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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.)

Chronicle AM: PA Gov Says State Not Ready for Legal Pot, New FDA Guidelines on MATS, More... (8/9/18)

The FDA has issued new draft guidance aimed at expanding the use of medication-assisted treatments (MATs) for opioid addiction, Pennsylvania's governor says the state isn't ready for legal weed, the Oklahoma medical marijuana fight isn't over yet, and more.

Pennsylvania Gov. Tom Wolf (D) isn't on the same page as his counterparts in New York and New Jersey. (Creative Commons)
Marijuana Policy

Pennsylvania Governor Says State Not Ready for Marijuana Legalization. Gov. Tom Wolf (D) said during a radio interview on Tuesday that he doesn't think the state is ready to legalize marijuana. "There are, what, six states that have legalized recreational marijuana in the United States," Wolf said. (The actual number is nine.). "I don't think the citizens of Pennsylvania are ready for it, and so the answer I would say is no… I don't think Pennsylvania's actually ready for recreational marijuana." The position puts Wolf at odds with two neighboring Democratic governors, Phil Murphy of New Jersey, who is strongly pushing legalization, and Andrew Cuomo of New York, who just signed off on the notion.

Los Angeles Won't Vote on Raising Pot Tax in November. The city council has reversed a decision to place a 1% marijuana tax increase on the November ballot. The city estimated it would raise approximately $30 million per year from the tax increase, but faced immediate blowback from industry groups who said pot taxes were already too high and are driving consumers to the black market.

Medical Marijuana

Oklahoma Agencies Still Have "Concerns" Over Legal Medical Marijuana. Interim health commissioner Tom Bates told lawmakers Wednesday that the Health Board still has concerns about how medical marijuana will be implemented and that a special session of the legislature may be needed to see the program properly implemented. The board wants lawmakers to amend the law so that, among other changes, commercial grows are indoor only, patient home grows are prohibited or require a special license, smokable marijuana is prohibited, THC levels are limited to 12% or less, a pharmacist is required on-site at dispensaries, and that a list of qualifying conditions for patients be created. Some of the changes are among those recommended in the Health Board's first try at setting interim rules, which were retracted in the face of loud public opposition. Any effort to re-adopt them is certain to lead to renewed clamor.

Heroin and Prescription Opioids

FDA Seeks to Expand Use of Medication-Assisted Therapies for Addiction. The Food & Drug Administration (FDA) on Monday released new draft guidance aimed at promoting the creation and more widespread use of medication-assisted therapies (MATs) for opioid use disorder. The guidance adjusts how FDA evaluates new treatments for opioid addiction. Instead of only determining whether a treatment lowers opioid use, the agency will now assess whether the medication could help lower overdose rates and limit the spread of infectious disease. "We must consider new ways to gauge success beyond simply whether a patient in recovery has stopped using opioids, such as reducing relapse overdoses and infectious disease transmission," said Scott Gottlieb, FDA commissioner.

Does Microdosing Psychedelics Really Improve Your Life?

Microdosing psychedelics has been a thing for awhile now. It is the practice of ingesting drugs such as LSD or psilocybin (the stuff that puts the magic in magic mushrooms) in amounts too small to create a psychedelic experience in a bid to improve focus and creativity, boost mood, or quell anxiety.

LSD blotters. How much is a microdose? (Creative Commons)
Microdosing has developed a laudatory literature -- see Ayelet Waldman's 2017 A Really Good Day: How Microdosing Made a Mega Difference in My Mood, My Marriage, and My Life and Michael Pollan's 2018 How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence -- but next to no serious scientific study.

Until now. In findings first presented at the June Beyond Psychedelics conference in Prague (and to be published as three separate research papers later this year), University of Toronto researchers offered fascinating insights into the how, why, and results of using small amounts of psychedelics for therapeutic effects.

In a research announcement, cognitive neuroscientist and study coauthor Thomas Anderson said his interest in the topic was sparked when reviewed the scientific literature and found plenty of anecdotal reports but a lack of scientific research on the practice.

"There's currently a renaissance going on in psychedelic research with pilot trials and promising studies of full-dose MDMA (ecstasy) use for post-traumatic stress disorder and of psilocybin use within healthy populations or to treat depression and end-of-life anxiety," said Anderson. "There hasn't been the same research focus on microdosing. We didn't have answers to the most basic epidemiological questions -- who is doing this and what are they doing?"

