August 31 is International Overdose Awareness Day, overdoseday.com

The fever may have broken, but the patient is still in critical condition. And there is one bit of data in the CDC report that is definitely not good news: While overall overdose deaths finally began to decline, overdose deaths involving stimulants were on the increase. For cocaine, the death toll started rising in about 2012; for psychostimulants (overwhelmingly methamphetamine), the climb began a couple of years earlier.

But the new data show a dramatic uptick in overdose deaths with stimulant involvement last year. Fatal overdoses where cocaine was mentioned were up 34 percent and those where methamphetamine was involved were up 37 percent. That's more than 14,000 people dying with cocaine in their systems and more than 10,000 dying with meth in their systems.

What is driving this spike in stimulant-involved overdose deaths? Some of it can be attributed to rising use levels for cocaine and meth, which can in turn be linked to increased supplies. Meth seizures were up dramatically last year and recent DEA reports suggest that cocaine availability has increased steadily since 2012, particularly in the south and east coast of the US. The UN Office of Drugs and Crime suggests that cocaine production and manufacture are at the highest rates ever recorded.

"There is some research to suggest that we are seeing slightly higher rates of recent cocaine and methamphetamine use compared to rates of use just a few years ago," said Sheila Vakharia, PhD, a researcher with the Drug Policy Alliance (DPA). "But increased rates of use do not always mean increased rates of addiction or overdose. Death rates are influenced by a variety of factors, including age of the user, the amount used, and other substances used, among other things."

They are also influenced by race, gender, and geographic location. A recent study looking at data from 2012 to 2015 and examining race and gender trends by drug found that white men had the highest rates of methamphetamine-involved overdose deaths more generally, while black men had highest rates of cocaine-involved overdose deaths. These racial differences persisted for women of each race as well, although their overdose rates were lower than the men in their racial groups.

"Methamphetamine-involved deaths are high on the West Coast and Midwest, while cocaine-involved deaths are high on the East Coast. We are actually seeing that in some Western states that methamphetamine is either the top drug involved in overdose deaths or among the top drugs included in overdose deaths," Vakharia noted.

"Based on the latest CDC data, Nevada’s overdose crisis has been driven by prescription opioids and methamphetamine for the past several years- in fact, methamphetamine has been the #1 drug involved in overdoses there since November 2016. Similarly, in November 2016, Oregon saw methamphetamine become the top drug involved in overdose deaths," she specified.

"Meanwhile, the East Coast is seeing the involvement of cocaine in overdoses increase as well. While no eastern state has cocaine driving their overdose crisis, places like DC are seeing fentanyl as the top driver of deaths followed by cocaine. Last year, while fentanyl contributed to the majority of overdose deaths, there were more cocaine-involved deaths than heroin or prescription opioids," Vakharia added.

It appears that it is not rising simulant use rates but the use of multiple substances that is largely driving the overall stimulant death toll upwards. A CDC report from May suggests that, from 2003 to 2017, almost three-quarters of cocaine-involved deaths involved an opioid while half of all methamphetamine involved deaths involved an opioid.

"Those CDC numbers are based on autopsy reports," said Daniel Raymond, deputy director of planning and policy for the Harm Reduction Coalition (HRC). "In a lot of cases, there are multiple drugs involved, and just because an overdose involves a stimulant, it doesn't mean it was caused by stimulants."

Overdose deaths caused by stimulants look different from those caused by opioids, Raymond noted: "Fatal stimulant overdoses come from strokes, seizures, heart attacks, and potentially overheating," he said. "It's not like an opioid overdose with respiratory depression," he said.

"Some of this may be more a reflection that we still have lots of people dying from opioid-related overdoses, and it's just that more of them are also taking meth or cocaine, but the primary cause of death is the respiratory depression associated with opioid overdoses. In a lot of the cocaine deaths, medical examiners are finding both cocaine and opioids."

"We are seeing that toxicology reports of people who died with stimulants in their systems also had fentanyl or other opioids in their system," DPA's Vakharia concurred. She then listed a number of possible explanations:

1. "This is accidental. Cross-contamination of a stimulant with an opioid like fentanyl could have been accidental and occurred during transport or packaging, and opioid-naïve stimulant users were accidentally exposed to opioid-contaminated stimulants."
2. "This is due to co-use of opioids and stimulants in the form of speedballs (with cocaine) or goofballs (with methamphetamine), where both are used together for the desired effect of immediately stimulating high, followed by the euphoria of the opioid."
3. "Stimulants are being willfully adulterated with opioids by suppliers/sellers, and stimulant users naïve to opioids are overdosing because they have no tolerance. (We at DPA dispute this theory, because it makes little sense why a seller would want to kill off a customer.)
4. "Someone might have used a stimulant and opioids at different times within the past few days, but their toxicology could be showing the recency of use."

