Archives for posts with tag: heroin

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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The easiest, most effective step that the federal and state governments can take to stem the tide of deaths from opioid overdoses is to make naloxone easier to get …”

Megan McLemore of Human Rights Watch, as quoted in The Lancet[1]

 

[This is G. Sallust again. It’s said that more than 90 Americans die every day from opioid overdose.[2] That simple fact makes opioids truly blog-worthy, and worth an update, so I asked for volunteers to do the job.  Unfortunately I didn’t get any. Instead my loyal staff told me to write it myself. This isn’t a democracy; but everybody here is a volunteer, so I have to listen when they yell at me. And this time they made a good case.

It’s true that I’m uniquely qualified to talk about opioids. And no, that’s not because I’m a heroin addict. Actually I don’t take anything unless it’s prescribed by a doctor, and I especially I don’t like pain killers, no matter who wants me to take them, because they make us stupid.  I’m qualified because I (i) live in a rural area that has a horrible problem with opioids and (ii) am morally offended by the situation.

Actually they didn’t say it that way. Fred says I’m loud and abrasive, and an attention-getter, and that’s what’s needed. Phil says I often sound reasonable, even when I’m not, and that might help with some readers, the ones who are not too far gone in politics. And Larry, bless his heart, says that I can be persuasive when I stick to the facts, which isn’t always the case, and if I do that I might do a passable job. All of them had other pressing business, and none of them wanted to get involved. I call that mutiny, thinly disguised.

So I’m writing this myself. And speaking of politics, which I just did, let’s start by saying that in my opinion Donald J. Trump, is not responsible for the opioid epidemic. He’s been President only since January 20, 2017[3];  and the problem predates him by several years. Of course, the same could have been said of Barrack Obama, when he first took office in 2009. The economy had collapsed in the second half of 2008, and threatened to go belly-up. That pretty much gave the election of 2008 to the Democrats. Conservative pundits then argued that Obama, who wasn’t President at the time, was actually responsible for the 2008 crash, because the mere fact that he might be elected had upset the market. A few months later they followed up by complaining that the recovery was taking too long.

Well, that was then and this is now, and today we’re talking about crimes, the criminal law and public health, not about the economy. So far no one has blamed Trump for the opioid problem, but they will. At some point the loyal opposition is going to start asking why President Trump hasn’t done more to solve it. But before we go down that road, it might be best to take a look at where we are, medically speaking, in the battle to restrict opioids. Luckily there are a couple of recent articles, one in The Lancet[4] and the other in the New England Journal of Medicine[5], to help us understand the situation.]

The Lancet Says

Let’s take first things first. Heroin is an opioid, as are morphine, opium, and various synthetics, such as fentanyl and its numerous cousins.[6] One can overdose on any of these, but it’s more likely with street drugs because those are frequently mixed with one variety or another of fentanyl. Some versions of fentanyl (I don’t know how many) are extremely potent, and can kill with very, very small quantities. So if a dealer is an amateur, he can easily kill a lot of people.

Naloxone is an antidote that reverses the effect of overdose. (In my neighborhood it’s also called Narcan.) Many jurisdictions are equipping their first responders with it, so that they can treat an overdose on the spot, rather than cart the victim off to an ER. That’s a good thing, because [apparently] it saves lives. But that doesn’t necessarily reduce the addiction rate. In fact, one can speculate that the more addicts survive overdose, and if new addicts continue to enter the population at the usual rate [whatever that is], the total number of addicts will grow over time. And as the numbers increase, the addiction rate will as well.

So that brings us to the bigger problem: How do we, in the U.S., treat addicts to reduce their numbers? Well, the Administration resolved to study the matter, which sounds like a good idea, and interim recommendations are due the 27th of this month. That sounds like something we ought to read. In the meantime The Lancet reports that a policy is beginning to emerge. So far –

  • The president’s budget for the next fiscal year (FY 2018) calls for a $279.7 million increase in funding for drug control efforts;
  • That includes a $103 million increase to the Department of Justice’s budget to “fight against opioids and other illicit drugs”.
  • Last March, the new Attorney General said “we need to focus on…preventing people from ever taking drugs in the first place”. On May 13 he ordered federal prosecutors to utilize mandatory minimum sentencing for heroin offenses. This would “prescribe that possessing any amount of heroin would be a minimum fine of $1000 and 1 year in prison.”[7]

So far none of those initiatives sound like slam-dunk wins. Do they?

Then, of course, there are the current Congressional efforts to repeal and replace Obamacare. That effort, if successful, might throw many of the addicted into the ranks of the uninsured. “The American Society of Addiction Medicine, a professional society of physicians, warned that [if so] a ‘critical lifeline for people with addiction’ would be severed.”[8] That’s interesting, but speculative. So far Congress hasn’t really done anything. I’m going to wait until there’s actual legislation on the table before I start an argument.

