12/12/17

Greed with OxyContin is NOT Good

© Linda Bucklin | 123rf.com

The health insurer Cigna announced that effective January 1, 2018, it will no longer cover OxyContin as a preferred medication. The company is in the process of notifying customers with current OxyContin prescriptions and their doctors of the upcoming change. Individuals who have begun using OxyContin for hospice care or cancer treatments will continue to be covered through 2018. If a doctor believes the use of OxyContin is medically necessary, Cigna will consider approving coverage. Needless to say, Purdue Pharmacy, the manufacturer of OxyContin, disagrees with the Cigna decision.

Cigna will offer an oxycodone equivalent medication with abuse deterrent properties, Xtampza ER with Collegium Pharmaceuticals. Collegium signed a “value-based contract” with Cigna, which will hold the company financially accountable if average daily dosage strengths of Xtampza ER prescribed for Cigna customers exceed a specific threshold. If the threshold is exceeded, Collegium will reduce the cost of the medication. “Linking financial terms to dosage metrics may encourage more education to prevent overprescribing.”

The Fix reported a Purdue spokesperson said there were few differences between OxyContin and Xtampza ER. “Unfortunately, Cigna’s decision limits the tools prescribers can use to help address the opioid crisis as both products are formulated with properties designed to deter abuse.” Cigna responded by saying the point is to change prescription practices. “The insurer hopes that doctors will begin to prescribe drugs like Xtampza ER ‘in lesser quantities and for lesser amounts of time.’”

Cigna’s decision comes in the midst of increasing pressure on Purdue Pharmacy for their aggressive, and at times illegal marketing practices of OxyContin. The pharmaceutical company came under scrutiny partly because of a series of investigative reports by the LA Times that noted a series of issues. The issues including how Purdue Pharma knew pain relief with OxyContin did not last the 12 hours as it claimed; but the company continued to insist the drug did last, in part, to protect its revenue. When doctors complained about the duration, Purdue instructed them to prescribe stronger, not more frequent doses. “OxyContin’s market dominance and premium price hinge on its 12-hour duration.” Purdue allegedly knew of this issue for more than twenty years.

For years, Purdue Pharma lied to federal regulators and the public about the addictiveness of OxyContin and countless patients got hooked on this deadly painkiller. We need to know if Purdue once again lied about the longevity of OxyContin’s pain-relieving properties and hold Purdue accountable.

Additionally, Purdue knew OxyContin was being overprescribed and illegally trafficked, but in many cases, did nothing about it. With one such operation, Lake Medical, Purdue did not stop supplying OxyContin and did not tell authorities what it knew for several years until the clinic was out of business and its leader indicted. By that time, 1.1 million pills has been put on the street.

A Los Angeles Times investigation found that, for more than a decade, Purdue collected extensive evidence suggesting illegal trafficking of OxyContin and, in many cases, did not share it with law enforcement or cut off the flow of pills. A former Purdue executive, who monitored pharmacies for criminal activity, acknowledged that even when the company had evidence pharmacies were colluding with drug dealers, it did not stop supplying distributors selling to those stores.

In 2015 Kentucky received $24 million from Purdue to settle the state’s 2007 against the company over their allegedly illegal promotion of OxyContin. As is usual in cases where pharmaceutical companies settle outside of court, they requested the records gathered in the court case be sealed and destroyed. In this case, there were 17 million pages of documents, including a deposition of Dr. Richard Sackler, the former president of Purdue Pharma and a member of the family who owns the privately held company. As part of the agreement, the Kentucky attorney general destroyed its copies of the documents provided by Purdue. However, copies of several key documents, including the Sackett deposition, filed under seal at the Pike County court, were not destroyed.

STAT News learned of the existence of these documents and filed a motion in March of 2016 to unseal the documents. In May of 2016 a Kentucky judge ordered that the documents be unsealed by June 12th. The judge said he would stay the release of the records if there was an appeal filed before then.  As of June of 2017, the documents were still not released. Purdue appealed the ruling to the Kentucky Court of appeals and although the appeals court said it expected to rule on the matter by the end of August, there was still no announcement by the middle of October.

The President of the Kentucky state Senate planned to file a motion to support the efforts by STAT to unseal the documents, saying that shielding the records from public view was “inappropriate.” He acknowledged his request to intervene could be unsuccessful, and it seems that it was. He thought the documents could help evaluate whether the $24 million payment from Purdue was a good settlement for Kentucky. “Two prior attorneys general valued the case at between $100 million and $1 billion.” Senate President Robert Stivers was concerned the state settled for “pennies on the dollar.”

Purdue was already pivoting to go overseas with its marketing strategy by 2011. With the growing concern over the opioid crisis in the U.S. and the awareness of the role OxyContin played in it, prescriptions fell by almost 40% since 2010, meaning billions in lost revenue for Purdue. Again, the LA Times documented this market expansion by Purdue in a December 2016 article, “OxyContin Goes Global.” Using a network of international companies owned by the Sackler family, Purdue Pharma is moving rapidly into Latin America, Asia, the Middle East, Africa and other regions. “In this global drive, the companies known as Mundipharma, are using some of the same controversial marketing practices that made OxyContin a pharmaceutical blockbuster in the U.S.”

In 2011, operations were started in China, Russia, Turkey, Hong Kong and South Africa. 2013 saw activity in Indonesia, Vietnam, Thailand and Taiwan. Dubai, Brazil, Columbia and Spain came on board in 2014. Lebanon and Portugal opened operations in 2015; Argentina in 2016. Chile, Ecuador, Peru, Uruguay and Venezuela plan to launch operations in the near future.  There is an interactive map on “OxyContin Goes Global” that graphically illustrates this expansion.

In Brazil, China and elsewhere, the companies are running training seminars where doctors are urged to overcome “opiophobia” and prescribe painkillers. They are sponsoring public awareness campaigns that encourage people to seek medical treatment for chronic pain. They are even offering patient discounts to make prescription opioids more affordable.

Like the initial marketing of OxyContin in the U. S., some Mundipharma representatives and promotional material minimize the risks that patients will become addicted to opioid medications. While U.S. public health officials were warning of the growing pain killer threat in 2015, a Mundipharma executive in Seoul South Korea was saying doctors there worry too much about addiction: “Many studies have shown that it’s almost impossible for those with chronic or severe pain to become addicted to narcotics, as long as the drug is used for pain relief.” The opioid problem in the U.S. is said to be largely due to recreational abuse of the drugs.

“That is exactly the same thing they were teaching U.S. physicians when they launched OxyContin in this country,” said Sharon Walsh, an addiction expert who advises the FDA on risks from pain medications.

Mundipharma uses consultants (referred to as thought leaders in the U.S.), as did Purdue and other pharma companies, to overcome this opiophobia among doctors reluctant to prescribe narcotics. Top company officials have said their success in new markets depends on defeating this mind-set.

In Spain, Mundipharma used a series of actors, musicians and models in a campaign against chronic pain. “Ebélate contra el dolor (Rebel against the pain).” The ads did not recommend a specific medication, but urged viewers to seek out a healthcare professional (call your doctor?).  “The campaign is part of a strategy to redefine back pain, joint aches and other common conditions as a distinct malady — chronic pain — that doctors and patients should take seriously.” Mundipharma sales were up seven-fold since 2007.

Around the world, Mundipharma companies cite statistics suggesting there is a great unmet need for their products. Opening an office in Mexico in 2014, Mundipharma officials declared that 28 million citizens were suffering from chronic pain. In Brazil, the company cited a figure of 80 million. In Colombia last year, a company news release said 47% of the population — about 22 million people — were afflicted by ‘this silent epidemic.’”

Meanwhile, back in the US, the lawsuits against Purdue Pharma just keep on coming. In May of 2017 the NYT reported Purdue and three current and former executives pleaded guilty in federal court to criminal charges “that they misled regulators, doctors and patients” about the drug’s addiction risk and potential for abuse. In order to resolve criminal and civil charges stemming from the drug’s “misbranding,” Purdue agreed to pay $600 million, one of the largest amount ever paid by a drug company in such cases. Three executives, including its president and its top lawyer pleaded guilty as individuals to misbranding, which is a criminal violation. “They agreed to pay a total of $34.5 million in fines.”

Purdue Pharma acknowledged in the court proceeding today that “with the intent to defraud or mislead,” it marketed and promoted OxyContin as a drug that was less addictive, less subject to abuse and less likely to cause other narcotic side effects than other pain medications.

Reuters reported that New Hampshire announced in the beginning of August of 2017 that it was suing Purdue for engaging in deceptive marketing practices. The lawsuit followed similar cases against Purdue and other pharmaceutical companies by Oklahoma, Mississippi, Ohio and Missouri and several cities and counties in California, Illinois, Ohio, Oregon, Tennessee and New York.

A week later, South Carolina filed suit against Purdue Pharma, according to Reuters. Again the company is accused of unfair and deceptive marketing of opioid painkillers. South Carolina had been part of a 2007 settlement when Purdue and three executives pleaded guilty to federal charges of misbranding OxyContin. In the August 2017 lawsuit, “South Carolina claimed that since the 2007 settlement, Purdue has continued to engage in misleading opioid marketing practices rather than reforming them to conform with the law.”

In the 1987 movie Wall Street, Michael Douglas as Gordon Gekko famously said, “Greed, for lack of a better word, is good.”  He went on to claim that greed captured the essence of the evolutionary spirit. “In all of its forms; greed for life, for money, for love, knowledge has marked the upward surge of mankind.” At the end of his speech, he was applauded. The greed of Purdue Pharma and the Sackett family, which privately owns Purdue Pharma and OxyContin, is not good. Their unrestrained greed has contributed to the current opioid epidemic in the U.S., despite the denials of the company. And now they want to export the same drug and marketing strategy to the world.

12/1/17

Snorting Chocolate

© deandrobot |stockfresh.com

You probably won’t see any of this product in your kids Trick or Treat stash, but keep a lookout for a tin of Coco Loko in their rooms just in case. Yes, you read that correctly. Coco Loko is snortable chocolate powder. Marketed by Legal Lean, the Florida-based company founded by Nick Anderson, Coco Loko is the first product of its kind in the US. Similar products have been available in Europe for several years. After ordering and trying one, Anderson decided to create his own “raw cacao snuff.” So he invested $10,000 with an Orlando-based supplement company and created Coco Loko.

The Washington Post quoted Anderson as saying the effect is “almost like an energy-drink feeling, like you’re euphoric but also motivated to get things done.” He said he uses his product as an alternative to drinking and at music festivals and in “those types of social situations when you feel anxious.” Rolling Stone reported that Coco Loko promised a “30-minute buzz,” that would lift moods, reduce anxiety and give you a surge of energy. “Legal Lean claims Coco Loko will cause a rush of endorphins and serotonin, boost energy, and bring about a sense of calm. But the company hasn’t provided concrete research to back up those claims.”

However, the company website now refers to its product as “Coco Snuff” and the overt claims noted in Rolling Stone and other media write ups just after its release and attributed to Legal Lean are now not directly attributed to Coco Loko/Coco Snuff. Legal Lean makes no such claims anymore about Coco Snuff. You learn about endorphins, that a serotonin rush produces “an elevated mood and a state similar to the feeling of ecstasy [not the drug ecstasy]. This is the feeling that will make the music sound better and overall happiness.” Gee, isn’t that why the drug ecstasy was used at raves?

