CJ Trowbridge

2020-06-16

Drugs and Society

Reaction Paper – Section 7

• inside the story of america’s 19th century opiate addiction
  • Morphine was seen as a wonder drug which could immediately ameliorate many common symptoms in the short-term
  • Morphine quickly created an addiction epidemic. By 1895, morphine addiction was commonplace in America.
    • Benjamin Franklin took opium regularly
  • During the civil war, the union issued over twelve million doses of opium to its soldiers, leading to widespread addiction
    • Doctors used opium to treat chronic pain from war wounds, so even those who came home from the war not addicted would likely become addicted later as a result
  • Opium quickly became one of the most prescribed drugs.
    • 60% of opium addicts were women. Doctors prescribed opium for many common conditions. By 1861, opium addiction became more common than all over diseases combined.
  • By 1900, germs had been discovered, and doctors began to take addiction concerns seriously, but addiction was already widespread.
  • Chinese immigrants brought traditions of smoking opium unproblematically; they had an ancient cultural knowledge of safe practices and limited opium behaviors, unlike white people who used opium to excess in an information vacuum.
  • As a result of widespread opium addiction and rising awareness of the dangers of overprescribing, doctors began cutting back on the opium prescriptions. People then began smoking it at home, and opium dens sprang up across the country.
  • Roosevelt saw an international political opportunity in opposing the opium trade in order to take power and wealth from pacific islanders and consolidate American power in The Philippines.
  • At a time when Heroin was still sold by Bayer in every drug store, authorities “responded” to the nascent crisis of white opium addiction in America by leveraging racism and ignorance to blame these white problems on Chinese immigrants and ban the smoking of opium; an unproblematic Chinese custom which was completely unrelated to issue of white addiction.
    • This led to widespread mass incarceration and laid the foundation for many future “drug bans” which were actually bans on the customs of ethnic minorities in order to facilitate mass incarceration by the white ethnostate.
  • Overnight, opium prices shot up by more than a factor of ten.
  • Because so many Americans were already addicted to opium, they responded to rising prices by seeking out stronger and more concentrated alternatives like morphine and heroin.
  • When the US first banned opium, it established nationwide narcotics clinics to treat addiction. These lasted about two years before they were closed in 1921, ending any serious attempt to address the problem of opium addiction as a public health issue.
  • Since then, pharmaceutical companies have been allowed to develop and market ever more concentrated forms of opiates, via doctors who have never learned their lesson, to an ever more opiate addicted population.
• Why are more Americans than ever dying from drug over doses
  • Overdose deaths are rising exponentially, more than doubling for both of the last two decades
  • The drugs epidemic… has spread across the whole country
  • illegal narcotics are more readily available than ever, as drug distribution networks have expanded to rural and suburban areas
  • In the 1990s, pharmaceutical companies aggressively lobbied doctors to prescribe new formulations such as OxyContin, which they falsely claimed could provide effective pain relief with no real addiction risk even to long-term patients
    • As a result, medical opioid consumption more than tripled, soaring far beyond levels seen in other countries. Today, the US medical sector ranks second in the world for opioid use behind only Canada, which is struggling with its own overdose crisis.
  • The article proposes no solution and offers no hopeful message about the situation improving in the future.
• Prescribed painkillers didn’t cause the opiate crisis
  • “A 5-sentence letter helped trigger America’s deadliest drug overdose crisis ever.” (Vox)
  • “The One-Paragraph Letter From 1980 That Fueled the Opioid Crisis” (The Atlantic)
  • “1980 NEJM Letter the Genesis of the Opioid Crisis?” (Medscape)
  • The letter in question was entitled “Addiction Rare in Patients Treated with Narcotics.” It noted that the researchers had examined records of more than 10,000 hospitalized patients treated with opioids for pain and found only four new cases of addiction.
  • The paper had no details about methodology whatsoever
  • The paper was cited over 600 times
  • citations increased dramatically at the time when the makers of Oxycontin were marketing the drug as being unlikely to cause addiction, which was no coincidence.
  • evil drug companies pushed greedy doctors to prescribe unnecessary drugs, which turned innocent pain patients into people with heroin addiction.
