Archives for posts with tag: drugs

In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to prescription opioid pain relievers, and healthcare providers began to prescribe them at greater rates. This subsequently led to widespread diversion and misuse of these medications before it became clear that these medications could indeed be highly addictive.

National Institute on Drug Abuse[1]

 [This is Fred and I’m here with more bad news about heroin and the other opioids now destroying us, plus some cheerful speculation. Note the paragraph quoted above. Apparently in the 1990s we didn’t understand that opium and its relatives are highly addictive, even though it was obvious 200 years earlier. See our recent blog[2] on Thomas de Quincey’s Confessions of an English Opium Eater.[3] So I guess our great planners didn’t expect patients to start abusing opioids once those drugs became plentiful by prescription. And once more people became addicted certainly no one expected the criminal class to fill the increased demand with their own, informal products. Who would ever dream such a thing?

Also, we still don’t know if opioids actually treat pain when they are used in the long term. According to one recent study: “Evidence is insufficient to determine the effectiveness of long-term opioid therapy for improving chronic pain and function. Evidence supports a dose dependent risk for serious harms.”[4] Translation?  The long term benefits are unclear, but the dangers are obvious.

Not to worry, the National Institutes of Health [NIH], and their parent, the Department of Health and Human Services [HHS] have swung into action. Today society has a problem with opioid addiction and they will solve it by:

  1. Improving access to treatment and recovery services;
  2. Promoting use of overdose-reversing drugs;
  3. Strengthening our understanding of the epidemic through better public health surveillance;
  4. Providing support for cutting-edge research on pain and addiction; [and]
  5. Advancing better practices for pain management.[5]

So what could go wrong? Well, think about it. If we’re going to improve access to “treatment and recovery” services [Point 1], what does that mean? Do we have some magic cure that will wipe away addiction? I don’t think so. It’s very difficult to ween an addict from his [or her] opioid of choice. It was that way for Thomas de Quincey, and the situation hasn’t changed.  And if the weening process takes a long time, that sounds expensive. Taxpayers beware!

OK, but surely it would be a good thing to promote “overdose-reversing drugs.” [Point 2] Yes it would, because those drugs prevent death by overdose and it’s always good to do that. But overdose drugs don’t cure addiction, so we still have the problem of treating the survivors.

All right, then what about Point 3? NIH wants to know more about the size of the problem, how many addicts there are, and so forth. Again, who can quarrel with that? “Knowledge is power,” we’re told;[6] and why rent a rowboat for addicts if we really need a passenger liner? So yes, by all means study the problem, but not at the expense of making progress elsewhere. And by the way, the early returns are in. See Crappy News, the next section.

How about “cutting edge research” [Point 4]; is that a good idea? Practically always, say I. If our scientists research pain, perhaps they’ll develop new ways to treat sufferers without dosing them with addictive substances. That’s got to be a “better practice” [Point 5] than what we’ve been doing.

Then what about “cutting edge research” on addiction itself? Should we work on that as well? Yes, and we’ll discuss that later, under Vaccines.]

The Crappy News, or Why One Should Avoid the Drudge Report Early in the Morning

So the other day I was minding my own business, checking the Drudge Report, when I happened on a piece from Reuters that said: “More than third of [all] U.S. adults [were] prescribed opioids in 2015.[7] [Drudge is my substitute for a morning tabloid; feel free to pick a different service if you want; but definitely we all need something to read at breakfast.]

Ugh? Looking further I found the original data, or at least an abstract of it.[8] Officially the study is called the 2015 National Survey on Drug Use and Health [NSDUH]. So let’s sketch the findings. What else can you do with an Abstract?

  • In 2015 72,600 eligible civilian, noninstitutionalized adults were selected to participate in the study, and 51,200 completed the survey interview.
  • Based on these inputs, NSDUH estimated that, in 2015, 91.8 million (37.8%) of U.S. civilian, noninstitutionalized adults used prescription opioids.
  • 11.5 million people (4.7% of all adults) misused opioids; and 1.9 million (0.8%) had an opioid use disorder.
  • Among adults with a prescription, 12.5% reported they misused it; and of these, 16.7% reported a “prescription opioid use disorder.”
  • Most commonly people who misused opioids did so to relieve physical pain (63.4%). Does that sound familiar? Check out Thomas de Quincy’s story, referenced above.
  • Misuse and use disorders were most common with adults who were uninsured, unemployed, had low income, or had behavioral health problems.
  • Among adults who misused opioids, 59.9% reported using them without a prescription, and 40.8% obtained prescription opioids – for their most recent episode – for free from friends or relatives.[9]

So there you have it. Lots of doctors prescribe opioids; more than one-thired of U.S. adults had prescriptions in 2015; and some of those also used opioids without a prescription. Thank you, NSDUH, for that insight.