Anderson and a team of researchers decided to do something no one had done before: ask the users themselves about their experiences. The researchers identified microdosing communities on Reddit and other social media forums and sent them an anonymous online survey asking about the quantity and frequency of their psychedelic use, reasons for microdosing, effect on mood, focus and creativity, and the benefits and drawbacks of the practice. The survey generated 1.390 initial responses, with 909 respondents answering all questions. Two-thirds of the respondents were either current or past microdosers.

"We wanted to ensure the results produced a good basis for future psychedelic science," Anderson said.

What they found was that microdosers reported positive effects, including improved focus and productivity, better connection with others, and reductions in migraines. Quantitatively, microdosers scored lower than non-microdosers on scales measuring negative emotionality and dysfunctional attitude.

Microdosers did report some drawbacks to the practice, but those were related more to the illegal status of psychedelics than to the practice itself.

"The most prevalently reported drawback was not an outcome of microdosing, but instead dealt with illegality, stigma and substance unreliability," says Anderson. "Users engage in black market criminalized activities to obtain psychedelics. If you're buying what your dealer says is LSD, it could very well be something else."

The survey did help clarify the frequency of microdosing -- most respondents reported using every three days, while a smaller group did it once a week -- and just what constituted a microdose.

"Typical doses aren't well established," said Anderson. "We think it's about 10 mcg or one-tenth of an LSD tab, or 0.2 grams of dried mushrooms. Those amounts are close to what participants reported in our data."

But accurate dosing was another problem area: "With microdoses, there should be no 'trip' and no hallucinations. The idea is to enhance something about one's daily activities, but it can be very difficult to divide a ½-cm square of LSD blotting paper into 10 equal doses. The LSD might not be evenly distributed on the square and a microdoser could accidentally 'trip' by taking too much or not taking enough," Anderson said.

"The goal of the study was to create a foundation that could support future work in this area, so I'm really excited about what these results can offer future research," he explained. "The benefits and drawbacks data will help ensure we can ask meaningful questions about what participants are reporting. Our future research will involve running lab-based, randomized-control trials where psychedelics are administered in controlled environments. This will help us to better characterize the therapeutic and cognitive-enhancing effects of psychedelics in very small doses."

Eventually, the science will catch up to the practice. In the meantime, microdosers are going to microdose. Anderson has a scholarly caution for them: "We wouldn't suggest that people microdose, but if they are going to, they should use Erlich reagent (a drug testing solution) to ensure they are not getting something other than LSD."

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

How to Prevent Opioid Overdoses? Provide Hard-Core Addicts Free Pharmaceutical Heroin

With Ohio beset by a massive public health crisis around opioid use and overdoses -- more than 4,000 Ohioans died of opioid overdoses in 2016 -- the Cleveland Plain Dealer sent travel editor Susan Glaser to Amsterdam in search of innovative approaches to the problem. While there, she rediscovered Holland's longstanding, radical, and highly-effective response to heroin addiction and properly asked whether it might be applied to good effect here.

The difference in drug-related death rates between the two countries is staggering. In the US, the drug overdose death rate is 245 per million, nearly twice the rate of its nearest competitor, Sweden, which came in second with 124 per million. But in Holland, the number is a vanishingly small 11 per million. In other words, Americans are more than 20 times more likely to die of drug overdoses than Dutch.

For Plain Dealer readers, the figures that really hit home are the number of state overdose deaths compared to Holland. Ohio, with just under 12 million people, saw 4,050 drug overdose deaths in 2016; the Netherlands, with 17 million people, saw only 235.

What's the difference? The Dutch government provides free heroin to several score hardcore heroin addicts and has been doing so for the past 20 years. Public health experts there say that in addition to lowering crime rates and improving the quality of life for users, the program is one reason overdose death rates there are so low. And the model could be applied here, said Amsterdam heroin clinic operator Ellen van den Hoogen.

"It's been an enormous success. I think it would work elsewhere," she told Glaser.

It already has. The Dutch program was modeled on a similar effort in Switzerland, which has also proven successful. Germany and Canada are among the several other countries with similar programs.

