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Book Review: Drug Use for Grown-Ups

Drug Use for Grown-Ups: Chasing Liberty in the Land of Fear, by Carl Hart (2021, Penguin Press, 290 pp., $28.00 HB)

Dr. Carl Hart is a one-man drug and drug user destigmatization machine. In his new book, Drug Use for Grown-Ups, the Columbia University psychology professor blasts drug prohibition as both an affront to the American dream of the pursuit of happiness and as a tool of racial oppression. And he makes a strong, informed argument that recreational drug use can be, and usually is, a good thing.

You could hardly find someone more qualified to make the case. Hart has spent years in the trenches of neuropsychopharmacology research, handed out drugs (or placebos) to thousands of research subjects, published numerous scientific papers and popular articles in the field, and risen to the top of his profession along the way. And here is his bottom line:

"[O]ver my more than 25-year career, I have discovered that most drug-use scenarios cause little or no harm and that some responsible drug-scenarios are actually beneficial for human health and functioning. Even 'recreational' drugs can and do improve day-to-day living... From my own experience -- the combination of my scientific work and my personal drug use, I have learned that recreational drugs can be used safely to enhance many vital human activities."

Hart is refreshingly -- and deliberately -- open about his own recreational drug use. Given the stigmatization and persecution of people identified as "drug users," he feels that justice demands privileged partakers come out of the closet and give voice to their own, non-destructive drug use histories as a necessary remedy for that demonization. He certainly does so himself, revealing a disciplined yet curious mind most definitely not averse to sampling various substances.

Those substances include heroin, which he describes as his current favorite drug, one that he's been using episodically for years now: "There aren't many things in life that I enjoy more than a few lines by the fireplace at the end of the day... Heroin allows me to suspend the perpetual preparation for battle that goes on in my head... The world is alright with me. I'm good. I'm refreshed. I'm prepared to face another day, another faculty meeting, another obligatory function. All parties benefit."

But Hart is not quite so mellow when it comes to people and institutions he sees as helping to perpetuate overly negative depictions of various drugs or the persecution of drug users. He rips into Dr. Nora Volkow, head of the National Institutes on Drug Abuse (NIDA) over her "addiction is a brain disease" mantra and the rigid ideological control she has over research funding. He rips into journalists for uncritically and sensationally reporting salacious scientific findings about the evils of drugs that he argues are not supported by the evidence they are supposedly based on. He even calls Bernie Sanders "ignorant" (that word shows up more than a few times) for complaining that marijuana shouldn't be in the same drug schedule as "killer drugs like heroin."

Dr. Carl Hart (Columbia University)
Hart doesn't deny the potential dangers of drug use but makes the case that they are dramatically overstated. In that sense, Drug Use for Grown-Ups is a corrective to more than a century of anti-drug propaganda. In a deep dive into opioids, for instance, he notes that most opioid overdose deaths are actually opioid/benzodiazepines/alcohol deaths, and that a large number of them are due to ignorance (there's that word again) -- in that, in the black market that currently exists, drug users do not and cannot know what exactly is in that pill or powder they purchased.

As long as we are in a prohibition regime, the least we can do is widespread drug testing for quality control, as is done at some European music festivals, Hart argues. But that's the only kind of drug testing he's down with; he calls the urine drug testing industry "parasitic," a sobriquet he also applies to the drug treatment industry.

But hang on, he's not done yet. Although he is an advocate for harm reduction practices, he has a bone to pick with the term itself: It's too damned negative! Drug use doesn't typically involve harm, he argues, but pleasure-seeking. As I pondered this, I came up with "benefit enhancement" as an upbeat alternative to harm reduction, but Hart went with "health and happiness."

And he's got a bone to pick with "psychedelic exceptionalism," the notion, dear to folks like Decriminalize Nature, that psychedelics, or better yet, "plant entheogens," are somehow "better" than dirty old drugs like meth or heroin and thus deserve to be treated differently, more gently. He also snarks at the notion that taking drugs for spiritual or religious purposes is of a higher order than taking them for fun and rebels at the notion of having a shaman or guide during a tripping session: "Some people find this comforting. I find it creepy and have never done so myself."

Drug Use for Grown-Ups is bracing, informative, and provocative contribution to the literature. Even the most ardent drug reformers and defenders would benefit from reading it and reexamining their own assumptions. Maybe Carl Hart is onto something.

Two Takes on the Global Drug War and Global Drug Cultures [FEATURE]

America shows signs of emerging from the century-long shadow of drug prohibition, with marijuana leading the way and a psychedelic decriminalization movement rapidly gaining steam. It also seems as if the mass incarceration fever driven by the war on drugs has finally broken, although tens if not hundreds of thousands remain behind bars on drug charges.

As Americans, we are remarkably parochial. We are, we still like to tell ourselves, "the world's only superpower," and we can go about our affairs without overly concerning ourselves about what's going on beyond our borders. But what America does, what America wants and what America demands has impacts far beyond our borders, and the American prohibitionist impulse is no different.

Thanks largely (but not entirely) to a century of American diplomatic pressure, the entire planet has been subsumed by our prohibitionist impulse. A series of United Nations conventions, the legal backbone of global drug prohibition, pushed by the US, have put the whole world on lockdown.

We here in the drug war homeland remain largely oblivious to the consequences of our drug policies overseas, whether it's murderous drug cartels in Mexico, murderous cops in the Philippines, barbarous forced drug treatment regimes in Russia and Southeast Asia, exemplary executions in China, or corrupted cops and politicians everywhere. But now, a couple of non-American journalists working independently have produced a pair of volumes that focus on the global drug war like a US Customs X-ray peering deep inside a cargo container. Taken together, the results are illuminating, and the light they shed reveals some very disturbing facts.

Dopeworld by Niko Vorobyov and Pills, Powder, and Smoke by Antony Loewenstein both attempt the same feat -- a global portrait of the war on drugs -- and both reach the same conclusion -- that drug prohibition benefits only drug traffickers, fearmongering politicians, and state security apparatuses -- but are miles apart attitudinally and literarily. This makes for two very different, but complementary, books on the same topic.

Loewenstein, an Australian who previously authored Disaster Capitalism and Profits of Doom, is -- duh -- a critic of capitalism who situates the global drug war within an American project of neo-imperial subjugation globally and control over minority populations domestically. His work is solid investigative reporting, leavened with the passion he feels for his subject.

In Pills, Powder, and Smoke, he visits places that rarely make the news but are deeply and negatively impacted by the US-led war on drugs, such as Honduras. Loewenstein opens that chapter with the murder of environmental activist Berta Caceres, which was not directly related to the drug war, but which illustrates the thuggish nature of the Honduran regime -- a regime that emerged after a 2009 coup overthrew the leftist president, a coup justified by then-Secretary of State Hillary Clinton, and which has received millions in US anti-drug assistance, mainly in the form of weapons and military equipment.

Honduras doesn't produce any drugs; it's only an accident of geography and the American war on drugs that we even mention the country in the context of global drug prohibition. Back in the 1980s, the administration of Bush the Elder cracked down on cocaine smuggling in the Caribbean, and as traffickers sought to evade that threat, Honduras was perfectly placed to act as a trampoline for cocaine shipments taking an alternative route through Mexico, which incidentally fueled the rise of today's deadly and uber-wealthy Mexican drug cartels.

The drug trade, combined with grinding poverty, huge income inequalities, and few opportunities, has helped turn Honduras into one of the deadliest places on earth, where the police and military kill with impunity, and so do the country's teeming criminal gangs. Loewenstein walks those mean streets -- except for a few neighborhoods even his local fixers deem too dangerous -- talking to activists, human rights workers, the family members of victims, community members, and local journalists to paint a chilling picture. (This is why Hondurans make up a large proportion of those human caravans streaming north to the US border. But unlike Venezuela, where mass flight in the face of violence and economic collapse is routinely condemned as a failure of socialism, you rarely hear any commentators calling the Honduran exodus a failure of capitalism.)