And some patients get violent if their doctors refuse to write prescriptions.[10] The states are upset; they argue over-prescription and the resulting addictions are impacting state resources;[11] and they’re beginning to sue the drug companies [and others] they think are responsible. Congress is alert, and will hold hearings on the matter.[12] Mexico is producing more and more opium to satisfy the demand growing in the U.S.[13] [Frankly, I didn’t know Mexico produced any opium; I thought most of the world’s supply came from our dependency, Afghanistan.] And, of course, our medical establishment is studying the problem that, one could argue[14], it created.

Vaccines

None of this is good, but is there sunlight behind the clouds? A month or so ago a friend[15] sent us an article about medicines that fight opioids and other addictive substances.[16] Apparently this has been researched since the 1970s, although without much recent success. Right now therapists have only three medications – methadone, buprenorphine, and naltrexone – to use to help the opioid addicted “get clean” and stay drug free. They work, but “not perfectly.”[17]

Current research is directed toward finding vaccines to directly counter opioid addiction. Most foreign substances are blocked from entering the brain by something called the blood-brain barrier. Opioids are an exception to that. They are very tiny molecules; can penetrate the barrier and enter the brain; and then do their damage unopposed. Opioids may lose their advantage – of small size – if they are attacked by antibodies “that bind to the drug molecules, creating complexes that are too large to cross into the brain.”[18] If the brain isn’t accessed, “there’s no high.”[19] And, one might add, there’s no corresponding brain damage to reinforce later addictive behaviors.

So the research is directed at triggering the human immune system to directly attack opioids. To (i) convert opioids to larger things that will not pass into the brain, or (ii) flush them out of the body before they reach the brain, or (iii) to do both. The Scripps Research Institute in La Jolla, CA, and the Walter Reed Army Institute of Research in Silver Spring, MD, have promising lines of study, and may have vaccines ready to begin human trials in the not too distant future. There are other candidates out there as well.

Conclusion

The situation with opioids is grim and looks worse every day, but perhaps there really is sunlight behind the clouds. The important thing for Congress to remember is that, when they’re throwing oodles of money at law enforcement to chase bad guys with drugs, they shouldn’t forget the scientists who, with funding and a bit of luck, may solve this problem for everybody.

Until the next one comes along, of course. Humans are weak, and our criminals are very ingenious. Didn’t you know?

 

[1] This is from the website of the National Institute on Drug Abuse, an organization within NIH. You can find it at https://www.drugabuse.gov/drugs-abuse/opioids/opioid-crisis . It was last updated in June of this year.

[2] That’s the blog of 07/16/2017, Opium Portrayed, at  https://opsrus.wordpress.com/2017/07/16/opium-portrayed/

[3] That’s Confessions of an English Opium Eater, Being an Extract from the Life of a Scholar. It’s currently in print from the Oxford University Press.  It was first published in 1821 in London Magazine, and was picked up in 1886 by George Routledge and Son. You can find the hard copy on Amazon. However, in keeping with blog policy, we found an alternate, free source for the text, this time in an eBook from Project Gutenberg.  Go to http://www.gutenberg.org/files/2040/2040-h/2040-h.htm .

[4] See Annals of Internal Medicine, The Effectiveness and Risks of Long-Term Opioid Therapy for Chronic Pain: A Systematic Review for a National Institutes of Health Pathways to Prevention Workshop (February 17, 2015) at Abstract, available at http://annals.org/aim/article/2089370/effectiveness-risks-long-term-opioid-therapy-chronic-pain-systematic-review .

[5] See n. 1.

[6] See Knowles, Oxford Dictionary of Quotations (6th Ed., 2004) at Proverbs, p. 624, n. 45.

[7] It’s at Reuters Health News, Seaman, More than a third of U.S. adults prescribed opioids in 2015 (July 31, 2017), available at http://www.reuters.com/article/us-health-opioids-prescriptions-idUSKBN1AG2K6 .

[8] The Abstract appears as Prescription Opioid Use, Misuse, and Use Disorders in U.S. Adults: 2015 National Survey on Drug Use and Health (August 1, 2017). You have to pay for a copy if you want to read the underlying article. I don’t know why that’s the case, since the study apparently was funded by our government. Anyway, the abstract is available at https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4782928/pdf/nihms753305.pdf .

[9] These findings are paraphrased or directly quoted from the Abstract.

[10] See, e.g., Fox 5, Hundreds mourn doctor slain after denying opioids to patient (August 2, 2017)), available at http://www.fox5ny.com/news/271464646-story .

[11] See Reuters, Raymond, State attorneys general probe opioid drug companies (June 15, 2017) available at http://www.reuters.com/article/us-usa-opioids-idUSKBN1962JJ

[12] See Clair McCaskill speaking to the DNC on July 28, 2016, available at https://www.bing.com/search?q=hthtps%3A%2F%2Fwww.yahoo.com%2Fnews%2Fu-senator-launches-probe-five-top-opioid-drugmakers-165514279 finance.html&form=EDGEAR&qs=PF&cvid=59500fa1e8204d0a8a8906e8292f9679&cc=US&setlang=en-US&elv=AXXfrEiqqD9r3GuelwApuloTP6wVwkOjONBqpuAMtOReD2p9Vv8km70BwEANJJDGrbYQZQruLL%21jduPgTqpAT%212GMOjDF0L2w7LKJr4QVFIa

[13] See RT, US offers to help fund Mexico’s heroin eradication efforts – report (22 April 2017) available at https://www.rt.com/usa/385656-mexico-fund-heroin-reuters/

[14] In fact, there doesn’t really seem to be an argument about this. See n. 1 and the quote that accompanies it.