The Dutch approach is an example of the country's policy of gedogen (pragmatic tolerance), the same principle that led the Dutch to pioneer quasi-legal access to marijuana in the 1980s. It is also rooted in the notion that, for some, drug addiction is a chronic disorder, not a condition to be "cured," and one that can be treated with supervised drug use under clinical supervision. And the complete cessation of drug use need not be the ultimate goal; rather, the Dutch look for reductions in criminal activity and increases in the health and well-being of the drug users.

"It's not a program that is meant to help you stop," acknowledged van den Hoogen. "It keeps you addicted."

That's not a sentiment sits well with American moralizers, such as George W. Bush's drug czar, John Walters, whom Glaser consulted for the story. He suggested that providing addicts with drugs was immoral and not "real treatment," but he also resorted to lies about what the Dutch are doing.

He claimed the Dutch are "keeping people addicted for the purpose of controlling them" and that the Dutch have created "a colony of state-supported, locked-up addicts."

Actually, the Dutch are dealing with older, hardcore addicts who have repeatedly failed to quit after repeated stints in treatment, including methadone maintenance therapy, and they are neither "controlling them" or locking them up. Instead, the people in the program show up at the clinic twice a day, get their fix, then go about their business. This heroin-assisted treatment (HAT) allows those hardcore users to live less chaotic and more productive lives.

And heroin-assisted treatment is "real treatment," said Peter Blanken, a senior researcher with the Parnassia Addiction Research Centre in Rotterdam. He pointed out that one-quarter of program participants make a "complete recovery," including better health and quitting illegal drugs and excessive drinking. Many others continue to use heroin, but do so with better outcomes, he said.

There is also a real safety benefit to using state-supplied pharmaceutical heroin. It's potent, but it's a known quantity. Users face no risk of adulteration with more dangerous drugs, such as fentanyl, which is deeply implicated in the current US overdose crisis.

In the current political atmosphere in the United States, providing heroin to hardcore addicts is a hard sell indeed. Other, lesser, harm reduction interventions, such as needle exchanges remain controversial, and the country has yet to see its first officially sanctioned safe injection site. And drug decriminalization, which has led to a dramatic reduction in heroin addiction and overdose deaths in Portugal, remains off the table here, too. But with an annual drug overdose death toll of more than 50,000 people a year, it may time to start asking how many more Americans we are willing to sacrifice on the altar of moralistic drug prohibition.

Advocates Claim "Overdose Prevention" Bill Would Drive People Out of Treatment and Increase Overdoses [FEATURE]

A bill ostensibly aimed at reducing opioid overdoses passed the House last month, but rather than cheering it on, drug treatment and recovery advocates are lining up to block it in the Senate. That's because instead of being aimed at reducing overdoses, the bill is actually a means of removing patient privacy protections from some of the most vulnerable people with opioid problems, including people using methadone-assisted therapy to control their addictions.

The measure is now before the Senate. (Creative Commons)
And that, advocates say, is likely to increase -- not decrease -- opioid overdoses by pushing users away from drug treatment out of fear the information they reveal could be used against them. The fear is real: Unlike other medical conditions, drug addiction leaves patients open to criminal prosecution, as well as stigmatization and other negative social consequences if their status as drug treatment or maintenance patients is revealed.

This bill, H.R. 6082, the Overdose Prevention and Patient Safety Act, would remove drug treatment patients' ability to control the disclosure of information to health plans, health care providers, and other entities, leaving them with only the lesser privacy protections afforded to all patients under the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

"The confidentiality law is often the only shield between an individual in recovery and the many forms of discrimination that could irreparably damage their lives and future," said Paul Samuels, President/Director of the Legal Action Center. "Unfortunately, there is a very real danger of serious negative consequences for people whose history of substance use disorder is disclosed without their explicit consent."

The Legal Action Center is spearheading the effort to block this bill with the Campaign to Protect Patients' Privacy Rights, which counts more than a hundred organizations, including the American Association for the Treatment of Opioid Dependence, AIDS United, Community Catalyst, Faces and Voices of Recovery, Facing Addiction, Harm Reduction Coalition, National Advocates for Pregnant Women, National Alliance for Medication Assisted Recovery and the, National Council on Alcoholism and Drug Dependence.

The current patient privacy protections, known as 42 C.F.R. Part 2 ("Part 2"), were established more than 40 years ago to ensure that people with a substance use disorder are not made more vulnerable to discriminatory practices and legal consequences as a result of seeking treatment. The rules prevent treatment providers from disclosing information about a patient's substance use treatment without patient consent in most circumstances. The bill's plan to replace Part 2's confidentiality requirements with HIPAA's more relaxed standards would not sufficiently protect people seeking and receiving SUD treatment and could expose patients to great harm, the advocates charge.