What Is to Be Done?

The Drug Policy Alliance and the Harm Reduction Coalition have both released reports on the rise in stimulant-involved overdose deaths, Stimulant Use: Harm Reduction, Treatment, and Future Directions from the former and Cocaine, Speed, and "Overdose": What Should We Be Doing? from the latter. Raymond and Vakharia took a few minutes to address those topics, too.

"There is no naloxone for stimulant overdose," Raymond pointed out. To reduce those overdoses "is about developing harm reduction strategies and outreach specifically targeting stimulant users," he said. "We spend so much time focusing on the opioid overdose crisis that our messages are oriented toward that. If we want to start a conversation, we need to not just tack it onto the opioid messaging. Even if you're not an opioid user, we want to talk about symptoms and warning signs."

HRC has moved in that direction, said Raymond. "We did some work on stimulant overdoses, we talked to a lot of people who used stimulants, we put out a guide -- Stimulant "Overamping”"Basics -- and went with the terms people used. Using 'overamping' opened a space for conversation for people who didn't identify as heroin users. If you talk overamping instead of overdosing, stimulant users have had that experience of using too much. Part of it is really just listening to the people who use the drugs. In harm reduction, we learn from the people we work with."

"People who use stimulants need access to sterile equipment beyond syringes, since many stimulant users smoke, so we are talking about sterile smoking equipment like pipes and filters," Vakharia said. "We need to teach users how to stay safe while using -- make sure to take breaks for hydration and to eat, get enough rest. It is easy to lose track of time when you've been up for days and when you have no appetite. This also puts undue stress on your heart and can exacerbate health issues," she noted.

"For many people, we should also talk about distributing safer sex supplies, because many people engage in risky sexual practices while they are using," Vakharia continued. "We also need to educate users on the risks associated with mixing different classes of drugs and the impact it can have on your body, knowing your limits, keeping naloxone on hand in case you are using opioids too, and not using alone."

It's not just harm reduction that's needed, though. Other policy prescriptions could help reduce the toll.

"Medicaid expansion and policies to increase access to basic health care and mental health care, as well as substance use treatment can greatly improve the health and well-being of people who use all drugs," Vakharia said. "And whether opioids are a person's primary drug or not, expanding access to naloxone helps anyone who is using them. Similarly, expanding Good Samaritan laws that reduce barriers to calling 911 can only help."

And then there's not treating drug uses like criminals.

"Decriminalizing drugs and paraphernalia would be a huge step forward," said Vakharia. "We know that contact with the criminal justice system increases harms and also presents barriers to going into recovery, which impacts job prospects, the ability to find work, and things like that."

"Drug decriminalization is crucial," said Raymond. "Criminalization just makes everything worse. It makes people more fearful of seeking help, and ends up locking so many people up in ways such that when they leave jail or prison, they're even more vulnerable. All of our work in harm reduction takes place in this context of mass criminalization. That keeps us swimming against the tide."

This article was produced by Drug Reporter, a project of the Independent Media Institute.

The Drug Policy Alliance is a funder of both Drug Reporter and Drug War Chronicle.

Marijuana and medical marijuana bills are seeing action in the states, South Dakota's governor vetoes an industrial hemp bill, a key UN organization calls for global drug decriminalization, and more.

New Jersey Gov. Phil Murphy (D) says he has reached an agreement with key legislators to legalize weed by month's end. (CC)

Colorado Bill to Allow Social Consumption Filed. State Rep. Jonathan Singer (D) and cosponsors filed House Bill 1230 last Friday. The bill would pave the way for legal marijuana “tasting rooms” beginning in January. The bill would also allow hotels, spas, and other businesses to apply for cannabis licenses. A similar bill was vetoed by Gov. John Hickenlooper last year, but now the governor is the more marijuana-friendly Jared Polis.

Minnesota Senate Committee Kills Legalization Bill. The Senate Judiciary Committee on Monday killed a bill that would have legalized marijuana on a 6-3 vote along party lines. SF 619 would have allowed adults to use, possess, grow, and buy marijuana from licensed retailers.