[15] That’s Dave Feagles. Many thanks, Dave!

[16] See Science News, Gaidos, Vaccines could counter addictive opioids, Vol. 190, No. 1, p. 22 et seq. (July 9, 2016), While we have this article in our library, we don’t have a web  address for it, so we’re citing to the hard copy magazine.

[17] Id. We’re citing to the print version of the article, but don’t have the printed pages before us. We estimate that this information appears around p. 23.

[18] Id. at around p. 24.

[19] Id.

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Oh, just, subtle, and mighty opium! [T]hat to the hearts of poor and rich alike, for the wounds that will never heal, and for “the pangs that tempt the spirit to rebel,” bringest an assuaging balm; eloquent opium! that with thy potent rhetoric stealest away the purposes of wrath; and to the guilty man for one night givest back the hopes of his youth, and hands washed pure from blood; and to the proud man a brief oblivion for Wrongs [unaddressed] and insults unavenged ….. Thou only givest these gifts to man; and thou hast the keys of Paradise, oh, just, subtle, and mighty opium!

Thomas de Quincey[1]

 [This is Fred. Phil’s out with exhaustion, heat and otherwise, and asked me to take over today’s lesson. This isn’t an easy thing to do, because he has a list of heavy-duty subjects to cover some day, but most are not in my area of interest, and I don’t know enough to lecture about the rest. It would take too long to research “Philosophical Aspects of Modern Rap,” or “A Linguistic Analysis of Feminist Theory,” or “Will Ancient Spells Work on Mars?” [Although that last one really looks interesting.[2]]

But we’re not blazing new paths today; there’s a deadline; so let’s look for an old subject, one we know something about. How about opioids and our collective addiction to them? Heroin, an opioid, has been around and afflicting people in this country for some time.[3] Opium, the original opioid, has caused problems in the East for centuries and has addicted folks in the West for generations. Most of us kind of know about these things, but ignore them. The current furor about opioids only erupted because there are synthetics now loose in the drug economy. They’re very potent, and deadly, and their users die at a high rate.

So why not frame our current situation with some history? Did you know that opium was a big problem in England in the 18th and 19th Centuries? And what’s the evidence for that? Well, for one thing there’s a very famous book, first published in London Magazine in 1821, that chronicles the opium addiction of an upper class Englishman. My friends in sociology say it’s a classic. The book tells us quite a bit about how the author got addicted, who supplied the stuff, and how many users there were.

It says London had a well-established opium trade in the early 19th Century. The author reported: “Three respectable London druggists, in widely remote quarters of London … assured me that the number of amateur opium-eaters … was at [that] time immense; and that the difficulty of distinguishing those persons to whom habit had rendered opium necessary from such as were purchasing it with a view to suicide, occasioned them [the druggists] daily trouble and disputes.”[4] So why would druggists back then worry about would-be suicides? I don’t know. Perhaps it was a legal requirement. But apparently the prospect of suicide didn’t inhibit sales all that much. The population of users “was immense.”

Also, opium addiction was not just an upper class London phenomenon. Blue-collar types in other parts of England were getting into it, “so much so, that on a Saturday afternoon the counters of the druggists were strewed with pills of one, two, or three grains, in preparation for the known demand of the evening.”[5] The author said this happened because, for a time, opium was less expensive than alcohol, so the working class went with the new thing. But, he said, if the pricing reversed, the new addicts would not follow. “[T]hose eat now who never ate before; [a]nd those who always ate, now [will] eat the more.”[6] That is, opium addicts, once made, would not go back to the old vices simply because the market ordered it.]

The book is Confessions of An English Opium-Eater: Being an Extract from the Life of a Scholar, written by Thomas de Quincey.[7] He lived from 1785 to 1859, and was severely addicted from about 1813 until 1819. If you want to know more, there are some web-based biographies available[8]; but in my view they pretty much track the book; so that’s where we’ll concentrate. As to why De Quincey was a user, look at the quote that opens this piece. Opium held the keys to Paradise.[9]

De Quincey’s Life and Addiction

Or at least it did when he used opium sparingly, and at great intervals, for recreation. But I’m getting ahead of the story. Let’s look at the milestones on his road to and from addiction:

  1. Thomas de Quincey was born on August 5, 1785. His father was a merchant, just starting out, and had good prospects until he died, 7 years later. By my count, that would have been in 1792.
  2. Young Thomas had 4 guardians after that, and was shipped off to various schools for his education, apparently including Eton and an unnamed school at Oxford. “I was sent to various schools, great and small; and was very early distinguished for my classical attainments, especially for my knowledge of Greek. At thirteen I wrote Greek with ease; and at fifteen my command of that language was so great that I not only composed Greek verses in lyric metres [today, “meters”], but could converse in Greek fluently and without embarrassment …”[10]
  3. He tried opium for the first time at age 18, which would have been in 1803. He liked it, and over the next 10 years continued to use it “for the sake of the exquisite pleasure it gave me ….”[11]; but, he said, he spaced out the doses to preserve their effect, and that protected him “from all [the] material bad consequences”[12] of addiction. Or perhaps he just didn’t have the money to buy in quantity. Who knows?
  4. The situation changed in 1813, when he was 28. He had an eruption of a gastro-intestinal problem that first had hit him when he was a teenager. Apparently it was both painful and chronic; so much so that he began to treat himself with daily doses of his favorite drug. “It was not for the purpose of creating pleasure, but of mitigating pain in the severest degree, that I first began to use opium as an article of daily diet.”[13]
  5. He continued until he was thoroughly addicted, and didn’t kick the habit until 1819, six years later. How did he escape? By incrementally reducing his intake until he achieved a zero dose rate; and that wasn’t easy! He tried to do it in the early days, but failed. And he was a mess even after he succeeded. “Think of me as one, even when four months had passed, still agitated, writhing, throbbing, palpitating, shattered, and much perhaps in the situation of him who has been racked …. Meantime, I derived no benefit from any medicine, except one prescribed to me by an Edinburgh surgeon of great eminence, viz., ammoniated tincture of valerian.”[14]
  6. Valerian is an herb you can buy today at the vitamin store, but I’m not saying it will help you conquer opioids. So far as I can tell, there still aren’t any easy cures. Right now a cynic might say our technology isn’t much more effective than what was available to De Quincey 200 years ago. Reports are that there may be a vaccine in our future, but they’re speculative and a subject for a different blog.

Conclusion

His milestones sound pretty contemporary, don’t they? De Quincy, an occasional user of opium, the opioid of his day, liked it so long as he didn’t use a lot. Then one day he used it as a pain killer, began to take daily doses, and went straight down the toilet. And today what are our most popular pain medications? Opioids, for the most part. And where do we get them? Why, from druggists, doctors or street vendors, depending on our budgets. Oh brave new world, you look pretty old to me! I wonder, did 19th Century Londoners have street druggists like ours? If so, did they call them “pushers”? Or was everybody just a druggist?

I’m guessing it’s as hard to kick an opioid addiction today as it was for Thomas de Quincey. He said it was like being born:

[Some conjecture] that it may be as painful to be born as to die.  I think it probable; and during the whole period of diminishing the opium I had the torments of a man passing out of one mode of existence into another.  The issue was not death, but a sort of physical regeneration …. [15]

And once regenerated it was possible for him to be happy again. “[A]nd I may add that ever since, at intervals, I have had a restoration of more than youthful spirits, though under the pressure of difficulties which in a less happy state of mind I should have called misfortunes.”

Opium and its modern relatives can be very attractive until they take control of our lives. Thomas de Quincey discovered that, got out, and was better for it. Myself, I think it’s better not to get in.

See you next week!

 

[1] This quote is from Thomas de Quincey, Confessions of an English Opium Eater, Being an Extract from the Life of a Scholar. Believe it or not, this book is currently in print from the Oxford University Press.  It was first published in 1821 in London Magazine, then was picked up in 1886 by George Routledge and Son. You can find the hard copy on Amazon. However, in keeping with blog policy, we have found an alternate, free source for the text, this time in an eBook from Project Gutenberg.  Go to http://www.gutenberg.org/files/2040/2040-h/2040-h.htm “This eBook is for the use of anyone anywhere at no cost and with almost no restrictions whatsoever.  You may copy it, give it away or re-use it under the terms of the Project Gutenberg License included with this eBook or online at www.gutenberg.net .” Henceforth the eBook will be cited as “Opium Eaters at __.” Page numbers, if given, will be approximations. The eBook version doesn’t appear to have such things. See Opium Eaters at Part II, The Pleasures of Opium, p. 28-29 for our quote. Even our quote is just a small part of what he actually wrote.

[2] I also like his partial draft of “Faces and Other Things on the Planets,” in which he argues that with modern digital technology any collection of pixels can be morphed into anything else, so why believe NASA’s pictures of celestial objects or any pictures at all?

[3] Check out the Wikipedia posting at https://en.wikipedia.org/wiki/Heroin for more information on this subject.

[4] See Opium Eaters at To the Reader, p. 3.

[5] Id.

[6] Id. “… I do not readily believe that any man having once tasted the divine luxuries of opium will afterwards descend to the gross and mortal enjoyments of alcohol ….”

[7]  See note 1.

