Showing posts with label opioids. Show all posts
Showing posts with label opioids. Show all posts

Tuesday, January 23, 2024

The war on drugs is a war

The war on drugs doesn't begin at U.S. borders.

Here's a dispatch from Ecuador, in the WSJ:

Ecuador Is at War With Drug Gangs, President Says. Troops patrolled the country’s largest city a day after a series of attacks against the new government  By Kejal Vyas and Ryan DubĂ©

"Ecuador is at war with drug gangs, President Daniel Noboa said Wednesday, as troops patrolled the country’s largest city, Guayaquil, a day after gunmen took over a TV studio and launched a series of attacks against the Andean nation’s new government.

“We are in a noninternational armed conflict,” Noboa said in a radio interview. “We are in a state of war. We cannot give in to those terrorist groups.”

"The armed forces and national police scrambled to bring order to Guayaquil, and shops and schools were closed after a series of coordinated attacks Tuesday on shopping centers, hospitals and a university left at least 11 people dead.

"Drug-trafficking gangs in recent years have turned Ecuador into one of the world’s most violence-plagued nations as they battled over the cocaine trade.
...
" Once relatively peaceful, Ecuador has seen the homicide rate shoot up from less than six per 100,000 in 2018 to more than 40 in 2023, said police."
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And here's one from Belgium, in the Washington Post:

Belgian customs officers seized three times as much cocaine in the port of Antwerp last year as U.S. customs and border officials seized in all of the United States.  By Gerrit De Vynck

"The head of Belgium’s customs service said in an interview that especially big seizures in the fall appeared to have prompted a violent backlash, along with a new issue: Authorities haven’t always been able to destroy what they’ve confiscated before drug gangs try to steal it back.

“Attacking the police, attacking the customs, this is not something you see in Europe,” said Kristian Vanderwaeren, director general of Belgium’s customs agency. “I was really afraid that my people would be killed if this would continue.”
...
"“The criminal organization was not afraid to come to a facility and capture their cocaine, even if it meant they would kill a customs officer,” Vanderwaeren said.
...
"According to Europol, the European Union’s law enforcement agency, Ecuador and its main port of Guayaquil have been the biggest sources of cocaine destined for Europe, reflecting how Mexican and Albanian gangs have infiltrated the country. This month, the president of Ecuador declared a “state of war” against drug gangs, after a series of assassinations, prison breaks and bombings there."



Saturday, December 30, 2023

Some year-end good news: U.S. homicides are down

To put deaths in their grim perspective, we have a lot more deaths from drug overdoses than from homicides.  But we're headed in the right direction on one of those. 

The NYT has the story:

After Rise in Murders During the Pandemic, a Sharp Decline in 2023. The country is on track for a record drop in homicides, and many other categories of crime are also in decline, according to the F.B.I. By Tim Arango and Campbell Robertson  Dec. 29, 2023

"In 2020, as the pandemic took hold and protests convulsed the nation after the murder of George Floyd by a police officer in Minneapolis, the United States saw the largest increase in murders ever recorded. Now, as 2023 comes to a close, the country is likely to see one of the largest — if not the largest — yearly declines in homicides, according to recent F.B.I. data and statistics collected by independent criminologists and researchers.

"The rapid decline in homicides isn’t the only story. Among nine violent and property crime categories tracked by the F.B.I., the only figure that is up over the first three quarters of this year is motor vehicle theft. The data, which covers about 80 percent of the U.S. population, is the first quarterly report in three years from the F.B.I., which typically takes many months to release crime data.

Thursday, December 7, 2023

Drug addiction: not just opioids

 Consumption of addictive drugs seems to come in deadly cocktails these days, which is making interdiction of drugs, and treatment of addiction more complicated.

The NYT has the story:

‘A Monster’: Super Meth and Other Drugs Push Crisis Beyond Opioids. Millions of U.S. drug users now are addicted to several substances, not just opioids like fentanyl and heroin. The shift is making treatment far more difficult.  By Jan Hoffman

"The United States is in a new and perilous period in its battle against illicit drugs. The scourge is not only opioids, such as fentanyl, but a rapidly growing practice that the Centers for Disease Control and Prevention labels “polysubstance use.”

Over the last three years, studies of people addicted to opioids (a population estimated to be in the millions) have consistently shown that between 70 and 80 percent also take other illicit substances, a shift that is stymieing treatment efforts and confounding state, local and federal policies.

“It’s no longer an opioid epidemic,” said Dr. Cara Poland, an associate professor at the Michigan State University College of Human Medicine. “This is an addiction crisis.”

...

"The incursion of meth has been particularly problematic. Not only is there no approved medical treatment for meth addiction, but meth can also undercut the effectiveness of opioid addiction therapies. Meth explodes the pleasure receptors, but also induces paranoia and hallucinations, works like a slow acid on teeth and heart valves and can inflict long-lasting brain changes.


