment. But they also urge doctors to first resort to "nonopioid therapies" for both chronic and acute pain.

The new guidelines are the first comprehensive revisions of the CDC's 2016 guidelines, and attempt to find the proper balance between alleviating severe pain and exposing patients to the perils of opioids. The new guidelines have now been published in the Federal Register and are open for comments. Comment here.

Surgeon General Say Don't Jail People for Pot, ME Law Ends Civil Asset Forfeiture, More... (7/19/21)

The AMA Advocacy Update chronicles one doctor's problems trying to prescribe for chronic pain and addicted patients, Maine becomes the fourth state to end civil asset forfeiture, and more.

US Surgeon General Vivek Murthy says it is time to stop locking people up for marijuana. (hhs.gov)
Marijuana Policy

US Surgeon General Says Time to Stop Locking People Up for Marijuana. Surgeon General Vivek Murthy said Sunday that it is time to stop locking up people for using marijuana. "When it comes to decriminalization, I don't think that there is value to individuals or to society to lock people up for marijuana use," Surgeon General Vivek Murthy said in a CNN appearance. "I don't think that serves anybody well." His comments came in response to a question about a new draft marijuana legalization bill, and are in line with President Biden, who supports marijuana decriminalization, but not commercial legalization. "When it comes to marijuana, I think we have to let science guide us," Murthy said in the CNN interview. "And we know that the science tells us that there are some benefits to marijuana from a medical perspective but there are also some harms that we have to consider -- and we have to put those together as we think about the right policy."

Heroin and Prescription Opioids

AMA on a Doctor's Trials Trying to Treat Pain Patients in the Context of Arbitrary Policies. The American Medical Association (AMA) Advocacy Update has published a piece on the travails of southern Illinois family medicine and addiction medicine specialist Dr. Aaron Newcomb, whose patients found themselves unable to refill prescriptions after he was "blacklisted" by a pharmacy chain citing 2016 Centers for Disease Control and Prevention (CDC) guidelines aimed at reducing opioid prescribing in the face of a rising opioid overdose death toll.

"When the CDC guidelines came down in 2016 basically saying we needed to take as many people as we could off opioids, I knew that my patients were in for a world of trouble," said Dr. Newcomb. "I was particularly concerned about my patients who were stable on low-dose opioid therapy for years. And my concerns have translated into an even worse reality for both me and my patients. Getting blacklisted by a national chain who had no clue about my practice was professionally wrong, but it also hurt my patients and my community."

Newcomb had to explain the nuances of pain prescribing to the pharmacy chain: "When they got back to us, they basically questioned a specific formulation of buprenorphine I was prescribing for stable patients with cost or tolerability problems that isn't a preferred type unless there is a clinical reason," Dr. Newcomb explained. "They were also concerned about opioid therapy in general as well as the dose of buprenorphine used to effectively treat patients, and their algorithm out of context painted a misrepresentative picture of my controlled-substance prescribing habits."

Newcomb was eventually able to get back in the chain's good graces and his patients are now receiving their medication, but his case illustrates the challenges faced by pain physicians and their patients in a time where the opioid-prescribing pendulum has swung so dramatically back to the conservative side.

Asset Forfeiture

Maine Becomes 4th State to End Civil Asset Forfeiture. A new law barring asset forfeiture without a criminal conviction went into effect without the signature of Gov. Janet Mills (D), making Maine the fourth state to abolish the practice of civil asset forfeiture. The legislature earlier this year passed LD 1521, which fully repeals the state's civil forfeiture laws, while also strengthening the criminal forfeiture process. While touted as a tool against drug dealers, one report found that half of all forfeitures in the state were under $1,670 dollars. The other three states that have ended civil asset forfeiture are North Carolina (1985), New Mexico (2915) and Nebraska (2016).

International

Mexico President Makes Rare Call for Dismissal of a State Attorney General. President Andres Manuel Lopez Obrador called last Friday for the resignation of Guanajuato state Attorney General Carlos Zamarripa after the state registered 1,562 murders in the first five months of this year. That figure is higher than any other state, even though Guanajuato is only the country's sixth most populous states. He also suggested there was corruption or collusion with some of the drug cartels battling to control the state. "If he [Zamarripa] were the manager of a company, with this kind of performance they would have fired him," López Obrador said Friday. "When officials do not act with honesty, with rectitude, when there is no division between criminals and the authorities, no progress can be made." López Obrador said.