"They should call this the Taking Away Protections Act," said Jocelyn Woods, head of the National Alliance for Medication-Assisted Recovery. "People will be afraid to go into treatment. I'm getting emails from people who want to leave treatment before this happens. If I were going into a program and they can't tell me my information will be safe, I would think about turning around and walking out," she said.

"Many of us would not have gone to treatment or accepted services if we thought that our information would have been shared with other entities without our permission. We would not have put our careers, reputation or families at risk of stigma and discrimination if we were not assured that information about our substance use disorder was safe and would only be shared with our consent," added Patty McCarthy Metcalf, executive director of Faces and Voices of Recovery.

The push for the bill is being led by health information software companies and behavioral health providers, such as Hazelden and the Betty Ford Center, and it prioritizes convenience over patient privacy.

"This is because the behavioral health people see complying with the privacy requirements as a pain in the ass," said Woods. "They're going to have to fix their computer systems to block out any treatment program licensed by the federal government -- not just methadone programs -- and they don't want to do that. One of the software companies, Netsmart, complained that they don't want to mess with their programming," she said.

"We need Part 2," Woods continued. "It keeps police out of the program. Without it, police can walk right in. They already sit outside methadone clinics and bust people for DUI on the way out. If this passes, they will walk right in. If the police see anyone they think has a warrant or committed a crime, they're gone."

While the bill has made its way through the House, advocates are hopeful it will stall in the Senate.

"The House pushed this through because they wanted to look like they were doing something and because the behavioral health people were pushing for it," Woods said, "but my sense is that it's moving slowly in the Senate. We have this crazy president, and there's immigration, and the congressional break, and then campaign season. My hope is we can push this past the elections and a blue wave in November will give us a fighting chance."

But the campaign isn't taking any chances and is mobilized to fight on the Hill in the next few months to block the bill. As Mark Parrino, President of the American Association for the Treatment of Opioid Dependence warned: "In the midst of the worst opioid epidemic in our nation's history, we cannot afford to have patients fearful of seeking treatment because they do not have faith that their confidentiality will be protected."

Can Magic Mushrooms Treat Cocaine Dependency?

The hunt for a pharmacological agent to help people strung out on cocaine get off the marching powder has been a long one, and non-traditional types of treatments are among the possibilities being studied. Ibogaine is one pharmacological therapy being studied. Another is href="https://www.uab.edu/news/research/item/9565-study-can-taking-a-hallucinogen-curb-cocaine-use" target=_blank_>psilocybin, the chemical that puts the magic in magic mushrooms.

Scientists at the University of Alabama-Birmingham's (UAB) School of Public Health are now conducting a clinical trial to see whether psilocybin can help break cocaine addiction.

The trial currently has almost 20 people enrolled, but researchers are looking for more subjects -- people who are currently using cocaine and have a strong desire to quit.

"Our goal is to create a tool or drug that provides significantly better outcomes for individuals addicted to cocaine than those that currently exist," said Sara Lappan, Ph.D., a postdoctoral scholar in the Department of Health Behavior

In the trial, participants receive a dose of psilocybin and are monitored for six hours, about the duration of the experience. Then, the researchers track his or her cocaine use.

"Our idea is that six hours of being under the effects of psilocybin may be as productive as 10 years of traditional therapy," Lappan said.

The researchers theorize that psilocybin works on three levels: the biochemical, the psychological, and the spiritual. In terms of biochemistry, psilocybin disrupts brain receptors thought to reinforce addictive behaviors. Psychologically, the drug is believed to reduce cravings, increase motivation, and increase one's sense of self-efficacy. Spiritually -- or transcendentally -- psilocybin (along with other psychedelics) is thought to increase both a person's sense of purpose and his or her sense of universal connectedness or oneness.

"If our hypotheses are supported, this has the potential to revolutionize the fields of psychology and psychiatry in terms of how we treat addiction," Lappan said.

But don't run out and start gobbling down magic mushrooms to quit cocaine just yet, the researchers cautioned.

"We aren't advocating for everyone to go out and do it," said Peter Hendricks, Ph.D., associate professor of health behavior in the School of Public Health at UAB. "What we are saying is that this drug, like every other drug, could have appropriate use in a medical setting. We want to see whether it helps treat cocaine use disorder."