"The Biden administration has been pouring billions into opioid interventions and policing traffickers, but has otherwise lagged in keeping pace with the evolution of drug use. There has been comparatively little discussion about meth and cocaine, despite the fact that during the 12-month period ending in May 2023, over 34,000 deaths were attributed to methamphetamine and 28,000 to cocaine, according to provisional federal data.

...

"Like opioids, which originally came from the poppy, meth started out as a plant-based product, derived from the herb ephedra. Now, both drugs can be produced in bulk synthetically and cheaply. They each pack a potentially lethal, addictive wallop far stronger than their precursors."

Friday, October 13, 2023

Fentanyl

 The NY Times has the story:

Some Key Facts About Fentanyl. It’s lowering American life expectancy and influencing the nation’s politics. By Josh Katz, Margot Sanger-Katz and Eileen Sullivan

"Overdose deaths have been increasing in the United States for decades, but the introduction of fentanyls has led to a staggering rise, accounting for the vast majority of overdose deaths in recent years.


"Around 77,000 Americans died from overdoses involving synthetic opioids like fentanyl in the 12-month period ending in April of this year, according to provisional estimates from the Centers for Disease Control and Prevention. In 2022, the most recent year with complete data, this number was around 74,000. Those three wars  [Vietnam, Iraq and Afghanistan] killed a little over 65,000 Americans combined.

"For comparison, around 55,000 Americans died in 1972 from car crashes, the year with the most such deaths. Around 49,000 died from guns in 2021 (including suicide), the year with the most such deaths.

"Fentanyl alone has become a leading cause of U.S. deaths. It was responsible for a third of deaths among Americans 25 to 34 in 2022, according to a New York Times analysis of C.D.C. mortality data.

...

"Most of the fentanyl sold in the United States is coming from Mexico, where drug cartels synthesize the drugs from precursor chemicals believed to come from factories in China. Some fentanyls are also shipped directly from China into the United States."

Friday, September 1, 2023

Innovations in addiction technology--illicitly manufactured fentanyl (IMF) combined with xylazine

 The fight against addictions is complicated by the fact that those who sell addictive goods can be innovative on many levels. (In the case of legal addictive substances such as nicotine, we are becoming accustomed to that competition, e.g. in connection with the growth of non-combustible vaping.)

Here's an article about innovation involving illegal opioids.

The emerging fentanyl–xylazine syndemic in the USA: challenges and future directions, by David T Zhu, Joseph Friedman, Philippe Bourgois, Fernando Montero, Suzanne Tamang, Lancet, August 24, 2023 DOI:https://doi.org/10.1016/S0140-6736(23)01686-0

"Xylazine, a non-opioid analgesic and sedative approved only for non-chronic veterinary use, is spreading across unregulated North American drug markets and becoming increasingly implicated in opioid overdoses. Between 2018 and 2021 in the USA, estimated fatal drug poisonings involving xylazine, often co-occurring with synthetic opioids such as fentanyl, increased from 260 to 3480 cases.1 This use of xylazine takes place in the context of the ongoing US opioid overdose crisis, which is expected to claim an estimated 1·2 million additional lives by 2029, barring urgent substantial policy reforms.2 The White House Office of National Drug Control Policy identified fentanyl adulterated or associated with xylazine (FAAX) as an emerging threat and in July, 2023, issued a response plan leveraging the Emerging Threats Committee and other vital stakeholders.3 Although this is a welcome strategy that sets out the federal government's plan to address xylazine, further non-punitive efforts and public health interventions are needed from health-care systems, policy makers, and community leaders to address the longer-term structural factors driving this crisis.

...

"Although more evidence is needed about why xylazine is combined with fentanyl, some reports suggest that by adding xylazine as an adulterant for synthetic opioids such as IMF, manufacturers can potentially maximise profits and distinguish their brand in the market, attracting a wider customer base.6,  7 This has most notably been observed in Philadelphia, PA, USA—regarded as an epicentre of the emerging xylazine crisis in mainland USA—where over 90% of the city's street opioid supply has shifted to FAAX.8 Further, xylazine has been described by people who use drugs as lengthening the sedative effects of IMF—solving the disadvantage of fentanyl's short duration of effect—thereby postponing craving and physical withdrawal symptoms"

Tuesday, August 8, 2023

Homelessness and fentanyl, in Oregon and California

 Both the criminal justice system and the harm reduction movement seem to be facing an intractable problem with fentanyl and homelessness.  (We lost the war on drugs, but surrender isn't working either.)

Here are two NYT stories, from Oregon and California.

The Struggle to Save Portland, Oregon. The city has long grappled with street homelessness and a shortage of housing. Now fentanyl has turned a perennial problem into a deadly crisis and a challenge to the city’s progressive identity.  By Michael Corkery

"This city of 635,000 ...  has long grappled with homelessness. But during the pandemic this perennial problem turned into an especially desperate and sometimes deadly crisis that is dividing Portland over how to fix it.

