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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.

Chronicle AM: Denver Psilocbyin Init Will Go to Voters, White House Issues Drug Strategy, More... (2/4/19)

The White House belatedly released the National Drug Control Strategy, a Denver magic mushroom initiative has qualified for the May ballot, Northeastern marijuana legalizers are busy, and more.

Denver will vote on removing criminal penalties for psychedelic mushrooms. (Greenoid/Flickr)
Marijuana Policy

World Health Organization Urges Removal of Marijuana from Drug Treaties. The World Health Organization (WHO) last Friday published a letter to the United Nations advising that marijuana and cannabis resin should no longer be considered controlled substances under international drug treaties. WHO specifically asked that the substances be moved out of Schedule IV of the Single Convention on Narcotic Drugs, which includes drugs thought to have no therapeutic value.

Cory Booker Enters Presidential Race With Call for Marijuana Legalization, Criminal Justice Reform. Sen. Cory Booker (D-NJ) formally entered the race for the Democratic presidential nomination last Friday and called for marijuana legalization and broader criminal justice reforms. There is a need for "changing our drug laws," including "ending the prohibition against marijuana," he said. "We do not have equal justice under the law," Booker said of the disproportionate rate at which black people are incarcerated under the country's drug laws. I believe in redemption."

New York Governor Wants Marijuana Legalized by April 1. Gov. Andrew Cuomo (D) said last Friday he wanted to see marijuana legalized by the state budget deadline of April 1. His remarks came after Assembly Speaker Carl Heastie said that lawmakers might have to wait until after the budget to take up legalization. But Cuomo said Friday he isn't giving up on his timetable and that a lot can happen in the legislature in six weeks.

Pennsylvania Legalization Bill Coming. Rep. Jake Wheatley (D-Allegheny County) will file a legalization bill that expunges criminal records for past pot convictions, releases inmates currently serving time for such offenses, and allows people 21 and over to use, buy, and grow marijuana.

Vermont Attorney General Supports Legalizing Pot Sales. Vermont became the first state to legalize marijuana legislatively last year but did not legalize marijuana commerce. Now, there's an effort underway to do so with SB 54, and Attorney General TJ Donovan supports it. "We have to have a regulated market," he said last Thursday. "This is common sense." The bill is currently before the Senate Judiciary Committee.

Medical Marijuana

Wyoming Medical Marijuana Bill Filed. Republican House Majority Leader Eric Barlow has filed a bill to legalize medical marijuana, HB 278. The bill would create a strictly regulated system for the use and distribution of medical marijuana in the state.

Psychedelics

Denver Will Vote on Magic Mushroom Initiative in May. City officials announced last Friday that the Decriminalize Denver initiative to make adult use and possession the lowest law enforcement priority and bar the city from using its resources to arrest and prosecute people for the hallucinogenic fungi has qualified for the ballot and will go before voters in the May municipal election. This marks the first time any jurisdiction in the US will have voted on decriminalizing psychedelics.

Drug Policy

Trump Administration Unveils National Drug Control Strategy. The White House last Thursday released its long-awaited National Drug Control Strategy, which typically is released annually, but which the Trump administration failed to do last year. The document contains little new policy but instead emphasizes existing Trump priorities: reducing drug supply through stricter law enforcement, lowering first-time opioid prescription rates, and expanding access to addiction treatment. Despite its emphasis on supply reduction, it acknowledges the risk of reducing access for chronic pain patients. Although it talks about drugs coming across the Mexican border, the strategy does not contain the words "border wall."

Drug Testing

North Dakota School Board and Employee Drug Testing Bills Die. A pair of bills that would have mandated random, suspicionless drug tests for school employees and school board members have been killed in the Senate. SB 2310 was aimed at school employees, while SB 2337 was aimed at board members.

Sentencing

Mississippi Bill Targets People Who Provide Drugs in Fatal Overdoses. After a conviction for "depraved heart" murder in the case of a fatal overdose was overturned on appeal, state legislators have filed HB 867, which would allow sentences of 20 years to life without parole for people charged with selling drugs that result in the deaths of others. The bill would also increase penalties for the sale of heroin or fentanyl. The bill passed out of the House Judiciary Committee last week and is now headed for the House floor.

(This article was prepared by StoptheDrugWar.org's 501(c)(4) lobbying nonprofit, the Drug Reform Coordination Network, which also pays the cost of maintaining this website. DRCNet Foundation takes no positions on candidates for public office, in compliance with section 501(c)(3) of the Internal Revenue Code, and does not pay for reporting that could be interpreted or misinterpreted as doing so.)