Raw cacao is said to give you a steady rush of euphoric energy that helps party goers “Dance the nigh away without a crash.” Then it claims raw cacao can give you a “calm focus,” reducing the chatter in your brain. “It is also known to help with anxiety and to reduce stress.”

The revisions to product description are likely the result of action taken by Senator Chuck Schumer where he called on the FDA to formally launch an investigation into “Coco Loko.” He said the product was a “brazen example of ‘narcotic marketing.’” He said it was like cocaine on training wheels. Schumer, The Washington Post and others (like The Fix) have reported it contains caffeine, guarana and taurine, which are ingredients commonly found in energy drinks. You won’t find that information on their website.

This suspect product has no clear health value. It is falsely held up to be chocolate, when it is a powerful stimulant. And they market it like a drug – and they tell users to take it like a drug, by snorting it. It is crystal clear that the FDA needs to wake up and launch a formal investigation into so-called Coco Loko before too many of our young people are damaged by it. ‘Coco Loko’ isn’t even pure chocolate at all. Instead, it is chock full of concentrated energy drink ingredients masked and marketed under the innocence of natural and safe chocolate candy. Parents and doctors don’t want kids snorting anything at all, especially not dangerous stimulants proven to wreak havoc on the bodies and brains of young kids and teens. That’s why the FDA must formally investigate this dangerous ‘party goer’ fad before it hurts our kids, not after.

The Washington Post reported in July of 2017 the FDA had not decided on how or whether to regulate the product. An FDA spokesperson said: “In reaching that decision, FDA will need to evaluate the product labeling, marketing information, and/or any other information pertaining to the product’s intended use.” Thus the changes in product effects on the website. The company is trying to keep under the FDA’s radar A representative for the DEA said he was not aware of any agency concerns with chocolate inhalants. According to reports mentioned by Schumer, the Legal Lean said the effects were “equal to about two energy drinks.”

Anderson said he didn’t consult any medical professionals when he created Coco Loko, “nor have scientists tested the snortable snuff before it was released to the public,” according to Rolling Stone. A company spokesperson said they used research data on the market in Europe. “There are no health issues … everyone seems fine. . . . It says not to do more than half the container, I think everything is self-explanatory, there are warning labels on it and I don’t think I would be responsible.”

There have been previous concerns raised about the health effects of energy drinks containing the ingredients reported to be in Coco Loko— caffeine, taurine and guarana. There can be increased blood pressure or heart palpitations. Those effects could be magnified when someone inhales these stimulants. The director for the John Hopkins Sinus Center said as yet, there is no data reported on health consequences, but he did have a few concerns.

First, it’s not clear how much of each ingredient would be absorbed into the nasal mucus membranes. And, well, putting solid material into your nose — you could imagine it getting stuck in there, or the chocolate mixing with your mucus to create a paste that could block your sinuses.

Another sinus specialist, Dr. Jordan Josephson, said you could expect more pulmonary problems like asthma or bronchitis. Blocked sinuses could lead to snoring and even sleep apnea, which in some cases could be fatal. There are multiple social media and online reports of trying snortable chocolate products like Coco Loko.

Hopefully, this product will go the way of Palcohol, a powered alcohol product that Senator Schumer took on in 2015. As with Coco Loko, his concern was it would be marketed to teens. One of the voiced concerns then was that powered alcohol could be snorted. According to The Hill, the manufacturer of Palcohol fought back by saying: “Listen, people can snort black pepper … so do we ban it? No, just because a few goofballs use a product irresponsibly doesn’t mean you ban it.” The company reported that although its product was approved on March 10, 2015 for legal sale in the US, it would not be manufacturing Palcohol. Rather, it would be “auctioning off the secret formula and manufacturing process.” Let’s hope Coco Loko ends up with a similar fate. For more on Palcohol, see: “Hype Over Powered Alcohol” or “Down For The Count?”

11/21/17

Cunning, Baffling, Powerful

© Nico Smit | 123rf.com

Vincent Dole was one of the three physicians who originated methadone as a maintenance drug treatment for heroin addiction in the 1960s. Rather unexpectedly, he was asked to serve as a Class A, non-alcoholic, trustee for the General Service Board of Alcoholics Anonymous. He thought they had made a mistake so before accepting the position, he discussed his research into “chemotherapy for narcotic addiction” with executives of the A.A. Fellowship. They didn’t see any problem or conflict of interest with his appointment and Dr. Dole served as a trustee for A.A. for eleven years, from April of 1965 until April of 1975.

At one point in his tenure as a trustee, he served as a co-chair for the General Service Board. In his farewell letter to the A.A. GSO, printed in the August-September issue of Box 4-5-9, the newsletter from the General Service Office of A.A., he said he would always remain identified with A.A. “My heart is with the Fellowship.”

Like most in A.A., I have gained more in the association than I have been able to give. Especially, it has been a privilege to witness the power of love when focused and unsentimental. I have seen that: Salvation is found in helping others; help stems from knowledge, humility, compassion, and toughness; success is possible.My greatest concern for the future of A.A. is that the principle of personal service might be eroded by money and professionalism. Fortunately, most of the membership of A.A., especially the oldtimers, know that A.A. cannot be commercialized. It is not a trade union of professional counselors or an agency hustling for a budget. The mysterious wisdom of A.A. will discover how to cooperate in reaching out to sick alcoholics while maintaining its Traditions.

In a 1991 article he wrote for the journal Alcoholism, “Addiction as a Public Health Problem,” Dr. Dole said that throughout his time as a trustee he was puzzled by why he specifically was asked to serve. He ended by assuming he had been “brought in as a smoke alarm, a canary in the mine” to guard against “the Fellowship being distorted by aggressive person with dogmatic opinions.” Then, in the late 1960s, he believed a more specific reason emerged, not long before Bill W.’s death. An excerpt from that article is available here: “The Methadone/AA Link.”

A more specific answer, however, emerged in the late 1960s, not long before Bill’s death. At the last trustee meeting that we both attended, he spoke to me of his deep concern for the alcoholics who are not reached by AA, and for those who enter and drop out and never return. Always the good shepherd, he was thinking about the many sheep who are lost in the dark world of alcoholism. He suggested that in my future research I should look for an analogue of methadone, a medicine that would relieve the alcoholic’s sometimes irresistible craving and enable him to continue his progress in AA toward social and emotional recovery, following the Twelve Steps. I was moved by his concern, and in fact subsequently undertook such a study.

Dr. Dole went on to say he unsuccessfully sought to find that analogue in his laboratory until it closed in 1991. But he thought the work had just begun. Other laboratories and investigators would continue to work on the analogue problem. “With the rapid advance in neurosciences, I believe that Bill’s vision of adjunctive chemotherapy for alcoholics will be realized in the coming decade.”

Since Dr. Dole made that optimistic prediction, several different medications have been used as a harm reduction strategy for individuals with alcohol dependence or alcohol use disorders. Two opioid antagonists, nalmefene and naltrexone and three drugs acting on the gamma-aminobutyric acid (GABA)ergic system (baclofen, acamprosate and toprimate) has been used formally or informally to reduce alcohol consumption or maintain abstinence. Recently in the journal Addiction, Palpacuer et al. did a meta-analysis of 32 double-blind randomized controlled trials of these five medications. The studies were published between 1994 and 2015, and had a combination of 6,036 patients between them. They concluded:

There is currently no high-grade evidence for pharmacological treatment to control drinking using nalmefene, naltrexone, acamprosate, baclofen or topiramate in patients with alcohol dependence or alcohol use disorder. Some treatments show low to medium efficacy in reducing drinking across a range of studies with a high risk of bias. None demonstrates any benefit on health outcomes.

There was no evidence of any significant reduction in serious adverse events or mortality. Studies that sought to assess the efficacy of these medications as maintenance drugs, similar to how methadone is used, “were inadequate to investigate” whether they reduced serious adverse events. “In addition, any pharmacological approach that might benefit patients by reducing their alcohol consumption might also harm them because of safety issues.” As a result, the researchers advocated for long-term mega-trials exploring health outcomes.

To conclude, our results suggest that no treatment currently has high-grade evidence for pharmacologically controlled drinking in the treatment of patients suffering from alcohol dependence or alcohol use disorders. At best, some showed low to medium efficacy in reducing drinking, but across a range of studies with a high risk of bias. Although based on all available data in the public domain, this meta-analysis found no evidence of any benefit of the use of drugs aiming for a controlled drinking strategy on health outcomes. We invite researchers and stakeholders to set up a coherent agenda to demonstrate that pharmacologically controlled drinking can be translated into genuine harm reduction for patients. From the clinical perspective, while this new approach is often presented as a ‘paradigm shift’ in terms of therapeutics, doctors and patients should be informed that the critical examination of the pros and cons of the evidence clearly questions the current guidelines that promote drugs in this indication.

Reporting for The Guardian, Sarah Boseley further noted that one of the reasons for the inconclusive findings in Palpacuer et al. was because of the high drop out rates in the studies. “So many people dropped out of the trials that 26 of the 32 studies – 81% of them – had unclear or incomplete outcome data.” The lead author for the study, Clément Palpacuer, said the report did not mean the drugs weren’t effective. “It means we don’t yet know if they are effective. To know that, we need more studies.” There have also been concerns raised about the drugs by some studies already.

Bosley cited Fitzgerald et al., a review of the trial evidence used to approve nalmefene for use in the NHS. The researchers said at best, there was only modest evidence of efficacy in reducing alcohol consumption. This was despite stacking the deck in how the data was analyzed for approval of the drug.

Important weaknesses in nalmefene trial registration, design, analysis and reporting hamper efforts to understand if and how it can contribute to treating alcohol problems in general practice or elsewhere. The efficacy of nalmefene appears uncertain; a judgement of possible limited efficacy in an unusually defined and highly specific posthoc subgroup should not provide the basis for licensing or recommending a drug.

There are issues noted with baclofen as well. A co-author of Fitzgerald et al. noted one French study raised concerns with the safety of baclofen, with more deaths in the treatment group (7 of 162) than the placebo group (3 of 158). A further study by France’s medicines safety agency drew attention to additional adverse effects: “In particular, the risk of intoxication, epilepsy and unexplained death [on the death certificate] increases with the dosage of baclofen.” See “Sure Cure for Drunkenness” and “A ‘Cure’ for Alcoholism” and “The End of Alcoholism?” Part 1, Part 2 and Part 3 for more concerns with baclofen and nalmefene.

Vincent Dole’s search for a methadone analogue or adjunctive chemotherapy for alcoholism is unlikely to be successful. As Carleton Erickson pointed out in The Science of Addiction, alcohol is different than other drugs. He said: “Unlike other drugs, alcohol has no specific receptor to activate in the brain.” Cocaine works on the dopamine transporter. Heroin and other opioids work on the opioid receptor; and marijuana works on the cannabinoid receptor. “Alcohol is known to affect the GABA receptor, the NMDA receptor, and probably others.”

There isn’t a hand-in-glove fit between a receptor and alcohol as there is with the opioid receptor and heroin or other opioids. So there isn’t a medication that can single handedly block alcohol as there is with heroin and other opioids. As Bill W. knew from personal experience, alcohol is cunning, baffling and powerful.