...

"In 2022, Portland experienced a spate of homicides and other violence involving homeless victims that rattled many in the community.

...

"The search for answers points in many directions — to city and county officials who allowed tents on the streets because the government had little to offer in the way of housing, to Oregon voters who backed decriminalizing hard drugs and to the unrest that rocked Portland in 2020 and left raw scars.

"But what has turbocharged the city’s troubles in recent years is fentanyl, the deadly synthetic drug, which has transformed long standing problems into a profound test of the Portland ethos.

"Outreach workers in Portland say rampant fentanyl use has coincided with the increasing turmoil among many homeless residents.

"Doctors who care for people living on the streets say fentanyl addiction is proving harder to treat than many other dependencies."

***********

Homeless Camps Are Being Cleared in California. What Happens Next? One of the state’s largest homeless encampments was recently shut down in Oakland, but that didn’t stop the problem of homelessness.  By Livia Albeck-Ripka

"The evictions have brought into sharp relief one of the most intractable challenges for American cities, particularly those in California. As homelessness has surged, more people have congregated in large encampments for some semblance of security and stability. But such sites are often unsanitary and dangerous, exhausting neighbors and the owners of nearby businesses.

"What happens after the closure of Wood Street and other camps in California will serve as the latest test of how effectively the state is addressing homelessness. Nearly half of the nation’s unsheltered population — those who sleep on the streets, in tents, in cars or in other places not intended for human habitation — resides in California, according to last year’s federal tally of homelessness. The state makes up about 12 percent of the country’s overall population.

"In California, Democratic leaders who previously tolerated homeless camps have lost their patience for the tent villages and blocks of trailers that proliferated during the pandemic.

"Governor Newsom has helped clear homeless camps himself and has told mayors he was trying to set an example. San Diego recently banned encampments on public property. And Karen Bass, the mayor of Los Angeles, has moved more than 14,000 homeless people into temporary housing since taking office in December, her office said last month.

...

"Community cabins and safe camping sites usually provide only temporary shelter, falling short of the permanent housing that is considered ideal. But they seem to be the best that California can do, with a severe housing shortage and high costs. Despite the state’s spending of more than $30 billion since 2019 on housing-related programs, the homeless population there has continued to grow.

“This is a very difficult population to serve, with very complex needs. And if we can bring someone inside even for a little bit, that’s a victory for that person,” said Jason Elliott, the deputy chief of staff for Governor Newsom. “We may not have permanent housing stick the first time, or the fourth time or the fifth time, but we’re going to keep trying.”

"According to a September audit of Oakland’s homelessness services, close to half of the people housed in community cabins ended up back on the street in the 2020-21 fiscal year."

***********

Earlier:

Friday, July 14, 2023

Saturday, July 29, 2023

Drug markets: the replacement of agriculture by chemistry

Labs are replacing fields as the source of addictive drugs. Here are two stories, from National Affairs, and the Financial Times.

The current issue of National Affairs has this essay on drugs, drug use, and overdose deaths:

How to Think about the Drug Crisis by Charles Fain Lehman

"A reported 111,219 Americans died from a drug overdose in 2021. That figure has risen more or less unabated, and at an increasing pace, since the early 1990s. Back in 2011, 43,544 Americans died from a drug overdose — less than half the 2021 figure. Ten years earlier, in 2001, it was 21,705 — less than half as many again. And the problem keeps getting worse: The 2021 figure is nearly 50% higher than it was in 2019.

...

"The National Center for Health Statistics estimates that there were roughly 110,000 overdose deaths in the year ending December 2022 — essentially unchanged from a year earlier.

...

"Historically, illicit drugs — heroin, cocaine, marijuana, etc. — were derived from plants grown in fields or greenhouses. But licit pharmacology has long been able to use simple, widely available precursor chemicals to synthesize the active ingredients in these substances. This sidesteps the complex processes of farming altogether. At some point in the past several decades, drug-trafficking organizations learned to use the same techniques at scale. Using precursors sourced primarily from China, they now synthesize a variety of opioids — the class of drugs that includes heroin.

"The most widely known of these is fentanyl, a synthetic opioid conventionally used in anesthesia that is 50 times stronger than heroin. Some are stronger still — carfentanil, the most potent opioid known thus far, is roughly 100 times stronger than fentanyl. In 2021, synthetic opioids were involved in roughly two out of every three overdose deaths.

...

"Complicating the story further is the increasing purity and declining cost of methamphetamine, another synthetic drug with an exploding death rate. After synthetic opioids, methamphetamine is now the second most common cause of drug overdose death. It's also the only tracked drug where deaths not involving synthetic opioids are increasing. That these two lab-produced substances are replacing "organic" drugs at the same time is not a coincidence.