New Jersey Governor, Key Lawmakers Announce Agreement on Legalization Bill. Gov. Phil Murphy (D) and legislative leaders announced Tuesday that they had reached agreement on a bill to legalize marijuana. They also announced that they planned to pass the bill on March 25. "I believe that this legislation will establish an industry that brings fairness and economic opportunity to all of our communities while promoting public safety by ensuring a safe product and allowing law enforcement to focus their resources on serious crimes," the governor said.

New York Legalization Bid Hits Bump. Gov. Andrew Cuomo (D) said Monday that it is now unlikely that marijuana legalization will be included in the state budget, which is due this month, suggesting that there are roadblocks remaining on the path to legalization. "I’m no longer confident marijuana will be done in the budget," Cuomo told reporters at the Capitol, adding that legislative leaders are still far apart on a path forward. "I’ve had discussions with them on it. There is a wide divide on marijuana. I believe ultimately we can get there, and we must get there," he said. "I don’t believe we get there in two weeks. And also that’s what the legislative leaders have said."

Washington Senate Approves Expungement Bill. The Senate on Monday approved SB 5605, which would expunge some 69,000 past convictions for misdemeanor marijuana possession in the state. A companion measure is moving in the House.

Medical Marijuana

Earl Blumenauer Reintroduces Veterans Medical Marijuana Bill. Rep. Earl Blumenauer (D-OR) is back once again with a bill that would allow doctors at the Veterans Administration to recommend medical marijuana to veterans. HB 1647 is similar to bills that Blumenauer has sponsored for the past several years but were blocked by intransigent House Republican leaders. This year, though, the Democrats control the House.

Michigan Adds Cerebral Palsy to List of Qualifying Conditions. The Department of Licensing and Regulatory Affairs announced Monday that it had added cerebral palsy to the list of qualifying conditions to use medical marijuana. It rejected adding chronic aggressive behavior after panel members unanimously recommended denial.

New Mexico Medical Marijuana Access Expansion Bill Passes Senate. The Senate on Monday approved SB 406, which would allow for onsite consumption of medical marijuana at dispensaries, allow people living on Indian land to grow their own, and create civil protections for patients for schooling, child custody, and medical care. A similar bill was vetoed by Gov. Susana Martinez (R) last year, but she’s gone now.

Hemp

South Dakota Governor Vetoes Hemp Bill. Gov. Kristi Noem (R) on Monday vetoed HB 1191, which would have legalized industrial hemp production in the state. In her veto message, she said it could be a first step toward legalizing marijuana and that it could make law enforcement’s job more difficult. The bill passed the House overwhelmingly but passed the Senate by a margin just short of veto-proof. It’s not clear yet whether the legislature will attempt an override.

International

Key UN Organization Calls for Global Drug Decriminalization. The UN Chief Executives Board (CEB), representing 31 UN agencies including the Office on Drugs and Crime, had adopted a position calling on member states to adopt science-based, health-oriented approaches to drug policy—namely decriminalization. The policy shift came in January, but was not publicly announced.

Israel’s Netanyahu Says He’s Open to Marijuana Legalization. Faced with a party that advocates marijuana legalization gaining momentum in the weeks before national elections, Israeli Prime Minister Benjamin Netanyahu said Monday he was looking into legalizing it himself. Younger voters have been drifting toward support for the Zehut Party before the April 9 elections.

UN Reports Methamphetamine Production Skyrocketing in Southeast Asia. The UN Office on Drugs and Crime reported Monday that methamphetamine production in Southeast Asia is booming, with prices dropping and usage expanding even as seizures hit record highs. "Data on seizures, prices, use, and treatment all point to continuing expansion of the methamphetamine market in East and Southeast Asia," said Tun Nay Soe, the agency's inter-regional program coordinator. "The shift to methamphetamine has affected even countries traditionally known to have a relatively large market for heroin, such as China and Malaysia,” he added. “In Malaysia, the number of methamphetamine users detected by law enforcement authorities surpassed that of heroin users for the first time in 2017." 

While there are signs that the country's drug overdose crisis may have plateaued, the number of people dying from drug overdoses continues to be unconscionably high. Shockingly, the number of overdose deaths has increased tenfold since 1980 when there were only 6,000 nationwide and nearly doubled just in the past decade to more than 72,000 last year.

The number of drug overdose deaths remains unconscionably high.

Three drug classes are involved: prescription and non-prescription opioids, benzodiazepines, and stimulants. Often, fatal overdoses involve more than one drug, whether it is drugs in the same class (heroin and fentanyl) or combinations of drug classes (heroin and benzos or fentanyl and cocaine.