11/10/17

Here’s Some Gray Death

© Artlover | stockfresh.com

The fact-checking website Snopes looked into a report from Indiana claiming there is a new and dangerous drug called “Gray Death.” The report claimed Gray Death could cause the overdose or death of a drug user if it was accidentally inhaled after it became airborne or if it was absorbed through the skin after contact. Their investigation found the report was true.  A local Indiana TV station, WDRB, was the source for the Snopes investigation, saying the Indiana Department of Homeland Security announced Gray Death was found in the Hoosier state beginning in May of 2017. But it seems Indiana was late to the Gray Death party.

Gray Death is a drug cocktail of heroin, fentanyl, carfentanl, and often U-47700 known on the street as “Pink” or “U4.” Heroin is two to three times as powerful as morphine. Fentanyl is about 50 to 100 times more powerful than heroin. Carfentil is about 100 times more powerful than fentanyl. U4 is the weakest drug in the mix after heroin, at only 7. 5 times the strength of morphine. The drug cocktail looks like concrete mix, thus the nickname of gray death.

Russ Baer of the DEA told NBC News on May 5, 2017 that Gray Death was initially limited to the Gulf Coast and states like Georgia and the mid-West state of Ohio. But it’s also been spotted in places like Chicago, San Diego, and Lexington. A “Pink”-free precursor to Gray Death was spotted in the Atlanta area back in 2012. “We are more routinely seeing deadly cocktails of heroin, fentanyl, various fentanyl-class substances, along with combinations of other controlled substances of varying potencies including cocaine, methamphetamine, and THC. . . . No one should underestimate the deadly nature associated with these cocktails.”

CNN noted that not only do the ingredients of Gray Death vary from sample to sample, some are present in such low concentrations (because of their strength) they may not show up on tests. Donna Ula, director of forensic chemistry at a biochemical company working with state and federal officials to identify unknown street drugs, said “It’s going to constantly vary, and it’s going to keep the chemists and the medical examiners on their toes.” She said Gray Death is “a fast-track route to the morgue.” A forensic chemist with the Georgia Bureau of investigation said even its gray color is a mysterious. “Nothing in and of itself should be that color.”

There have been several overdoses and overdose-related deaths in Georgia and Alabama linked to Gray Death. The Georgia Bureau of Investigation issued a public safety alert on May 4, 2017 about illegal synthetic opioids (Gray Death). The GBI Crime Lab has received about 50 cases of suspected Gray Death this year. Many contain three or four different opioids. One Metro-Atlanta law enforcement agency seized around 8 kilograms of a substance that when field-tested, didn’t identify what the mixture was. Further analysis at the GBI Lab found furanyl fentanyl and U-47700, two of the opioids regularly found in the Georgia Gray Death cocktail.

On May 10, 2017 The Morning Call reported there is Gray Death in the Lehigh Valley of Pennsylvania. After making two undercover drug buys at a woman’s home in Bethlehem PA, investigators had the drug packets tested because of their off-white color. They suspected they might contain fentanyl.  But the preliminary results showed the packets contained a mixture of heroin, fentanyl and U4—Gray Death. After the preliminary identification, a search warrant was quickly issued: “We wanted to get it off the street as fast as possible.”

The woman’s three children, between the ages of 3 and 9, were living in the home with their mother. Police found some of the drug in a cup sitting on the shelf of a kitchen cabinet” within east reach of the children. The woman was arrested and charged with endangering the welfare of children, drug possession and possession of drug paraphernalia. She was freed after posting $5,000 bail. No word was reported on the children, but they were likely not in their mother’s custody given her charges.

According to Healthline News, the combination of synthetic opioids and/or heroin making up Gray Death varies widely. Given that the drugs or their precursors are created in unregulated labs, domestic drug dealers don’t always know how strong a batch is. “The potency can change from one batch to the next.” Dr. Seonaid Nolan, a clinical scientist in addiction medication at the University of British Columbia said: “Because it’s so potent, a small misstep in the preparation of the drug can lead to lethal consequences.”

This high potency also means it’s more difficult for customs and law enforcement to make searches and seizures, as it allows the drug syndicates to ship less physical product across the border. Sometimes the drugs are even shipped directly through the postal system. “Drug traffickers can move a high quantity or high volume of the product in a fairly small package.”

Traditional opiates like heroin are derived from the poppy plant, meaning the poppy plants have to be grown, harvested and then processed before heroin can be manufactured. “However, synthetic opioids can be produced entirely from chemical precursors.” This makes their production much simpler than heroin, since the entire manufacturing process can be done in a lab.

Fentanyl and its analogues have a high lipid solubility, meaning they readily pass through fatty tissues in the body. So fentanyl is used in transdermal patches and even lollipops, allowing it to enter the blood stream without having to be digested in the stomach. Since it doesn’t get metabolized, you need smaller amounts of fentanyl because it can go directly to the brain through the blood system. This also explains its danger if it becomes airborne or comes in contact with exposed skin. Edward Bilsky, a professor of Biomedical Sciences at Pacific Northwest University said:

[These drugs] are very fast acting and produce profound depression of respiration and other central nervous system functions leading to many deaths. . . . First responders and others around the victim need to be careful due to secondary exposure.

According to the DEA, fentanyl analogs, like acetyl fentanyl and furanyl fentanyl are manufactured in China by clandestine labs, and then smuggled into the U.S. through established drug smuggling routes in Mexico. Mexican drug traffickers also manufacture their own analogs of fentanyl. In the past, the Chinese government denied they were the source of illicit fentanyl being smuggled into the U.S. But DEA officials and others met with Chinese officials in 2016, which prompted China to regulate four fentanyl-related substances in an effort to help stem the flow of these opioids into the U.S. in action that went into effect in March of 2017.

Carfentanil was one of these substances. Because of its off-the-charts strength, it was receiving a lot of press coverage in 2016. See “Fentanyl: Fraud and Fatality” and “The Devil in Ohio.” But unless you followed news on the death of Prince, you may not have heard of “Pink” (U-47700 or U4) before. In addition to fentanyl and Percocet (oxycodone-acetaminophen), Pink was found in his system. In November of 2016, the DEA temporarily classified U-47700 as a Schedule I controlled substance, due to its “immanent threat to public health and safety.” The DEA received at least 46 confirmed reports of deaths associated with U-47700—31 in the state of New York and 10 in North Carolina. “This scheduling action will last for 24 months, with a possible 12-month extension if DEA needs more data to determine whether it should be permanently scheduled.”

In addition to Georgia, Pennsylvania and Ohio, drug busts in multiple states are reporting they have seized quantities of Grey Death. Traffic stops in Greenville County South Carolina found 17 pounds of heroin and one pound of Grey Death. There have been two reported seizures of Grey Death in Virginia. Grey Death has been reported in Florida since November of 2016. It’s been found in Alabama. In a video from WCPO in Cincinnati, Ohio, Detective Jim Larkin of the Lorain County Sheriff’s Department wondered why anyone would try something called Grey Death. “Here’s some Grey Death. Now what do think is going to happen to you? Why do you think it’s called Grey Death?”

10/31/17

Mistaken Beliefs About Addiction Relapse

© kwest | stockfresh.com

The coroner’s report on Carrie Fisher’s death listed sleep apnea as the primary cause of death with drug intake as a contributing factor. In addition to the medications prescribed for her bipolar disorder (Abilify, Lamictal and Prozac), toxicology results found cocaine, methadone, heroin, oxycodone, and MDMA (ecstasy) in her system at the time of her death. Fisher’s family objected to a full autopsy, so the coronor’s conclusions were based on the toxicology results and an external examination of her body. “Based on the available toxicological information, we cannot establish the significance of the multiple substances that were detected in Ms. Fisher’s blood and tissue, with regard to the cause of death.”

The above information was from an article in Variety, but several media outlets were citing the coroner’s report and the same information. People said the coroner’s report indicated Ms. Fisher used cocaine sometime in the 72 hours prior to her death. During her 10-hour flight, she had multiple apneic episodes, which her personal assistant said was normal for her. Towards the end of the flight, she could not be roused. The report also noted she suffered from atherosclerotic heart disease, but then said: “The manner of death has been ruled undetermined.”

Although the official coroner’s report listed the manner of death as undetermined, it seems reasonable to assume from the toxicological information that Ms. Fisher had relapsed into active substance use. Billie Lourd, her daughter, said in a statement to People: “My mom battled drug addiction and mental illness her entire life. She ultimately died of it.” The cocktail of substances in Carrie Fisher’s system at the time of death, along with her history of heart disease, coupled with the increased risk of sudden cardiac death due to the medications used to treat her bipolar disorder lends credibility to Ms. Lourd’s statement.

The use of psychiatric medication to treat her bipolar disorder may have been a contributing factor to Ms. Fisher’s heart failure. See the article, “Blind Spots with Antipsychotics” Part 1 and Part 2 for more on the health problems with antipsychotics. But the range of substances she used just before her death may also have been enough to precipitate a sudden cardiac death, particularly since she already suffered from heart disease. Struggling with a concurrent bipolar disorder and a substance use disorder is a double whammy to anyone in recovery. Instability with either issue is a serious risk factor for relapse. I knew of someone with a bipolar diagnosis and cocaine dependence. They bounced back-and-forth between active cocaine use and inpatient psychiatric treatment for depression ten times within a single year.

Ms. Lourd said her mother would want her death to encourage people to be open about their struggles, and to seek help for them. Historically, Carrie Fisher talked openly about her proneness to relapse. She told People in 1987: “I couldn’t stop, or stay stopped. It was never my fantasy to have a drug problem.” She would stop for a couple of months and then celebrate her abstinence by using again. “I got into trouble each time. I hated myself. I just beat myself up. It was very painful.” With that in mind, let’s assume the immediate cause for her untimely death was due to an apparent relapse into active drug use, and then discuss some mistaken beliefs about addiction relapse.

Terrance Gorski is a leading expert on addiction relapse prevention. He’s written several books on the subject, many of which are available through Herald House Independence Press at relapse.org. He also has a blog, Terry Gorski’s Blog, where he has made a significant amount of his material available for free. Here we’ll concentrate on his article, “Relapse Does not Mean Failure?

Gorski said there were three mistaken beliefs that often interfered with helping relapse prone individuals. They are: (1) Relapse is self-inflicted; (2) Relapse is an indication the person is a failure who doesn’t want to recover; and (3) Once relapse occurs the patient will never recover.

In most cases, relapse is not self-inflicted. There isn’t a fully conscious, willful decision to throw over abstinence and return to active drinking or drug use. Relapse-prone individuals “experience a gradual progression of symptoms in sobriety that create so much pain that they become unable to function in sobriety. They turn to addictive use to self-medicate the pain.” They can learn to stay sober by recognizing these symptoms as early relapse warning signs. Next is identifying the self-defeating thoughts, feelings and actions used to cope with the symptoms and then learn more effective coping mechanisms, more healthy ways of responding to them.

Unfortunately, most relapse-prone patients never receive relapse prevention therapy, either because treatment centers don’t provide it or their insurance or managed care provider won’t pay for it.

Relapse is not automatically a sign that treatment has failed or the person really doesn’t want to recover. It is more likely that the root-cause of the person’s problems wasn’t addressed by the “standard package of treatment offered.” If this is the case, the risk of relapse increases dramatically. Learning to recognize relapse warning signs and how to cope with them would minimize this risk.