Zammaripe, who has been attorney general for 12 years, has been accused by businessmen and local experts of being close to the Santa Rosa de Lima cartel, which had such control over an oil refinery that it could brazenly steal fuel in and around the plant, leading to a federal troop deployment. "Carlos Zamarripa for many years protected El Marro," the leader of the Santa Rosa de Lima gang who was arrested in 2020," said security expert David Saucedo. But now, said Saucedo, Zamarripa seems to have changed sides, expecting the Santa Rosa gang to fall apart as the Jalisco New Generation cartel moved in. Instead, the Sinaloa cartel sent reinforcements to assist the Santa Rosa gang, and the death toll has skyrocketed. "Definitely, Zamarripa is part of the problem," Saucedo said.

Fatal Drug ODs Hit Record Last Year, Senate Majority Leader Rolls Out Draft Marijuana Legalization Bill, More... (7/14/21)

There is now a marijuana legalization bill from the Senate majority leader, New York prisons face a second lawsuit over their crackdown on pain pill prescribing for inmates, and more.

CDC preliminary data has drug overdose deaths at more than 90,000 last year. (Creative Commons)
Marijuana Policy

Senate Majority Leader Rolls Out Draft Marijuana Legalization Bill. Senate Majority Leader Chuck Schumer (D-NY) and colleagues Cory Booker (D-NJ) and Ron Wyden (D-OR) held a press conference Wednesday to unveil their first draft of a bill to federally legalize marijuana. The bill would federally legalize marijuana by removing it from the Controlled Substances Act, let states set their own marijuana policies, expunge prior convictions and allow people to apply for resentencing, and end collateral consequences, such as people being deported for marijuana possession offenses. The bill, known as the Cannabis Administration and Opportunity Act, faces uncertain prospects in the narrowly divided Senate, and just minutes after the Wednesday press conference, White House Press Secretary Jen Psaki said the President Biden remains opposed to marijuana legalization. If the bill were to pass, it would have to be reconciled with the marijuana legalization bill passed by the House in December, the MORE Act (HR 3884). Look for out feature article on the rollout coming shortly.

Missouri Activists Take Initial Steps for 2022 Marijuana Legalization Initiative. A group calling itself Fair Access Missouri filed a petition Tuesday for a marijuana legalization initiative aimed at the 2022 ballot. The initiative would take the form of a constitutional amendment that would legalize the possession of up to eight ounces for people 21 and over and allow residents to cultivate up to 25 square feet of flowering marijuana. It would also set up a system of licensed cultivation, manufacturing, and sales. Previous marijuana legalization initiative campaigns in the state have failed to meet signature-gathering requirements. This one is at the very beginning of the process, with the state now having 65 days to review the initial petition.

Heroin and Prescription Opioids

Former New York Prison Doctor Sues Over Restrictive Painkiller Policy. A doctor who formerly worked in the state prison system and says he faced harassment and was forced to quit for seeking appropriate pain relief for his inmate patients has filed a federal lawsuit against the state Department of Corrections, saying its policies leave patients suffering unnecessary agony. Four years ago, the department tightened its opioid prescribing policies amidst the ongoing opioid crisis, requiring prison doctors to get permission from medical administrators for prescribing certain medications, including not just opioids, but all gabapentine, Claritin-D, Robitussin DM, and the diarrhea drug Imodium. Dr. Michael Salvana charges in the lawsuit that the department violated his right to speak out against the policy and said his superiors' "inhumane” interference in his patients' care caused him to leave his role as facility director in central New York at Walsh Regional Medical Unit in Rome, New York, that has 125 beds for prisoners with complicated medical needs." The policy led to the "abrupt" cut off of "effective treatments for hundreds of inmates." Inmates in the state prison system have also failed a lawsuit charging they are being forced to live with untreated chronic pain because medications are now so difficult to obtain.

Psychedelics

California Psychedelic Decriminalization Bill Wins Another Committee Vote. Sen. Scott Wiener's (D-San Francisco) psychedelic decriminalization bill, SB 519, has won a second committee vote in the Assembly after successfully passing out of the Senate. The Assembly Public Health Committee voted 8-4 Tuesday to advance the measure, which would remove criminal penalties for possessing psychedelics including psilocybin. But the committee amended the bill to set specific personal possession limits, leading the pro-psychedelic group Decriminalize Nature to call for it to be tabled, arguing that it is 'just a creative way to say when can law enforcement arrest you." The bill now awaits an Assembly floor vote.