They're not the only ones looking into the secrets of psilocybin. UAB is one of a half-dozen universities studying its potential medicinal benefits. The others are Johns Hopkins University, Imperial College London, New York University, University of California-San Francisco and Yale.

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

Different Psychedelics Share a Common Trait: Enhancing ‘Neural Plasticity"

New research suggests that different classes of psychedelic drugs all share the tendency to promote the growth of new brain cells, especially the kind that reach out and forge connections with other brain cells. This finding could help explain both the mind-expanding properties of the drugs and the mechanisms by which they appear to act as valuable treatments for a broad range of psychiatric disorders.

Earlier research had identified the dissociative anesthetic ketamine as promoting growth in key brain cells (as well as being a fast-acting and effective treatment for depression), but this new research finds similar effects in amphetamine-based psychedelics such as DOI (2,5-dimethoxy-4-iodoamphetamine), ergoline psychedelics (such as LSD), and tryptamines (such as DMT).

Using experiments in cell culture and with animals, researchers led by Dr. David Olson of the University of California at Davis found that various classes of hallucinogenic drugs acted on the structure and function of cortical neurons using the same mechanisms as ketamine. The findings could point to new treatment approaches for depression, anxiety, PTSD, and addiction, the researchers wrote last Tuesday in the peer-reviewed journal Cell Reports.

"The state-of-the-art, prototypical, fast-acting antidepressant is ketamine -- a compound that promotes neural plasticity and repairs circuits involved in mood and anxiety disorders," Olson told MedPage Today. "Our work demonstrates that psychedelics produce comparable effects on neuronal structure and function, providing a potential explanation for why MDMA, psilocybin, and ayahuasca seem to have antidepressant and anxiolytic effects in the clinic."

Using test tubes, as well as rats and fruit fly larvae, the researchers found that all of these classes of psychedelics increased "neural plasticity," the ability to create new connections among brain cells. The drugs all excited the growth of dendritic spines and axons, the cerebral hangers-on that brain cells use to reach out and create connections, or synapses, with other brain cells.

That's the opposite of what happens with depression, anxiety, PTSD, and addiction. The current theory is that these disorders may occur when neurites retract, not allowing brain cells to connect at synapses.

"One of the hallmarks of depression is that the neurites in the prefrontal cortex -- a key brain region that regulates emotion, mood, and anxiety -- those neurites tend to shrivel up," Olson said in a statement.

Olson's research found that the neural plasticity effect found with ketamine was also "remarkably potent" with even very small doses of LSD, which could help explain the popularity of "microdosing" among people seeking happier and more creative lives. Chemical compounds that mimicked psilocybin and MDMA also increased neural plasticity on the same level as ketamine, and that could mean new opportunities for researchers working with psychiatric disorders.

The studies also showed that the effect outlasted the action of the drugs. In rats, for example, psilocybin produced results that lasted for hours after the drug had left the body. Similarly, rats given a single dose of DMT not only saw an increase in dendritic spines similar to ketamine but saw that effect last for 24 hours when the drug itself had been eliminated within one hour.

This is potentially very good news for researchers working on treatments for anxiety, depression, and addiction, which all seem to act on the same brain circuits.

"Prior to this study, there was only one player in town and that was ketamine. This opens up some new doors," Olson said. "As the diversity of chemical structures capable of producing ketamine-like plasticity effects continues to grow, so does my hope that we will find a safe and effective fast-acting treatment for depression," he said.

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

Chronicle AM: House Passes "Dangerous" SITSA Act, NY Adds MedMJ for Opioids, More... (6/18/18)

Arizona Republicans go one way, Texas Republicans go another; the House passes the SITSA Act, New York will allow medical marijuana for opioid use, and more.

The House has passed a new, old school drug war bill. (Creative Commons)
Marijuana Policy

Poll: Arizona Republicans Still Don't Like Weed. A new poll from OH Predictive Insights finds that nearly three-quarters of state Republican primary voters oppose marijuana legalization. Only 21% were in favor. Still, a marijuana legalization nearly passed statewide in 2016.

Top New York Health Official Says Cuomo Panel Will Endorse Legalization. Dr. Howard Zucker, the state's top health regulator, said Monday a Cuomo administration panel will recommend that the state legalize marijuana. "We looked at the pros. We looked at the cons… the pros outweigh the cons," Zucker said of the panel's work.