  • the drug companies irresponsibly and reprehensibly misused the legitimate concern that pain was being undertreated to sell massive amounts of product
  • Purdue Pharma inaccurately claimed that Oxycontin was a less addictive opioid
  • salespeople pressured many doctors into prescribing far more than made sense
  • people who developed new addictions in recent years were overwhelmingly not pain patients
    • they were mainly friends, relatives, and others to whom those pills were diverted, typically young people
  • Among the older patients, many who appeared to be newly addicted had actually relapsed or never recovered from prior addictions
  • less than a quarter of people who start misusing these drugs obtained them directly from one or multiple doctors
    • Half of new users, in fact, say they got them from a friend or relative for free
    • an early study of people being treated for Oxycontin addiction found that 77 percent of them had also taken cocaine
  • only 3.6 percent of people who misuse prescription opioids ever even try heroin.
  • This speaks to the unlikelihood that many prescription pain patients became addicted to heroin without having had a prior history of drug problems
  • The vast majority of people who use opioids do not become addicted
  • one study of more than 640,000 surgical patients who had never previously taken opioids found that few used the drugs for more than three months after recovery from surgery: rates varied from less than 0.12 percent for people who had C-sections up to 1.4 percent for those who had knee surgery
  • the idea that patients who take medications as prescribed are the cause of this problem is inaccurate
  • While the media loves to highlight “innocent victims” who became addicted through medicine, the fact is that this group is a minority. Medical use surely increased access to the drugs—but the people who got hooked tended to do so while using medication that was either prescribed for someone else or otherwise distributed illegally.
  • stop thinking that simply cutting the medical supply will work
    • People who start opioid use illegally are not going to have problems finding substitutes for prescription medications on the illicit market—indeed, shunting them away from medical sources will increase their risk of dying.
  • research finds that 67 percent of surgical patients do not take all of the opioids they are prescribed. Limiting initial prescriptions to several days with refills only as needed will help dry up this supply, with little harm to patients
  • ensuring that chronic pain patients have been given appropriate access to alternatives before starting long-term opioid use makes sense—as does making sure patients are benefiting
  • pain patients report that their doctors have either cut them of entirely or involuntarily tapered them to doses that aren’t sufficient—due to increasing scrutiny from medical boards, insurers, and police.
    • This is inhumane and does nothing to prevent addiction. In fact, more than 90 percent of all addictions start when people are in their teens or early 20s: the people we need to be most careful with when prescribing opioids are not typically older folks in chronic pain, but youth.
  • American drug policy tends to make irrational swings from being too relaxed about opioid prescribing to being too harsh.
    • Perhaps if we actually tried to understand how and why people really become addicted we could find a happy medium
  • opioid epidemic white-washed
    • Opioid-related deaths doubled between 2000 and 2015, and rose more than 20% between 2015 and 2016.
    • African American men and women, and Latino men, experienced an increase in opioid death rates from 2015 to 2016, according to the Centers for Disease Control and Prevention. At the same time, deaths among other demographic groups fell or remained the same.
      • Across Illinois, nearly one out of four opioid overdose deaths was of an African American in 2016.
      • In Chicago, nearly half of all opioid overdose deaths were of African Americans. Since African Americans account for only about 15% of the state’s population and about 32% of Chicago’s population, those statistics show that black people are dying at a disproportionately high rate.
    • this crisis has been “whitewashed,” leaving out the communities of color who have been powerfully impacted by the epidemic for decades
    • If a drug crisis is perceived to affect white Americans, it’s a public health crisis. If a drug crisis is perceived to impact African Americans, it’s a criminal justice problem.
    • The structural racism in our health and criminal justice systems has led to public policy that, again and again, pointedly targets African Americans. The false narrative continues: Blacks need – no, require – prison. There is no drug treatment that will work.
      • Examples of historically racist commentary and legislation are given
    • The failure to make this clear is not just an affront to the devastation wreaked in our communities. It also ignores this truth: In all issues, including this one, Black Lives Matter.
  • the chronic pain quandary
    • Dr Kertesz is a leading advocate against policies that call for aggressive reductions in longterm opioid prescriptions or have resulted in forced cutbacks. He argues that well-intentioned initiatives to avoid the mistakes of the past have introduced new problems. He’s warned that clinicians’ decisions are destabilizing patients’ lives and leaving them in pain — and in some cases could drive patients to obtain opioids illicitly or even take their lives.