Drug Policy

Drug Overdose Deaths Jumped to More Than 90,000 Last Year. The Centers for Disease Control and Prevention released preliminary statistics Wednesday showing that drug overdose deaths totaled more than 90,000 last year, the largest single-year increase ever recorded. Drug overdoses increased in every state except New Hampshire and South Dakota, with big jumps in the South and the West. The year also saw the most fatal opioid overdoses in a year, the most fatal methamphetamine overdoses in a year, and the most deaths from fatal fentanyl overdose deaths in a year. "It’s huge, it’s historic, it’s unheard of, unprecedented, and a real shame," said Daniel Ciccarone, a professor of medicine at the University of California, San Francisco, who studies heroin markets. "It’s a complete shame." Social isolation, disrupted drug markets, and hampered access to drug treatment during the pandemic are getting some of the blame, but the pre-pandemic increase in fentanyl availability is also playing a role, as is the country's refusal to embrace harm reduction measures, such as safe injection sites and safe drug supplies.

Clarence Thomas Questions Federal Marijuana Prohibition, ONDCP Reports on Colombia Coca, More... (6/28/21)

A major pharmaceutical company settles with the state of New York over opioid distribution, Minnesota lawmakers are on the verge of passing policing reforms, and more.

US Supreme Court Justice Clarence Thomas questions the viability of federal marijuana prohibition. (Creative Commons)
Marijuana Policy

Clarence Thomas Says Federal Marijuana Prohibition May No Longer Make Sense. One the Supreme Court's most conservative justices said Monday that because marijuana is already legalized either medically or recreationally in a growing number of states, federal pot prohibition may no longer make sense. "A prohibition on interstate use or cultivation of marijuana may no longer be necessary or proper to support the federal government's piecemeal approach," wrote Justice Clarence Thomas as the high court declined to hear the appeal of a Colorado medical marijuana dispensary that was denied federal tax breaks. "Federal policies of the past 16 years have greatly undermined its reasoning," he said. "The federal government's current approach is a half-in, half-out regime that simultaneously tolerates and forbids local use of marijuana."

Heroin and Prescription Opioids

Johnson & Johnson Settles With New York for $230 Million, Agrees to Stop Selling Opioids. Pharmaceutical company Johnson & Johnson has agreed to a $230 million settlement with the state of New York over its role in the country's opioid crisis, which has led to nearly half a million dead of overdoses in the past two decades. As part of the settlement, the company agreed to not promote opioids and confirmed it has quit distributing them in the US. Pharmaceutical companies and distributors have faced a barrage of lawsuits over opioids, with governments arguing that the companies pushed the drugs and caused people to become addicted and then turn to illegal opioids as states and the federal government cracked down. The companies argued that they were distributing medically necessary opioids for people who need them. The crackdowns on opioid prescribing have left one group of people in particular in the lurch: chronic pain patients, who must seek opioids and doctors willing to prescribe them in large quantities in the midst of the retrenchment.

Law Enforcement

Minnesota Lawmakers Reach "General Agreement" on Policing Reforms. Legislative leaders of both the Democratic Farm Labor Party and the Republicans have reached "general agreement" on a broad-ranging police reform bill, leaders of both parties said late Saturday. Among other things, the bill would restrict the use of no-knock warrants, civil asset forfeiture reforms (but not an outright ban), reforms of fines and fee structures, restrict the use of confidential informants to better protect them, and make modifications to state police misconduct database to create an early warning system to keep bad cops off the street. The legislature is working under a deadline: If the broader public safety bill that includes the policing reforms is not passed by Wednesday, key government public safety functions, such as running state prisons and the State Patrol, would theoretically face shutdowns. But Gov. Tim Walz (DFL) said he will keep those operations functioning, even if that is legally questionable.

International

US Drug Czar's Office Says Colombia Coca Cultivation Expanded Last Year. Colombian coca cultivation increased 15% last year and potential cocaine production rose 7.9% to around a thousand metric tons, the White House Office of National Drug Control Policy (ONDCP -- the drug czar's office), said Friday. The report from ONDCP differed from a report issued by the UN Office on Drugs and Crime (UNODC) released on June 9, which had a lower figure for crop cultivation but a higher figure -- 1,228 metric tons -- for potential cocaine production. In either case, Colombia remains the world's largest coca and cocaine producer, ahead of second place Peru and third place Bolivia.