[8] See, e.g., the home page for the most recent printed edition of De Quincey’s book, at http://robertjhmorrison.com/thomas-de-quincey/ ; and the Wikipedia entry for him at https://en.wikipedia.org/wiki/Thomas_De_Quincey .

[9] The Oxford Dictionary of Quotations has a ridiculously shortened version of the original. See Knowles [editor], Oxford  Dictionary of Quotations (6th Edition, 2004) [hereafter, ODQ at __]  at Thomas de Quincy, p. 264, n. 20. “Thou hast the keys of Paradise oh just, subtle and mighty opium.” That reads like someone’s note on a page, next to the real thing, rather than a genuine effort to reflect the original.

[10] See Opium Eaters at Preliminary Confessions, p. 5.

[11] See Opium Eaters at Preliminary Confessions, p. 4.

[12] Id.

[13] See Opium Eater at Preliminary Confessions, p. 4-5

[14] See Opium Eaters at Part II, June 1819, p. 46

[15] See Opium Eaters at Part II, June 1819, p. 46

[Hi! This is Larry, this blog’s occasional legal pundit, with a few ideas I’d like to share. But first, let me repeat: I’m retired, not looking for new clients, and not in business. I have opinions, but no ulterior motives. Fred was going to write this week’s post, but he’s lost in research, so I’m the last-minute substitute.

Fred’s topic was very much post-election, i.e. to speculate about what other catastrophes might befall us here on planet Earth, but he got lost in the data. It’s always a mistake to start any project with You Tube. One tends to get buried in “information” that really isn’t informative. Remember when the U.S. did moon shots and lunar landings back in the 1960’s? We had a spate of bad weather at home back then, and my Great Aunt blamed it on the U.S. space program. That was interesting, of course, – I discovered we had a crank in the family – but not important. She knew absolutely nothing about weather forecasting, or the space program. Folks who repeated her views were accurate in that they reported what she thought.  But doing that didn’t tell us much about the world because my aunt didn’t know what she was talking about.

I’m not sure why all that comes to mind, except perhaps because of the similarities between my aunt’s views of the weather and today’s punditry. We all lived through the recent episode of perpetually negative polls – Donald Trump couldn’t win the Republican nomination, then he couldn’t win the election – and punditry, warning that he should drop out of the race before he ruined the Republican Party. Come to find out, Trump will be the next President and the Republicans will retain control of the U.S. House of Representatives and the Senate. Not bad for a loser like Trump!  And the Republicans elected a bunch of Governors as well.

Democrats, or at least those in the Chattering Class, seem to be in denial about this. That’s what happens when people in a closely-knit group suffer a major disconfirmation of a strongly held belief.[1] Expect them to double-down and be even shriller before they’re done. That’s not my field – perhaps Phil will offer some comments at a later date – so I’m going to change the subject, from politics and grieving Democrats, to recent developments in something that should concern all of us.]

Of course, I’m talking about the catastrophic spread of opioids, natural and synthetic, in today’s drug culture. I’m not an expert, but I have done a couple of blogs on the subject[2], and there’s new information out there that’s worth looking at. And by “information” I mean concrete examples about what’s happening, not some amateur’s unsupported opinions [or bogus videos].

Pink

So this brings us to the story for today. As we know from our previous work on heroin overdose[3], there are two forms of opioid: (i) the “natural” version, based on the opium poppy; the poppies are grown in Afghanistan, and are the source of heroin; and (ii) various synthetic opioids – produced in laboratories from chemicals, and not derived from the poppy.  In general the synthetic compounds, many of them grouped as “fentanyl,” are far more potent than natural heroin. They are made in laboratories, but probably not in someone’s kitchen, because the technology isn’t there yet.[4] Or so I’m told.

Known opioids – natural and synthetic -are federally regulated, although that doesn’t necessarily stop organized crime from making or selling them. Nevertheless, state and federal pressure does help restrict the illicit supply; or at least I like to think so.

Recently a new and deadly opioid entered the market. “’Pink’, known to chemists as U47700, comes from a family of deadly synthetic opioids that are far more potent than heroin, and is imported to the United States mainly from China.”[5] How about that? Another benefit to Americans from world trade! Much more deadly[6] and probably less expensive illicit drugs are available from overseas, so customers don’t have to buy American!

Pink was unregulated largely because federal and state authorities didn’t know about it; and, being technically not illegal in most states, there were no obvious criminal liabilities for owning it! But that changed when Pink killed at least 46 people in 2015 and 2016. [7] On November 14 our federal government, through its Drug Enforcement Administration, used its emergency authority to add Pink to “Schedule I” of DEA’s list of controlled substances.[8]

The Controlled Substances Act

Is this important? Yes. The DEA is responsible for implementing and enforcing titles II and III of the Comprehensive Drug Abuse Prevention and Control Act of 1970, as amended. [9] DEA collectively refers to Titles II and III as the “Controlled Substances Act.” Implementing regulations are published in the Code of Federal Regulations (the “CFR”). This legal/ bureaucratic enterprise is designed to “prevent, detect, and eliminate the diversion of controlled substances and listed chemicals into the illicit market while ensuring an adequate supply is available for the legitimate medical, scientific, research, and industrial needs of the United States.”[10]  All this is necessary, of course, “to protect the public health and safety.”