He reexamines one of the DEA's most deadly recent incidents, where four poor, innocent Hondurans were killed by Honduran troops working under DEA supervision in a raid whose parameters were covered up for years by the agency. Loewenstein engaged in extended communication with the DEA agent in charge, as well as with survivors and family members of those killed. Those people report they have never received an apology, not to mention compensation, from the Honduran military -- or from the United States. While the Honduran military fights the drug war with US dollars, Loewenstein shows it and other organs of the Honduran government are also deeply implicated in managing the drug traffic. And news headlines bring his story up to date: Just this month, the current, rightist president of Honduras, Juan Orlando Hernández, of meeting with and taking a bribe from a drug trafficker. This comes after his brother, former Honduran Senator Juan Antonio Hernández, was convicted of running tons of cocaine into the United States in a trial that laid bare the bribery, corruption, and complicity of high-level Hondurans in the drug trade, including the president.

Loewenstein also takes us to Guinea-Bissau, a West African country where 70 percent of the population subsists on less than $2 a day and whose biggest export is cashews. Or at least it was cashews. Since the early years of this century, the country has emerged as a leading destination for South American cocaine, which is then re-exported to the insatiable European market.

Plagued by decades of military coups and political instability, the country has never developed, and an Atlantic shoreline suited for mass tourism now serves mainly as a convenient destination for boatloads and planeloads of cocaine. Loewenstein visits hotels whose only clients are drug traffickers and remote fishing villages where the trade is an open secret and a source of jobs. He talks with security officials who frankly admit they have almost no resources to combat the trade, and he traces the route onward to Europe, sometimes carried by Islamic militants.

He also tells the tale of one exemplary drug bust carried out by a DEA SWAT team arguably in Guinean territorial waters that snapped up the country's former Navy minister. The DEA said he was involved in a "narco-terrorist" plot to handle cocaine shipments for Colombia's leftist FARC guerillas, who were designated as "terrorists" by the administration of Bush the Junior in a politically convenient melding of the wars on drugs and terror.

It turns out, though, there were no coke loads, and there was no FARC; there was only a DEA sting operation, with the conspiracy created out of whole cloth. While the case made for some nice headlines and showed the US hard at work fighting drugs, it had no demonstrable impact on the use of West Africa as a cocaine conduit, and it raised serious questions about the degree to which the US can impose its drug war anywhere it chooses.

Loewenstein also writes about Australia, England, and the United States, in each case setting the historical and political context, talking to all kinds of people, and laying bare the hideous cruelties of drug policies that exert their most terrible tolls on the poor and racial minorities. But he also sees glimmers of hope in things such as the movement toward marijuana legalization here and the spread of harm reduction measures in England and Australia.

He gets one niggling thing wrong, though, in his chapter on the US. He converses with Washington, DC, pot activists Alan Amsterdam and Adam Eidinger, the main movers behind DC's successful legalization initiative, but in his reporting on it, he repeatedly refers to DC as a state and once even mistakenly cites a legal marijuana sales figure from Washington state. (There are no legal sales in DC.) Yes, this is a tiny matter, but c'mon, Loewenstein is Australian, and he should know a political entity similar to Canberra, the Australian Capital Territory.

That quibble aside, Loewenstein has made a hardheaded but openhearted contribution to our understanding of the multifaceted malevolence of the never-ending war on drugs. And I didn't even mention his chapter on the Philippines. It's in there, it's as gruesome as you might expect, and it's very chilling reading.

Vorobyov, on the other hand, was born in Russia and emigrated to England as a child. He reached adulthood as a recreational drug user and seller -- until he was arrested on the London Underground and got a two-year sentence for carrying enough Ecstasy to merit a charge of possession with intent to distribute. After that interval, which he says inspired him to write his book, he got his university degree and moved back to Russia, where he picked up a gig at Russia Today before turning his talents to Dopeworld.

Dopeworld is not staid journalism. Instead, it is a twitchy mish-mash, jumping from topic to topic and continent to continent with the flip of a page, tracing the history of alcohol prohibition in the US at one turn, chatting up Japanese drug gangsters at the next, and getting hammered by ayahuasca in yet another. Vorobyov himself describes Dopeworld as "true crime, gonzo, social, historical memoir meets fucked up travel book."

Indeed. He relates his college-boy drug-dealing career with considerable panache. He parties with nihilistic middle-class young people and an opium-smoking cop in Tehran, he cops $7 grams of cocaine in Colombia and tours Pablo Escobar's house with the dead kingpin's brother as a tour guide, he has dinner with Joaquin "El Chapo" Guzman's family in Mexico's Sinaloa state and pronounces them nice people ("really chill"), and he meets up with a vigilante killer in Manila.

Vorobyov openly says the unsayable when it comes to writing about the drug war and drug prohibition: Drugs can be fun! While Loewenstein is pretty much all about the victims, Vorobyov inhabits the global drug culture. You know: Dopeworld. Loewenstein would bemoan the utter futility of a record-breaking seizure of a 12-ton load of cocaine; Vorobyov laments, "that's 12 tons of cocaine that will never be snorted."

Vorobyov is entertaining and sometimes laugh-out-loud funny, and he brings a former dope dealer's perspective to bear. He's brash and breezy, but like Loewenstein, he's done his homework as well as his journalistic fieldwork, and the result is fascinating. To begin to understand what the war on drugs has done to people and countries around the planet, this pair of books makes an essential introduction. And two gripping reads.

Dopeworld: Adventures in the Global Drug Trade by Niko Vorobyov (August 2020, St. Martin's Press, hardcover, 432 pp., $29.99)

Pills, Powder, and Smoke: Inside the Bloody War on Drugs by Antony Loewenstein (November 2019, Scribe, paperback, 368 pp., $19.00)

How to Legalize Ecstasy -- and Why [FEATURE]

Every weekend, hundreds of thousands of young club- and concert-goers buy and consume black market pills and powders they hope are MDMA, the methamphetamine relative with a psychedelic tinge known on the streets as Ecstasy or Molly. A tiny percentage of them -- a few dozen each year in the United States or Britain -- die. It doesn't have to be that way.

Ecstasy pills (Erowid.org)
Granted, those numbers are miniscule when compared with the tens of thousands who die each year in the US using opioids, benzos, and stimulants like cocaine and meth, much less from the legal substances alcohol and tobacco. But that relative handful of deaths could almost certainly be eliminated by bringing Ecstasy in from the cold -- making it legal and regulated instead of subjecting its users to black market Russian roulette.

And now somebody has a plan for that. The British Beckley Foundation, which has been advocating for research into psychoactive substance and evidence-based drug policy reform for the past two decades, has just released a new report, Roadmaps to Regulation: MDMA, that takes a good, hard look at the drug and charts a path to a saner, less harmful way of handling Ecstasy than just prohibiting it, which, the report notes, "has never meaningfully disrupted its supply, nor its widespread use."

That's because, despite it being illegal, for many, many people, Ecstasy is fun. And the Beckley report does something rare in the annals of drug policy wonkery: it acknowledges that. "Hundreds of thousands of people break the law to access its effects, which include increased energy, euphoria, and enhanced sociability," the report says.

The authors concede that Ecstasy is not a harmless substance, and take a detailed dive into acute, sub-acute, and chronic harms related to its use. They point to overheating (hyperthermia) and excess water intake (hypnoatraemia) as the cause of most Ecstasy deaths, and they examine the debate over neurotoxicity associated with the drug, very carefully pointing out that "there is evidence to suggest that heavy use of MDMA may contribute to temporary impairments in neuropsychological functions."