Cuba Reiterates Zero Tolerance Drug Policies. Cuba used the occasion of the UN's International Day Against Drug Abuse and Illicit Trafficking on Saturday to make clear that its zero tolerance policy toward drug use, production, and trafficking remains unchanged. In a tweet, Foreign Minister Bruno Rodríguez vowed that the island nations will never be a place to use, store, or traffic illicit drugs.

Reform Groups Call for Marijuana Legalization Amidst COVID Crisis, DEA Part of Federal Anti-Crime Surge, More... (7/23/20)

The initial draft of the Democratic platform calls for not interfering with state marijuana laws but doesn't call for legalization, a North Dakota legalization campaign comes up short, hospitals are warning of IV opioid shortages, and more.

The Mexican military is being cited (again) for human rights abuses in its prosecution of the drug war. (Creative Commons)
Marijuana Policy

Democratic Draft Platform Does Not Include Marijuana Legalization. The initial version of the national Democratic Party platform, released by the Democratic National Committee's platform drafting panel, calls for allowing states to set their own marijuana laws, but stops short of calling for federal legalization. Various marijuana policy reforms in the draft include decriminalizing cannabis possession, automatic expungement of prior marijuana convictions, federal rescheduling through executive action, legalizing medical cannabis, and allowing states to set their own laws. The draft could still be amended when the full platform committee meets next Monday.

Coalition of Justice and Drug Reform Groups Call on Congress to Legalize Marijuana Amid Coronavirus Crisis. The ACLU, the Drug Policy Alliance, NORML, and Human Rights Watch are among a coalition of civil rights and drug reform groups calling on Congress to pass comprehensive marijuana legalization legislation that emphasizes restorative justice. Calling themselves the Marijuana Justice Coalition, the group says legalization is now especially urgent in the context of the coronavirus pandemic and nationwide protests over police brutality. Given the current situation, "marijuana reform as a modest first step at chipping away at the war on drugs is more relevant and more pressing than ever before," they wrote in a letter to Congress.

North Dakota Legalization Initiative Comes Up Short on Signatures. The campaign to put a marijuana legalization initiative on the November ballot has come up short on signatures. The North Dakota Freedom of Cannabis Act needed some 27,000 valid voter signatures by Wednesday, but had only 24,000 raw signatures to hand in. A second legalization initiative campaign, Legalize ND, came up short earlier. Now, both groups say they are aiming at 2022.

Heroin and Prescription Opioids

Hospitals Say IV Opioid Painkillers Running Short Amid Coronavirus Crisis Because of DEA Quota Policy. One of the biggest hospital groups in the country, Premier, Inc., is warning that intravenous painkillers are in short supply during the pandemic because of the DEA's restrictions on legal opioid production. As part of the federal government's response to the opioid epidemic, DEA has slashed the amount of opioids producers can manufacture over the past two years. That's made them harder to get for everyone, including hospitals. Unless the agency gives hospitals more access to IV painkillers, hospitals will keep running short of the medications needed to help ventilate coronavirus patients and sedate patients before surgery, Premier Inc. wrote in a Wednesday letter to the DEA.

Law Enforcement

DEA Participating in Federal Law Enforcement Surge Aimed at Big Cities. As part of the Trump administration's surge of federal law enforcement in cities including Albuquerque, Chicago, and Kansas City, the DEA will participate in what the feds are calling Operation Legend. "The surge of violent crime in many of our great American cities is unacceptable and cannot be left unchecked," said DEA Acting Administrator Timothy J. Shea. "DEA plays a vital role in combatting violent crime by targeting drug trafficking organizations who employ violence and intimidation to further their criminal enterprise. Violence is an essential element of drug trafficking. Our agents, working alongside our state, local, and federal counterparts, will bring additional resources and specialized investigative skills to help reduce violent crime plaguing so many communities." Shea did not address the role of drug prohibition in encouraging violence.