"Why have these drugs taken over the market? Because they're a much better value proposition for sellers. Synthetic drugs significantly reduce production costs, both because chemistry is less labor- and input-intensive per unit produced than farming and because lab production is much easier to obscure from interdiction efforts that drive up costs. Furthermore, because the potency per dose is higher, drug-smuggling operations can move a smaller amount of fentanyl than heroin for the same profit.

"Of course, the stronger the drug, the higher the risk of overdose. Drug-overdose death rates used to be low in part because for the first century or so of modern American drug use, the potency of illicit drugs was constrained by what traffickers could grow in a field. Synthetic drugs remove this limit."

********

And this from the FT:

How fentanyl changed the game for Mexico’s drug cartels.  by Christine Murray

"In the last decade, fentanyl has become the leading cause of death for young adults in the US. Mexico’s illegal drug trade has also adapted to the shift from plant-based drugs towards synthetics, creating a new, streamlined and highly profitable arm of the illicit business with fewer workers and lower costs — but just as much violence.

"The change has caused friction in two of Washington’s most important relationships, with China and Mexico.

...

"Instead of employing tens of thousands of agricultural labourers, the entire fentanyl industry in Mexico could function with “cooks” estimated to number in the hundreds, who were mostly not qualified chemists, Reuter said. Fentanyl’s growth appears to have hit heroin production in particular, with poppy growing in Mexico still well below its peaks, according to the UN Office for Drugs and Crime."





Sunday, May 21, 2023

Drug Overdose Deaths Topped 100,000 Again in 2022

 

The WSJ has the story: the headline speaks for itself  

Drug Overdose Deaths Topped 100,000 Again in 2022 https://www.wsj.com/articles/drug-overdose-deaths-topped-100-000-again-in-2022-37cd1709

Friday, March 31, 2023

Opioids and Appalachia by Sally Satel

 Sally Satel, who has treated patients in Appalachia, writes movingly of the drug addiction problem there. Here's a paragraph that sets the stage.

"The history of opioid pain relievers in Appalachia is a prime illustration of the fact that drug epidemics rarely burst onto the scene out of nowhere. Instead, they find their place in regions that are already home to an established base of individuals who abuse similar drugs. Thus illicit OxyContin, a more potent opioid, efficiently gained popularity over Percocet and Vicodin in the same way heroin would substitute for prescription opioids as the latter grew scarce after 2010."

That's from Opioids and Appalachia by Sally Satel, in the current issue of National Affairs.

The whole thing is well worth reading; here are a few more paragraphs that caught my eye.

"The churn of pills — diverting, using, and selling them — soon had eastern Kentucky, southeastern Ohio, and West Virginia pulsing with crime. Realtors routinely told home sellers not to leave pills in their medicine chests during open houses. Funeral directors and hospice nurses cautioned the bereaved not to mention in obituaries that their loved ones had succumbed to cancer — a red flag signaling that huge bottles of pills were likely on the premises. In eastern Kentucky, local law enforcement was often stymied by close ties between people within communities. Loyalty within large families and fear of retaliation by neighbors made it hard to cultivate informants and to impanel neutral juries that would convict when prosecutors proved their case.

...

"Appalachians seemed to take the corruption in grudging stride. In one survey, 90% of over 100 Kentuckians working in law enforcement, health, and community governance said the rural OxyContin problem in the early 2000s was "fueled by a cultural acceptance of drug misuse." Indeed, many residents tolerated unlawful activity, since it generated revenue for the community from sales of pills to outsiders. This happened in places like Williamson, West Virginia — dubbed "Pilliamson" — where the local Wellness Center was a hub of reckless prescribing. Cash-laden out-of-staters flocked there to buy painkillers and, in a small area near the center, trade and sell those pills.

"Pablo Escobar and El Chapo couldn't have set things up any better," wrote Eyre. "The coal barons no longer ruled Appalachia. Now it was the painkiller profiteers."

...

"Today, opioid pills are no longer pouring into Appalachia as they once did; highly lethal products like fentanyl-laced heroin, methamphetamine, and counterfeit fentanyl pills are what people are selling."

Tuesday, February 14, 2023

Canada experiments with decriminalization of opioids and other drugs in British Columbia

 From the CBC:

What you need to know about the decriminalization of possessing illicit drugs in B.C.  B.C. granted exemption by federal government in November 2022; pilot will run until 2026  by Akshay Kulkarni ·

"it is no longer a criminal offence to possess small amounts of certain illicit drugs in B.C. for people aged 18 or above.

"It's part of a three-year pilot by the federal government, which granted B.C. an exemption from the Controlled Drugs and Substances Act (CDSA) on May 31, 2022. 

...

"Under the exemption, up to 2.5 grams of the following four drug types can be legally possessed:

"Cocaine (crack and powder). Methamphetamine. MDMA. Opioids (including heroin, fentanyl and morphine).