Science from the NEJM

OK, from what little we know of President Trump’s program, he doesn’t seem to be counting on any scientific breakthroughs to solve the opioid problem. How about the scientists? What do they think? Well, the National Institutes of Health say that since April of this year they have been working with pharmaceutical industry in three important areas:

  • Overdose Treatment. Naloxone is good, and has saved lives, but other, more effective overdose treatments are possible. The NIH/ industry objective is to develop “better overdose-reversal and prevention” therapies[9];
  • Curing Addicts. Currently “sustained treatment over years or even a lifetime is often necessary to achieve and maintain long-term recovery.” There are only three medications available for treating Opioid Use Disorder. These are methadone, buprenorphine and extended-release naltrexone. We need more and better medicines in this area.[10]
  • Managing Pain. For many, addiction starts with opioids prescribed by a doctor to relieve chronic pain. If we develop “safe, effective, non-addictive interventions” to deal with pain, we can greatly restrict the use of opioids in medical practice. That should reduce the rate of addiction as well.[11]

The NIH expect “some advances” may occur rapidly, “such as such as improved formulations of existing medications, opioids with abuse-deterrent properties, longer-acting overdose-reversal drugs, and the repurposing of treatments approved for other conditions.[12]” Others may take longer. Nevertheless, the goal “is to cut in half the time typically required to develop new safe and effective therapeutics.”[13]

Conclusion

To date the new Administration seems to have focused primarily on law enforcement to control the opioid crisis. That’s short-sighted. Addiction is a problem for doctors and scientists, as well for the police. I’m not in a position to judge the validity of the initiatives the National Institutes of Health have proposed, but they are our experts; so perhaps we should fund their initiatives, or over-fund them if necessary, to see what they can do for us. The problem with addicts is that they’re, well, addicted. There’s no talking them out of their addiction, and locking them up doesn’t seem to be helpful. Speaking for the public, we need a damned cure!

[1] See The Lancet, Reinl, Trump administration and the opioid epidemic in the USA (June 17, 2017), available at http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31543-X/fulltext?elsca1=etoc (The proper citation for this, I think, is Reinl, Trump & Opioids at 389 World Report 2181 (June 3, 2017). We’ll just call it Trump & Opioids, until someone corrects us. To access this article [apparently] you need to register with The Lancet. Do that [it’s free] and you can download a pdf version.

[2] See New England Journal of Medicine, Volkow & Collins, The Role of Science in Addressing the Opioid Crisis (May 31, 2017), available at http://www.nejm.org/doi/full/10.1056/NEJMsr1706626#t=article There are no page numbers; henceforth we will cite this as Opioid Crisis at __ and reference the § in which the quote appears.

[3] See the President’s inauguration speech at https://www.nytimes.com/video/us/politics/100000004863342/donald-trump-full-inaugural-address-2017.html

[4] See n. 1.

[5] See n. 2.

[6] For a more full discussion of the subject, take a look at the Wikipedia entry at https://en.wikipedia.org/wiki/Opioid .

[7] All quotations are from Trump & Opioids.

[8] Id.

[9] See Opioid Crisis at Overdose-Reversal Interventions.

[10] See Opioid Crisis at Treatments for Opioid Addiction.

[11] See Opioid Crisis at Nonaddictive Treatments for Chronic Pain .

[12] See Opioid Crisis at Public-Private Partnerships.

[13] Id.

[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

 

Greetings from the heroin overdose capital of the country. I went to Home Depot yesterday to find decorations to celebrate. H.D. has its Halloween stuff out, so I settled on a 7 ft. plastic skeleton of a horse. I think it glows in the dark. “And I looked, and behold a pale horse; and his name that sat on him was Death.” [Revelations, Ch. 6, v. 8.]  No, I’m not religious, but I try to be literate.

G Sallust[1]

[Hi, this is G. Sallust, and this post no doubt is a first. First and foremost, it’s the first time anyone here has quoted himself in an introduction. You may think that’s not particularly noteworthy; in fact that it’s a ridiculous case of unbridled narcissism, common in the blogosphere; but let’s face it: I’m the only one who’s put those words to paper and they are – really – quite good. It’s also the first time I’ve used a quote within a quote, something you certainly won’t see in the traditional media. That’s a nice touch, don’t you think? And, last but not least, it’s the first time anyone here has reacted directly to local news, rather than skating over the horizon to pursue more lofty goals. Although I’ll admit today’s story will wind up in Afghanistan before we’re done.]