International

Mexican Human Rights Commission Says Military Abducted 27 People at Border in 2018, 12 Later Found Dead. The Mexican government's human rights commission said Tuesday that Mexican marines abducted 27 people in the border town of Nuevo Laredo in 2018 and that 12 of them were later found dead. The other 15 haven't been seen. The commission more broadly accused the marines of engaging in "illegal searches and arbitrary detentions." At the time, the military was engaged in running battles with the Zetas cartel. The commission issued non-binding recommendations that criminal investigations be opened and changes be made in Navy patrol procedures.

Mexican Border City Sees 26 Killings in 72 Hours. Chihuahua Attorney General Cesar Augusto Peniche said Wednesday that Ciudad Juarez had seen 26 homicides in the past 72 hours and that they can be attributed to a rapidly escalating war between rival gangs fighting for control of the city's drug franchise. The groups at war are the Aztecas and the La Empresa cartel. The latest killings bring the death toll to 969 so far this year in the city.

The Drug Policy Alliance is a funder of StoptheDrugWar.org.

AMA Releases Recommendations for Opioid Use Disorder, Pain During COVID-19, More... (4/9/20)

The AMA makes some progressive recommendations on dealing with opioid use disorder and pain in the time of the pandemic, Massachusetts recreational pot retailers sue to become "essential" businesses, and more.

The coronavirus pandemic continues to impact drug policy. (CDC)
Marijuana Policy

Massachusetts Recreational Marijuana Retailers Sue Governor to Become Essential During Pandemic. Five in-state recreational marijuana dealers have filed a lawsuit against Gov. Charlie Baker (R) in a bid to get their businesses deemed "essential" and allowed to open during the coronavirus pandemic. Baker had declared them non-essential and ordered them shut down until at least May 4. The stores are seeking an injunction to allow all 43 of the state's recreational retailers to reopen. Baker has argued that because the state is the only one in the region that allows recreational sales, open pot shops would draw customers from other states, undercutting social distancing measures. "Significant numbers of the customers who procure cannabis at recreational marijuana dispensaries in Massachusetts are not from Massachusetts," he said.

Harm Reduction

AMA Releases Recommendations for Opioid Use Disorder, Pain During COVID-19. The American Medical Association (AMA) has released policy recommendations to help meet the needs of patients with opioid use disorder (OUD) and chronic pain. The recommendations aim to sustain "harm reduction efforts in communities across the United States." First, the AMA called for medications used in the treatment of addiction, as well as treatments for overdoses to be deemed essential services to ensure that patients with OUD continue to have access to care. This designation can improve access to crucial medications that may be difficult to obtain in cities with formal shelter-in-place or quarantine orders. They also suggested that criminal justice measures, such as drug testing, counseling, and reporting requirements, be curtailed to ensure that patients do not lose public benefits or become incarcerated. Second, the AMA urged policymakers to increase protections for patients with pain disorders by waiving limits on prescriptions for controlled substances. For patients with chronic pain, they suggested waiving testing and in-person counseling requirements for refills, allowing consultation via telephone, and offering home delivery options for medications. Finally, the AMA raised the question of harm reduction. To prevent overdoses and quell the spread of infectious disease, the AMA proposed that policymakers reduce barriers to accessing critical supplies by designating harm reduction organizations as essential services. They also advocated for assistance designated for harm reduction organizations to maintain adequate availability of naloxone in affected communities.

International

Ontario Allows Marijuana Delivery and Curbside Pick-up from Authorized Retail Stores During COVID-19. Due to the COVID-19 outbreak, the Alcohol and Gaming Commission of Ontario (AGCO) is authorizing cannabis retail stores in Ontario to offer delivery and curbside pick-up services. This new temporary measure is the result of an emergency order introduced Thursday by the Government of Ontario to help fight against the illegal cannabis market. The order will last for 14 days, with the possibility of an extension if the government's Emergency Order on business closures is extended.

Chronicle AM: Philly Safe Injection Site Could Open Soon, VT House Approves Pot Sales Bill, More... (2/27/20)

The Vermont House has passed that bill to allow taxed and regulated marijuana sales, a California bill would allow paying meth users not to use, the INCB issues its annual report, and more. 

Crystal meth. A California bill would allow payments to meth users to stop using. (dea.gov)
Marijuana Policy

Maine Wants to "Harmonize" Medical, Adult Use Marijuana Programs. The Office of Marijuana Policy told state lawmakers Wednesday that it wants the medical and adult-use programs to abide by the same state rules whenever possible. It introduced a bill to apply the same plant size restriction, labeling rules, manufacturing safety and background checks to both programs. The plan is generating pushback from small operators, who say the plan would drive up prices and force them out of business.