"Fentanyl and its analogues were detected in nearly 86 per cent of drug toxicity deaths from 2019 until 2022, according to the latest report from the B.C. Coroners Service."



Wednesday, November 30, 2022

Opioids and pain management: revised CDC guidelines

 Concerned over the opioid addiction epidemic in the U.S., and the increasing number of overdose related deaths, the CDC issued the 2016 CDC Opioid Prescribing Guideline, which led to reduced opioid prescriptions by doctors. Sometimes this led to the undertreatment of pain, which in turn may have led to patients accessing opioids on the black market, where they are less safe. It may also have led to suicides of patients with unbearable pain.

The CDC has now issued some updated guidelines that appear aimed at balancing concerns with over-prescription against concerns with under-treatment.

Here are the updated guidelines:

CDC Clinical Practice Guideline for Prescribing Opioids for Pain — United States, 2022

"This guideline provides recommendations for clinicians providing pain care, including those prescribing opioids, for outpatients aged ≥18 years. It updates the CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016 (MMWR Recomm Rep 2016;65[No. RR-1]:1–49) and includes recommendations for managing acute (duration of <1 month), subacute (duration of 1–3 months), and chronic (duration of >3 months) pain.

...

"CDC recommends that persons with pain receive appropriate pain treatment, with careful consideration of the benefits and risks of all treatment options in the context of the patient’s circumstances. Recommendations should not be applied as inflexible standards of care across patient populations. This clinical practice guideline is intended to improve communication between clinicians and patients about the benefits and risks of pain treatments, including opioid therapy; improve the effectiveness and safety of pain treatment; mitigate pain; improve function and quality of life for patients with pain; and reduce risks associated with opioid pain therapy, including opioid use disorder, overdose, and death.


A central tenet of this clinical practice guideline is that acute, subacute, and chronic pain needs to be appropriately and effectively treated regardless of whether opioids are part of a treatment regimen. 

...

"To avoid unintended consequences for patients, this clinical practice guideline should not be misapplied, or policies derived from it, beyond its intended use (67). Examples of misapplication or inappropriate policies include being inflexible on opioid dosage and duration, discontinuing or dismissing patients from a practice, rapidly and noncollaboratively tapering patients who might be stable on a higher dosage, and applying recommendations to populations that are not a focus of the clinical practice guideline (e.g., patients with cancer-related pain, patients with sickle cell disease, or patients during end-of-life care)

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Earlier post:

Tuesday, March 15, 2022

Saturday, November 19, 2022

Why is it so easy to get drugs, and so hard to get drug abuse treatment? Overdose deaths continue to climb.

 Here's an update on drug abuse in the U.S., from the WSJ. One quote particularly struck me, from a mom whose child died: "it’s so easy to get drugs,”  “It’s so much more available than treatment.”

How Meth Worsened the Fentanyl Crisis. ‘We Are in a Different World.’ Methamphetamine fatalities are rising, increasingly in combination with opioids  By Jon Kamp and Arian Campo-Flores.

"One in five of the total fatal overdoses last year involved an opioid and a psychostimulant, a drug class dominated by meth, preliminary federal data show. A decade earlier, about 2% of drug deaths involved such combinations.

...

"The rise in fatalities involving stimulants, often combined with opioids, has created a fourth wave of the decadeslong U.S. overdose-death crisis, according to Dr. Daniel Ciccarone, a professor of addiction medicine at the University of California, San Francisco. Deaths from combinations of opioids and cocaine, another stimulant, are also climbing.

...

"Fentanyl drove U.S. overdose deaths to a record-breaking tally of more than 108,000 last year, according to the federal data.

"Now, the combination of meth and opioids—especially fentanyl—is supercharging those numbers. Meth-related deaths, though smaller in number, are increasing at a faster rate than opioid and overall drug fatalities.

"About 33,400 deaths last year involved psychostimulants such as meth, up more than 340% from roughly 7,500 five years earlier, the federal data show. In the same time span, deaths involving synthetic opioids like fentanyl rose about 270% to around 72,000, and overall drug fatalities rose about 71%.

...

"it’s so easy to get drugs,” said Mr. Ryan’s mother, Alicia Vigil-Ryan. “It’s so much more available than treatment.”

Saturday, April 30, 2022

Opioid deaths are behind increases in deceased organ donation

 Medpage Today warns us not to take credit for increases in organ donation that are due to rising numbers of opioid overdose deaths. 

'Shocking Mismanagement' in Our Organ Donation System Is Causing Needless Death— OPTN and OPOs are mischaracterizing organ donation data to block system reform  by DJ Patil, PhD, Greg Segal, Ebony Hilton, MD, and Lachlan Forrow, MD

"The magnitude of the opioid crisis shows no signs of peaking. New data from the CDC's National Center for Health Statistics show that deaths from the opioid epidemic soared by 50% from October 2019 to October 2021, some of which reflected second-order effects of the COVID-19 pandemic. Similarly, alcohol-related deaths, according to recent CDC reports, were also up by a shocking 25% in 2020, from an average increase of 3.6% per year from 1999-2019.