Gorski said that between one half and two-thirds of all individuals treated for alcohol and drug use problems will relapse. At least one half of those who relapse will establish long-term recovery within five to seven years of their first treatment experience. Believing that relapse means both the person and the treatment failed ignores the reality that for many, recovery involves a series of relapse episodes. “Each relapse, if properly dealt with in a subsequent treatment, can become the a learning experience which makes the patient less likely to relapse in the future.”

Chemically dependent people can be grouped into three types based upon their recovery and relapse histories. The first type is recovery prone and maintains total abstinence from their first serious attempt at change. Another type is relapse prone, with a series of short-term, low consequence relapse episodes before finding long-term abstinence. The third type is chronically relapse prone, who can’t seem to find long-term sobriety regardless of what they do.

Recovery prone individuals tend to be dependent on a single drug. They also have higher levels of social and economic stability. They may have steady employment, friendships and stable living situations. And they don’t have coexisting mental health issues, as Carrie Fisher did, or physical health issues, like chronic pain problems. These “garden variety addicts” have chemical addictions with few additional serious personal or social problems.

The second type of transitionally relapse-prone individuals, seem to have more severe addictions that are complicated by other problems. However, they learn from each relapse episode and take steps to modify their recovery programs to avoid future relapses. For example, they may downplay the risks of going around good friends who still drink or use drugs until they find themselves actively drinking or drugging again. Afterwards, they set and keep boundaries with those friends that better support their recovery.

The third type— chronically relapse-prone individuals—not only have the primary addiction for which they are being treated, but also a combination of the following coexisting issues. They may have multiple drug addictions, especially with opiates and methamphetamines. They can have an undiagnosed physical condition, a personality disorder or other mental health problem. There could be issues with severe post acute withdrawal (PAW), which becomes even more severe when the person is under high levels of stress.

Many relapse-prone patients fail to recover because these coexisting [issues] are not properly diagnosed and treated and they interfere with the primary treatment being given.

The third mistaken belief sees recovery as an all-or-nothing process—you either have it or you don’t. And if you relapse, you just don’t want recovery bad enough. Actually, recovery is a learned skill, acquired mostly by trial and error.  Rarely does someone with long-term recovery get there without one or more short series of relapse episodes. “They learned from these experiences and figured out how to put together a meaningful and comfortable long-term recovery.”

So when you think about Carrie Fisher’s toxicology report, don’t assume she threw away her sobriety like it was an old, worn out Alderaan gown. Her relapse was likely the result of a gradual progression of symptoms occurring in her life. In time, they created so much pain in sobriety that she wasn’t able to function. So she tried to self-medicate. She also wasn’t a failure who didn’t want to recover. The openness in her life about her struggles with addiction and mental health belie such an assessment.

Like thousands of others each year, she died with multiple psychoactive substances in her system. But that doesn’t mean she would have never made it back to abstinence. Remember, she was Princess Leia; and Leia Organa never gave in to the tyranny of the Empire. Carrie Fisher would never have given up fighting against her addiction and mental health demons.

I have read and used Terence Gorski’s material on relapse and recovery for most of my career as an addictions counselor. I’ve read several of his books and booklets; and I’ve completed many of his online training courses. He has a blog, “Terry Gorski’s Blog”, where he graciously shares much of what he has learned, researched and written over the years. This is one of a series of articles based upon the material available on his blog and website.

10/24/17

Feuding Ideologies, Part 3

© Navakun Phuangchan

“Dying To Be Free,” an article on the opioid addiction crisis, was well written and effectively communicated its message. That message was that abstinence-based treatment “didn’t work well for opioid addicts.” Medication-assisted treatment (MAT), especially with Suboxone, should be the standard of care. Nominated for a Pulitzer, “Dying To Be Free” was said to have influenced “a series of state and federal policy changes” away from abstinence to embrace MAT. But it has a glaring blind spot with regard to MAT, particularly Suboxone.

Pragmatically speaking, abstinent-based treatment and MAT need to learn to work together in order to effectively address the opioid addiction crisis in the U.S. “Dying To Be Free” systematically put these two approaches as being at odds with each other. It suggested we need to choose between the two, and argued that we should choose MAT. In order to support Suboxone MAT, it failed to acknowledge several serious concerns with Suboxone and other MATs. In this sense the persuasive rhetoric of the article had a blind spot.

In what follows, I hope to shine a light on what was missed with regard to Suboxone and other MATs. My intent is to bring to light the potential cons with Suboxone treatment in order to counterbalance the many pros found in “Dying To Be Free.” In order to make a truly informed addiction treatment choice both the strengths and weaknesses, the pros and cons need to be known and understood.

On September 20, 2017, Scott Gottlieb, the FDA Commissioner released a statement that said combined with counseling and behavioral therapies, MAT (medication-assisted treatment) was one of the main pillars of the federal response to the opioid epidemic. According to the Substance Abuse and Mental Health Services Administration (SAMHSA), it cuts the risk of death from all causes in half among individuals who use MAT to treat their opioid use disorder. But methadone and buprenorphine are themselves opioids and when they are combined with benzodiazepines or other central nervous system (CNS) depressants, there is a risk of serious side effects, such as difficulty breathing, coma and death.

Since the harm caused by untreated opioid addiction can outweigh these risks, the FDA advised against withholding buprenorphine or methadone-based MAT from individuals taking benzodiazepines or other CNS drugs. Nevertheless, the agency is requiring changes to the MAT drug labels to help decrease the risks of combining these drugs. Heath care professionals should educate patients about the risks of combined use, “including overdose and death.” They should taper the benzodiazepine or CNS depressant to discontinuation, if possible. They should verify the diagnosis if a patient was prescribed these drugs for anxiety or insomnia, and consider other treatment options for these conditions.

The new labeling recommends that health care providers develop a treatment plan that closely monitors any concomitant use of these drugs, and carefully taper the use of benzodiazepines, while considering other treatment options to address mental health conditions that the benzodiazepines might have been initially prescribed to address.

The FDA prescribing information for buprenorphine already notes that: “significant respiratory depression and death has occurred in association with buprenorphine,” particularly when it is used intravenously (IV) or in combination benzodiazepines or other CNS depressants, including alcohol. “Many, but not all post-marketing reports regarding coma and death associated with the concomitant use of buprenorphine and benzodiazepines involved misuse by self-injection.” Unintentional exposure of buprenorphine to children, which can cause possibly fatal respiratory depression, was warned against. It also notes the potential for dependence:

Buprenorphine is a partial agonist at the mu-opioid receptor and chronic administration produces physical dependence of the opioid type, characterized by withdrawal signs and symptoms upon abrupt discontinuation or rapid taper. The withdrawal syndrome is typically milder than seen with full agonists and may be delayed in onset. Buprenorphine can be abused in a manner similar to other opioids. This should be considered when prescribing or dispensing buprenorphine in situations when the clinician is concerned about an increased risk of misuse, abuse, or diversion.

Buprenorphine and methadone are both opioids, with the potential for physical dependence. Therefore, they are both diverted from legitimate medical treatment for illicit use. Buprenorphine is a Schedule III controlled substance, while methadone is a Schedule II controlled substance. Buprenorphine is said to have a tolerance ceiling with respiratory depression, meaning it has a lower potential when used alone to cause respiratory depression and death. Given that buprenorphine is a partial agonist, its physical euphoria is less intense than other opioids. But tolerance to many of the effects will develop with prolonged and repeated use.

Methadone was first synthesized by the Nazis, who never brought it into widespread use because of side effects, which included its addictive potential. After WWII, the Americans took control of the factory where methadone, then known as dolophine or polamidon, had been invented. A 1947 study demonstrated its addictive potential, warning if the manufacture and use was not controlled, “addiction to it could become a serious health problem.” See “The Consequences of Ignoring the Past,” for more on methadone.

The addictive potential and the abuse potential for buprenorphine or methadone was not readily discussed in “Dying To Be Free.” Nor were the above-noted concerns of mixing buprenorphine and CNS depressants. The author, Jason Cherkis, did say that neither drug was a miracle cure. Suboxone blocks both the effects of heroin withdrawal and an addict’s craving and, if used properly, does it without causing intoxication.” But saying both drugs were comparable to “the insulin that a diabetic needs to live” was inaccurate and disingenuous. Chronic, long term use could lead to a lifelong dependency.

There is no getting around this. Chronic, long term use of buprenorphine and methadone produces physical dependence. A too rapid taper or an abrupt discontinuation will produce symptoms of withdrawal. Extended, chronic use over months or years could result in a lifelong reliance on the medication to avoid the discontinuation or withdrawal crisis—and the danger of returning to active illicit opioid use. In the documentary Methadonia, about methadone maintenance in New York City, one individual referred to methadone as “liquid handcuffs.”

Another disturbing blind spot in Dying To Be Free” was its discussion of a 2009 study, “Illicit Use of Buprenorphine/Naloxone Among Injecting and Noninjecting Opioid Users.” Cherkis cited it, stating the majority of addicts surveyed were buying Suboxone on the black market “in an attempt to get sober.” 74% of those surveyed said they were using Suboxone to “ease withdrawal symptoms; 64% said they were using it because they couldn’t afford drug treatment. “Even when purchased on the black market, regardless of the intentions of the user, the medication works as intended — as harm reduction.”

The study abstract contains the information Cherkis noted. But let’s take a closer look at the further results reported in the full article. First recognize the sample size was small: 51 injection opioid drug users (IDUs) and 49 noninjection opioid dug users (non-IDUs). It was also drawn from a limited area, opioid users in Providence, RI. Only 7% reported current employment and 52% reported current homelessness. The 64% who were using diverted Suboxone because they couldn’t afford treatment are easily explained by the high unemployment and homelessness figures.

In addition to the results reported by Cherkis was the following data. Among those who had used diverted buprenorphine, 60% reported using it for less than 1 week; 13% for 1 week; and 28% for more than 1 week. Of those using diverted buprenorphine less than 1 week, 32% said they only used it for one day. Fifty seven percent said they used diverted buprenorphine because they couldn’t obtain heroin; a greater percentage (68%) of IDUs than non-IDUs (41%). Forty seven percent said they used diverted buprenorphine to ‘get high’; a greater percentage of non-IDUs (69%) than IDUs (32%). Seventy six percent said it was easy or very easy to obtain Suboxone on the street.

The following quote by Tom Frieden, the former director of the Centers for Disease Control and Prevention (CDC), appeared after the selective reporting on the above study, arguing for the need of more MAT programs: “If buprenorphine is being used and being bought on the street to self-treat addiction, that’s a reflection of a need to have better medically assisted treatment programs out there.”

I don’t really think these patterns of and reasons for diverted buprenorphine use are best described as harm reduction, as Cherkis said. Technically, there are high percentages of individuals saying they used it to reduce withdrawal, and/or self-treat opioid addiction, as well to stay “clean” for some time. But most also said they used buprenorphine because they couldn’t obtain heroin. The reported time of buprenorphine use for the majority of individuals was less than a week; 32% said it was for only one day! In addition, 32% of IDUs and 69% of non-IDUs said they used it to “get high.” It seems it would be more accurate to describe this behavior as attempting a time period of controlled opioid use, rather than harm reduction.