But they also point out that most of the problems with Ecstasy are artifacts of prohibition: "Our evidence shows that many harms associated with MDMA use arise from its unregulated status as an illegal drug, and that any risks inherent to MDMA could be more effectively mitigated within a legally regulated market," they write.

The most serious harmful effect of treating Ecstasy use and sales as a criminal matter is that users are forced into an unregulated, no-quality-control black market and they don't know what they're getting. Tablets have been found with as little as 20 milligrams of MDMA and as much as 300 milligrams. And much of what is sold as MDMA is actually adulterated with other substance, including some much more lethal ones, such as PMA (paramethoxyamphetamine) and PMMA (paramethoxymethamphetamine). This is how people die. As the authors note:

"The variability in MDMA potency and purity is a direct result of global and national prohibitionist policies. Recent developments around in situ drug safety testing are an attempt to mitigate the risks of such variability. These risks, such as overdose and/or poisoning, are by no means inevitable or inherent to the drug. If MDMA were clinically produced and legally distributed, users would be assured of the product content and appropriate dosage and be able to make more informed decisions regarding their MDMA use. In this way the principal risks we associate with MDMA use would be greatly reduced."

But the report also addresses a whole litany of other prohibition-related harms around Ecstasy that exacerbate the risks of its use. From making users less likely to seek medical help for fear of prosecution to making venues adopt "zero tolerance" policies that actually increase risks (such as drug dog searches that encourage users to take all their drugs at once before entering the venue) to the rejection of pill testing and other harm reduction measures, prohibition just makes matters worse.

In addition to harms exacerbated by prohibition, there are harms created by prohibition. These include "a lucrative illegal MDMA market that generates wealth for entrenched criminal organizations," the saddling of young users with criminal records, the risk that people who share or sell drugs among their friends could be charged as drug dealers, and the development of black markets for new psychoactive substances (NSPs), many of which are more dangerous than Ecstasy. Also not to be forgotten is the loss of decades of research opportunities into the therapeutic use of MDMA, research that was showing tremendous potential before the drug was prohibited in the mid-1980s.

Prohibition of Ecstasy is not only not working but is making matters worse. So what should we do instead? Beckley is very clear in its conclusions and recommendations. First, these preliminary steps:

  • Reschedule MDMA from Schedule I to Schedule II of the Controlled Substances Act (the Misuse of Drugs Regulations in Britain) in order to reduce barriers to research and to improve our understanding of its physiological effects.
  • "Decriminalize the possession of MDMA and all drugs to remove the devastating social and economic effects of being criminalized for drug possession or limited social supply."
  • Use decriminalization to comprehensively roll out drug safety testing (pill testing) and other proven harm reduction measures.

Once those preliminary steps are done, it's time to break big:

  • Award licenses to selected pharmaceutical manufacturers to produce MDMA under strict manufacturing requirements.
  • Allow licensed MDMA products to be sold at government licensed MDMA outlets. The report suggests pharmacies in the first instance.
  • For harm reduction purposes, retail outlet staff would need to be specially trained to educate users on the risks associated with MDMA.
  • Users who wish to purchase licensed MDMA products would be required to obtain a "personal license" to do so. Such a license would be granted after an interview with trained sales staff demonstrates that the would-be user understands the risks and how to reduce them.
  • Develop adults-only MDMA-friendly spaces where the risks associated with the drug can be combatted with the full panoply of harm reduction measures.
  • "User controls" to encourage responsible MDMA use. These would include "a strictly enforced age limit, pricing controls, mandated health information on packaging and at point of sale, childproof and tamperproof packaging, a comprehensive ban on marketing and advertising, and a campaign to minimize the social acceptability of driving under the influence of MDMA and to promote alternatives such as designated drivers."
  • "Sales of MDMA would be permitted to adults over 18 years of age. Prohibitive penalties would be in place to restrict underage sales."
  • Education campaigns focusing on MDMA safety and responsible use that would cover sales outlets and schools and universities. Such campaigns would include information about how to recognize and manage adverse events related to MDMA products.
  • Monitor and evaluate the impact of these changes to continue an evidence-based approach and allow feedback into policymaking.

There you have it, a step-by-step plan to break with prohibitionist orthodoxy and create a legal, regulated market for a popular recreational drug. Whether you or I agree with every plank of the plan, it is indeed a roadmap to reform. The evidence is there, a plan is there; now all we need is the political pressure to make it happen somewhere. It could be the United Kingdom, it could be the United States, it could be the Netherlands, but once somebody gets it done, the dam will begin to burst.

Faced with Fentanyl, Is It Time for Heroin Buyers' Clubs? [FEATURE]

In the past few years, the powerful synthetic opioid fentanyl and its derivatives have been the primary driver of the drug overdose death epidemic. A wave of addiction that began with prescription opioids two decades ago and morphed into one driven by heroin after the crackdown on pain pills one decade ago has now clearly entered a third phase: the era of fentanyl.

Pharmaceutical heroin. (Creative Commons)
Beginning in about 2014, fentanyl-related overdose death rates skyrocketed as Chinese chemical manufacturers and Mexican drug distribution gangs began flooding the country with the cheap, easily concealable narcotic—and not through unwalled borders but through points of entry and package delivery services, including the U.S. Postal Service. By 2017, fentanyl was implicated in some 28,000 overdose deaths, more than either heroin or prescription opioids, and involved in nearly half of all overdose deaths.

The responses have ranged from the repressive to the pragmatic. Some state and federal legislation seeks a harsher criminal justice system response, whether it's increasing penalties for fentanyl trafficking or charging hapless drug sharers with murder if the person they shared with dies. In other cases, the opioid epidemic has emboldened harm reduction-based policies, such as the calls for safe injection sites in cities such as Denver, New York, Philadelphia, San Francisco, and Seattle.

Just a couple of hours up the road from Seattle, Vancouver, British Columbia, has been grappling with the same wave of opioid addiction and now, the arrival of fentanyl. And it has arrived with a real wallop: According to the British Columbia Coroner’s Service, fentanyl was implicated in 85 percent of overdose deaths in the province last year, up from only four percent just six years earlier. And with the arrival of fentanyl and, in 2016, its cousin, carfentanil, overdose deaths in B.C. jumped more than four-fold in that same period, from 333 in 2012 to 1,489 in 2018.

But while American cities are just now moving toward opening safe injection sites, Vancouver has had them for years, part of the city’s embrace of the progressive Four Pillars strategy—prevention, treatment, harm reduction, and enforcement—of dealing with problems around drug misuse and addiction. In fact, more than a dozen safe injection sites are now operating in the city, as well as a couple of programs that involve providing pharmaceutical grade heroin or other opioids to hard-core addicts who have proven unamenable to traditional forms of treatment.

Such harm reduction programs have not prevented all overdose deaths, but they have radically reduced the toll. B.C. Chief Coroner Lisa Lapointe has estimated that without those programs, B.C. would have seen triple the number of fatal overdoses.

Vancouver has been on the cutting edge of progressive drug policy reforms for the past 20 years, and now, faced with the fentanyl crisis, some researchers are proposing a radical next step: heroin buyers’ clubs.

In a report published last week, the B.C. Center on Substance Use, which has strong ties to the provincial government, called for the clubs as part of a broader plan for "legally regulated heroin sales in B.C." to protect users from fentanyl-adulterated heroin and cut the profits of organized crime.

The proposal "is inspired by cannabis compassion clubs and buyers' clubs, both of which emerged in the 1980s and 1990s in response to the AIDS epidemic," the authors note.