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.

Chronicle AM: Denver to Expunge Pot Convictions, Columnist Calls for Prescription Heroin, More... (12/5/18)

 A Washington Post columnist calls for prescription heroin, the federal hemp bill will apparently ban the participation of people with drug felonies, Denver joins the movement to expunge old pot convictions, and more.

Prescription heroin--Washington Post columnist suggests it could save lives in the face of fentanyl. (Creative Commons)
Marijuana Policy

Denver Becomes Latest City to Expunge Low-Level Marijuana Offenses. Mayor Michael Hancock announced Tuesday that his administration will "move to vacate low-level marijuana convictions for Denver residents." The move comes after months of preliminary work by the Office of Marijuana Policy and the City Attorney's Office. "For too long, the lives of low-income residents and those living in our communities of color have been negatively affected by low-level marijuana convictions," Hancock said in a press release. "This is an injustice that needs to be corrected, and we are going to provide a pathway to move on from an era of marijuana prohibition that has impacted the lives of thousands of people."

Industrial Hemp

Federal Bill to Legalize Hemp Bans Drug Felons from Participating. Congressional negotiators have agreed on compromise language for the hemp provision of the farm bill that would ban people with felony drug convictions from participating in the hemp industry. The ban was inserted into the Senate version of the bill late in the process and over the objections of drug policy reformers. It's not quite a done deal—the language could be changed in conference committee—but at this point, it looks like the ban is in.

Heroin and Prescription Opioids

Washington Post Columnist Calls for Prescription Heroin. In a piece published Tuesday, Washington Post columnist Megan McArdle has called for access to prescription heroin in a bid to prevent fentanyl-related overdose deaths. In the column titled An Incredibly Unpopular Idea That Could Stem Heroin Deaths, McArdle notes that "most people don't want addiction made safer or easier; they want it stopped, cold…but you don’t free slaves by killing them, and as long as fentanyl suffuses the illicit drug markets, that’s what a 'tough love' policy amounts to." Harm reduction measures and increased access to treatment would help, McArdle writes, but "lowering the death toll may well require a more drastic step: legalizing prescriptions of stronger opiates. Prescription heroin? 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 U.S. 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."

Asset Forfeiture

Nashville Bends to Police Pressure, Extends Federal "Equitable Sharing" Program. Under pressure from local law enforcement and seeking to avoid raising taxes, the Nashville Metro Council voted 25-5 to renew its participation in the federal asset forfeiture equitable sharing program, which allows state and local law enforcement agencies to divert drug-related cash seizures to the federal government, which in turn returns 80% of the booty back to the seizing agency. 

Chronicle AM: Mexico Supreme Court Ends Marijuana Prohibition, Feds Reject WI Medicaid Drug Tests, More... (11/1/18)

Mexico's Supreme Court strikes a fatal blow against marijuana prohibition, medical marijuana is now available by prescription in the United Kingdom, a Colorado jury rejects an effort to blow up the state's legal marijuana system, and more.

Marijuana Policy

Colorado Federal Jury Throws Out RICO Case Threatening State Marijuana Law. That didn't take long. A Denver federal court jury took only a few hours Wednesday to reach a verdict against a couple who claimed a marijuana cultivation operation was ruining their property values and threatening their lifestyle. The couple, aided by anti-marijuana attorneys, had attempted to use federal RICO statutes to undermine the state law, arguing that because marijuana is still federally illegal, its production violates federal racketeering laws. But the jury didn't buy it.

Drug Testing

Wisconsin Governor's Plan to Require Drug Testing for Medicaid Rejected. The federal Center for Medicare and Medicaid Services has rejected a proposal from Gov. Rick Scott (R) to require drug testing as a condition for receiving Medicaid benefits. Walker had proposed several changes to the state program, known as BadgerCare, and the administration approved requiring childless adults to work or lose coverage, but not the proposed drug testing. Instead of requiring drug screening and testing, Medicaid applicants will now have to complete a health assessment with questions about drug use. If the assessment indicates concerns about drug use, the applicant will be referred to treatment, but not required to go.