About fourteen months before “Dying To Be Free” was published, “Addiction Treatment With A Dark Side” appeared in The New York Times. It too looked at Suboxone treatment, but presented a different, more nuanced side to Suboxone treatment. Cherkis selected out one aspect of the article, that it “linked hundreds of deaths in the U.S. to buprenorphine and Suboxone.” He focused in on the phrase used to say buprenorphine was a “primary suspect” as a cause of death in CDC data analyzed by the NYT. He then noted there should be caution used before attributing a “primary suspect” drug as a cause of death, which he neglected to show is exactly what the NYT article did do.

The NYT article said the 420 deaths with buprenorphine as a “primary suspect” paled in comparison to those reported to the FDA from methadone for the same time period. It also said “The F.D.A. information, which is spare, does show that more than half of the American buprenorphine deaths involved other substances and that only two of 224 cases specifying ‘route of administration’ indicated injection — the primary concern of regulators.” Fifty deaths were noted as suicides, 69 as unintentional overdoses from drug abuse, and 30 were fetal or infant deaths after exposure in the womb.

The NYT claimed some experts believe buprenorphine is not being monitored systematically enough to gauge the full scope of its misuse. The CDC does not track buprenorphine deaths. Most medical examiners, emergency rooms, prisons, jail and drug courts don’t routinely test for it. The director of the Center for Substance Abuse Research at the University of Maryland said: “I’ve been studying the emergence of potential drug problems in this country for over 30 years. . . . This is the first drug that nobody seems to want to know about as a potential problem.”

Then “Addiction Treatment With A Dark Side” had a section noting some of the aggressive actions taken by Reckitt Benckiser, the company that brought Suboxone to market, “to protect its lucrative franchise.” I’ve noted these and similar actions by Reckitt Benckiser in previous articles: “A Double-Edged Drug,” “The Seduction of Opioid Substitution” and “The Opioid Buzzard.” The Times article documented the widespread association between Reckitt Benckiser and the federal government in bringing Suboxone to market, and in providing a place for lucrative employment when government officials left public service for employment in the private sector.

At one point in “Dying To Be Free,” Cherkis said the “squeeze of regulation” was responsible for opportunistic forces, such as “cash only Suboxone clinics and shady doctors,” as well as the “vibrant black market for illicit buprenorphine. Read the section, “Troubled Histories” in the NYT article and the follow up NYT article, “At Clinics, Tumultuous Lives and Turbulent Care” to get a clearer, more accurate picture of the problems with some of the existing Suboxone treatment centers and providers.

You also find a lengthy section describing the benefits of Suboxone treatment. Cherkis did say in “Dying to Be Free” that the NYT article did not question the efficacy of Suboxone when it was used properly. But why didn’t he discuss or cite some of the concerns? I think it was because “Dying To Be Free” was intended to be a persuasive piece of rhetoric to promote the widespread use of buprenorphine in MAT.

Undoubtedly, “Dying To Be Free” has had a significant influence on opioid treatment. But it seems that it did not present a well-rounded picture of both the problems and the benefits with MAT, specifically Suboxone. It seems to have a biomedical bias with regard to conceiving and treating opioid addiction. In Part 1 of “Feuding Ideologies,” I indicated how its rhetoric was a straw man attack on abstinent-based treatment while it extolled MAT. In Part 2, I showed how it misrepresented the recovery philosophy of Alcoholics Anonymous. Here in Part 3, I looked at how its biomedical bias seemed to dismiss or ignore many of the problems with Suboxone as a MAT for opioid addiction.

10/13/17

Feuding Ideologies, Part 2

© Michal Bednarek | 123rf.com

In the first paragraph of “Dying To Be Free,” you are introduced to Patrick, a smiling 25 year-old who had just completed a 30-day drug treatment center. Among his possessions was “a talisman he’d been given by the treatment facility: a hardcover fourth edition of the Alcoholics Anonymous bible known as ‘The Big Book.” It pages were full of highlights and Post-It notes. He was said to be a “natural” 12-step convert. Four days later, his father found him dead of an overdose.

As you read about Patrick’s struggles with addiction, you get a picture of how he and his parents tried to help him establish sobriety. There is a reference to his residential treatment stay as a “30-day wonder,” where he received a crash course on the tenets of the 12-steps. “Staff at the center expected addicts to reach a sort of divine moment but gave them few days and few tools to get there.” In Part 1 of this article, I addressed concerns that an underlying ideology of addiction as a strictly biomedical disease contributed to a biased, distorted picture of addiction treatment in the U.S. by the author of “Dying To Be Free.” Here we will look at how he also misrepresents the recovery philosophy and history of A.A.

There is a preponderance of religious or magical rhetoric when describing 12 Step, abstinent-based change in “Dying To Be Free.” Already we’ve noted the main text of Alcoholics Anonymous, also called Alcoholics Anonymous, was referred to as a talisman and a “bible.” Patrick was a “natural 12-step convert.” Another reference described the AA Big Book as being the size of a hymnal, with an appeal to faith made in “the rat-a-tat cadence of a door-to-door salesman.” Addicts at a certain treatment center were supposed to “reach a sort of divine moment” in treatment or recovery. Entering the drug treatment system, which is dominated by the principles of abstinence embedded in the 12-Steps, was said to require a “leap of faith.”

In a description of the Grateful Life Treatment Center in northern Kentucky, it was noted that the wall above the desk of the center’s intake supervisor had a “Jesus bumper sticker.” Why add that detail unless you are trying to capture the scene in a particularly religious way? When describing treatment facilities modeling themselves on the 12 Steps, not only were recovering addicts said to be cheap labor, they were said to provide the “evangelism” to shape the curricula of the facilities. A resident of Grateful Life was noted to be “as close to a true believer as the program produces.”

At one point, the author of “Dying To Be Free,” Jason Cherkis, said AA came out “evangelical Christian movements.” More accurately, there is a clear historical connection between a nondenominational Christian movement popular during the 1920s and 1930s called the Oxford Group and Alcoholics Anonymous. The two cofounders of A.A., Bill W. and Dr. Bob met as a result of their personal association with the Oxford Group. A.A. approved books, such as Pass It On, Doctor Bob and the Good Oldtimers and AA Comes of Age freely acknowledge the connection and give further details about it. However, a crucial distinction made by A.A. within its 12 Steps is glossed over by Cherkis and others, namely the spiritual, not religious understanding of God and recovery embodied in the Twelve Steps.

Drawn from the thought of the American psychologist, William James, this distinction between religious and spiritual experience seems to underlie the widespread sense of generic spirituality in American culture today. The Varieties of Religious Experience  (VRE) by James had a fundamental influence on Bill W., the formulation of the Twelve Steps and the spirituality based upon them. In VRE James made a distinction between institutional and personal religion. Worship, sacrifice, ritual, theology, ceremony, and ecclesiastical organization were the essentials of what he referred to as institutional religion.

Personal religion/spirituality for his [James’] purposes was defined as “the feelings, acts, and experiences of [the] individual . . . in their solitude, so far as they apprehend themselves to stand in relation to whatever they may consider the divine.” In the broadest sense possible, this spirituality consisted of the belief that there was an unseen order to existence, and supreme good lay in harmoniously adjusting to that order.

Whether their disregard of the spiritual, not religious distinction is intentional or not, Cherkis and others give an incomplete and biased picture of Twelve Step recovery when they fail to note it. The very heart of Twelve Step spirituality is the permissibility of the individual to formulate a personal understanding of their “god.” So what unites members of Twelve Step groups like A.A. is the diversity of religious and spiritual belief permitted—even to accepting a lack of belief. I’ve written several other articles on the similarities and differences between the spirituality of the Twelve Steps and religious spirituality on this website. There are three particular articles that discuss the influences on the spiritual, not religious distinction of Twelve Step recovery: “What Does Religious Mean?”, “Spiritual Not Religious Experience” and “The God of the Preachers.”

Another example of how “Dying To Be Free” misrepresents the recovery philosophy of A.A. is the following. While introducing a discussion of Charles Dederich and the origins of Synanon, Cherkis said Dederich and others took a “hardline” message” from some of Bill W.’s written philosophy. Cherkis wrote: “Those who can’t stick with the program are ‘constitutionally incapable of being honest with themselves,’ reads the Big Book. ‘They seem to have been born that way.’” The two selective quotes were from the first paragraph of chapter five, “How It Works,” in Alcoholics Anonymous. Notice how the context of the complete paragraph changes your understanding of what Bill W. said in his “philosophy”:

Rarely have we seen a person fail who has thoroughly followed our path. Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average.

As Cherkis began to discuss the history of the expansion of drug treatment facilities in the 1960s, he quoted Nancy Campbell, a professor at Rensselaer Polytechnic Institute, as saying: “The history of 12-step came out of white, middle-class, Protestant people who want to be respectable.” She added that it offered community and belonging that was predicated on being normal, respectable and having a stake in mainstream society.  Campbell may be a historian, but she seems to have a distorted view of the early history of 12 Step recovery in A.A.

From the sociological perspective of labeling theory A.A. and other organizations based on their 12 Steps, like N.A. (Narcotics Anonymous), can at least partially be seen as social movements that seek to combat negative images associated with socially deviant drinking or drugging behavior, “in effect denying that their actions make them deviants.” This applies the idea of tertiary deviance, first described by John Kituse in: “Coming Out All Over: Deviants and the Politics of Social Problems.” Kituse noted that some people stigmatized as deviant (here as alcoholics) “rebel against their labels and attempt to reaffirm their self-worth and lost social status.” The above quote and reference to Kituse is found in a standard social science textbook by Clinard and Meier, Sociology of Deviant Behavior.  So part of Campbell’s assessment of 12 Step groups as social movements seeking to offer community and belonging, with a “stake in mainstream society” is accurate. However, the quote attributed to her glosses over the early history of A.A., which was the beginning of the 12 Step movement.

A.A. celebrates the anniversary of its founding on June 10, 1935. That was in the midst of the Depression. Bill W. and his wife Lois were living then in a house owned by her father on Clinton Street in New York City. In September of 1936, Lois’s father died and the house was taken over by the mortgage company, which allowed them to stay on for a small rental. In the midst of the Depression, they didn’t want the house to be empty. While struggling with “their acute poverty,” Bill was almost persuaded to accept a position as a paid alcoholism therapist at Towns Hospital, where he himself had been treated several times. He eventually declined the offer.

Almost two and a half years after the founding of A.A., Bill W. was jobless and Dr. Bob was in danger of losing his house. In 1938, through the charity of John D. Rockefeller Jr., $5,000 was approved for a fund that would pay off Dr. Bob’s mortgage and allow a weekly draw of $30 for each of them. Rockefeller told one of his associates afterwards: “But please don’t ever ask me for any more.” In 1939, as the Depression eased, the mortgage company was able to sell the Clinton Street house and Bill and Lois became homeless. They lived “as vagabonds,” as various places for two years. Bill W. and Lois eventually led a respectable, middle class lifestyle, but that wasn’t what it was like for them in the beginning of A.A.

This history is found in Pass It On, published by Alcoholics Anonymous World Services, Inc. In the early days of A.A., Bill W. repeatedly turned down offers to professionalize his work with A.A. This doesn’t entirely sound like a movement trying to gain white, middle class respectability. The Traditions of A.A., formally adopted in July of 1950, articulated this philosophy of non-professionalism and a focus on helping other alcoholics in the fifth, sixth and eighth Traditions.