The quote is based on current events; a week or so ago the papers in my area were full of news about an outbreak of heroin overdoses in my state, West Virginia. One small city reported 27 deaths from overdose in just 4 hours.[2] Heroin is not one of my areas of expertise, thank God; but even I knew this wasn’t normal. So I checked into the matter, and what I found is alarming. Heroin overdose deaths are on the rise nationwide, and, while the blight is everywhere, some areas suffer more than others.  Nevertheless, the count of 27 deaths in 4 hours is spectacular; a standout in a dismal field

Overdoses Rising

The Centers for Disease Control report that, as of the end of CY 2014, “… the rate of deaths from drug overdoses [since 2000] has increased 137%, including a 200% increase in the rate of overdose deaths involving opioids (opioid pain relievers and heroin).” [3] That is:

  • Nearly half a million people in the U.S. died from drug overdoses from 2000 to 2014.
  • In 2014 more people died from drug overdoses in the U.S. than in any previous year. Drug overdoses killed approximately 1.5 times more people than motor vehicle crashes.
  • Opioids, primarily prescription pain relievers and heroin, are the main drugs associated with overdose deaths. In 2014, opioids were involved in 28,647 deaths, or 61% of all drug overdose deaths; the rate of opioid overdoses has tripled since 2000. [4]

Also the 2014 data show “two distinct but interrelated” trends: (i) a 15-year increase in overdose deaths involving prescription opioid pain relievers; and (ii) a recent surge in illicit opioid overdose deaths, driven largely by heroin.[5]

What is Heroin? What are Opioids?

That part is easy. Opioids are, simply, drugs derived from or based on opium, or synthesized to emulate opium. They include pain relievers, such as oxycodone and hydrocodone,[6] which are legal if prescribed by a physician; and heroin, which is not.[7] So why do some people chase the opioid experience? Is their pain all that bad? Not necessarily, but opioids also affect the brain regions involved in reward, and can [and apparently often do] induce euphoria.[8]

Synthetic opioids, principally fentanyl and tramadol, are a big problem today. The pharmaceutical versions can be abused, and overdose can be fatal. Additionally there’s a non-pharmaceutical version of fentanyl, manufactured in illegal laboratories that can be toxic. Taken together, overdose deaths due to legal and illegal synthetic opioids “nearly doubled between 2013 and 2014.”[9]

According to the Centers for Disease Control, people who misuse prescription opioids often graduate to heroin, in large part because heroin is cheaper and more available on the street. So it should be no surprise that heroin overdose in the U.S. is rising. “The increased availability of heroin, combined with its relatively low price (compared with diverted prescription opioids) and high purity appear to be major drivers of the upward trend in heroin use and overdose.”[10]  Unfortunately the “trend” looks more like a moonshot than a gentle rise. “Heroin overdose death rates increased by 26% from 2013 to 2014 and have more than tripled since 2010, from 1.0 per 100,000 in 2010 to 3.4 per 100,000 in 2014.”[11]

West Virginia figures[12] indicate that, at the end of 2014, the overdose death rate in the county where I live was 52.3 per 100,000[13], while the rate in the county next door was 104.6 per 100,000.[14] In short, my neighborhood far surpasses the national average. On the bright side, the city I referenced earlier [the one that lost 27 people to heroin in 4 hours] is not in my area. Those 2016 numbers will not affect our local score. Nevertheless the local news isn’t good, and I’m not optimistic for this year.

Afghanistan

If you buy heroin on the street, what actually may kill you: the heroin, or the stuff it’s mixed with? The answer may be, that either can do it. It’s thought, for example, that the heroin responsible for the 27 deaths [in 4 hours] in West Virginia might have been “laced” with something that made it more deadly than usual. The matter was being studied as of mid-August.[15] So what might that substance be? My guess is the non-pharmaceutical version of fentanyl; that’s the illegal version, made for and peddled by drug dealers, and used to give an extra boost to plain, old heroin. But we won’t really know until the toxicology reports come out.

While I don’t know much about fentanyl, or where it’s made, I do know something about heroin. It’s made from opium, which comes from poppies, which mostly are grown in Afghanistan. You remember Afghanistan, don’t you? That’s the country that hosted Osama bin Laden while he planned the [successful] attack on the original World Trade Center. That was September 11, 2001. We and NATO attacked Afghanistan in October of that year, sided with indigenous forces and chased out bin Laden, and then stuck around for years trying to “reconstruct” the country and build a modern democracy there.[16] The direct cost, to us, of that adventure so far amounts to about $686 billion, but the total costs, counting money we haven’t spent yet on wounded veterans, replacement weapons, and so forth,  may be far higher, in excess of $1  trillion.[17]

So we [and NATO] were in Afghanistan for 11 – 12 years, and probably still have forces in the area. You know, “advisors,” “special” forces and so forth. In all that time we didn’t seem to reduce Afghanistan’s opium production. Perhaps it wasn’t a priority. Perhaps it was just too hard to do. Perhaps our leaders thought it was in our interest to let all of that stuff out into the world; but why would anybody think that? Ask the White House. The people there make those kinds of decisions.