    • Around 2015, Dr Kertesz started hearing that patients who had been taking opioid painkillers for years were being taken off their medications. Sometimes it was an aggressive reduction they weren’t on board with, sometimes it was all at once. Clinicians told patients they no longer felt comfortable treating them.
    • “I think I’m particularly provoked by situations where harm is done in the name of helping.”
    • “What really gets me is when responsible parties say we will protect you, and then they call upon us to harm people.”
    • It’s a case that Kertesz, 52, has tried to make with nuance and precision, bounded by an emphasis on the history of overprescribing and the benefits of tapering for patients for whom it works. But against a backdrop of tens of thousands of opioid overdose deaths each year and an ongoing reckoning about the roots of the opioid addiction crisis, it’s the dialectical equivalent of pinning the tail on a bucking bronco. Kertesz’s critics have questioned his motives. He’s heard he’s been called “the candyman.”
    • as doctors try to move beyond their days of overprescribing while responsibly treating chronic pain, the debate is playing out
    • as of October 20182020, 33 states had codified some prescription limits into law. Pharmacies and insurers capped prescriptions at 90 MME. Law enforcement agencies warned high prescribers.
    • Some initiatives have focused on avoiding “new starts,” not on tapering legacy patients.
    • “It is imperative that healthcare professionals and administrators realize that the Guideline does not endorse mandated involuntary dose reduction or discontinuation,” read a March letter2323 coauthored by Kertesz calling on the CDC to reiterate its recommendations were not binding. The letter continued: “Patients have endured not only unnecessary suffering, but some have turned to suicide or illicit substance use.”
      • More than 300 patient advocates and experts, including three former White House drug czars, signed it.
    • Pills that Kill
      • fentanyl is 100 times more potent than morphine
      • fentanyl is 50 times more potent than heroin
      • a single pill can kill
      • A very small amount ingested, or absorbed through the skin, can kill you
      • most people who use fentanyl don’t even know they’re taking it
        • After Prince died, investigators found pills labelled as prescription hydrocodone, but made of fentanyl, in his home, suggesting he bought them on the black market. The police concluded he died from a fatal mix of the opioid and benzodiazepine pills, a particularly dangerous combination. It is likely Prince did not even know he was taking fentanyl.
        • Jerome Butler, a former driver for Budweiser beer who was training to be a security guard, thought he was taking a prescription pill called Norco. His mother’s voice breaks as she recounts what she knows of her son’s last hours. Natasha said she was aware he used cannabis, but had no idea he was hooked on opioid painkillers. She said her son at one time had a legitimate prescription and may have become addicted that way. She has since discovered he was paying a doctor, well known for freely prescribing opioids, to provide pills.
      • The ingredients for fentanyl, on the other hand, are openly available in China and easily imported ready for manufacture. It is so much more powerful than heroin that only small quantities are needed to reach the same high. That has meant easy profits for the cartels. The Drug Enforcement Administration (DEA) has said that 1kg of heroin earns a return of around $50,000. A kilo of fentanyl brings in $1m.
      • making pills with a drug like fentanyl is a fairly exact science. A few grammes too much can kill. “It’s very lethal in very small doses,” said Morris. “Even as little as 0.25mg can be fatal. One of our labs had a dime next to 0.25mg and you could barely see it. It’s about the size of the head of a pin. Potentially that could kill you.”
      • When investigators sent counterfeit pills seized after the Sacramento poisonings for testing at the University of California, they found a wide disparity in the amount of fentanyl each contained. Some pills had as little as 0.6mg. Others were stuffed with 6.9mg of the drug, which would almost certainly be fatal
        • The DEA thinks the difference was probably the result of failing to mix the ingredients properly with other powders, which resulted in the fentanyl being distributed unevenly within a single batch of counterfeit pills
      • authorities don’t know for sure how many people fentanyl kills because of the frequency with which it is mixed with heroin, which is then registered as the cause of death
      • The DEA reported 700 fatalities from fentanyl in 2014 but said it is an underestimate, and rising. In 2012, the agency’s laboratory carried out 644 tests confirming the presence of fentanyl in drug seizures. By 2015, the number of positive tests escalated to 13,002.
      • some Mexican cartels have long relationships with legitimate Chinese firms which for years supplied precursor chemicals to make meth amphetamine.