Tradition Five Reads: “Each group has but one primary purpose—to carry its message to the alcoholic who still suffers.” Tradition Six reads: “An A.A. group ought never endorse, finance, or lend the A.A. name to any related facility or outside enterprise, lest problems of money, property, and prestige divert us from our primary purpose.” Tradition Eight reads: “Alcoholics Anonymous should remain forever non-professional, but our service centers may employ special workers.”

Alternative addiction treatment ideologies regularly attack A.A. as “religious,” ignoring or rejecting the spiritual-religious distinction A.A. made within the Twelve Steps from the very beginning. The abstinent-based recovery philosophy embedded in the Twelve Steps seems to be the primary target of these critiques. I see the same tendency in “Dying To Be Free.” The first part of this article addressed the biased portrayal of abstinent-based addiction treatment by Jason Cherkis in “Dying To Be Free.” The third and final part will address how it skimmed over the problems with MAT, specifically Suboxone.

10/3/17

Feuding Ideologies, Part 1

© Lightsource | stockfresh.com

In August of 2017, the now former Health and Human Services Secretary, Tom Price, said he didn’t think it was necessary to declare the opioid epidemic to be a national emergency. This was despite the president’s own opioid commission recommending it as the “first and most urgent recommendation.” Two days later, the President reversed Price’s statement, saying: “The opioid crisis is an emergency, and I’m saying officially right now it is an emergency.” The response was mixed. While President Trump’s announcement could be used to help free up federal resources and help to prioritize responses to the disaster, it could also permit the administration to push for new sentencing legislation in order to get “tough on crime” related to drug use.

What isn’t disputed is that the U.S. does have a serious opioid problem and something needs to be done about it. Drug overdose is the leading cause of death in Americans under the age of fifty. Forecasts by STAT News are the annual death rate will increase by at least 35 percent by 2027. The CDC reported that from 2002 to 2015 there was a 5.9-fold increase in the overdose deaths from heroin and non-methadone synthetic opioids.

The latest statistics for the U.S. opioid epidemic is now available in the 2016 National Survey on Drug Use and Health (NSDUH). Among the myriad of statistics reported there was news that heroin users increased 230% from 2002 to 2016, while heroin deaths increased 630%. An estimated 948,000 people aged 12 or over reported they used heroin in the past year. That translates to .4% of the country’s population. There were also an estimated 11.5 million people who misused pain relievers in the past year, 4.3% of the population aged 12 or over. Combined, there are 11.8 million people who misused opioids, 4.4% of the population, in 2016.

The 2016 NSDUH Report can be accessed here. A shorter, graphic-based report of key findings, including those noted above, is here.

One of the treatment approaches often touted to address the opioid crisis is medication-assisted treatment (MAT) with Suboxone. In January of 2015, Jason Cherkis wrote “Dying To Be Free.” His subtitle asked why we weren’t using a treatment for heroin addiction—Suboxone—that actually worked. The opioid problem in Kentucky was the focus of his article, which I found to be rhetorically persuasive and well written. You are introduced to individual after individual who wouldn’t or couldn’t use Suboxone and ended up dead from an eventual overdose.

“Dying To Be Free” was a finalist for a Pulitzer in 2016 for its “deeply researched reporting on opioid addiction” that showed how many drug overdoes deaths could have been prevented. The cover letter submitted for its entry for the Pulitzer by The Huffington Post said it triggered a series of state and federal policy changes that rejected abstinence for opioid misuse and embraced medication-assisted treatment. “‘Dying To Be Free’ offered readers an immersive experience that included audio and video documentaries and photo and data displays.”

This was not fake news. “Dying to Be Free” captured the agony of individuals and families who struggle with opioid misuse. But it also made abstinence-based approaches to treatment and recovery a bogeyman responsible for many of the unnecessary deaths from opioid overdoses. The rhetoric of the article was a straw man attack on abstinent-based treatment while it extolled MAT. Its biomedical treatment bias seemed to dismiss or ignore many of the problems with Suboxone as a MAT for opioid addiction. Nor did it tell the whole story behind Suboxone. It also misrepresented the recovery philosophy of self-help groups like Alcoholics Anonymous. Here’s what I mean.

In the last paragraph of his second chapter, Cherkis said: “There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer.” This succinctly captures the problem as he sees it with existing treatment approaches to the opioid crisis. Heroin addiction is a medical disease and should be treated as a medical disease. Modern medicine has a scientific treatment for heroin addiction that is resisted because of stigma, a deep-rooted adherence to self-help, and the criminalization of heroin addiction. If you question or oppose MAT, you are apparently mired in a kind of scientific dark age.

To enter the drug treatment system, such as it is, requires a leap of faith. The system operates largely unmoved by the findings of medical science. Peer-reviewed data and evidence-based practices do not govern how rehabilitation facilities work. There are very few reassuring medical degrees adorning their walls.

Dr. Mary Kreeft, one of the pioneers of methadone maintenance, was liberally quoted to support the medical model of addiction. She noted how opioid addiction alters multiple regions in the brain, including those that regulate reward, memory, learning, stress, hormonal response and stress sensitivity. According to Dr. Kreeft, after a long cycle of opiate addiction, a person needs specific medical treatment. Some people may be OK in time. But “the brain changes, and it doesn’t recover when you just stop the drug because the brain has been actually changed.”

An abstinence-only treatment that may have a higher success rate for alcoholics simply fails opiate addicts. “It’s time for everyone to wake up and accept that abstinence-based treatment only works in under 10 percent of opiate addicts,” Kreek said. “All proper prospective studies have shown that more than 90 percent of opiate addicts in abstinence-based treatment return to opiate abuse within one year.” In her ideal world, doctors would consult with patients and monitor progress to determine whether Suboxone, methadone or some other medical approach stood the best chance of success.

This is a rigid, strict medical model of opioid addiction. And it gives a mixed message regarding whether or not the individual will ever be able to stop taking Suboxone or methadone. Neither drug, said Cherkis, is a miracle cure. But they buy addicts time to fix their lives, seek counseling and allow their brains to heal. So far, so good. But here comes the caution: Doctors recommend tapering off the medication cautiously. The process could take years, as addiction is a chronic disease and effective therapy takes time. Then comes the typical analogy of the pure medical model of addiction:

Doctors and researchers often compare addiction from a medical perspective to diabetes. The medication that addicts are prescribed is comparable to the insulin a diabetic needs to live.

There is no mention of neuroplasticity—the brain’s ability to reorganize itself by forming new neural connections. “Neuroplasticity allows the neurons (nerve cells) in the brain to compensate for injury and disease and to adjust their activities in response to new situations or to changes in their environment.”

Jeffrey Schwartz and Rebecca Gladding use an almost identical description of neurological action to that given above by Dr. Kreeft to describe how to change the brain; to modify bad habits (including addiction) and unhealthy thinking. In You Are Not Your Brain, they describe how we teach our brains to act in unhealthy ways. The brain does not distinguish between beneficial and destructive habits, “it just responds to how you behave and then generates strong impulses, thoughts, desires, cravings, and urges that compel you to perpetuate your habit, whatever it may be.”

Clearly, the brain can exert a powerful grip on one’s life—but only if you let it. The good news is that you can overcome the brain’s control and rewire your brain to work for you by learning to debunk the myths it has been so successfully selling you and by choosing to act in healthy, adaptive ways.

Neuroplasticity, as described by Schwartz and Gladding, does not reject Kreeft’s neurological description of addiction.  But it does say it isn’t the whole story. An ideology of addiction as a purely biomedical condition seems to permeate “Dying To Be Free.” Addiction, when conceived strictly as a brain disease, rejects or ignores the non-scientific construct of mind. If we are conceived as only biological beings, then addiction is explained and treated within a biomedical worldview. Any treatment approach to addiction not based on this premise is therefore faulty.

Drug treatment facilities were said in “Dying To Be Free” to “generally” fail to distinguish between addictions. They have a one-size-fits-all approach.  Addicts in residential treatment experience a “hodgepodge” of drill-instructor tough love and self-help lectures. Programs appear simultaneously excessively rigid and wildly disorganized. “And with roughly 90 percent of facilities grounded in the principle of abstinence, that means heroin addicts are systematically denied access to Suboxone and other synthetic opioids.”

After describing two older, drug treatment programs with a therapeutic community model of care that used coercive techniques—Synanon and Daytop (Drug Addicts Yield TO Persuasion)— he said:

The number of drug treatment facilities boomed with federal funding and the steady expansion of private insurance coverage for addiction, going from a mere handful in the 1950s to thousands a few decades later. The new facilities modeled themselves after the ones that had long been treating alcoholics, which were generally based on the 12-step methodology. Recovering addicts provided the cheap labor to staff them and the evangelism to shape curricula. Residential drug treatment co-opted the language of Alcoholics Anonymous, using the Big Book not as a spiritual guide but as a mandatory text — contradicting AA’s voluntary essence. AA’s meetings, with their folding chairs and donated coffee, were intended as a judgment-free space for addicts to talk about their problems. Treatment facilities were designed for discipline.

In support of this claim, Cherkis referred to a 2012 study conducted by the National Center on Addiction and Substance Abuse at Columbia University. It apparently was a reference to “Addiction Medicine: Closing the Gap between Science and Practice.” He said the study concluded the U.S. treatment system was in need of a “significant overhaul” and questioned whether the low levels of care received by addiction patients constituted a from of medical malpractice.

While medical schools in the U.S. mostly ignore addictive diseases, the majority of front-line treatment workers, the study found, are low-skilled and poorly trained, incapable of providing the bare minimum of medical care. These same workers also tend to be opposed to overhauling the system. As the study pointed out, they remain loyal to “intervention techniques that employ confrontation and coercion — techniques that contradict evidence-based practice.” Those with “a strong 12-step orientation” tended to hold research-supported approaches in low regard.

The Columbia University study did state a significant overhaul was needed in current treatment approaches; and it raised the question if the insufficient care received by addiction patients constituted “a form of medical malpractice.” It also pointed to the need for medical schools to “educate and train physicians to address risky substance use and addiction.” Unsurprisingly, it went on to say that all aspects of stabilization and treatment with addictions should be managed by a physician “as is the case with other medical diseases.” Remember that the Columbia study and Cherkis were both advocating for a physician-centered, medical model approach to addiction treatment.

However, I couldn’t find where it was supposed to have said the majority of front-line treatment workers were low-skilled and poorly trained. There was a section stating that physicians and other health professionals should be on the front line addressing addiction. Then it said: “Paraprofessionals and non-clinically trained and credentialed counselors can provide auxiliary services as part of a comprehensive treatment and disease management plan.”

It did not say the majority of front-line treatment workers were low-skilled and poorly trained “incapable of providing the bare minimum of medical care.” Yet in the case study examples found in “Dying To Be Free,” that is what Cherkis presented. The Columbia study did cite another study, which found that recovering support staff had little enthusiasm for evidence-based practices. “They also were more likely to support intervention techniques that employ confrontation and coercion–techniques that contradict evidence-based practices.” But these paraprofessionals only made up “24 percent of the treatment provider workforce.”

Cherkis seems to have mis-remembered what the Columbia study actually claimed in this matter. I wonder if, because of his commitment to a strictly medical model ideology for opiate treatment, he was reading into the study. His quote above supported the description of the treatment facilities he highlighted in his article, but wasn’t found by me in the article he cited on the Columbia study.