Anyway, today Afghanistan is the premier world exporter of opium. Wikipedia reports, for example, that “Afghanistan’s opium poppy production goes into more than 90% of heroin worldwide.”[18] Isn’t that interesting? I wonder, when “reconstructing” Afghanistan did we pay for new roads to carry that deadly cargo out of the country?

There’s a lot of money in legal drugs, and apparently even more in the illegal ones. I’m sure lots of people made lots of cash off of Afghan poppies while we were there. It just frosts me that so many profited while our troops fought and died there. Who thought that was a good idea? Who benefitted? Does anybody know? If not, why not? Were there “consequences” for the profiteers, or did they just get rich?

Afghanistan leads the world in opium poppy production. In many ways we made that possible. Our reward, or part of it, is that we have a flood of heroin in the world, including here. That’s no reason for us, or the world, to love the Afghan people, or their political leadership.

[1] I’m quoting myself, and more specifically words from an email I sent to an artist friend who’s currently traveling. She was in Finland at the time.

[2] See CNN, Marco, West Virginia city has 27 heroin overdoses in 4 hours (August 18, 2016), available at http://www.cnn.com/2016/08/17/health/west-virginia-city-has-27-heroin-overdoses-in-4-hours/index.html

[3] See CDC Morbidity and Mortality Weekly Report (MMWR), Rudd, et al., Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014 (Jan. 1, 2016), available at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6450a3.htm?s_cid=mm6450a3_w Henceforth I’ll refer to this report as MMWR Heroin at __.

[4] See MMWR Heroin at Discussion. Note: Pages of this document are not numbered. Subtopics will be used.

[5] Id.

[6] For a list of other legal opioids, check out WebMD, Opioid Drugs: Dosage, Side Effects, and More Opioid Drugs: Dosage, Side Effects, and More Opioid Drugs: Dosage, Side Effects, and More Opioid Drugs: Dosage, Side Effects, and MoreOpioid Drugs: Dosage, Side Effects and More, at http://www.webmd.com/pain-management/guide/narcotic-pain-medications

[7] Id.

[8] See NIH, National Institute on Drug Abuse, Prescription Drug Abuse, at How do opioids affect the brain and body? available at https://www.drugabuse.gov/publications/research-reports/prescription-drugs/opioids/how-do-opioids-affect-brain-body

[9] See MMWR Heroin at Discussion. “Toxicology tests used by coroners and medical examiners are unable to distinguish between prescription and illicit fentanyl. Based on reports from states and drug seizure data, however, a substantial portion of the increase in synthetic opioid deaths appears to be related to increased availability of illicit fentanyl (7), although this cannot be confirmed with mortality data. For example, five jurisdictions (Florida, Maryland, Maine, Ohio, and Philadelphia, Pennsylvania) that reported sharp increases in illicit fentanyl seizures, and screened persons who died from a suspected drug overdose for fentanyl, detected similarly sharp increases in fentanyl-related deaths (7).§ Finally, illicit fentanyl is often combined with heroin or sold as heroin. Illicit fentanyl might be contributing to recent increases in drug overdose deaths involving heroin. Therefore, increases in illicit fentanyl-associated deaths might represent an emerging and troubling feature of the rise in illicit opioid overdoses that has been driven by heroin.”

[10] See MMWR Heroin at Discussion.

[11] See MMWR Heroin (before the Discussion).

[12] See WV Public Radio, Mistich, Data Viz: When Did West Virginia’s Heroin Problem Begin? Which Counties Are Hurting the Most? (May 22, 2015)

[13] That’s Jefferson County, WV.

[14] That’s Berkeley County, WV.

[15] See CNN, Marco, West Virginia city has 27 heroin overdoses in 4 hours (August 18, 2016), available at http://www.cnn.com/2016/08/17/health/west-virginia-city-has-27-heroin-overdoses-in-4-hours/index.html

[16] For a good timeline, see Council on Foreign Relations, U.S. War in Afghanistan (1999 – present), available at http://www.cfr.org/afghanistan/us-war-afghanistan/p20018

[17] See Time, Thompson, The True Cost of the Afghanistan War May Surprise You (January 1, 2015), available at http://time.com/3651697/afghanistan-war-cost/ . See also Harvard Kennedy School, Bilmes, The Financial Legacy of Iraq and Afghanistan: How Wartime Spending Decisions Will Constrain Future National Security Budgets (March 2013, RWP 13-006) available at https://research.hks.harvard.edu/publications/workingpapers/citation.aspx?PubId=8956&type=WPN

[18] See the Wikipedia entry on opium production in Afghanistan, at https://en.wikipedia.org/wiki/Opium_production_in_Afghanistan