        • Mexican cartels use ingredients from labs in China where production of fentanyl’s ingredients is legal.
      • The Wrong Way to Treat Opioid Addiction
        • Case study
          • Before Joe Thompson switched treatments for his opioid addiction, he was a devoted stay-at-home father, caring for his infant son after his wife returned to work. His recovery was aided by the anticraving medication buprenorphine. But after over two years free of heroin, Mr. Thompson, a former United Parcel Service worker from Iowa, relapsed and decided to try another kind of treatment program. Unfortunately, his new counselors insisted that continuing his buprenorphine, though it was approved by the Food and Drug Administration, was just as bad as using heroin, according to his wife, Deborah. He wasn’t even allowed to start therapy until he’d been abstinent for several weeks. Stressed by withdrawal, he went to a third center. It, too, banned medication. Within a week of entering the program, he was dead from a heroin overdose. He was 35.
        • Buprenorphine is one of only two treatments proven to cut the death rate from opioid addiction by half or more.
          • The programs Mr. Thompson tried viewed abstinence as the only true recovery — even though abstinence treatment has not been shown to reduce mortality and is less effective than medication at preventing relapse.
        • Only about one-third of American addiction programs offer what many experts worldwide see as the standard of care — long-term use of either methadone or buprenorphine.
        • This widespread rejection of proven addiction medications is the single biggest obstacle to ending the overdose epidemic.
          • Funding isn’t the barrier: Outpatient medication treatment is both more effective and significantly cheaper than adding inpatient beds at rehabilitation centers.
          • The problem is an outdated ideology that views needing a medication to function as a form of addiction.
        • Rather than defining addiction as destructive, compulsive behavior, this ideology focuses on physical dependence. If you need a drug to avoid being physically ill, you are considered addicted. So Prozac would be considered addictive, but not cocaine, because quitting Prozac abruptly can cause flulike symptoms while stopping cocaine doesn’t, even though it elicits extreme craving.
        • both the National Institute on Drug Abuse and the Diagnostic and Statistical Manual of Mental Disorders reject the idea that addiction is synonymous with dependence. Unfortunately, many clinicians, including doctors, haven’t caught up.
        • What is addiction, then? The root problem is craving, which drives a compulsion to use drugs despite the harm they cause. That’s what makes crack addictive, while Prozac can be therapeutic.
        • Because methadone and buprenorphine are opioids themselves, it’s easy to assume that using them is “substituting one addiction for another.” However, the pattern of taking the same dose every day at the same time means that there is no high or intoxication. Patients on maintenance doses are able to nurture a baby, drive, work and be a loving spouse.
        • we need to publicly recognize that recovery on medication is every bit as valid as any other treatment. What matters is whether, as Freud put it, you can love and work, not the chemical content of your brain or urine.
      • east bay doctors treat heroin users on the street
        • A veteran and his wife who are both homeless and addicted to heroin are being treated by the Oakland Street Team with suboxone or buprenorphine.
          • They haven’t used in a month
          • This drug blocks cravings and withdrawals
          • The street team arrives at the homeless encampments and doctors prescribe and treat patients on the spot
        • Studies conducted since the national opioid epidemic started claiming record numbers of lives show people who take buprenorphine and other similar medications are less likely to die from overdoses and more likely to stay in treatment
        • Doctors require at least eight hours of special training to prescribe buprenorphine, and in Contra Costa County, where Morris was fortunate enough to land a prescription, only about 3 percent of providers are licensed to write them, a figure roughly 2 percentage points below the national average.
        • A county civil grand jury last May concluded that there were not enough treatment options of any kind available for opioid addiction.
          • “There is a need for on-demand treatment, but delays in access to medical care result in missed opportunities to reduce harm, aid recovery, and prevent overdose deaths,” the report read.
        • Dr Mega leads the Oakland Street Team which attempts to meet some of the unmet needs for the homeless population
          • “If you create multiple barriers to accessing something, they’re just going to say, ‘Forget it, I can’t do this,’”
        • Once users receive prescriptions, they can pick up their medicine at any local pharmacy. Mega’s street medicine team has prescribed Suboxone to 58 people on the streets in the past year. The program has a nearly 45 percent retention rate — defined as the percentage of patients who went on to receive at least three prescriptions.