"The compassion or buyers' club would function as a cooperative (or ‘co-op’), as an autonomous and democratic enterprise owned and operated by its members," the report explains. "A member-driven purchasing cooperative is an arrangement among businesses or individuals whereby members agree to aggregate their demand in order to purchase a certain product at a lower price from a supplier," it continues. "By aggregating their purchase orders and relevant resources, members are able to take advantage of volume discounts, price protection, shared storage and distribution facilities and costs, and other economies of scale to reduce their overall purchasing costs."

It wouldn't exactly be the Dallas Buyers Club, the 2013 film that portrayed unorthodox methods of obtaining AIDS medications in the 1980s. There would be some structure: To be accepted into the club, people addicted to opioids would have to undergo a medical evaluation, and once admitted to the club, they would still have to buy their own heroin, but with many advantages over buying black market dope. The main advantage would be that they would be receiving pure, pharmaceutical grade heroin (known as diacetylmorphine in countries where it is part of the pharmacopeia)—not an unknown substance that is likely to contain fentanyl.

Club members could inject the drug at a designated location—the report suggests that existing safe injection sites could be used—or take small amounts of the drug with them for consumption at home. The report also calls for each club to include related services, such as overdose response training, access to the opioid overdose reversal drug naloxone, and options for members to access social services such as detox, rehab, and other treatment options.

Not only could buyers' clubs create a safer, cheaper heroin-using experience for members, the report argues, but they could also erode the black market and its tendency to produce more potent drugs—the so-called Iron Law of Prohibition.

"Fentanyl adulteration in the illicit drug supply is a predictable unintended consequence of drug prohibition," the report concludes. "The same forces that pushed the market away from relatively bulky opium towards heroin, a more concentrated opioid that was easier to transport clandestinely, have continued to push the opioid market to increasingly potent synthetic opioids, including a range of fentanyl analogs. A cooperative could undermine the illegal market wherever it is set up."

Such a plan faces legal and political challenges in Canada, but those can be overcome if the provincial and federal governments get on board. Obstacles to such a plan being rolled out in the United States are even greater, especially given an administration hostile toward harm reduction in general that would most likely view legal heroin sales as anathema.

But here in the U.S., we're a decade or so behind Vancouver when it comes to progressive drug policies, so it's time to get the conversation started. After all, these sorts of approaches to the problem are likely to be more effective than throwing addicts in jail or building boondoggle border walls. 

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

What's Killing Us: The Ten Drugs Most Implicated in Overdose Deaths [FEATURE]

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.
Now, in a new report, the Centers for Disease Control and Prevention (CDC) sheds some new light on precisely which drugs are most implicated in these deaths. While the report examines overdose deaths from 2011 to 2016, we're going to zero in on the 2016 data to get as close as possible to the present.

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.

Study: Crackdowns on Heroin, Pain Pills Gave Rise to Fentanyl Overdose Epidemic [FEATURE]

A new report on illicit US drug markets from researchers at the University of San Francisco has found that that the spread of fentanyl, a powerful synthetic opioid implicated in nearly 29,000 overdose deaths last year alone, is tied to enforcement-driven shortages of heroin and prescription opioids, as well simple economics for drug distributors -- not because users particularly desire the drug.

meet the law of unintended consequences (Creative Commons)
Illicit fentanyl has swept through American drug markets in waves -- the super strong "China white" heroin of the 1970s was actually a heroin-fentanyl mixture -- most recently in the past decade after rising levels of opioid addiction and the spread of "pill mills" prompted multifaceted moves to restrict opioid prescribing.

From a drug distributor's perspective, fentanyl is a most excellent substitute for heroin or prescription pain pills. Produced entirely in labs or chemical factories, it is far more powerful and cheaper to produce than heroin. Because it's more potent, it is easier to smuggle -- often coming into the US via postal and delivery service parcels, not by the semi load. And it doesn't require months of growing time and period of intense peasant labor in lawless regions of weak states.

Fentanyl is typically sold deceptively -- marketed as heroin or prescription drugs such as OxyContin or Xanax -- and users and street-level dealers often don't even know that the drugs they are using or selling contain fentanyl, the researchers found. Fentanyl is making its way into the supply chain at the wholesale, not the retail level. That, the researchers said, suggests that demand is not the key driver in the drug's spread.

"Fentanyl is rarely sold as fentanyl," said Sarah Mars, PhD, a researcher in the Department of Family and Community Medicine at UCSF. "The dealers selling fentanyl directly to the users often don't know what's in it. Not only is this particularly dangerous, but it also means penalizing low-level dealers isn't going to make any difference in the fentanyl poisoning epidemic."

According to Mars, users are split on fentanyl, which produces a more sudden and powerful high than heroin, but one that fades faster. Some said fentanyl brought back the euphoria they had lost the ability to feel with long-term heroin use, but others said they feared fentanyl and found its effects too harsh.

"Whether or not they prefer fentanyl, users don't have any influence over what drugs are being sold," Mars said. "Without accurate information about these drugs, they can't make an informed choice about what they are buying. Also, very little drug slang has developed to describe fentanyl, which lends support to the notion that this is not a demand-driven epidemic."

The presence of drugs adulterated with fentanyl is uneven, Mars said.

"Most of the illicit fentanyl has been in the Northeast and Midwest," she specified. And that's where opioid overdose death rates are the highest.

Another contributing factor to the fentanyl overdose toll is that it has dozens of analogs with wildly varying potency. Some, like carfentanil, are amazingly powerful, as much as 10,000 times as potent as morphine. Some are so new they have not yet been made illegal.

"We believe it's the fluctuation in the potency of the drugs containing fentanyl that makes them so dangerous," said Daniel Ciccarone, MD, MPH, a professor of family and community medicine at UCSF and senior author of an ongoing National Institutes of Health-funded study, Heroin in Transition. "You might have one dose that had hardly any fentanyl in it or none at all. Then, you might have one with a different fentanyl analog, of different potency, or even mixtures of multiple fentanyls and heroin."

Here is the paradox of drug prohibition: Trying to crack down on drugs tends to lead not to less drug use but to more dangerous drugs, and in the case of opioids, tens of thousands of dead drug users. There is an inexorable logic at play: The more law enforcement comes down on a drug, the greater the tendency for suppliers to make it more potent and compact -- and dangerous.

Perhaps that's why we now see mainstream calls for a radically different approach, such as the one from Washington Post columnist Megan McArdle earlier this week. In her column "The Incredibly Unpopular Idea That Could Stem Heroin Deaths," McArdle argues that current drug policy is only running up the overdose death toll and that we need "to start talking about ways to make safe, reliable doses of opiates available to addicts who aren't ready to stop."

That would involve increasing access to opioid substitutes such as methadone and buprenorphine, "but lowering the death toll may require a more drastic step: legalizing prescriptions of stronger opiates," McArdle writes.

"Prescription heroin?" she continues. "Remember, I said you might not like the solution. I don't like it, either -- and frankly, neither do the drug policy researchers who told me it may be necessary. But when fentanyl took over the US illicit drug markets, it also got a lot of addicts as hostages. We'll never be able to rescue them unless we can first keep them alive long enough to be saved."

There is a better way to deal with the opioid crisis than relegating tens of thousands of American opioid users to early, preventable deaths. We know what it is. Now it's a matter of implementing smarter, more humane policies, and that's an ongoing political struggle -- one where lives are literally at stake.

Four Ways Fentanyl Could Radically Disrupt the Global Drug Trade

The synthetic opioid fentanyl isn't just killing American drug users by the thousands. Its emergence also signals a shift in the decades-old contours of the global drug trade, with ramifications not only for traditional drug-producing countries and drug trafficking networks but also for US foreign policy.