Vermont House Approves Marijuana Sales Bill. The House on Wednesday voted 90-54 to approve Senate Bill 54, which would tax and regulate legal marijuana sales in the state. The Senate approved the bill with a veto-proof margin last year, the first year of the biennial session. Since it was amended in the House, the House and the Senate will have to reconcile differences before sending the bill to the governor's desk.

Methamphetamine

California Bill Would Pay Meth Users Not to Use. State Sen. Scott Weiner (D-San Francisco) has filed Senate Bill 888, which would make public funding available for programs that provide financial incentives to participants to stop using drugs. The bill would expand substance abuse treatment options that qualify for Medi-Cal, the program that provides health care to the poor, to include contingency management programs that use vouchers or small cash awards to motivate people to stay off drugs. Weiner said he was motivated by a growing methamphetamine problem in the city.

Harm Reduction

Philadelphia Safe Injection Site Could Open as Early as Next Week. Officials with Safehouse, the nonprofit group that is moving to open a safe injection site, said Wednesday that the facility could be open as soon as next week. The announcement came hours after a federal judge ruled that it would not violate federal law. It would be the first legally permitted safe injection site in the country. But US Attorney William McSwain said the government will seek to stop the site from opening, as the government intends to appeal the judge’s decision.

International

International Narcotics Control Board Issues Annual Report. The Vienna-based International Narcotics Control Board (INCB) has released its INCB Annual Report 2019, which examines the global drug control situation and makes recommendations to national governments and international organizations. Among other things, the report said the INCB wants more done to ensure pain relief medications are available to everyone who needs them and it warns of the "dangers" of non-medical marijuana developments, i.e. the trend toward marijuana legalization.  

Chronicle AM: Pot Vaping Bans, DEA Shrugs Shoulders at Pain Patient Complaints, More... (10/15/19)

The vaping crisis has impelled two more states to restrict marijuana vaping products, Mexican cartel gunmen kill 14 police in a bloody ambush, and more.

Hydrocodone. Pain patients are complaining over DEA cuts to opioid production quotas, but DEA is sanguine. (Creative Commons)
Marijuana Policy

Colorado Regulators Prepare Ban on Certain Additives in Marijuana Vape Products. The state's Marijuana Enforcement Division has proposed final rules on vaping products that will ban a set of additives for those products. The move comes amidst the emergence of a mysterious lung disease linked to e-cigs and marijuana vape pens. The proposed prohibitions in ingredients used in marijuana concentrates or products intended for inhalation include: Polyethylene glycol (PEG); Vitamin E Acetate; and Medium Chain Triglycerides (MCT Oil) -- all of which are used to thin THC oil so it can be atomized or vaporized.

Oregon Bans Flavored Marijuana Vaping Products for Six Months. Oregon has now imposed a six month ban on flavored marijuana vaping products, becoming the third state to impose a form of ban on such products since the vaping crisis unfolded. Gov. Kate Brown (D) had issued an executive order on October 4 banning the sale of all flavored vaping products; state officials filed rules last Friday putting the order into effect. The move comes after nine people fell ill in the state, with five of them having bought marijuana products in licensed stores.

Heroin and Prescription Opioids

DEA Swats Away Pain Patient Complaints About Reduced Opioid Production Levels. Hundreds of chronic pain patients have implored the DEA to reconsider its proposed cuts to opioid production, which would reduce production quotas for popular opioids for the fourth year in a row, but the agency is just shrugging its shoulders. The cuts should have no impact on decisions made by doctors and "legitimate pain patients," the DEA said. "The agency does not regulate the practice of medicine. We do not get between a doctor and his or her patient," a DEA spokesperson said. "We also want legitimate pain patients, their families and caregivers to know that DEA does not seek to limit or take away their vital prescriptions."

International

Mexican Cartel Gunmen Ambush Police, Killing More than a Dozen. Gunmen of the Jalisco New Generation Cartel (CJNG) ambushed a police convoy in the western state of Michoacan on Monday, killing 14 police officers in one of the bloodiest attacks on security forces since President Andres Manuel Lopez Obrador took office. Photos from the scene showed burning police videos, the bodies of slain officers, and placards signed "CJNG" warning police not to support rival crime groups, such as Los Viagras.

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