Another example of how his treatment ideology distorted his portrayal of Suboxone treatment was with how he described Hazelden’s Suboxone treatment program. “Dying To Be Free” mentioned that Hazelden, now the Hazelden Betty Ford Foundation, developed its own Suboxone treatment program for opioid addicts. But it failed to note this wasn’t accompanied by a rejection of “Twelve Step practices.” Within “The History of Hazelden,” on the Hazelden Betty Ford Foundation website, was the statement of how it “integrates the cornerstone Twelve Step practices of mutual support along with multidisciplinary clinical care, evidence-based therapies and the latest research in brain science.” Why weren’t there some case study examples from Hazelden in “Dying To Be Free”?

The facilities Cherkis highlighted in Kentucky were not representative of abstinent-based addiction treatment centers in the U.S.; ones that use the 12 Steps to structure their treatment program. In reading “Dying To Be Free” I see an underlying ideology of conceiving and treating addiction, specifically opiate addiction, through a strict biomedical lens. That is not the whole story of addiction. As a result, the rhetoric of the article constituted a straw man attack on abstinent-based treatment while it extolled MAT. This bias presents readers with an implied choice, a dichotomy, between Suboxone as an MAT for addiction and 12 Step, abstinent-based treatment. Ironically, Hazelden, an historically important treatment center that pioneered 12 Step, abstinence-based treatment, did not choose MAT over the 12 Step-based treatment, but combined the two. But you don’t get that information in “Dying To Be Free.”

Parts 2 and 3 of this article will look at how “Dying To Be Free” misrepresented the recovery philosophy of self-help groups like Alcoholics Anonymous; and skimmed over the problems with MAT, specifically Suboxone.

09/22/17

Be Careful Out There

© cylonphoto | 123rf.com

Recently, around 6 a.m. on a Wednesday, several law enforcement agencies executed federal search warrants at three locations in the West End area of Pittsburgh. In one home, when the SWAT team members entered, one of the suspects was trying to escape through a back window. Another one of the suspects knocked over a table where they had been bagging drugs, “causing the powder narcotics to become airborne” and exposing the SWAT officers to the airborne drug. Eighteen of them were taken to the hospital suffering from various symptoms.

According to Brenda Waters of KDKA, the CBS Pittsburgh affiliate, all eighteen were medically cleared. “None of the … law enforcement officers taking part in the early morning raid were adversely affected by the drugs.” The agencies participating in the raid included Pittsburgh Police, Pittsburgh SWAT, U.S. Immigration and Customs, state police and Homeland Security. In addition to the airborne substance, they found more than 1,000 stamp bags, 250 grams of unpackaged drugs and a “significant quantity of white powder” on a plate in the kitchen. The airborne substance was probably fentanyl; maybe carfentanil.

Dr. Tureurro, the chief of Emergency Services at UPMC Mercy Hospital, where the officers were treated, said they were fortunate to get out of the situation quickly, thus minimizing their symptoms. They had burning sensations in their throats; some became lightheaded; others were nauseous. “The big thing that we did for them is we basically decreased the chance that they could be exposed to anything that was laying on their bodies or on their clothes.” By removing their clothes, then showering and decontaminating themselves, the officers decreased their chances of exposure to any of the substance. The Justice Department press release said:

Fentanyl exposure is an all too real risk to law enforcement as we learned this morning. Quick and professional action by first responders helped avert a potential catastrophe.

The Pittsburgh Post-Gazette reported that the raid originated from a May investigation by Customs and Border Protection when agents intercepted a fentanyl package marked as “plastic fittings” that was shipped from Hong Kong. The accused leader of the drug operation had a history of repeated arrests for felony drug convictions and disregarding bond conditions in his repeated arrests for drug related charges. He had been initially arrested for possession and distribution on June 1st in relation to the intercepted package of fentanyl from Hong Kong. He was rearrested on July 20th, discarding a brick of fentanyl on the floor of a police car taking him to jail, and then again on August 2nd. Each time he was released on bond he resumed his criminal activities. This time he did not receive bail.

This is not an isolated or freak occurrence. In September of 2016, The Washington Post reported on a raid in Harford Connecticut when 11 SWAT officers were exposed to airborne fentanyl and heroin. The powder may have blown into the air after the tactical team tossed a flash-bang grenade, or the suspects could have swept the table where they were packaging the drugs. The officers moved through a “cloud of dust in the air.” Several officers were lightheaded, nauseous; they had sore throats and headaches. As a precaution, the entire team went to a local hospital for treatment.

Jim Pasco, executive director of the National Fraternal Order of Police, said this has been an inherent risk for law enforcement for decades, beginning with “The granddaddy of all problems—being exposed to meth labs.” A DEA spokesperson said law enforcement officers are concerned with protecting themselves and the public.

Law enforcement officers do carry a bigger burden than ever — we are fighting to protect the American public from poisons that bring death and destruction to our communities — but we are also faced with challenges of educating the public as to the deadly risks of these substances and about the inextricable links between misuse of prescription opioids to heroin and fentanyl use and addiction.

Kelly Burch reported for The Fix that in May of 2017 when an East Liverpool Ohio police officer helped in the arrest of drug suspects, they tore open bags of the drugs in an attempt to destroy evidence. Back at the station, the officer noticed a white powder on his uniform and tried to brush it away. “I had placed my thumb, and index finger in it and tried to brush it off. I don’t know if it went through my skin or if it became airborne when I wiped it off, or a combination of both.” Within a few minutes, he didn’t feel like himself. The last thing he remembered was falling backwards into the door.

He received a dose of Narcan at the station and a few more at the hospital. “Never in a million years did I think I would be in the hospital for something that serious, for overdosing.” He knew the job was dangerous and might encounter guns and knives. But “you’re not thinking that a particle of dust or drug killing you.” The experience made him even more determined to keep these powerful drugs off the streets: “I am not letting drug dealers win, you may have almost killed me, but you’re not going to win, you’re not going to come to this city and bring that poison.”

Another Ohio encounter with fentanyl took place in early August of 2017 in Massillion, about 50 miles south of Cleveland. Three nurses at the Affinity Medical Center in Massilon lost consciousness while they were cleaning a room where an overdose victim had been treated. All three were treated with naloxone and are said to have recovered. The nurses union at the hospital  wanted to meet with hospital officials to discuss protocols for environmental contamination, but the hospital declined, saying it already has effective policies. Hmmm … with three nurses becoming unconscious, it seems a review of the policies woudn’t hurt.

CTV Vancouver reported in October of 2016 that the CBSA, Canada’s Border Services Agency advised its officers to avoid contact with a package they suspect contains fentanyl. The president of Canada’s Customs and Immigration Union said: “What we’re telling our officers at this time, from a health and safety point of view, is that if there’s a package and they think there could fentanyl, they shouldn’t touch it. They shouldn’t approach it.” If an agent believes a package contains the drug, they are advised to give it to supervisors. “We need to approach this so our officers have the right tools, right training and the right equipment.”

In a June 2016 press release, the DEA announced they had released a short Roll Call Video to all law enforcement agencies about the dangers of improperly handling fentanyl. You can watch the video here. The press release said the DEA was concerned about law enforcement coming in contact with fentanyl on the streets in the course of enforcement activities, such as buy-walk or buy-bust operations. “Officers should be aware that while unadulterated fentanyl may resemble cocaine or heroin powder, it can be mixed with other substances which can alter its appearance.” The report noted the current outbreak involved not just fentanyl, but fentanyl compounds (like carfentanil) as well.

Universal precautions must be applied when conducting field-testing on drugs that are not suspected of containing fentanyl. Despite color and appearance, you can never be certain what you are testing. In general, field-testing of drugs should be conducted as appropriate, in a well ventilated area according to commercial test kit instructions and training received. Sampling of evidence should be performed very carefully to avoid spillage and release of powder into the air. At a minimum, gloves should be worn and the use of masks is recommended. After conducting the test, hands should be washed with copious amounts of soap and water. Never attempt to identify a substance by taste or odor.

The DEA published “A Briefing Guide for First Responders” on fentanyl. It contained a history of fentanyl, a description of illicit forms of fentanyl and fentanyl-related substances, the risks of exposure and treatment, as well as decontamination recommendations.

Fentanyl was first synthesized in 1959 by a Belgian chemist. Other forms of pharmaceutical fentanyl were developed for pain management, including a transdermal patch, a nasal spray, a sublingual tab and a flavored lollipop—yes a fentanyl lollipop. While pharmaceutical fentanyl is diverted on a small scale, the current problem is due to transnational criminal organizations competing for the U.S. market.

China and Mexico appear to be the main source countries for illicit fentanyl smuggled into the United States for domestic‐based processing and distribution. Seizures indicate that China supplies lower volumes of high‐purity fentanyl, whereas fentanyl seizures from Mexico are higher volume but lower in purity. Fentanyl is also routed and smuggled through Canada. China‐based trafficking organizations have also been known to use the internet to distribute fentanyl, fentanyl‐related substances, and synthetic opioids globally.

Among the current fentanyl-related substances on the illicit market are: 4‐fluoroisobutyryl fentanyl, furanyl‐fentanyl, acryl‐fentanyl, acetyl‐fentanyl, carfentanil, and 3‐methylfentanyl, and other synthetic opioids such as U‐47700. I’ve written previously on this website about the fentanyl-related substance, carfentanil (“The Devil in Ohio”). Recently I received an unsolicited email from a “company” in Shanghi offering to send me a free sample of carfentanil. The DEA “Briefing Guide for First Responders” warned that some organizations are distributing pure fentanyl.

During the first quarter of 2017 the DEA indentified 230 instances of fentanyl, fentanyl-related substances and other synthetic opioids in seized drug evidence. The following graphic illustrates the results of their analysis. Fentanyl accounted for about 58% of the identifications. Of those 134 fentanyl identifications, 61% of the samples were combined with heroin; 28% were fentanyl alone. Carfentanil was found in six identifications. U-47700, alprazolam (Xanax) and cocaine’s were found in others.

Because of their hazardous nature, fentanyl and fentanyl-related substances are a serious threat to the health and safety of law enforcement officers and other first responders, such as EMTs. As little as 2-3 milligrams of fentanyl could bring on respiratory depression and possibly death. “When visually compared 2 to 3 milligrams of fentanyl is about the same as five to seven individual grains of table salt.” See the above photo of a penny.

The “Briefing Guide for First Responders” went on to describe treatment for any exposure to fentanyl, repeating some of the actions taken in the above situations:

  • seek immediate medical attention.
  • remove the person from the contaminated environment, preferably where there is fresh air.
  • If a suspected fentanyl-related substance has been inhaled, move the person to fresh air.
  • If there are overdose symptoms, immediately administer naloxone, which can quickly reverse an opioid overdose.
  • Multiple doses may be necessary, depending upon the drug’s purity and potency. Continue to administer a dose of naloxone every 2-3 minutes until the individual is breathing on their own for at least 15 minutes or until EMS arrives.
  • Someone who entered a badly contaminated area or was otherwise exposed to a suspected fentanyl-related laboratory or milling operation without wearing the proper protective clothing should undress and shower with soap and water as soon as possible.
  • If a suspected fentanyl-related substance was ingested through the mouth or eyes and the person is conscious, rinse their eyes and mouth with cool water.
  • When there has been any skin contact, wash the exposed area immediately with soap and water.
  • Do NOT use hand sanitizer, as it may contain alcohol, which is a skin penetrant. This may increase the absorption of fentanyl through the skin.