Black market fentanyl is not just wreaking havoc on the streets of American cities. (Creative Commons)
Synthesized from chemicals -- not from papaver somniferum, the opium poppy -- fentanyl is about 50 times stronger than heroin and is severely implicated in the country's drug overdose crisis, accounting for almost 20,000 deaths in 2016.

Illicit fentanyl is typically mixed with other opiates, such as heroin, resulting in much stronger doses of opioids than users expect, thus leading to opioid overdoses. But it is also increasingly also showing up in non-opiate drugs, resulting in fentanyl overdose deaths among unsuspecting methamphetamine and cocaine users.

But the havoc super-potent fentanyl is wreaking among drug users pales in comparison with the dramatic changes it could prompt in the global illicit drug production industry. As academic researchers Vanda Felbab-Brown, Jonathan Caulkins, and Keith Humphreys write in the current issue of Foreign Affairs, fentanyl's rise has the potential to cause disruption and innovation in black markets.

Here are four ways fentanyl alters the illegal drug production and distribution status quo:

1. It doesn't require an agricultural base. Virtually all of the other opioids on the black market, from heroin to morphine, oxycodone, and hydrocodone, require land to grow poppies on. And they require land that is outside cdthe effective control of the state. Non-state actors who can control such areas, whether it's the Taliban in Afghanistan or the drug cartels in southern and western Mexico, reap the profits and power of that control. With the ascent of lab-produced fentanyl made out of chemicals, traditional opiate producers should see their profits and their influence undermined.

2. It doesn't require a large workforce. Traditional opium production requires a large seasonal workforce of people to plant and tend the poppies, score the pods and scrape off the leaking opium, and then process and package the raw opium. Other workers will get jobs processing raw opium into heroin. All of those jobs bring money into the hands of poor agricultural families and political capital to the traffickers, whether it's the Taliban in Afghanistan or the cartels in Mexico. With fewer job opportunities to offer up, the traffickers lose clout.

3. It doesn't require an elaborate smuggling infrastructure. Because fentanyl is so potent, small amounts of the drug can contain huge numbers of doses, and that means it doesn't require transportation networks of trucks, planes, and boats to get an agricultural crop from the valleys of Afghanistan or the mountains of Mexico to consumers in the US Fentanyl is so potent, medicinal doses are measured in micrograms, and packages of it worth hundreds of thousands of dollars can fit inside a Priority Mail envelope. With smuggling fentanyl as easy as dropping a package in the mail, international drug smuggling organizations now have competition they never had before.

4. All of this can change the dynamics of US foreign policy. If plant-based opiates lose market share to synthetics in the future, this can weaken both insurgencies (Afghanistan) and criminal networks (Mexico). Ever since the US invasion of Afghanistan in 2001, drug warriors have been constrained in their efforts to go after the Afghan opium crops because of fears it would drive poppy-dependent peasants into the hands of the Taliban. If opium production becomes relatively less important vis-à-vis fentanyl production, that constraint on an aggressive US response to Afghan opium production is weakened. Similarly, in Mexico, to the degree that fentanyl displaces peasants and processors and weakens the link between drug cartels and rural populations, it increases the ability of the Mexican government and its American backers to crack down even harder on the cartels.

Under drug prohibition, there is a strong impetus to come up with more pure, more potent, and more compact products. Fentanyl is the ultimate expression of that imperative, and its arrival is changing the contours of the global drug industry. Who knows how it will play out?

America, We Can Fix This: 24 Ways to Reduce Opioid Overdoses and Addiction [FEATURE]

Drugs, mainly opioids, are killing Americans at a record rate. The number of drug overdose deaths in the country quadrupled between 1999 and 2010 -- and compared to the numbers we're seeing now, those were the good old days.

Some 30,000 people died of drug overdoses in 2010. According to a new estimate from the New York Times, double that number died last year. And the rate of increase in overdose deaths was growing, up a stunning 19% over 2015.

The Times' estimate of between 59,000 and 65,000 drug overdose deaths last year is greater than the number of American soldiers killed during the entire Vietnam War, greater than that number of people killed in the peak year for car crash deaths, greater than the number of people who died in the year the AIDS epidemic peaked, and higher than the peak year for gun deaths.

In the first decade of the century, overdoses and addiction rose in conjunction with a dramatic increase in prescription opioid prescribing; since then, as government agents and medical professionals alike sought to tamp down prescribing of opioids, the overdose wave has continued, now with most opioid OD fatalities linked to illicit heroin and powerful black market synthetic opioids, such as fentanyl and carfentanil.

The Centers for Disease Control and Prevention says we are in the midst of "the worst drug overdose epidemic in history," and it's hard to argue with that.

So, what do we do about it? Despite decades of failure and unintended consequences, the prohibitionist reflex is still strong. Calls for more punitive laws, tougher prosecutorial stances, and harsher sentences ring out from state houses across the land to the White House. But tough drug war policies haven't worked. The fact that the overdose and addiction epidemic is taking place under a prohibition regime should make that self-evident.

More enlightened -- and effective -- approaches are now being tried, in part, no doubt, because today's opioid epidemic is disproportionately affecting white, middle class people and not the inner city black people identified with heroin epidemics of the past. But they are also being tried because for the past quarter-century an ever-growing drug reform movement has articulated the failures of prohibition and illuminated more effective alternatives.

The drug reform movement's most powerful organization, the Drug Policy Alliance, this spring published A Public Health and Safety Approach to Problematic Opioid Use and Overdose, which lays out more than two dozen specific policy prescriptions in the realms of addiction treatment, harm reduction, prevention, and criminal justice that have been proven to save lives and reduce dependency on opioids. These policy prescriptions are doable now -- and some are being implemented in some fashion in some places -- but require that political decisions be made, or that forces be mobilized to get those decisions made. Some would require a radical divergence from the orthodoxies of drug prohibition, but that's a small price to pay given the mounting death toll.

Here are 24 concrete policy proposals that can save lives and reduce addiction right now. All the facts and figures are fully documented in the heavily-annotated original. Consult it if you want to get down to the nitty-gritty. In the meantime:

Addiction Treatment

1. Create Expert Panel on Treatment Needs: States should establish an expert panel to address effective treatment needs and opportunities. The expert panel should evaluate barriers to existing treatment options and make recommendations to the state legislature on removing unnecessary impediments to accessing effective treatment on demand. Moreover, the panel should determine where gaps in treatment exist and make recommendations to provide additional types of effective treatment and increased access points to treatment (such as hospital-based on demand addiction treatment). The expert panel must also set evidence-based standards of care and identify the essential components of effective treatment and recovery services to be included in licensed facilities, especially with regards to medication-assisted treatment, admission requirements, discharge, continuity of care and/or after-care, pain management, treatment programming, integration of medical and mental health services, and provision of or referrals to harm reduction services. The expert panel should identify how to improve or create referral mechanisms and treatment linkages across various healthcare and other providers. The panel should establish clear outcome measures and a system for evaluating how well providers meet the scientific requirements the panel sets. And, finally, the expert panel should evaluate opportunities under the ACA to expand coverage for treatment.

2. Increase Insurance Coverage for Medication-Assited Treatment (MAT): Seventeen state medical plans under the Patient Protection and Affordable Care Act (ACA) do not provide coverage for methadone or buprenorphine for opioid dependence. Moreover, the Veterans Administration's (VA's) insurance system has explicitly prohibited coverage of methadone and buprenorphine treatment for active duty personnel or for veterans in the process of transitioning from Department of Defense care. As a result, veterans obtaining care through the VA are denied effective treatment for opioid dependence. Insurance coverage for these critical medications should be standard practice.