Texas GOP Endorses Marijuana Decriminalization, More. At the party's state convention this past weekend, delegates approved platform planks calling for the decriminalization of marijuana possession, support for hemp farming, expanding access to medical marijuana, and calling for the rescheduling of marijuana.

Medical Marijuana

New York Health Department of Health Announces Opioid Use to be Added as a Qualifying Condition for Medical Marijuana. The Health Department on Monday announced it will develop a regulatory amendment to add opioid use as a qualifying condition for medical marijuana. "The opioid epidemic in New York State is an unprecedented crisis, and it is critical to ensure that providers have as many options as possible to treat patients in the most effective way," said New York State Health Commissioner Dr. Howard Zucker. "As research indicates that marijuana can reduce the use of opioids, adding opioid use as a qualifying condition for medical marijuana has the potential to help save countless lives across the state." Opioid use joins 12 other qualifying conditions under the state's Medical Marijuana Program. Currently, patients can be eligible if they have been diagnosed with one or more of the following severe debilitating or life-threatening conditions: cancer; HIV infection or AIDS; amyotrophic lateral sclerosis (ALS); Parkinson's disease; multiple sclerosis; spinal cord injury with spasticity; epilepsy; inflammatory bowel disease; neuropathy; Huntington's disease; post-traumatic stress disorder; or chronic pain.

Drug Policy

House Passes SITSA Act. Over the protests of drug reform and other groups, the House last Friday approved HR 2851, the Stop Importation and Trafficking of Synthetic Analogues (SITSA) Act. The bill has already passed out of committee and awaits a House floor vote. The bill is an old-school drug war response to new psychoactive substances that relies heavily on the criminal justice system. The Drug Policy Alliance called the bill "dangerous" because it grants the Justice Department "broad new powers to ban synthetic analog drugs, decide what the sentences should be, and take away the requirement for Congressional oversight that has been in place for 40 years." The bill now heads to the Senate.

International

France Poll for First Time Finds Majority for Marijuana Legalization. A new poll from the Institut français d'opinion publique (Ifop) for Terra Nova and Echo Citoyen, a think tank and a citizens' political group, for the first time reports a majority for legalization. The poll had support at 51%, with 40% opposed and 9% undecided. The poll marks a "turning point," said Thierry Pech, head of Terra Nova. "French people made the finding that prohibition and repression did not work to preserve the health of users," Pech said. Under current French law, pot possession is punishable by up to a year in jail and a fine of more than $4,000.

Making Matters Worse: DEA's Move to Restrict Opioid Prescriptions Pushed Users to the Dark Web

By the end of 2013, the country's quiet opioid addiction crisis was no longer so quiet. Opioid overdose deaths that year topped 16,000, more than four times the same statistic for 1999. That prompted a number of measures at the state and federal level to rein in opioid prescriptions, including a move by the DEA in October 2014 to tighten its policies around some of the most commonly prescribed opioids.

Dark Web fentanyl sales rose after the DEA restricted some prescription opioids. (Creative Commons)
The new DEA policy -- aimed at popular opioids such as Vicodin and Lortab -- imposed restrictions on doctors' prescribing and made it more difficult for patients to get refills. In one sense, the policy was a success: Prescriptions for those drugs decreased almost immediately. But new research adds to an increasing body of evidence that restricting opioid prescribing has not solved the opioid crisis but instead worsened it.

Since the DEA policy shift, opioid overdose deaths continued to grow with more than 40,000 fatal opioid overdoses in 2016. And while prescription opioid overdose deaths have slightly decreased -- there were about 14,000 that year -- overdose deaths from heroin and non-prescription synthetic opioids such as fentanyl went through the roof. Heroin and illicit synthetics accounted for nearly two-thirds of all opioid overdose deaths in 2016.

In the new study, published this week in the British Medical Journal, researchers examining the impact of the DEA policy shift found evidence that while the change indeed lowered prescribing rates for the opioids in question, it was also linked to an increase in illicit online sales of those drugs in Dark Web drug markets.