Harm Reduction

New York City Legislation Would Expand Opioid Treatment at Homeless Shelters. City Councilman Stephen Levin (D-Brooklyn) Wednesday filed legislation to increase access to opioid treatment at city homeless shelters. The bill would allow for easier access "We can't continue to sit by and do nothing," said Levin. "As we've seen in New York City and throughout the country, the status quo is not working. People are overdosing on opioids every day in New York City -- more than homicides and traffic fatalities combined."

International

Mexico Supreme Court Strikes Down Marijuana Prohibition. In a pair of rulings Wednesday, the Supreme Court of Mexico ruled that the country's ban on marijuana violates individual autonomy protections in the Mexican constitution. The court said adults have the right to grow, possess, and use marijuana, but that the government retains the right to regulate consumption. It also directed the federal health agency to begin to develop regulations reflecting the decision. The ruling does not legalize marijuana commerce; it would be up to the Mexican congress to take up that issue.

Medical Marijuana Now Legal in Great Britain. As of Thursday, November 1, some medical marijuana patients will be able to legally seek and obtain their medicine. Legal access to medical marijuana will be limited to patients who have "an unmet special clinical need that cannot be met by licensed products." It will be up to a special panel to determine who meets that condition, but there are worries that the system may prove too unwieldy to satisfy the needs of hundreds of thousands of potential patients.

Chronicle AM: No MedMJ for Vets This Year, Senate Takes Up Opioid Package, More.... (9/11/18)

A congressional conference committee has killed medical marijuana for veterans, the Senate is set to take up a package of opioid bills, the West African Commission on Drugs releases a model law for drug decriminalization, and more.

West African Commission on Drugs founder Kofi Annan. He may be gone, but his work lives on. (Creative Commons)
Marijuana Policy

California Governor Vetoes Mandatory Minimum Penalties for Pot Shops That Sell to Minors. Gov. Jerry Brown (D) on Monday vetoed a bill that set mandatory minimum penalties for marijuana shops caught selling weed to minors. The bill would have imposed mandatory 15-day license suspensions for a first offense, 25-day suspensions for a second, and revocation for a third offense. But "this bill is not necessary," Brown said. "The bureau already has the authority to revoke, suspend, and assess fines if a licensee sells to a minor."

Medical Marijuana

Congress Removes Military Veteran Medical Marijuana Provision from Funding Bill. A conference committee working on final details for the Veterans Affairs appropriations bill has decided not to include a provision allowing VA doctors to recommend medical marijuana to veterans. The Senate bill included the provision, but the House version did not. Two years ago, both houses passed VA spending bills that included versions of the provision, but that, too, was excised in conference committee.

Heroin and Prescription Opioids

Senate Expected to Vote on Opioid Legislation This Week. Senate leaders announced late last week they had reached an agreement to bring a package of bills aimed at the opioid crisis to a Senate floor vote this week. The Senate will consider a substitute amendment to the opioids package that passed the House in June. Progress had stalled over Democratic concerns that a grant program would benefit only one addiction advocacy group. That has now changed. There remains a divergence between the House and Senate packages regarding requirements for Medicaid to cover treatment at more inpatient facilities and loosening privacy protections for medical records for substance abuse patients.

Sentencing Policy

Ohio Governor Candidates Clash Over Drug Possession Defelonization Initiative. Buckeye State voters will have a chance to vote to defelonize drug possession in November with the Issue 1 constitutional amendment initiative. The amendment would also bar any jail time for a first or second offense within 24 months. Mike DeWine, the Republican candidate for governor, opposes it, saying it "takes vital tools away from judges." Democratic candidate for governor Richard Cordray, however, supports it, saying its passage would "set the way toward a policy of being smart on crime in the future, smart on how we use taxpayers' dollars, smart on how we build people's potential to be productive citizens in our society."

International

Expert Group Publish Blueprint for West Africa Drug Decriminalization. The West Africa Commission on Drugs has published a "model law" for decriminalizing drug possession and reducing related harms in West Africa. The commission is currently chaired by former Nigerian President Olusegun Obasanjo, who said on Tuesday: "West Africa faces three dangers from drugs: organized crime, corruption, and harms to people who use drugs. Our current laws increase those harms rather than help,"

This article was prepared by StoptheDrugWar.org's 501(c)(4) lobbying nonprofit, the Drug Reform Coordination Network, which also pays the cost of maintaining this website. DRCNet Foundation takes no positions on candidates for public office, in compliance with section 501(c)(3) of the Internal Revenue Code, and does not pay for reporting that could be interpreted or misinterpreted as doing so.)