3. Establish and Implement Office-Based Opioid Treatment for Methadone: Currently, with a few exceptions, methadone for the treatment of opioid dependence is only available through a highly regulated and widely stigmatized system of Opioid Treatment Programs (OTPs). Moreover, several states have imposed moratoriums on establishing new OTPs that facilitate methadone treatment despite large, unmet treatment needs for a growing opioid-dependent population. Patients enrolled in methadone treatment in many communities are often limited to visiting a single OTP and face other inconveniences that make adherence to treatment more difficult. Initial trials have suggested that methadone can be effectively delivered in office-based settings and that, with training, physicians would be willing to prescribe methadone to their patients to treat their opioid dependence. Office-based methadone may help reduce the stigma associated with methadone delivered in OTPs as well as provide a critical window of intervention to address medical and psychiatric conditions. Office-based opioid treatment programs offering methadone have been implemented in California, Connecticut, and Vermont.

4. Provide MAT in Criminal Justice Settings, Including Jails/Prisons and Drug Courts: Individuals recently released from correctional settings are up to 130 times more likely to die of an overdose than the general population, particularly in the immediate two weeks after release. Given that approximately one quarter of people incarcerated in jails and prisons are opioid-dependent, initiating MAT behind bars should be a widespread, standard practice as a part of a comprehensive plan to reduce risk of opioid fatality. Jails should be mandated to continue MAT for those who received it in the community and to assess and initiate new patients in treatment. Prisons should initiate methadone or buprenorphine prior to release, with a referral to a community-based clinic or provider upon release. In addition, drug courts should be mandated to offer participants the option to participate in MAT if they are not already enrolled, make arrangements for their treatment, and should not be permitted to make discontinuation of MAT a criterion for successful completion of drug court programs. The Substance Abuse and Mental Health Services Administration will no longer provide federal funding to drug courts that deny the use of MAT when made available to the client under the care of a physician and pursuant to a valid prescription. The National Association of Drug Court Professionals agrees: "No drug court should prohibit the use of MAT for participants deemed appropriate and in need of an addiction medication."

Medication-Assisted Treatment (MAT) can help.
5. Offer Hospital-Based MAT: Emergency departments should be mandated to inform patients about MAT and offer buprenorphine to those patients that visit emergency rooms and have an underlying opioid use disorder, with an appointment for continued treatment with physicians in the community. Hospitals should also offer MAT within the inpatient setting, and start MAT prior to discharge with community referrals for ongoing MAT.

6. Assess Barriers to Accessing MAT to Increase Access to Methadone and Buprenorphine: A number of known barriers prevent MAT from being as widely accessible as it should be. The federal government needs to reevaluate the need for and effectiveness of the OTP model and make necessary modifications to ensure improved and increased access to methadone. And, while federal law allows physicians to become eligible to prescribe buprenorphine for the treatment of opioid dependence, it arbitrarily caps the number of opioid patients a physician can treat with buprenorphine at any one time to 30 through the first year following certification, expandable to up to potentially 200 patients thereafter. Moreover, states need to evaluate additional barriers created by state law, including, among others, training and continuing education requirements, restrictions on nurse practitioners, insurance enrollment and reimbursement, and lack of provider incentives.

7. Establish and Implement a Heroin-Assisted Treatment Pilot Program: Heroin-assisted treatment (HAT) refers to the administering or dispensing of pharmaceutical-grade heroin to a small and previously unresponsive group of chronic heroin users under the supervision of a doctor in a specialized clinic. The heroin is required to be consumed on-site, under the watchful eye of trained professionals. This enables providers to ensure that the drug is not diverted, and allows staff to intervene in the event of overdose or other adverse reaction. Permanent HAT programs have been established in the United Kingdom, Switzerland, the Netherlands, Germany and Denmark, with additional trial programs having been completed or currently taking place in Spain, Belgium and Canada. Findings from randomized controlled studies in these countries have yielded unanimously positive results, including: 1) HAT reduces drug use; 2) retention rates in HAT surpass those of conventional treatment; 3) HAT can be a stepping stone to other treatments and even abstinence; 4) HAT improves health, social functioning, and quality of life; 5) HAT does not pose nuisance or other neighborhood concerns; 6) HAT reduces crime; 7) HAT can reduce the black market for heroin; and, 8) HAT is cost-effective (cost-savings from the benefits attributable to the program far outweigh the cost of program operation over the long-run). States should consider permitting the establishment and implementation of a HAT pilot program. Nevada and Maryland have introduced legislation of this nature and the New Mexico Legislature recently convened a joint committee hearing to query experts about this strategy.

8. Evaluate the Use of Cannabis to Decrease Reliance on Prescription Opioids and Reduce Opioid Overdose Deaths: Medical use of marijuana can be an effective adjunct to or substitute for opioids in the treatment of chronic pain. Research published last year found 80 percent of medical cannabis users reported substituting cannabis for prescribed medications, particularly among patients with pain-related conditions. Another important recent study reported that cannabis treatment "may allow for opioid treatment at lower doses with fewer [patient] side effects." The result of substituting marijuana, a drug with less side effects and potential for abuse, has had profound harm reduction impacts. The Journal of the American Medical Association, for instance, documents a relationship between medical marijuana laws and a significant reduction in opioid overdose fatalities: "[s]tates with medical cannabis laws had a 24.8% lower mean annual opioid overdose mortality rate compared with states without medical cannabis laws."Another working paper from the RAND BING Center for Health Economics notes that "states permitting medical cannabis dispensaries experienced a 15 to 35 percent decrease in substance abuse admissions and opiate overdose deaths." There is also some emerging evidence that marijuana has the potential to treat opioid addiction, but additional research is needed.

Harm Reduction

9. Establish and Implement Safe Drug Consumption Services: States and/or municipalities should permit the establishment and implementation of safe drug consumption services through local health departments and/or community-based organizations. California and Maryland have introduced legislation to establish safe drug consumption services, and the City of Ithaca, New York has included a proposal for a supervised injection site in their widely-publicized municipal drug strategy. In Washington State, the King County Heroin an Prescription Opiate Addiction Task Force has recommended the establishment of at least two pilot supervised consumption sites as part of a community health engagement program designed to reduce stigma and "decrease risks associated with substance use disorder and promote improved health outcomes" in the region that includes the cities of Seattle, Renton and Auburn.

10. Maximize Naloxone Access Points, Including Lay Distribution and Pharmacy Access, As Well As Immunities for Prescription, Distribution and Administration:Naloxone should be available directly from a physician to either a patient or to a family member, friend, or other person in a position to assist in an overdose, from community-based organizations through lay distribution or standing order laws, and from pharmacies behind-the-counter without a prescription through standing order, collaborative agreement, or standardized protocol laws or regulations. Though some states, including California, New York, Colorado and Vermont, among others, have access to naloxone at each of these critical intervention points, many others only provide naloxone through a standard prescription. Civil and criminal immunities should be provided to prescribers, dispensers and lay administrators at every access point. In addition, all first responders, firefighters and law enforcement should be trained on how to recognize an overdose and be permitted to carry and use naloxone. Naloxone should also be reclassified as an over-the-counter (OTC) medication. Having naloxone available over-the-counter would greatly increase the ability of parents, caregivers, and other bystanders to intervene and provide first aid to a person experiencing an opioid overdose. FDA approval of OTC naloxone is predicated on research that satisfies efficacy and safety data requirements. Pharmaceutical companies, however, have not sought to develop an over-the-counter product.88 Federal funding may be needed to meet FDA approval requirements.

11. Provide Dedicated Funding for Community-Based Naloxone Distribution and Overdose Prevention and Response Education: Few states provide dedicated budget lines to support the cost of naloxone or staffing for community-based opioid overdose prevention programs. The CDC, however, reports that, between 1996 and 2014, these programs trained and equipped more than 152,280 laypeople with naloxone, who have successfully reversed 26,463 opioid overdoses.89 Without additional and dedicated funding, community-based opioid overdose prevention programs will not be able to continue to provide naloxone to all those who need it, and the likelihood of new programs being implemented is slim. A major barrier to naloxone access is its affordability and chronic shortages in market supply, 90 which overdose prevention programs, operating on shoestring budgets, can have a difficult time navigating.