The researchers used software called DATACRYPTO to crawl encrypted Dark Web marketplaces where people can anonymously buy damned near anything, from drugs to guns to credit card numbers. DATACRYPTO harvested data on which drugs were for sale, their country of origin, and the number of customer comments on each seller's comments page. Researchers used that last figure as a proxy for how much of a drug that seller sold. They examined sales of prescription opioids, sedatives, stimulants, and steroids, as well as heroin. It was only with prescription opioids that they found a significant Dark Web sales bump.

Here's what they found: "The sale of prescription opioids through US cryptomarkets increased after the schedule change, with no statistically significant changes in sales of prescription sedatives, prescription steroids, prescription stimulants, or illicit opioids."

According to their data, prescription opioids doubled their market share of U.S. Dark Web drug sales thanks to the DEA policy change. By July 2016, opioids represented 13.7% of all drug sales in U.S. cryptomarkets, compared with a modeled estimate of 6.7% of all sales.

While the researchers were careful to not make claims of causation -- only correlation -- their conclusion speaks for itself: "The scheduling change in hydrocodone combination products coincided with a statistically significant, sustained increase in illicit trading of opioids through online US cryptomarkets. These changes were not observed for other drug groups or in other countries. A subsequent move was observed towards the purchase of more potent forms of prescription opioids, particularly oxycodone and fentanyl."

Not only is the DEA policy change linked to increased Dark Web opioid sales, it is also linked to a move toward more powerful, and thus more dangerous, opioids. The researchers noted that while fentanyl was the least purchased Dark Web opioid in the summer of 2014, it was the second most frequently purchased by the summer of 2016. Fentanyl killed as many people as prescription opioids that year.

This study -- one of the few that examines supply reduction (as opposed to demand reduction) as a means reducing drug use -- strongly suggests that supply-side interventions carry unintended consequences, especially the resort to more dangerous and more powerful substitutes. The study's authors refer to this effect as "the iron law of prohibition, whereby interventions to reduce supply, such as increased enforcement and changes to drug scheduling, lead to illicit markets dominated by higher potency products."

Perhaps better than restricting opioid prescriptions, which has deleterious impacts on the tens of millions of Americans suffering chronic pain, or other supply-side interventions, would be increased access to addiction treatment, as well as greatly expanded harm reduction measures to try to get people off opioids and keep them alive in the meantime.

Chronicle AM: NY Dems Endorse Marijuana Legalization, Surgeon General Talks Harm Reduction, More... (5/24/18)

The US Surgeon General has some surprisingly frank words about harm reduction and evidence-based drug policy, Cory Booker's Marijuana Justice Act picks up another sponsor, Arizona's Supreme Court throws out a state law criminalizing the use and possession of medical marijuana on campus and more.

The section on the Surgeon General's comments has an update, including a statement from the Department of Health and Human Services on the safe injection sites mention.

US Surgeon General Jerome Adams talks harm reduction and evidence-based opioid treatment. (Creative Commons)
Marijuana Policy

Jeff Merkley Signs on to Federal Marijuana Justice Act. And then there were five. Sen. Jeff Merkley (D-OR) has become the fifth cosponsor of Sen. Cory Booker's Marijuana Justice Act (S. 1689). The other cosponsors are Sens. Kirsten Gillibrand (D-NY), Kamala Harris (D-CA), Bernie Sanders (I-VT), and Ron Wyden (D-OR). Representatives Barbara Lee (D-CA) and Ro Khanna (D-CA) introduced a companion measure, H.R. 4815, in the House of Representatives earlier this year that has 35 cosponsors.

New York Democratic Party Officially Endorses Marijuana Legalization. Delegates to the state Democratic convention Wednesday adopted a resolution supporting marijuana legalization: "The New York State Democratic Committee supports the legalization of marijuana which should be regulated and taxed in a manner similar to alcohol," reads a resolution. The resolution adds that legalization is "an important social justice issue."

Medical Marijuana

Arizona Supreme Court Okays Medical Marijuana on College Campuses. The court ruled Wednesday that the state can't criminally charge card-carrying medical marijuana patients for possessing and using their medicine on campus. In Arizona v. Maestas, the court held that a 2012 law banning medical marijuana on campus violated the state's protections for voter-approved laws. The Supreme Court ruling upholds an appellate court ruling that also found in Maestas' favor.

Ohio Dispensary License Announcement Delayed. The state Board of Pharmacy announced Tuesday that its planned announcement of dispensary license awards Wednesday has been postponed and that provisional licenses will instead be issued in June. Legal medical marijuana sales are supposed to begin on September 8. Stay tuned.