So if you are a first responder or law enforcement officer—or if for some reason you find yourself exposed to fentanyl—remember the above advice. And first responders and law enforcement officers, remember the safety call given by Michael Conrad, who played the role of Sergeant Phil Esterhaus in Hill Street Blues: “Let’s be careful out there.”

09/12/17

Trouble in Plumas County

© Natallia Yeumenenka | 123rf.com; “Plumas” is Spanish for feathers.

Situated in the Sierra Nevada region of California, Plumas County is an attractive recreational destination for a wide variety of activities, including boating, camping, fishing, hiking, skiing, hunting and others. The Explore Plumas County webpage says it is “a Wilderness of Wonders,” where the wilderness is untouched. “Natural beauty is etched in the snow-capped peaks and towering pines.” It is said to be a four-season travel destination with fresh mountain air and pristine, blue waters. You are encouraged to explore the mountain ranges and wilderness, where there is “something new to discover with each experience”—including illegal marijuana growers.

I’m not a resident of Plumas County. But as I was completing another article (“Pot Market Getting a ‘Black’ Eye”) on the problems with how the expanding recreational marijuana has helped the black market for marijuana to flourish instead of weakening it, I ran across the current debate over marijuana in Plumas County. Looking closer at the issues in this small, rural county helps to illustrate some of the problems that come with the political and cultural pressures to legalize marijuana.

The photos on the Explore Plumas County webpage are seductively beautiful. I want to go visit; maybe for a very long time. The county is in the northern end of the Sierra Nevada range. The entire county population is only 20,007, as of the 2010 census. But Plumas County is in the midst of a political and culture war over whether or not there should be a greater presence of marijuana in the county. Cannabusiness Law noted currently there is a ban on the retail sales of marijuana as well as manufacturing. Current zoning codes do not permit commercial marijuana growing, but the codes are under review. The webpage also provides you with information to contact local officials and let them know you oppose the bans … or approve them, I’d add.

On November 8, 2016, California voters approved Proposition 64, the Adult Use of Marijuana Act (AUMA). Beginning in 2018, it allows “the sale of marijuana for adult use in licensed stores under regulations to be established by the state Dept. of Marijuana Control (DMC) in conjunction with local governments.” The possession and use of up to one ounce of marijuana (or 8 grams of concentrates) and personal use cultivation of up to six plants is also legal. It also reduces fines for most illegal cultivation, sale, transport and possession for sale offenses from felonies to misdemeanors—with possible exceptions for violent or repeat offenders. See the California NORML website for the following quote and more information on Proposition 64 and other California marijuana laws.

Commercial sale, cultivation, and production of marijuana are allowed only by licensed providers. Illegal sale, transport, manufacture, cultivation, or possession with intent to sell are generally punishable as misdemeanors, with felony enhancement allowed for special circumstances and three-time offenders. Minors under 18 are in no case subject to imprisonment, but may be punished by drug education and community service.

Medical marijuana has been legal in California since 1996 with Proposition 215, the Compassionate Use Act. And it is because of the fallout from that change that many of the current problems in Plumas County have occurred. The Los Angeles Times reported that four weeks before the 1996 general election where Proposition 215 was approved, Senator Diane Feinstein said “you’ll be able to drive a truckload of marijuana through the holes in it.” The devil is in the details, and she said this particular bill lacked details. Nevertheless, the assessment of the author of the LA Times article was it had been an incredible success, despite its vague wording and instances of abuse. Read on before you accept that statement.

After the approval of Proposition 215, the cultivation of marijuana took off in the so-called Emerald Triangle, consisting of the counties of Mendocino, Humboldt and Trinity, along the northern coast of California. Plumas County is on the opposite, eastern side of the state, at the same latitude as the Emerald Triangle counties. The Emerald Triangle has been estimated to produce 60% of America’s marijuana. As was noted above, Plumas County previously banned the retail sales and manufacturing of marijuana, and had zoning restrictions for the cultivation of marijuana. Nevertheless there have been serious problems with illegal activities involving marijuana within the county.

In July of 2015, Plumas County authorities reported that along with Forest Service law enforcement, they recovered about 23,000 marijuana plants at two separate locations. The estimated value of the plants was in excess of $10 million. Officers from Plumas County SWAT, the Forest Service and California Fish and Wildlife took part in the eradication raids. Two suspects were encountered near one site, but they avoided capture in the brushy steep terrain. Residents were encouraged to contact authorities if they saw any signs of marijuana gardens, such as drip lines, gardening tools, bags of fertilizer or pesticides, trash piles or remote campsites.

In August of 2016, John Bartell reported for KXTV how the Plumas National Forest was plagued with illegal grows. Reportedly, teams were finding illegal grows on a weekly basis. One local cattle rancher said he lived next to an illegal marijuana grow. “They had pit bulls running free and they attacked 2 cows and bit their ears off.” A Plumas County detective said they regularly encounter a number of individuals who are not residents of the United States cultivating the gardens. Often they turn out to be Mexican nationals. “Some are out here for 3 or 4 months and are promised $10,000 or $20,000 to grow.” There have been instances of hunters wandering into fields where they were killed. Safety in the Plumas National Forest is now a serious concern.

This is not simply an isolated problem for Plumas County. In Yosemite National Park, park rangers are regularly discovering and destroying large marijuana growing operations, attributed to the same Mexican cartels. Here is a video report on this problem from the Travel Channel. A park ranger is quoted as saying the park has had several marijuana growing plantations located within its borders. Some of these growing plantations have been worth as much as $14 million. “These are not simply a few people that want to have a garden and grow something for their use.”

There is a “Plumas People Opposed to Commercial Cannabis” Facebook page with multiple articles describing issues from the illegal marijuana grows. Banned pesticides are showing up in California water. A Reuters article, appearing on US News & World Report, noted toxic chemicals from illegal marijuana farms are found in California’s rivers and streams feeding the state’s water supply. The chemicals have turned thousands of acres into toxic waste dumps. Law enforcement officers who have inadvertently touched plants and equipment have been hospitalized. ”Scores of animals have died.”

A New York Times article noted that despite the promise of a legal market, many growers are not signing up. Hezekiah Allen, the executive director of the California Growers Association, estimated only about 11% of growers in the Emerald Triangle have applied for grow permits. The paperwork to obtain a permit, the fees and the taxes are given as reasons for not doing so. Lori Ajax, the chief of California’s Bureau of Cannabis Control said there are folks who have been operating for a long time with minimal local oversight or no oversight at all. She thought it was going to take some strong enforcement to bring people into the regulated market.

California, which by one estimate produces seven times more marijuana than it consumes, will probably continue to be a major exporter — illegally — to other states. In part, that is because of the huge incentive to stay in the black market: marijuana on the East Coast sells for several times more than in California.

The drastically reduced legal consequences in Proposition 64 for most of the illegal offenses related to the cultivation, sale, transport and possession of illegal marijuana from felonies to misdemeanors, at least for the first couple of offenses, means there is very little motivation for illegal growers to enter the legal market. The Mendocino County district attorney said people living in the urban centers of California, like San Francisco, Los Angeles, and San Diego don’t realize the crime rate in the rural areas where marijuana is being grown.

Among the cases he is handling are a robbery and slashing death of a grower; the murder of a man at a marijuana farm by a co-worker wielding a baseball bat; an armed heist in a remote area by men who posed as law enforcement officers; and a robbery by two men and a juvenile who were invited to a barbecue and then drew guns on their hosts and fled with nine pounds of marijuana.

There was a meeting of the Plumas County Cannabis Working Group on the afternoon of Thursday, September 7th, 2017. The Facebook page for the Plumas People Opposed to Commercial Cannabis Facebook page related some of the concerns expressed by residents. One concerned resident noted how the drafted ordinance document was written by a pro commercial growing committee, “whose members stand to make large amount of money.” She also raised the issue of the potential environmental impact of water, pesticides and drainage into their creeks and rivers. Another person during the meeting raised a concern that approving commercial grow operations would lead to less county and/or state support to address the anticipated increase in local crime. A pro grower responded by saying high fences, guard dogs and private security forces would keep criminals in check. The concerned individual responded: “Yes, that’s JUST what we want here.”

In an open letter to the Plumas County Supervisors, another Plumas county resident noted how some individuals said the best way to improve Plumas County was to bring in the anticipated influx of cash from approving commercial growing. “They urge us to look for the money, trust them for a higher standard of character and compliance than has been reported elsewhere, and trust the free market.” But that isn’t happening in other areas. See “Pot Market Getting a ‘Black’ Eye.”

Another resident also voiced her concerns that every member of the Cannabis Work Group was someone in favor of commercial cultivation. The Work Group was “not a balanced representation.” She noted where the issue of odor was minimized. See the above linked New York Times article for a report that a police reconnaissance helicopter could smell pungent marijuana plants from 800 feet above an illegal grow. Concerns over an increase in crime, homelessness and changes in the community culture have been largely unanswered, she said.

credit: Sierra REC Magazine

People move to or visit Plumas County for the natural beauty, rural lifestyle, recreational opportunities, the mountain air, the open vistas, to raise families, to escape the culture and crime of the city. All of these would be changed in some degree by widespread cannabis cultivation. High fences would predominate, along with heavily secured tall hoophouses. The oft-referenced Mexican Cartels are unlikely to simply pack their suitcases and go home; what will they do here instead? Who will buy up properties and small farms and lease acreage for this lucrative crop? What large commercial interests may impact land use, local politics, ecological concerns, the small town culture? How does greed divorced from responsible citizenship change a community?

The decision on commercial marijuana growing in Plumas County isn’t finalized yet. The next scheduled meeting of the Cannabis Working Group is Thursday September 14th, starting at 10 AM PDT. There are a number of issues it seems; these are only a few. Will the façade of an unbalanced work group be addressed? What about the impact on local crime and the environment? If this is supposed to bring money into the county, how will that work when already California produces multiple times the amount of cannabis that can be consumed in the state? And it will be illegal to send any cannabis grown in Plumas County out-of-state. Doesn’t that set the county residents up for an explosive increase in illegal grows if commercial marijuana growth is approved? That is what happened in Colorado, which was better prepared enforcement-wise for recreational marijuana than California seems to be.

I live in Allegheny County, Pennsylvania, in a township whose population in the 2010 census was over 8,000 more than the entire population of Plumas County. My home state approved the Pennsylvania Marijuana Act (for medical marijuana) on April of 2016. There aren’t any dispensaries open yet; the state has just begun to register practitioners. In June of 2017 twelve companies were awarded growing licenses, including one in western PA fronted by Jack Ham, a former linebacker for the Pittsburgh Steelers. Growing will only be done in warehouses.

The only types of medical cannabis allowed initially are pills, oils, gels, creams, ointments, tinctures, liquid, and non-whole plant forms for administration through vaporization. Given the issues noted above in Plumas County and other counties in California, I hope residents of my home state will work together, as the residents of Plumas County are currently doing, to prevent similar concerns from developing in Pennsylvania. Residents of other states that have started down the road to legalization, be forewarned and learn from the current trouble in Plumas County.

If you sympathize with those Plumas County residents opposed to commercial marijuana growth in their county, give them some encouragement on the “Plumas People Opposed to Commercial Cannabis” Facebook page.