12. Improve Insurance Coverage for Naloxone: Individuals who use heroin and other opioids are often both uninsured and marginalized by the healthcare system.91 States should insure optimal reimbursement rates for naloxone to increase access to those who need it most – users themselves.

Overdose reversal drugs need to be made much more widely available -- and affordable. (health.pa.gov)
13. Provide Naloxone to Additional At-Risk Communities: People exiting detox and other treatment programs as well as periods of incarceration are at particularly high risk for overdose because their tolerance has been substantially decreased. After their period of abstinence, if they relapse and use the same amount, the result is often a deadly overdose. States should require overdose education and offer naloxone to people upon discharge from detox and other drug treatment programs and jails/prisons. The Substance Abuse and Mental Health Services Administration has declared that prescribing or dispensing naloxone is an essential complement to both detoxification services as well as medically supervised withdrawal. Vermont passed legislation making naloxone available to eligible pilot project participants who are transitioning from incarceration back to the community. In addition, there are other programs/studies that provide naloxone to recently released individuals on a limited basis, including in San Francisco, California, King County, Washington and Rhode Island.

14. Encourage Distribution of Naloxone to Patients Receiving Opioids: Physicians should be encouraged to prescribe naloxone to their patients and opioid treatment programs should inform their clients about naloxone, if prescribing or dispensing an opioid to them. Pharmacists should similarly be encouraged to offer naloxone along with all Schedule II opioid prescriptions being filled, for syringe purchases (without concurrent injectable medication), and for all co-prescriptions (within 30 days) of a benzodiazepine (such as Valium™, Xanax™ or Klonopin™) and any opioid medication. The Rhode Island Governor's Overdose Prevention and Intervention Task Force found that offering naloxone to those prescribed a Schedule II opioid or when co-prescribed a benzodiazepine and any opioid would have reached 86% of overdose victims who received a prescription from a pharmacy prior to their death, and could have prevented 58% of all overdose deaths from 2014 to 2015.

15. Expand Good Samaritan Protections: "Good Samaritan" laws provide limited immunity from prosecution for specified drug law violations for people who summon help at the scene of an overdose. But, protection from prosecution is not enough to ensure that people are not too frightened to seek medical help. Other consequences, like arrest, parole or probation violations, and immigration consequences, can be equal barriers to calling 911. States with Good Samaritan laws already on the books should evaluate the protections provided and determine whether expansion of those protections would increase the likelihood that people seek medical assistance.

16. End the Criminalization of Syringe Possession: Syringes should be exempt from state paraphernalia laws in order to provide optimal access to people who inject drugs. Twenty-two states criminalize syringe possession. Thus, even if there is a legal access point, such as pharmacy sales, paraphernalia laws still permit law enforcement to arrest and prosecute individuals in possession of a syringe. Public health and law enforcement authorities should not be working at cross-purposes.

17. Reduce Barriers to Over-The-Counter Syringe Sales and Permit Direct Prescriptions of Syringes: While the non-prescription, over-the-counter sale of syringes is now permitted in all but one U.S. state, access is still unduly restricted.States should evaluate the potential barriers to accessing syringes over-thecounter and implement measures to improve access. Moreover, doctors should be permitted to prescribe syringes directly to their patients, a practice few states currently permit.

18. Authorize and Fund Sterile Syringe Access and Exchange Programs; Increase Programs: States should explicitly authorize and fund sterile syringe access and exchange programs, and states that have already authorized them should evaluate how to increase the number or capacity of programs to ensure all state residents – whether in urban centers or rural communities -- have access to clean syringes, as well as evaluate any possible barriers to access such as unnecessary age restrictions.

19. Provide Free Public, Community-Level Access to Drug Checking Services: Technology exists to test heroin and opioid products for adulterants via GC/MS analysis, but it has so far been unavailable at a public level in the US (aside from a mail-in service run by Ecstasydata.org). Making these services available in the context of a community outreach service or academic study would lower the number of deaths and hospitalizations and also allow for real-time tracking of local drug trends.

Prevention

20. Establish Expert Panel on Opioid Prescribing: Though the CDC has issued guidelines for prescribing opioids for chronic pain, the guidelines are voluntary and are likely to exacerbate disparities in treatment that already exist. Research has shown, for example, that African Americans are less likely than whites to receive opioids for pain even when being treated for the same conditions. Moreover, the CDC guidelines only address prescribing practices for chronic pain, not prescribing practices more broadly. States should accordingly establish an expert panel to undertake an assessment as to whether prescribing practices, such as co-prescriptions for benzodiazepines and opioids or overprescribing of opioids, have contributed to increased rates of opioid dependence, and, if so, the expert panel should develop a plan to address any such linkages as well as any treatment disparities. The plan must account for the potential negative effects of curtailing prescribing practices or swiftly reducing prescription opioid prescribing volume. A task force in Rhode Island found that while changes in opioid supply can have the intended effect of reducing availability of abuse-able medications, they have also been linked to an increase in transition to illicit drug use and in more risky drug use behaviors (e.g., snorting and injecting pain medications). The plan must also account for chronic pain patients, particularly those already underserviced, and not unduly limit their access to necessary medications. Finally, to the extent prescribing guidelines are issued as part of the plan, they should be mandatory and applied across the board.

21. Mandate Medical Provider Education: States should mandate that all health professional degree-granting institutions include curricula on opioid dependence, overdose prevention, medication-assisted treatment, and harm reduction interventions, and that continuing education on these topics be readily available.

22. Develop Comprehensive, Evidence-Based Health, Wellness, and Harm Reduction Curriculum for Youth: State education departments, in conjunction with an expert panel consisting of various stakeholders that ascribe to scientific principles of treatment for youth, should develop a comprehensive, evidence-based health, wellness, and harm reduction curriculum for use in schools that incorporates scientific education on drugs, continuum of use, and contributors to problematic drug use (e.g., coping and resiliency, mental health issues, adverse childhood experiences, traumatic events and crisis), as well as how reduce harm (e.g., not mixing opioids with benzodiazepines). Education departments should also establish protocols and resources for early intervention, counseling, linkage to care, harm reduction resources, and other supports for students.

CRIMINAL JUSTICE

23. Establish Diversion Programs, Including Law Enforcement Assisted Diversion (LEAD): LEAD is a pre-booking diversion program that establishes protocols by which police divert people away from the typical criminal justice route of arrest, charge and conviction into a health-based, harm-reduction focused intensive case management process wherein the individual receives support services ranging from housing and healthcare to drug treatment and mental health services. Municipalities should create and implement LEAD programs and states and the federal government should provide dedicated funding for such programs. Various other forms of diversion programs exist and can be implemented should LEAD prove unsuitable to a particular population or municipality.

24. Decriminalize Drug Possession: Decriminalization is commonly defined as the elimination of criminal penalties for drug possession for personal use. In other words, it means that people who merely use or possess small amounts of drugs are no longer arrested, jailed, prosecuted, imprisoned, put on probation or parole, or saddled with a criminal record. Nearly two dozen countries have taken steps toward decriminalization. Empirical evidence from the international experiences demonstrate that decriminalization does not result in increased use or crime, reduces incidences of HIV/AIDs and overdose, increases the number of people in treatment, and reduces social costs of drug misuse. All criminal penalties for possession of small amounts of controlled substances for personal use should be removed.