Schedule I

So where are the controlled substances called out? Answer: “In the Code of Federal Regulations.”[11] I would say “of course,” except that there are other ways to do it. Anyway, the most highly regulated substances are listed in Schedule I.[12] There are a lot of them, and “Pink,” or U47700, will appear as subparagraph (h) 18 of Schedule I. The listing will be valid for only 2 years, with a possible 1 year extension, unless there are further regulatory proceedings.

Next Steps

How many substances are in Schedule I? Well, you might take a look at Wikipedia to find out[13], but that wasn’t helpful to me; or you could look at Schedule I, except it’s not easy to get a current version from the Government Printing Office. I expect there are lots of recent changes – additions? – due to an uptick in opioid research and development. The Chinese, along with the Mexicans, Russians, etc. may be innovating at a good speed.

Anyway, DEA maintains an unofficial cuff list of what’s currently on record, or recently on record,[14] and going by that I count 152 substances in Schedule I, including “Pink.”. That’s a lot to look for, I guess.

How many will there be next year? I don’t know. Probably more.

 

[1] What’s “disconfirmation?” Check out the Wiktionary at https://en.wiktionary.org/wiki/disconfirmation . For “disconfirmed expectancy,” see the Wikipedia entry at https://en.wikipedia.org/wiki/Disconfirmed_expectancy For the classic study, read Festinger, Riecken, and Schachter When Prophecy Fails (1956). Flying saucers!

[2] See the blog of 2016/09/15, Drug Disaster, available at https://opsrus.wordpress.com/2016/09/15/1255/ ; and the blog of  2016/09/21, Questions, Questions, available at  https://opsrus.wordpress.com/2016/09/21/questions-questions/

[3] See the blog of  2016/09/21, Questions, Questions, available at  https://opsrus.wordpress.com/2016/09/21/questions-questions/

[4] At least that’s what Popular Science said last year. See Popular Science, Ossola, Home-Brewed Synthetic Opioids Are Finally A Reality (August 13, 2015), available at http://www.popsci.com/home-brewed-synthetic-opioids-are-finally-reality

[5] See Department of Justice, Drug Enforcement Administration, Schedules of Controlled Substances:  Temporary Placement of U-47700 into (2016/11/14), available at https://s3.amazonaws.com/publicinspection.federalregister.gov/2016-27357.pdf  Henceforth we’ll call this “Temporary Placement” at __.

[6] See NBC News, Connor, Feds Move to Ban Pink, Heroin Substitute That’s Killed Dozens (2016/11/10 ), available at http://www.foxnews.com/health/2016/11/10/dea-temporarily-bans-synthetic-opioid-pink-after-46-deaths.html “This stuff is so powerful that if you touch it, you could go into cardiac arrest … The problem is that if you have  a credit card and a cell phone, you have access to it.”

[7] See Fox News, DEA temporarily bans synthetic opioid pink after 46 deaths (2016/11/10), available at http://www.foxnews.com/health/2016/11/10/dea-temporarily-bans-synthetic-opioid-pink-after-46-deaths.html

[8] See “Temporary Placement” at __.

[9] See 21 U.S.C. §§801–971.

[10] See Temporary Placement at p. 2.

[11] See 21 C.F.R. Part 1308.

[12] See 21 C.F.R. Part 1308, §1308.11, Schedule I.

[13] It wasn’t really helpful and seemed a bit out of date, but you can find it under “Synthetic Opioids” at https://en.wikipedia.org/wiki/Category:Synthetic_opioids

[14] The one I found, the unofficial one, is available from the Cornell Law School, LII, and from DOJ at https://www.deadiversion.usdoj.gov/21cfr/cfr/1308/1308_11.htm

[Note: This one is for Dave Feagles, who helped me understand fentanyl and its problems.  That’s not to say that he agrees with all or any of my conclusions. No friend of mine should have to do that.]

[There was a brisk response to our last post, some of it about my personal habits and obvious failings as a copy editor, but some of it also on substance. Please, you all know Jeremy Bentham didn’t accept name calling and personal attacks as legitimate tools of debate. They’re usually irrelevant to the issues of the day, and are intended to distract listeners from the real stuff. And there’s no truth to the rumor that our story was a cheesy effort to drive down real estate values in my locality, West Virginia. The facts might do that, but I haven’t made up anything. And, by the way, I live here too. What we have here is simply a very dismal situation.

So I’ve picked the best of your comments, edited out the obscenities, etc., combined them with others on the same subject, and will now deal appropriately with what remains.]

All right, Mr. Sallust, you’ve done it this time! There you were, playing with words at the beginning of the last post, and you completely bollixed it up. You left out a key word, you ninny, and spoiled whatever effect you were trying to achieve! That’s a poor performance for someone who pretends to be educated. What have you done to make sure it doesn’t happen again? Have you fired the secretary?