The Opioid Crisis Could Cost a Half Million Lives in the Next Decade

The most recent data from the Centers for Disease Control and Prevention, released in mid-August, showed a record 72,000 drug overdose deaths last year, with 49,000 related to heroin, fentanyl and prescription opioids. According to the authors of a study released last week in the American Journal of Public Health, that could be the new normal.

The study, by Stanford researchers Allison Pitt, Keith Humphreys, and Margaret Brandeau, attempts to assess the number of opioid-related deaths we could expect to see over the next decade, as well as the impact of different policy responses on reducing the death toll.

The researchers said there are steps that can be taken to reduce the death toll, but also that some seemingly simple solutions, such as cracking down on opioid prescribing for chronic pain, could actually increase the toll. And even those policies that could cut the opioid death rate are likely to do so only marginally.

Using a mathematical model, the researchers estimate that some 510,000 people will die over the next decade because of opioid use. The number includes not only drug overdoses but also other opioid-related deaths, such as HIV infections caused by shared needles.

Even including the non-overdose deaths, the number is staggering. Last year was the worst year ever for opioid-related overdose deaths, but this research suggests we are going to see year after year of similar numbers.

Making the overdose reversal drug naloxone more widely available could cut opioid-related deaths by 21,200 over the next decade, allowing greater access to medication-assisted therapies with drugs such as buprenorphine and methadone would save another 12,500 lives, and reducing opioid prescribing for acute pain would prevent another 8,000 deaths, the researchers said. But those three policy moves combined would shave less than 10 percent off the overall death toll.

"No single policy is likely to substantially reduce deaths over 5 to 10 years," the researchers wrote.

While harm reduction interventions such as those above would save lives, some aspects of tightening opioid prescribing would actually increase opioid-related deaths by as much as the tens of thousands -- because they increase heroin deaths more than they cut painkiller deaths. Moves such as reducing prescribing for chronic pain, up-scheduling pain relievers to further restrict their prescribing, and prescription drug monitoring programs all tend to push existing prescription opioid users into the illicit heroin and fentanyl markers all end up contributing to net increases in opioid deaths over the 10-year period, the researchers found.

On the other hand, other interventions on the prescribing front, such as reducing acute prescribing for acute pain (pain that may be signficant but is short-term), reducing prescribing for transitional pain, reformulating drugs to make them less susceptible to misuse, and opioid disposal programs, appear to prevent more deaths than they cause.

Ultimately, reducing the opioid death toll includes reducing the size of the opioid-using population, the researchers say. That implies making addiction treatment more available for those currently using and preventing the initiation of a new generation of opioid users. Restrictions on prescribing, while possibly driving some current users to dangerous illicit markets, can have a long-term impact by reducing the number of people who develop a dependence on opioids.

Whether that's a tolerable tradeoff for those pain patients who don't get the relief they need from other medications -- or for patients and others who end up dying from street heroin but might have lived despite their prescription opioid use -- is a different question.

By all appearances, when it comes to the loss of life around opioids, it looks like a pretty sad decade ahead of us.

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

Chronicle AM: NY Gov Signs Opioid Bill, VT Dems Want Full MJ Legalization, More... (8/27/18)

An Arizona prosecutor gets challenged for trying to profit off small-time pot offenders, Oregon regulators slash the daily purchase amounts for medical marijuana patients, a Louisiana prisoner featured in the Chronicle years ago gets a break, and more.

Oregon patients will only be able to buy one ounce a day under new emergency rules. (Creative Commons)
Marijuana Policy

Arizona County Attorney Sued Over Drug Court Diversion Program for Smalltime Marijuana Offenders. The Civil Rights Corps, a Washington, DC-based advocacy group, and a local law firm have sued Maricopa County (Phoenix) Attorney Bill Montgomery. They allege that he and the county drug court diversion program are preying on and profiting off people charged with minor pot possession offenses. Under the state's harsh laws, possession of even small amounts is a felony, but first- and second-time offenders are eligible for a diversion program. The problem is the diversion program has a $1,000 fee, and those who cannot pay the entire fee linger in the program, paying $15 to $20 fees for drug testing as often as several times a week and face being tried as felons if they fail to complete the program. "The complaint explains that the marijuana diversion program operated by TASC Inc. and the Maricopa County Attorney's Office represents a two-tiered legal system," Civil Rights Corps Attorney Dami Animashaun said in a statement. "Wealthy people buy their way off diversion quickly, while poor people risk being expelled from the program and prosecuted for a felony solely because they cannot afford to pay."