Pennsylvania Judge Halts Medical Marijuana Research Program. A Commonwealth Court judge has granted a temporary injunction sought by numerous dispensaries and growers and processors to halt the state's medical marijuana research program. The plaintiffs worry that the regulations for the clinical research programs would give an unfair advantage to clinical research partners and growers. The Health Department is now pondering next steps.

Hemp

Illinois Governor Gets Bill Legalizing Industrial Hemp. With a 106-3 House vote Wednesday, the legislature has approved a bill legalizing industrial hemp, Senate Bill 2298. Now it's up to Gov. Bruce Rauner (R) to sign it.

Heroin and Prescription Opioids

US Surgeon General Urges ER Docs to Advocate for Evidence-Based Opioid Treatment. US Surgeon General Dr. Jerome Adams called Wednesday on emergency room physicians to advocate more vigorously for evidence-based opioid treatment, including harm reduction measures. Adams supported such harm reduction interventions as needle exchanges and safe injection sites. [The Department of Health and Human Services has issued a statement claiming that Dr. Adams does not support safe injection sites, and contesting the evidence on them. See update below.] He urged doctors to reach out to and educate stakeholders in their communities. "We have to understand that these policy interventions look different in different parts of the country," Adams said. "We have to understand that public policy means public and that we have to be able to go there and show them that we care before we can share what we know."

Update: A Department of Health and Human Services officer contacted us on Saturday, March 26th, claiming that the report news outlets relied on, including the one we linked to, was inaccurate in stating that Dr. Adams supports safe injection sites. We do not have other reports on his speech at this time to go on. The article linked above has been updated to include a copy of the HHS statement:

"The Administration and the Surgeon General do not support so-called 'safe' injection sites as a means to combat the opioid epidemic and its consequences. In addition, there is no evidence to demonstrate that these illegal sites reduce drug use or significantly improve health outcomes for those with opioid use disorder. So-called 'safe' injection sites lack the necessary scientific support to be considered a standardized evidence-based practice in the U.S."

Another article states that Adams mentioned safe injection sites as being "part of the conversation" in some communities.

Ed: We are in a position to address the administration's characterization of the evidence on safe injection sites, and it is false to the point of absurdity. There is significant evidence that safe injection sites improve health outcomes for persons with opioid use disorders. In fact, multiple journal articles to this effect are available on the website of the National Institutes of Health, a division of Health and Human Services. Here are a few of them:

  • A 2017 study in Canadian Family Physician found that "SISs are associated with lower overdose mortality (88 fewer overdose deaths per 100 000 person-years [PYs]), 67% fewer ambulance calls for treating overdoses, and a decrease in HIV infections."
  • A 2017 article in Harm Reduction Journal notes with citations that evaluation of Vancouver's Insite program showed it was "meeting its objectives of reducing public disorder, infectious disease transmission, and overdose and was successfully referring individuals to a range of external programs, including detoxification and addiction treatment programs.". The article further states that "over 40 peer-reviewed studies have been published which speak to the many benefits and lack of negative impacts of this site."
  • A 2008 article in the American Journal of Public Health reported that the supervised injection facilities in Sydney and Vancouver were "negatively associated with needle sharing... and positively associated with less-frequent reuse of syringes... less outdoor injecting... using clean water for injection... cooking or filtering drugs prior to injecting... and injecting in a clean location," that "[b]oth... were effective gateways for addiction treatment, counseling, and other services," and that there were no "reported overdose deaths in a SIF."
  • A 2014 article in Drug and Alcohol Dependence found that "[s]eventy-five relevant articles... converged to find that SISs were efficacious in attracting the most marginalized PWID, promoting safer injection conditions, enhancing access to primary health care, and reducing the overdose frequency" and that "SISs were found to be associated with reduced levels of public drug injections and dropped syringes."
  • A 2008 article in the Canadian Medical Association Journal found "Vancouver's supervised injection site is associated with improved health and cost savings."
  • A 2010 article in Addiction found that if Vancouver's supervised injection facility "were closed, the annual number of incident HIV infections among Vancouver IDU would be expected to increase from 179.3 to 262.8. These 83.5 preventable infections are associated with $17.6 million (Canadian) in lifetime HIV-related medical care costs, greatly exceeding Insite's operating costs, which are approximately $3 million per year."

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