"What does this have to do with organ donation? Drug overdoses and alcohol-related deaths fall into the subset of deaths that allow for organ donation to occur, so this sharp rise in opioid deaths has driven record-breaking organ donation numbers. That might sound like a silver lining to a very dark cloud, but as is often the case with public health data, the picture is much more complex.

"The government contractors in charge of organ donation -- both organ procurement organizations (OPOs), which oversee local organ recovery, and the organ procurement transplantation network (OPTN), which manages the system -- are hiding behind increases in these deaths of despair to deflect criticism from what the House Oversight Committee has characterized as "shocking mismanagement" in organ procurement.

"In fact, HHS has deemed the majority of OPOs to be failing key performance metrics, contributing to 33 Americans dying every day for lack of an organ transplant. And the Senate Finance Committee is investigating the United Network for Organ Sharing (UNOS), the OPTN contractor, over "serious concerns related to [its] role in overseeing our nation's OPOs, which have been severely underperforming for decades."

...

"We have more organ donors in America not because we have a strong -- or even remotely adequate -- organ procurement system, but because on a per capita basis among wealthy nations, we have many times more deaths in those subsets of deaths that allow for organ donation to occur. This includes 20 to 30 times more opioid deaths, 25 times as many gun deaths, the highest suicides rates, and more than twice as many fatal car accidents -- a number that spiked again precipitously last year."

Tuesday, March 15, 2022

Opioid prescription reductions and suicides

 Addictive drugs are repugnant, but painkillers are essential pharmaceuticals.  In an effort to reduce addiction, guidelines have been formulated that reduce prescription, and these sometimes backfire when applied to patients with unbearable pain.

The NY Times has the story:

What the Opioid Crisis Took From People in Pain  By Maia Szalavitz

"Though even some doctors are confused on this issue, addiction and physical dependence are not the same thing. Addiction, according to the National Institute on Drug Abuse, is compulsive drug seeking and use that occurs despite negative consequences. But pain patients like Mr. Slone are not considered addicted when medication improves their quality of life and the risks of side effects like withdrawal are outweighed by the relief medication offers.

"For people with chronic pain, research is only beginning to show how widespread the damage from opioid prescription cuts is. One study examined the medical records of nearly 15,000 Medicaid patients in Oregon who were taking long-term, high doses of opioids. Those whose medications were stopped were three and a half to four and a half times as likely to die by suicide compared to those whose doses were stable or increased. Another study, which included the medical records of over 100,000 people, found that drastically reducing a patient’s opioid dosage increased the risk of overdose by 28 percent and increased the risk of mental health crisis requiring hospitalization by 78 percent.

"Many opioid prescribing cuts were made under the auspices of guidelines published by the Centers for Disease Control and Prevention in 2016 to fight the overdose crisis. These guidelines recommend avoiding opioid prescriptions if at all possible and, when prescribing them for chronic pain, generally keeping the dosage below 90 morphine milligram equivalents, or M.M.E., per day 

...

"The C.D.C. is now updating those recommendations, admitting that the result has too often been unsafe changes in care.

...

"By 2019, the authors of the original guidelines warned in The New England Journal of Medicine that they were being misused, saying, “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.” That year, the Food and Drug Administration cautioned that it had “received reports of serious harm,” including suicides, associated with patients who suddenly had their medication discontinued or abruptly reduced.

"But by then, states had passed legislation giving some of the recommendations the force of law. The National Committee for Quality Assurance, which provides standards for insurers, government agencies and medical organizations, made keeping doses within the guidelines into a metric — incentivizing doctors to taper or stop seeing high-dose patients. Insurers, pharmacy chains and government agencies also use the guidelines to inform restrictions, and law enforcement uses them when prosecuting physicians for running “pill mills.”

"If these policies had reduced the death toll, some might argue that they are warranted. But they have not. Measured by the number of prescriptions written per capita, medical opioid use rates in 2020 were down to levels last seen in 1993, before OxyContin marketing helped spark the crisis. However, overdose deaths are still increasing dramatically, driven by illegally manufactured synthetic opioids and many who formerly got pharmaceuticals from doctors and now resort to dealers."

Sunday, January 30, 2022

Chemistry is replacing agriculture in the supply of black market drugs

 The war on drugs is getting more complicated, as chemistry replaces agriculture as a primary source.  This calls for changes in both law enforcement and harm reduction.