Vermont Democrats Call for Taxed, Regulated Legal Marijuana Sales. Vermont has already legalized the personal possession and home cultivation of marijuana, and now the state's Democratic Party has formally endorsed expanding legalization to include taxed and regulated legal marijuana sales. "We believe that marijuana should be legal, taxed and regulated in the interests of consumer and public health, and economic opportunity," reads a platform plank adopted by delegates at the Vermont Democratic Party's platform convention on Sunday.

Medical Marijuana

Oregon Regulators Slash Daily Purchase Limit for Patients. In a bid to reduce leakage into the black market, the Oregon Liquor Control Commission last Thursday dramatically reduced the amount of medical marijuana patients can purchase each day. Medical cardholders may now buy only one ounce a day, not the 24 ounces that had been the limit. The emergency change is in effect until December 27.

Illinois Governor Signs Hemp Bill. Gov. Bruce Rauner (R) on Saturday signed a bill legalizing industrial hemp, the Illinois Hemp Act. "Legalizing the farming of industrial hemp just makes good sense," Rauner said in a statement. "Roughly 38 states -- including our neighbors in Wisconsin, Kentucky, Indiana, Missouri and Tennessee -- have allowed or are considering allowing cultivation of this crop for commercial, research or pilot programs. Our farmers should have this option as well." The state Department of Agriculture will issue licenses to farmers who want to grow it, and regulators will establish rules for THC-level testing of industrial hemp crops.

Heroin and Prescription Opioids

New York Governor Signs Legislation To Expand Use Of Rehabilitation And Diversion Services To Combat Heroin And Opioid Epidemic. Governor Andrew Cuomo (D) last Friday signed legislation (A.10403/S.8760) to help in the fight against the heroin and opioid epidemic by diverting substance-dependent individuals who are involved in the criminal justice system. This legislation provides another form of support to prosecutors and law enforcement officers as they seek treatment and counseling for people who are addicted to opioids. These diversion models include law enforcement assisted diversion, known as LEAD, and other programs treating substance abuse and addiction. The legislation expands the allowable use of funding from seized or forfeited assets by law enforcement and the Office of Alcoholism and Substance Abuse."We must use every tool at our disposal to combat this nation's opioid epidemic and the underlying issues that lead people to commit crime, and this legislation makes available additional funding to help New Yorkers in need," Governor Cuomo said. "By helping New Yorkers turn their lives around, this program helps strengthen communities, increase public safety and break the vicious cycle of recidivism once and for all."

Sentencing

One Louisiana Man Gets a Sentence Cut. A Louisiana man sentenced to life in prison for marijuana possession as a habitual offender has received a sentence reduction that will allow him to go free in a matter of weeks. Jody Butler's case was covered by the Chronicle's Clarence Walker back in 2013, but it took until now for justice to be done. New Orleans Parish District Attorney, who made a career of imposing long sentences on small-time drug offenders, raised no objection to a sentence reduction in Butler's case, the latest in which he has backpedaled away from his earlier, harsher stance.

Chronicle AM: CA Senate Passes SIS Bill, Black Vets More Likely to Be Drug Tested, More... (8/22/18)

Louisiana doctors could soon treat more medical marijuana patients, black VA patients on opioid therapy are more likely to be drug tested and have their treatment halted for illicit drug use than whites, a Georgia judge throws out a heroin murder conviction, and more.

A facility like Vancouver's InSite could be coming to San Francisco. A bill to make it happen is moving in Sacramento. (CC)
Medical Marijuana

Louisiana Regulators Weight Raising Limit on Number of Patients Doctors Can Treat. The state Board of Medical Examiners is set to boost the number of medical marijuana patients a single doctor can treat. The board set a limit of 100 patients per doctor in 2016, but Vincent Culotta, the board's executive director, said the limit will be raised at the board's meeting next month. "We realize we're going to have to increase that number," he said.

Oklahoma Judge Rules Implementation of Medical Marijuana Rules Can Proceed. Cleveland County District Court Judge Michael Tupper ruled Tuesday that the Board of Health can proceed with implementing the state's medical marijuana rules and regulations. He ruled against a lawsuit by more than a dozen Oklahoma patients and businesses who challenged the rules. The decision Tuesday does not end the case. The judge could still throw out some or all the challenged rules at a later date or choose to leave them alone again. Another legal challenge is still pending in Oklahoma County District Court.