Actually, you’re right, at least about the preposition.  The commenter is talking about the introduction to the last piece – you know, the part in italics – where I jokingly quoted myself, and described that as possibly a “ridiculous case unbridled narcissism.” Of course, that should have been a “ridiculous case of unbridled narcissism.” A reader caught the mistake soon after publication, and I speedily corrected the published version. It was too late to change drafts that already had been circulated. So what? They were drafts, you know; not final copy.

The rest of the comment is mistaken. We don’t have a secretary here at Elemental Zoo Two. Everyone does his own typing so, I guess, for that piece I was the secretary [as I am for this one]. As a matter of policy, I will not fire myself. I’m too important to the health of the blog. Also, I need something to do on off days.

You have opinions about fentanyl, but don’t tell us much about it, except that it’s synthetic. Do you know anything more, or were you just pretending?

Now that’s a good question. I didn’t say much about fentanyl last time because I knew the subject generally but didn’t have a lot of detail. After the first couple of comments it was obvious that people wanted to know more; so I went back to the books, and here’s what I found.

The Drug Enforcement Administration [DEA] identified fentanyl as a problem drug just last year.[1] The drug had been around for a long time[2], but incidents and overdoses involving it were on the rise in 2015 and “occurring at an alarming rate throughout the United States.” As such they represented “a significant threat to public health and safety.”[3] Fentanyl and fentanyl derivatives are “often laced with heroin,” and that sort is up to “100 times more powerful than morphine, and 30 – 50 times more powerful than heroin.” [4]

The euphoric effects of fentanyl are the same as heroin[5], but “[i]ngestion of [fentanyl] doses as small as 0.25 mg can be fatal.”[6] Also, last but certainly not least, fentanyl is dangerous to law enforcement and “anyone else who [might come] into contact with it.”[7] It can hurt people who take, touch or breathe it.[8]

So – and this is my opinion – combining fentanyl with heroin doesn’t sound like a particularly bright move unless a dealer is out to exterminate his [or her] clientele, and possibly law enforcement as well. Addicts may disagree, and probably do.

Where does fentanyl come from? Is it, like heroin, a product of the opium poppy grown in Afghanistan?

The drug is synthetic, you know, and the chemists – amateur and professional – seem to be hard at work on it. At last count there were 15 versions – the so-called “fentanyl analogues” – in addition to the basic compound.[9] It’s not clear to me whether the opium poppy is necessary, or useful, to create synthetic fentanyl,[10] but I suspect it isn’t.

Fentanyl abuse is growing around the world, in Russia, Ukraine, Sweden and Denmark, for example, and Mexican authorities have seized fentanyl laboratories in their own country. Back in 2006, the U.S. found one in California.[11] So where one can be built, many are possible. Apparently the precursor chemicals for fentanyl are sold by companies in Mexico, Germany, Japan and China. Right now Afghan poppies don’t seem to be on any list of precursors.

Of course, my opinion is based only on information that’s currently public.[12] No doubt there’s a lot going on in the world that we don’t know about. One article reports, for example, that fentanyl is cheaper to make than heroin[13]; if that’s the case why wouldn’t customers, and dealers, migrate in that direction? So perhaps there are illegal fentanyl laboratories all over the place, not just in Mexico and California. Perhaps heroin from Afghanistan will be driven off the market by a newer, more potent [and deadly] synthetic. Of course that’s not necessarily a good thing, is it?

There’s an anti-overdose medication that police forces in some jurisdictions are authorized to use. Do you have it in your area, and, if so, is it effective?

I think you’re talking about naloxone [also called Narcan] which is highly recommended[14] as a treatment for opioid overdoses.[15] In an overdose the victim’s respiratory system is severely depressed, to the extent that he or she may stop breathing. Death follows. Naloxone reverses that, and can save the victim’s life. “The earlier the treatment the better the result,” or so I’m told.

Recently the Food and Drug Administration asked industry to develop a phone app to help “opioid users and their friends” locate naloxone when they need it.[16] That may be a good idea but, more to the point, today naloxone is used by doctors and in emergency rooms, etc., to treat the cases that come in the door. In some states it’s also included in kits issued to emergency responders [including law enforcement] and some drug users.[17] My state, West Virginia, does that.[18]

My personal opinion is that, while the kits are a good idea in today’s environment, and hopefully will reduce the death rate from overdose, they probably won’t reduce the rate of addiction. Addicts who die automatically drop out of the pool of current users. Those who survive have a second chance, but not all of them will enter treatment, abandon drugs, and get their lives back. Some will, and some won’t. At the same time new addicts reveal themselves every day, [19] lining up to pour money into the illicit drug trade. So my point is, without other changes, drug interdiction, better enforcement and so forth, the addiction rate may well go up even as overdose deaths decline.

Of course, that little speculation assumes we know how to count the addicts hidden in our society.