Here's a balanced view from the WSJ:

The Once and Future Drug War. During the 50 years the U.S. has battled the narcotics trade, illegal drugs have become more available and potent. But that’s no reason to give up. Governments must adapt and find answers beyond law enforcement  By James Marson, Julie Wernau  and David Luhnow 

"America’s longest war isn’t the 20-year fight in Afghanistan. That struggle is dwarfed by the War on Drugs, started by President Richard Nixon more than 50 years ago and still raging.

"The drug war—which has relied on both law enforcement and the military, at a cost of untold lives and hundreds of billions of dollars—has fared little better than the Afghan campaign. Since Nixon’s declaration of war in 1971, drug use has soared in the U.S. and globally, the range and potency of available drugs has expanded and the power of criminal narcotics gangs has exploded.

...

"The global spread of synthetic drugs like methamphetamine, fentanyl and synthetic opioids is complicating interdiction—the core of America’s strategy for 50 years.

...

"Fentanyl has now killed far more Americans than all U.S. conflicts since World War II combined. In the past decade, it has claimed more than a half million lives, a toll that is growing swiftly. The nation was reporting fewer than 50,000 fatal overdoses as recently as 2014. 

...

"The Biden administration is the first to name “harm reduction” a priority. The White House Office on National Drug Control Policy, which was often run in the past by former generals and law-enforcement officials, is now led, for the first time, by a physician, Dr. Rahul Gupta.

...

"Europe is also pursuing harm reduction. The U.K., the Netherlands, Austria and others have offered drug testing, often at music events, to reduce the risk of overdosing or poisoning. Switzerland, the U.K., Germany and the Netherlands prescribe heroin to dependent users to cut fatal overdoses and needle sharing.

"Portugal has gone further. It decriminalized all drugs in 2001 amid a surge in heroin use and drug-dependent prisoners. Anyone caught with less than a 10-day supply of any drug is sent to a local commission that includes a doctor, lawyer and social worker for treatment. Overdose deaths have fallen from about 360 a year to 63 in 2019.

...

"Growing social and legal tolerance of drugs dismays people like Mike Vigil, who had a 31-year career in the DEA, including chief of international operations. He acknowledges that interdiction and law enforcement have not solved the problem. But he says that the U.S. has failed to develop a comprehensive strategy, including investing in down-and-out communities where drug use flourishes and trying to reduce future demand through massive, sustained education programs.

...

“We aren’t going to be able to arrest our way out of this,” says Mr. Vigil. His frustration is widely shared. “The U.S. has never taken the demand side of things seriously,” says former Mexican President Felipe CalderĂłn."

Thursday, December 2, 2021

Supervised drug injection sites open in NYC

 The NY Times has the story:

Nation’s First Supervised Drug-Injection Sites Open in New York. During the first official day in operation at the two Manhattan facilities, trained staff reversed two overdoses, officials said.  By Jeffery C. Mays and Andy Newman

"New York, the country’s most populous city, became the first U.S. city to open officially authorized injection sites — facilities that opponents view as magnets for drug abuse but proponents praise as providing a less punitive and more effective approach to addressing addiction.

"Other cities including Philadelphia, San Francisco, Boston and Seattle have taken steps toward supervised injection but have yet to open sites amid debate over the legal and moral implications of sanctioning illegal drug use.

...

"Mayor Bill de Blasio began championing safe injection sites in 2018, citing their use and success in European and Canadian cities. The decision to officially allow the sites to open comes during the mayor’s last few weeks in office and as he considers a run for governor. He said in a statement that the decision will show other cities that “after decades of failure, a smarter approach is possible.”

"The mayor also sent a letter to the providers promising “not to take enforcement action” against their operations. Four of the city’s five district attorneys — excluding only the Staten Island district attorney, Michael McMahon — support supervised drug sites."

Thursday, November 18, 2021

Drug overdose deaths between April 2020 and 2021 reach 100,000

 The Washington Post has the story:

100,000 Americans died of drug overdoses in 12 months during the pandemic  By Dan Keating and Lenny Bernstein

"The U.S. drug epidemic reached another terrible milestone Wednesday when the government announced that more than 100,000 people had died of overdoses between April 2020 and April 2021. It is the first time that drug-related deaths have reached six figures in any 12-month period.

...

"The new data shows there are now more overdose deaths from the illegal synthetic opioid fentanyl than there were overdose deaths from all drugs in 2016."



We should be thinking about harm reduction...

Wednesday, August 25, 2021

Opioid prescription and curtailment are associated with increased rates of suicide among rural veterans:

 Chronic pain, followed by prescription of opioid pain medicines, is sometimes followed by opioid addiction.  A recent NBER working paper shows that policies to reduce prescriptions are associated with increased rates of suicide, particularly among rural military veterans.  Presumably some of these are related to addiction, and some are related to pain.