Heroin and Prescription Opioids

Study Finds African-American VA Patients More Likely to Be Drug Tested, Have Prescriptions Stopped. Black VA patients on long-term opioid therapy are more likely to be drug tested by their doctors and much more likely to have their opioid prescriptions halted if any illegal drug use is found, a new study finds. About 25% of black patients were tested within six months of being prescribed opioids, while only 16% of whites were. Black patients were twice as likely as white ones to have their opioid therapy halted if they tested positive for marijuana and three times as likely if they tested positive for cocaine. The findings were published in the journal Drug and Alcohol Dependence.

Georgia Judge Dismisses Indictment in Heroin Overdose Death. A Georgia judge has dismissed a murder indictment against a man accused of injecting heroin into another man who overdosed and died. In the case, Superior Court Judge John Goger found that the defendant injected the fatal dose at the victim's request and that the victim had purchased the drug himself. Goger held that that didn't amount to heroin distribution by the defendant, and without the underlying drug felony, there is no felony murder.

Harm Reduction

California Senate Passes Bill to Permit Safe Injection Sites in San Francisco. The state Senate Wednesday approved Assembly Bill 186, which would allow San Francisco to implement a safe injection site. AB 186 permits San Francisco to establish facilities where individuals can use controlled substances under the supervision of staff that are trained to treat and prevent drug overdose and link people to drug treatment, housing, healthcare, and other services. Mayor London Breed, the San Francisco Board of Supervisors, as well as a significant majority of the San Francisco electorate, support piloting safe injection sites in San Francisco.

Saying Goodbye to Mr. Methadone: Dr. Bob Newman Dead at Age 80

Dr. Robert Newman died earlier this month after being struck by an automobile earlier this summer. He was 80 years old.

Bob Newman at a Beth Israel staff meeting in 1985 (Arthur H. Aufses Jr. MD Archives at Mt. Sinai)
If any one man can be credited with carving out a space for the use of methadone as a treatment for heroin addiction, he is that man. Working as a New York City public health doctor in the 1960s, he was given the task of ensuring that heroin addicts who wanted treatment could get treatment with methadone. His boss, city health department head Gordon Chase, told him he would be known as "Mr. Methadone."

While he did not achieve the goal of providing treatment to everyone who wanted it, Newman oversaw the rapid expansion of the city's fledgling methadone program in the early 1970s. The number of patients on methadone went from a handful to more than 10,000 in two years, and 35,000 by 1975.

And he stood up for those patients. When the NYPD wanted Newman to turn over patients' methadone records, he refused. Instead, he took to the courts to defend his patients' right to privacy -- and he won.

After that, he devoted his career to advocating for evidence-based treatment, traveling the country and the world and picking up a second moniker, "the methadone pope," as he advanced harm reduction ideas decades before they became popularized.

He faced opposition from abstinence and 12-step proponents, as well as from elected officials like New York City Mayor Rudy Giuliani, who in 1998 tried to shut down the city's methadone program on the moralistic grounds that it merely substituted one addiction for another. The diplomatic Newman didn't challenge Giuliani head on but instead used interviews to make his case that methadone treatment allowed addicts to lead productive lives.

Newman also advocated for a humane approach toward addicted mothers and pregnant women, supporting groups such as National Advocates for Pregnant Women in their fight against the demonization and criminalization of those women. He was a drug policy reformer who served for decades on the board of the Drug Policy Foundation and then its successor the Drug Policy Alliance.

As this century's opioid epidemic deepened, Newman was cautiously optimistic that the work he had begun decades earlier would help further destigmatize addiction. "I'm hoping that pragmatism will win out," he said. "As more and more Congresspeople, people in the general community and physicians have children who develop a problem with prescription drug use and can't get treatment for it, I think it will make people more receptive to opening doors to treatment."

Newman was not only an influential physician in addiction issues, he was a giant in the hospital world as a whole. He served as President of Beth Israel Medical Center in New York, and then of the entity that acquired Beth Israel along with other facilities -- and then of the entity that acquired that entity. But one could still talk him at a drug policy conference, or send him an email, and you'd get an email back.

Dr. Robert Newman's contribution to an enlightened approach to addiction cannot be overstated. He will be missed, but his legacy lives on.

(Read Bob Newman's 1998 interview with this newsletter here.)

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