        • “We’ve been trained in medical school for a long time that opioid withdrawal is not dangerous in the sense that it won’t kill people,” Mega said. “But what happens after the withdrawal can be dangerous.”
          • The physiological effects of withdrawal are agonizing and compel some patients to leave the emergency room to find more heroin before they’re discharged, he said. So many people have died from opioid overdoses that by 2017, there was a decline in overall life expectancy.
          • only about 30 jails or prisons across the country widely offer Suboxone or methadone, according to U.S. Justice Department data. Yet research shows the consequences of not providing such treatment can be especially deadly. One 2018 study showed that people in custody are 40 times more likely than the general population to overdose after they’re released.
          • “People come into jail, quit cold turkey, and their cravings are increasing because they are addicted and their brain chemistry has changed,” said Jessica Hamilton, lead physician for Contra Costa County’s Detention Health Services. “When they are released, people often go back to the similar amount they were using and die.”
        • “What am I supposed to tell my patients? Die more slowly, be a little more sick?” Stalcup said. “We’re at a point in medical history where we have a clearly life-saving medication that people can’t get.”
      • Afghan Taliban Awash in Heroin Cash
        • Afghan police and American Special Forces keep running into heroin refining operations all over Afghanistan
        • the labs’ proliferation is one of the most troubling turns yet in the long struggle to end the Taliban insurgency.
        • the country has consistently produced about 85 percent of the world’s opium, despite more than $8 billion spent by the United States alone to fight it over the years
        • Various police forces bear the brunt of the drug war in Afghanistan, but are often complicit in the opium trade themselves, feeding corrupt networks within the Afghan government, both locally and nationally
        • A senior counternarcotics official in Kabul, who spoke on condition of anonymity to avoid reprisals, recounted how the elite unit was painstakingly following a network of money launderers in one opium-rich province who were helping to import the chemicals needed for refining heroin. The officers finally had enough evidence to make a high-level arrest, nabbing one of the network’s leaders — only to lose him when a powerful police commander personally stepped in to set the suspect free.
        • the small National Interdiction Unit, sequestered in a secure mountainside base in Kabul, has been one of the surest bets in striking against the opium and heroin networks.
          • Its top commander was replaced recently for failing a polygraph test and “was probably leaking information to hostile forces,” according to a report by the U.S. Special Inspector General for Afghanistan Reconstruction.
        • “The Taliban derives its funding from the narcotics taxing, sales and trafficking,”
        • elite forces and their American advisers, often flying up to six helicopters from Kabul, operate at night. They land miles away from the target to avoid fire, and then make their way by foot. The raids rarely, if ever, result in arrests; the suspects often flee as soon as they hear the motors
      • An Opioid Popularized by a Nazi Doctor is Ravaging Africa
        • Many Africans have become dependent on a pain pill called tramadol, which is milder than Oxycontin, though it can still get users quite high.
        • The opioids of abuse in America are highly regulated, but in Africa nearly anyone can get tramadol—and not just from street hawkers, but from legitimate pharmacists.
          • In Africa, the affected population are largely children.
        • The former director of the drug enforcement agency in Nigeria estimated in 2016 that seven in ten boys in northern states were abusing drugs like tramadol.
        • Nigeria is by far Africa’s most populous country, and the problem is particularly acute there. “About three years ago I started noticing that a lot of people would ADVERTISEMENT come and ask for it without prescription, especially young people, young boys and girls,” Oluwatosin Fatungase, a Nigerian pharmacist and youth counselor, told VICE. “I was wondering, ‘Why is everybody coming to look for tramadol?’”
          • pills of tramadol—which are made by the boatload in Indian factories and distributed in Africa through both legal and illegal channels—are incredibly cheap, roughly 30 cents for a pack of ten
        • Kids like them because they’re discreet (no smoking required), and can be taken between classes. “When you ask young people why they take it, they say ‘to get high,’ or ‘it makes me work longer,’ or ‘I can have sex for many hours,’” Fatungase told VICE. “But they are not looking at the side effects. They go into a coma and they die. It’s really alarming and heartbreaking.”
        • “Scheduling of tramadol in Africa would probably have a very limited impact on use, but create a huge and uncontrollable black market for the substance, and would most probably have a significant impact on the availability of tramadol for medical purposes.”