The Opioid Safety Initiative and Veteran Suicides by Joshua C. Tibbitts & Benjamin W. Cowan WORKING PAPER 29139, DOI 10.3386/w29139,  August 2021

"We investigate the relationship between opioid diverting policy and suicides among the veteran population. The opioid epidemic of the past two decades has had devastating health consequences among U.S. veterans and military personnel. In 2013, the Veterans Health Administration (VA) implemented the Opioid Safety Initiative (OSI) with the goal of discouraging prescription opioid dependence among VA patients. Between 2012 and 2017, prescription opioids dispensed by the VA fell 41% (VA, 2018). Because this involved the aggressive curtailing of opioid prescriptions for many VA patients, OSI may have had a detrimental effect on veterans’ mental health leading to suicide in extreme cases. In addition, because rural veterans have much higher rates of VA enrollment, more prescription opioid use and abuse, and lower rates of substance abuse and mental health treatment utilization, we expect any effect of OSI on veteran suicides to be concentrated in rural areas. We find that OSI raised the veteran suicide rate relative to the non-veteran (“civilian”) rate with rural veterans suffering the lion’s share of the increase. We estimate that OSI raised the rural veteran suicide rate by a little over one-third between 2013 and 2018."

Tuesday, June 29, 2021

‘Harm Reduction’ Gains Federal Support.

 Another shot has been fired in the American war against drugs, this time in the battle between those who insist that drug abuse is everywhere and always a criminal problem, and those who think that even drug abusers might be entitled so some support in their personal fight against fatal overdosing.

The NY Times has the story.

Helping Drug Users Survive, Not Abstain: ‘Harm Reduction’ Gains Federal Support. By Abby Goodnough.

"Overdoses have surged during the pandemic. Now, for the first time, Congress has appropriated funds specifically for programs that distribute clean syringes and other supplies meant to protect users."

...

"Overdose deaths rose by nearly 30 percent over the 12-month period that ended in November, to more than 90,000, according to preliminary federal data released this month — suggesting 2020 blew past recent records for such deaths. The staggering increase during the pandemic has many contributing factors, including widespread job loss and eviction; diminished access to addiction treatment and medical care; and an illegal drug supply that became even more dangerous after the country essentially shut down.

...

"Now, with the nation reopening, the Biden administration is throwing support behind the contentious approach ... known as harm reduction. Instead of helping drug users achieve abstinence, the chief goal is to reduce their risk of dying or acquiring infectious diseases like H.I.V. by giving them sterile equipment, tools to check their drugs for fentanyl and other lethal substances, or even just a safe space to nap.

"Such programs have long come under attack for enabling drug use, but President Biden has made expanding harm-reduction efforts one of his drug policy priorities — the first president to do so. The American Rescue Act includes $30 million specifically for evidence-based harm reduction services, the first time Congress has appropriated funds specifically for that purpose. The funding, while modest, is a victory for the programs, both symbolically and practically, as they often run on shoestring budgets.

...

"Still, many elected officials and communities continue to resist equipping people with supplies for drug use, including the recent addition of test strips to check drugs for the presence of illicitly manufactured fentanyl, which shows up in most overdose deaths. Some also say that syringes from harm reduction programs end up littering neighborhoods or that the programs cause an increase in crime. Researchers dispute both claims.

"West Virginia just passed a law making it far more difficult for syringe service programs to operate, even though it is seeing a surge in H.I.V. cases driven by intravenous drug use. North Carolina’s legislature weighed a similar proposal this spring, and elected officials in Scott County, Ind., whose syringe exchange helped curb a major H.I.V. outbreak six years ago, voted this month to shut it down. Mike Jones, a commissioner there who voted to end the program, said at the time that he feared the syringes it distributed could be contributing to overdose deaths."

***********

Earlier post: 

Friday, May 14, 2021

Friday, April 30, 2021

Not all excess mortality during the pandemic comes from infection: overdose deaths in Cook County

 A recent paper in JAMA reminds us that not all excess mortality during the pandemic is due to infection with Covid-19:

Mason M, Arukumar P, Feinglass J. The Pandemic Stay-at-Home Order and Opioid-Involved Overdose Fatalities. JAMA. Published online April 23, 2021. doi:10.1001/jama.2021.6700

"A total of 4283 opioid overdose fatalities occurred in Cook County from January 2018-December 2020, ranging from 12 to 53 weekly (eFigure in the Supplement). There was a mean of 23.0 deaths per week during the initial 100-week period (2018-2019), with little apparent seasonal variation. During the subsequent 15 weeks beginning in December 2019, deaths increased to a mean of 35.1 per week, followed by an even more pronounced increase during the 11-week stay-at-home order: 44.1 mean weekly deaths. In the 29 weeks after the stay-at-home order was lifted mean weekly deaths sharply declined and then began to increase toward the end of the period, at 32.7 deaths. Although deaths have declined below the peak weekly numbers seen during the stay-at-home period, opioid overdose deaths following the stay-at-home period remain elevated above pre-2020 levels."