I don’t mean to be macabre, but how is the 2006 heroin death rate shaping up in your area? Is it rising or falling?

It looks like the final numbers come out about 12 months after any year ends. There are anecdotes, but they lead nowhere. Let’s wait and see. “Time destroys the speculation of men, but it confirms nature.”[20]

[Will there be more questions and answers next week? Probably. If not next week, then soon.]

[1] See DEA, Headquarters News, DEA Issues Nationwide Alert on Fentanyl as Threat to Health and Public Safety (March 18, 2015), available at https://www.dea.gov/divisions/hq/2015/hq031815.shtml Henceforth this will be cited as DEA 2015 Alert.

[2] Since 1960, if you’re curious. See the Wikipedia entry on fentanyl at https://en.wikipedia.org/wiki/Fentanyl

[3] See DEA 2015 Alert.

[4] Id. “In the last two years, DEA has seen a significant resurgence in fentanyl-related seizures. According to the National Forensic Laboratory Information System (NFLIS), state and local labs reported 3,344 fentanyl submissions in 2014, up from 942 in 2013.  In addition, DEA has identified 15 other fentanyl-related compounds.”

[5] Id. “Its euphoric effects are indistinguishable from morphine or heroin.”

[6] Id.

[7] Id.

[8] Id. “DEA has also issued warnings to law enforcement as fentanyl can be absorbed through the skin and accidental inhalation of airborne powder can also occur. DEA is concerned about law enforcement coming in contact with fentanyl on the streets during the course of enforcement, such as a buy-walk, or buy-bust operation.” See also The Washington Post, Bever et al., Opioid epidemic’s hidden hazard, SWAT officers treated for fentanyl exposure during drug raid (September 14, 2014), available at https://www.washingtonpost.com/news/post-nation/wp/2016/09/14/eleven-swat-officers-treated-for-exposure-to-fentanyl-and-heroin-in-drug-raid/

[9] See n. 4. So far DEA has identified 15 other fentanyl-related compounds.

[10] I’ll try to answer that another day.

[11] See the Wikipedia piece on Fentanyl, under recreational use, available at https://en.wikipedia.org/wiki/Fentanyl

[12] See DEA 2015 Alert. “Globally, fentanyl abuse has increased the past two years in Russia, Ukraine, Sweden and Denmark. Mexican authorities have seizure fentanyl labs there [i.e., in Mexico], and intelligence has indicated that the precursor chemicals came from companies in Mexico, Germany, Japan, and China.”

[13] See New York Times, Seelye, Heroin Epidemic Is Yielding to a Deadlier Cousin: Fentanyl (March 25, 2016), available at http://www.nytimes.com/2016/03/26/us/heroin-fentanyl.html?_r=0 . “’For the cartels, it’s their drug of choice,” Ms. Healey said. “They have figured out a way to make fentanyl more cheaply and easily than heroin and are manufacturing it at a record pace.’”

[14] See CDCHAN-00350, Health Advisory, Recommendations for Laboratory Testing for Acetyl Fentanyl and Patient Evaluation and Treatment for Overdose with Synthetic Opioid (June 20, 2013) at p. 3 of 5, Recommendations, available at https://emergency.cdc.gov/han/han00350.asp

[15] Id. “We recommend that emergency departments and emergency medical services treat suspected opioid overdoses according to standard protocols. In addition, larger doses of naloxone may be required to reverse the opioid induced respiratory depression because of the higher potency of fentanyl and acetyl fentanyl compared to heroin.”

[16] See Los Angeles Times, Healy, FDA asks coders to create an app that matches opioid overdose victims with lifesaving rescue drug  (September 19, 2019), available at http://www.latimes.com/science/sciencenow/la-sci-sn-opioid-naloxone-app-20160919-snap-story.html

[17] See the Wikipedia discussion at Naloxone; available at https://en.wikipedia.org/wiki/Naloxone#Opiate_overdose    “[Naloxone is included as a part of emergency overdose response kits distributed to heroin and other opioid drug users and emergency responders. This has been shown to reduce rates of deaths due to overdose…”

[18] Metro News, Kercheval, Life-saving naloxone approved in WV (March 11, 2015), available at http://wvmetronews.com/2015/03/11/life-saving-naloxone-approved-in-wv/  “Hughes was on hand Monday when Governor Tomblin signed into law SB 335, authorizing the first responders to carry the opioid antagonist and allowing doctors to prescribe naloxone to relatives and friends of a person at risk of overdosing.”

[19] They can be anywhere. See USA Today, Bowerman, Sheriff’s candidate charged with heroin possession in West Virginia (August 3, 2013), available at http://www.usatoday.com/story/news/nation-now/2016/08/03/sheriffs-candidate-charged-heroin-possession-state-police/87998338/

[20] That’s from Marcus Tullius Cicero, a Roman dude I was once forced to translate. You can find it on Brainy Quote, at: http://www.brainyquote.com/quotes/keywords/speculation.html