Chronicle AM: NYT Says ODs at Record High, WI Gov Advances Medicaid Drug Testing, More... (6/7/17)

Drug overdoses are at an all time high, drug war dinosaur senators want to return to harsh sentencing, Wisconsin's GOP governor moves forward with first in the nation plan to drug test Medicaid applicants, and more.

Fatal drug overdoses totaled nearly 60,000 last year, the New York Times reports. (Wikimedia)
Marijuana Policy

Connecticut House Debates Legalization, But There is No Vote. The House debated the pros and cons of marijuana legalization Tuesday night, but Democratic leaders then ended debate without any vote. They said a legalization bill would have failed in the House, but the debate could increase the chances of legalization being included as part of a budget bill, although observers describe that prospect as "a long shot."

Wichita Reduces Pot Penalties. The city council voted Tuesday to adopt an ordinance that would reduce the penalty for possession of up to 32 grams (slightly more than an ounce) of marijuana to $50 plus court costs.

ACLU, Drug Policy Alliance Sue Southern California City Over Pot Cultivation Ordinance. The ACLU of California and the Drug Policy Alliance are suing Fontana, claiming that the city's marijuana ordinance conflicts with rights granted to all Californians under Proposition 64. Under Prop. 64, every Californian 21 or older has a right to cultivate up to six marijuana plants for personal use. But the law also says cities or counties can ban outdoor gardens and "reasonably regulate" indoor grows.Fontana -- a city of 200,000 people that sits 50 miles east of Los Angeles -- passed an ordinance in January that requires residents who want to cultivate up to six plants inside their home to first get a $411 permit from the city and not have any drug convictions within the past five years, a policy the groups describe as both illegal and "egregious."

Medical Marijuana

Arkansas Finalizes Process for Medical Marijuana Applications. In a meeting Tuesday, the state Medical Marijuana Commission finalized the process for accepting applications for medical marijuana growers and sellers. The move comes after the commission developed a more detailed scoring system for ranking applicants. The application period will open June 30 and go on for 90 days. The commission will distribute 32 dispensary licenses and five cultivation facility licenses.

Florida Lawmakers Reach Agreement on Implementing Medical Marijuana. Lawmakers on Wednesday came to agreement on how to implement the state's voter-approved medical law. Under the agreement, ten new growers will be licensed this year, with five licenses going to previous applicants, five going to new applicants, and at least one reserved for a black farmer. The state current licenses only seven commercial grows. The agreement also caps the number of dispensaries each grower can operate at 25.

Oregon Bill to Let Medical Growers Sell Up to 20 Pounds in Recreational Market Advances. A bill that seeks to reshape the state's medical marijuana program so it can coexist with legal recreational marijuana is advancing. House Bill 2198, which would let medical growers sell up to 20 pounds in the recreational market in a bid to stay viable, passed the Joint Committee on Marijuana Regulation last week and is now before Joint Committee on Ways and Means.

Heroin and Prescription Opioids

New York Times Investigation Finds Drug Overdose Deaths Reached All-Time High in 2016. The New York Times published on Monday an investigative report that found that drug overdose deaths last year reached an all-time high, suggesting that the country's long-term opioid crisis continues to worsen and that younger age groups in the U.S. are experiencing record numbers of opioid overdoses than in the past. The Times looked at preliminary overdose data for 2016 provided by hundreds of state and local health authorities, concluding: "Drug overdoses are now the leading cause of death among Americans under 50, and all evidence suggests the problem has continued to worsen in 2017." The report estimates that more than 59,000 people died from a drug overdose in 2016 -- an increase of 19% from 2015. The report does not elaborate on which drugs are behind the estimated jump in overdose deaths last year, nor does the report indicate which age groups under 50 saw the largest increase in overdose deaths over prior years.

Senate Drug Warriors Feinstein and Grassley Prepare Bill With Tough New Penalties for Synthetic Opioids. The senior members of the Senate Judiciary Committee are preparing a bill that would create tough new penalties for people caught with synthetic opioids. A draft of the bill would give the attorney general the power to ban all kinds of synthetic drugs and it would impose a 10-year maximum sentence on people caught selling them for a first offense. A second offense would see the sentence double. The bill would penalize people selling drugs at a low level in the US, critics said.

Drug Testing

Wisconsin Submits Request to Drug Test Medicaid Applicants. Gov. Scott Walker (R) on Wednesday officially submitted a request for a federal waiver to become the first state in the country to drug test applicants for Medicaid benefits. Walker said the plan would provide drug addicts with treatment and make them employable. "Healthy workers help Wisconsin employers fill jobs that require passing a drug test," Walker's administration said in a press release Wednesday announcing the waiver. But critics called the notion a waste of money and an insult to people who need Medicaid.

Chronicle AM: Seattle Safe Injection Site "Die-In," ME MJ Init Vote Recount, More... (12/5/16)

Foes challenging the narrow legalization victory in Maine got their recount going today, patients take to the courts in Arizona and to the streets in Michigan, Seattle health care professionals do a die-in for safe injection sites, Ireland takes another step toward medical marijuana, and more.

Vancouver's safe injection site. Doctors and nurses in Seattle are agitating for something similar there. (vcha.ca)
Marijuana Policy

Maine Legalization Initiative Recount Begins. The Question 1 initiative legalizing marijuana won by less than 1% of the popular vote, garnering 381,692 votes to the opposition's 377,619 votes, a difference of 4,073 votes. Citing the narrow margin of victory, foes called a recount, and it began Monday. The recount could take up to a month, delaying putting legalization into effect until it is completed.

Medical Marijuana

Pair of Arizona Patients Sue Over Fees. Attorneys for patients Yolanda Daniels and Lisa Becker filed suit last Friday to force a reduction in the annual fee for registration cards that patients are legally required to obtain. The state health department is charging $150 a year, even though it has nearly $11.5 million in its medical marijuana account. "In a time when medication is more expensive than ever, the state should be helping to make it cheaper for Arizonans," the patients' attorney argued. "The state is deliberately squatting on the excess fund instead of refunding it to patients or using it in furtherance of the Arizona Medical Marijuana Act, such as to help patients."

Michigan Protestors Denounce Kent County Dispensary Raids. A couple of dozen people gathered outside the Plainfield Township Hall last Friday to protest a series of raids last Monday that shuttered three dispensaries in Plainfield. Demonstrators said they have nowhere to go to get their medicine, but Plainfield officials countered that dispensaries had been banned there since 2011.

Harm Reduction

Seattle Nurses, Doctors Do Die-In at City Hall in Protest Calling for Safe Injection Sites. As Seattle officials ponder whether to move toward allowing a safe injection site, doctors and nurses are turning up the heat. Last Friday, more than 30 members of Health Care Workers for Supervised Consumption Spaces held a die-in at City Hall to imitate the corpses that will be created if safe injection sites aren't allowed. City officials have been generally sympathetic to the idea, and a Seattle/King County opioid task force recommended the move in September.

International

British Town to Allow Drug Testing at Clubs. In a harm reduction first for the United Kingdom, a town in Lancashire will be the first in the country to offer testing of drug samples provided by club-goers at night clubs. The tests will examine samples of cocaine and MDMA to test the strength and purity of the drugs in a bid to reduce deaths related to "adulterated or highly potent" drugs. The National Police Chief's Council reportedly said the scheme could be useful but was still not yet endorsed on a national basis.

Ireland Takes Another Step Toward Medical Marijuana. The Dáil Éireann, the lower house of parliament, last Thursday approved an amendment allowing for the medicinal use of marijuana. But the measure still has to undergo another round of approval before it becomes law.

Poll: More Irish Support Marijuana Legalization Than Not. As the parliament ponders medical marijuana, a new poll finds that more Irish than not support full-blown legalization. A poll asking "Should cannabis be legalized for recreational use?" had 48% saying yes, 41% saying no, and 11% undecided.

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