Before we get into the number-crunching, it's worth taking a moment to consider that each single overdose death is a tragedy. A human life has been lost prematurely, the potential snuffed out, and friends and family members suffer greatly. It doesn't have to be that way. While we're going to look at deadly drugs, it behooves us to remember that many of these deaths are a function not just of the drugs themselves, but of drug prohibition.

People overdose on fentanyl, for example, because in a black market there is no packaging, no quality control, no dosage information to inform them of just how powerful is that powder they're snorting or injecting. Added to heroin or crafted into counterfeit prescription opioids by unscrupulous black market operators, fentanyl kills people who didn't even know they were taking it. Even more insidiously, fentanyl is turning up in black market cocaine and methamphetamine, whose users aren't even looking for an opioid high and haven't developed any tolerance to them (although some may be speedballing, that is, taking both an upper and a downer at the same time.

That said, here are the drugs making the greatest contributions to the 63,352 overdose deaths in 2016. (The numbers add up to more than that figure because in some overdoses, more than one drug is mentioned.)

1. Fentanyl -- 18,335

In 2016, fentanyl vaulted into first place in the deadly drug sweepstakes. As recently as 2011, the synthetic opioid was in 10th place, with some 1,660 overdose deaths attributed to it, but the death toll has increased more than tenfold in just five years. More than two-thirds of fentanyl overdose deaths also involved other drugs, and fentanyl is involved in more than a quarter (28.5 percent) of all overdose deaths, including 40 percent of cocaine overdose deaths and nearly a third (32 percent) of heroin deaths.

2. Heroin -- 15,961

At the tail end of the prescription opioid phase of the current overdose crisis in 2011, more people died from oxycodone than heroin, but between 2012 and 2015, heroin resumed its role as the leading opioid linked to fatal overdoses, only to be overtaken by fentanyl in 2016. The vast majority -- 70 percent -- of people who died from heroin were also using other drugs. More than a third were also using fentanyl, while nearly a quarter (23.8 percent) were also using cocaine. As prescription opioids became more difficult to obtain, the number of people dying from heroin skyrocketed, nearly tripling in the five years ending in 2016.

3. Cocaine -- 11,316

Cocaine deaths rose dramatically beginning in 2015 and by 2016 the annual death toll was double what it had been five years earlier. With bumper crops in Colombia in recent years, cocaine is cheap and plentiful. It is also increasingly being cut with fentanyl, which is implicated in 40 percent of cocaine deaths, and mixed with heroin, which is implicated in a third of them. Cocaine is named in 17.8 percent of all overdose deaths.

4. Methamphetamine -- 6,762

Meth-related overdose deaths tripled between 2011 and 2016, a dramatic increase in what has become America's forgotten drug problem. In 2016, slightly more than one out of ten drug overdose deaths involved meth. Of the top ten overdose drugs, meth is by far the one most likely to have been the sole drug implicated in the death, but even so, fentanyl was implicated in one out five meth deaths and heroin in one out of ten.

5. Alprazolam -- 6,209You know it as Xanax. This short-acting benzodiazepine is a favorite of stimulant users seeking to take the edge off, but also often forms part of a sedative cocktail with opioids or other benzos. About three-quarters of Xanax overdose deaths involve other drugs, with fentanyl, heroin, and oxycodone each involved in about one-quarter of Xanax deaths. Xanax deaths increased by about 50 percent over the five year period.

6. Oxycodone -- 6,199

It's most infamous formulation is OxyContin, but it is also sold as Roxicodone, Xtampza ER, and Oxaydo. It may have been the primary killer opioid a decade ago, but has chugged along at around 5,000 deaths a year before going over 6,000 in 2016. Four out of five people who overdose on oxycodone were also using another drug, most often Xanax (25.3 percent), followed by fentanyl (18.6 percent).

7. Morphine -- 5,014

The granddaddy of opioids. Morphine deaths increased slowly beginning in 2011, but have still increased by about 40 percent since then. More than eight out of 10 morphine deaths involve other drugs as well, particularly fentanyl, which is involved in one out three morphine deaths. Cocaine (16.9 percent) and heroin (13.7 percent) are also frequent contributors to morphine ODs.

8. Methadone -- 3,493

Prescribed as an opioid maintenance drug, methadone is one of the few drugs on this list to have seen the number of deaths decline between 2011 and 2016. They've dropped from more than 4,500 a year down to less than 3,500, a drop of roughly a quarter. Nearly three-fourths of all methadone deaths implicate other drugs, with Xanax being most common (21.5 percent), followed by fentanyl (15.1) and heroin (13.8).

9. Hydrocodone -- 3,199

This semi-synthetic opioid is sold under a variety of brand names, including Vicodin and Norco, and has proven remarkably stable in its overdose numbers. Between 2011 and 2016, it never killed fewer than 3,000 or more than 4,000, almost always (85 percent of the time) in concert with other drugs. Xanax was implicated in one-quarter of all hydrocodone overdoses, followed by oxycodone (17.2 percent) and fentanyl (14.9 percent).

10. Diazepam -- 2,022

The most well-known diazepam is Valium. Like Xanax, this anti-anxiety drug can be used to take the edge off a stimulant binge, but it's not coke heads and speed freaks who are dying from it. In more than nine out of 10 fatal Valium overdoses, other drugs are involved, most commonly the opioids oxycodone and fentanyl, each implicated in about a quarter of the deaths, and heroin, implicated in a fifth.

Using these drugs is dangerous. Using them under a prohibition regime is even more so. Users don't always know what they're getting, and that lack of knowledge can be fatal. If you're going to be messing with these substances, be extremely cautious. Try a test dose first. And don't do it alone. Stay safe out there.

This article was produced by Drug Reporter, a project of the Independent Media Institute.

Like other Great Plains states, South Dakota has a methamphetamine problem. But it's becoming increasingly evident that South Dakota also has a problem with the way it deals with meth.

South Dakota women's prison in Pierre (KELO-TV screen grab)

Overall, about one-third of all inmates in the state are doing time for drug-related offenses, the majority of them for simple drug possession. That's a higher percentage than most other states, where drug offenders tend to make up somewhere around 20 to 25 percent of the inmate population.

The high drug-related incarceration overall and for women in particular stems less from the prevalence of drug use than from the conservative, largely rural state's reaction to it. South Dakota has not responded to decades of failed war on drug policies by reforming them, but by doubling down on them.

The state has not moved toward the defelonization of drug possession, as at least 16 others have. Instead, it has moved in the opposite direction. South Dakota has mandatory sentencing laws that include prison for not only for the manufacture and distribution of meth but also for simple possession.

State lawmakers and cops have long favored tough drug laws, and they are still at it. This year, state Attorney General Marty Jackley (R) guided bills through the legislature that heighten penalties for meth dealing and increase sentences for dealers whose clients overdose and die.

But the state's most notorious and contentious drug law -- bone that is sending hundreds of people to prison -- is the state's "possession by ingestion" statute. Otherwise known as an "internal possession" law, the statute allows for a felony conviction if a drug test reveals the presence of illicit drugs in a suspect's system. (The law also applies to marijuana, but the penalty for testing positive for pot is only a misdemeanor.)

The strictest in the nation, that law was upheld by the state Supreme Court in 2004. Last year, a bipartisan group of lawmakers filed a measure that would have slightly tweaked the law by removing marijuana, but that bill was killed by a unanimous vote in the first committee that heard it.

As of August, about nine percent of the male prison population and an astonishing 21 percent of the female prison population was doing time for unauthorized ingestion of a controlled substance. That's right: More than one out of five women prisoners in South Dakota is behind prison bars for nothing more than having used drugs.

South Dakota law enforcement and lawmakers may be happy with the status quo, but the man who actually runs the prison system isn't. State Corrections Secretary Denny Kaemingk told South Dakota News Watch that the cops' and courts' proclivity for busting and imprisoning women on drug charges is creating an expensive and ineffective cycle of imprisonment, release, and recidivism.

"We seem to think that locking individuals up is going to solve their addiction problem," said Kaemingk, a former drug officer. "They're coming to us in corrections and we're thinking that solves the problem, and I think in many cases it makes the problem worse."

Criminalizing addiction, especially among women who are mothers, Kraemingk said, creates a situation where the children are more likely to end up in prison themselves. He pointed to national studies showing that up to 80 percent of children who have parents behind bars will end up there themselves.

"Imprisonment in South Dakota is generational," Kaemingk said. "The females behind prison walls have experienced that as a child. The generation we have back there now as inmates experienced the same things when they were children."

Kraemingk and other relatively enlightened actors in the state are pushing for enhanced treatment opportunities and expanding drug courts, among other measures, to better deal with the situation, but nobody seems to be talking about not involving these women in the criminal justice system in the first place. A first step would be getting rid of that hideous "possession by ingestion" statute. The next step would be defelonization or outright decriminalization of drug possession in the state. Drug use absent harm to others should not be the state's business.

This article was produced by Drug Reporter, a project of the Independent Media Institute.