04/14/17

An Opioid Shell Game

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Heroin sales and overdoses get a significant mount of attention, but we need to also remember that since 2002, the number of deaths related to controlled prescription drugs (CPD) have outpaced those for cocaine and heroin COMBINED. And the number of individuals who report current use of CPDs is more than those reporting use of cocaine, heroin, methamphetamine, MDMD and PCP (phencyclidine) combined. Each day, 129 individuals die from a drug overdose in the U.S. And yes, five of the seven most prescribed CPDs are opioids. The other two are amphetamine (i.e., Adderall) and methylphenidate (i.e., Ritalin and Concerta).

This information was taken from a yearly statistical summary published by the DEA called the National Drug Threat Assessment (NDTA). The 2016 NDTA Summary covers a wide range of data and classes of drugs. There’s even information on the various drug cartels operating in the U.S. This article will focus on CPDs.

The first figure (Figure 26) gives a comparison of the drug poisoning deaths for prescription drugs, cocaine and heroin from 2007 to 2014. Then Figure 29 shows the top five CPDs distributed nationwide in the BILLIONS of dosage units. Far and away from all the other CPDs, hydrocodone and oxycodone are the most prescribed drugs in the U.S. Both of these figures were taken from the 2016 NDTA Summary.

Not surprisingly, the number of admissions to publically funded treatment facilities for non-heroin opiate/synthetic abuse was 24% higher in 2013 than in 2008. The number of admissions has declined since 2011, but that has been offset by an increase in heroin use between 2011 and 2013.

Recently there has been an increase in the abuse of stimulant medications, specifically amphetamine. Between 2006 and 2011 the nonmedical use of Adderall increased by 67%.  Emergency department visits related to Adderall almost tripled between 2005 and 2010. Misuse of ADHD medications as a class resulted in a 76% increase in poison control interventions from 2005 to 2010.

Young adults 18-25 years old represent the majority of the increase in Emergency Department visits, despite children comprising the largest subset of ADHD diagnoses. Many high school and college age students display limited knowledge of either the side effects or the addictive nature of Adderall. This coincides with the popular reputation of the drug on college campuses as a study-aid to improve concentration, and not something harmful or addictive. This contributes to the increased rate of non-medical use among adults.

Looking at concerns with prescription drug use and misuse from another perspective, a report by Quest Diagnostics suggested many Americans are misusing their prescription drugs. In their 2016 Prescription Drug Monitoring Report, Quest Diagnostics found that 54% of patient specimens showed signs of prescription drug misuse. For the purposes of their analysis, a consistent result was when a patient was taking a prescribed drug appropriately. An inconsistent result meant the patient was either not taking their prescribed drug, was taking drugs in addition to those that were prescribed, or was taking drugs that hadn’t been prescribed to them. These three combined causes of “inconsistent test results” indicated potential drug misuse in the Quest report.

About 45% of the inconsistent specimens showed evidence of patients taking drugs in addition to what was prescribed to them, “suggesting the potential for dangerous drug combinations in a sizeable number of patients.” This 2015 finding was considerably higher than other years. STAT News quoted Quest’s medical affairs director as saying, ““The discovery that a growing percentage of people are combining drugs without their physician’s knowledge is deeply troubling, given the dangers.” Of particular concern is the combination of opioids and sedatives, which can lead to respiratory depression, coma and death. The following graphic was taken from the Quest Diagnostics report.

Quest also examined the drug groups associated with the highest number of inconsistencies, by age groups. Unfortunately, given their composite sense of “inconsistent test results,” it is not clear what caused the top inconsistent drug classes. For example, we can speculate that in the under age 10 category, the top two drug inconsistent classes (amphetamine and methylphenidate) were likely due to no drug found, meaning those children were prescribed, but not taking their ADHD medications. The same can be said for the various places that “marijuana metabolite” appeared. However, the inconsistent classes for benzodiazepines, opiates and oxycodone are not distinguished by cause. So while benzodiazepines are noted as the top inconsistent drug class for every age group over 25, it is not clear if that meant they were taken in addition to what was prescribed or not.

One exception to this was with heroin and benzodiazepines. Quest found 1.56% of their tests were positive for heroin. Among adults who tested positive for heroin, 28.6% were also positive for benzodiazepines. Among those who combined these two drugs, 92.3% of the benzodiazepines were not prescribed.

The Fix, an addiction and recovery website, enlisted Peter Grinspoon, the author of Free Refills: A Doctor Confronts His Addiction, to look at the study. Dr. Grinspoon observed that Quest Diagnostics is in the business of doing urine drug testing, so they are interested in promoting drug testing. He went on to say:

Drug tests simply aren’t that accurate. They’re subject to human and lab error, and are rife with both false positives and false negatives. Savvy drug users can outsmart these tests. Any drug testing needs to be interpreted in the context of who is using the drug and why they are using it.

It is true that Quest Diagnostics makes money by increasing the amount of urine testing it does; that it is interested in promoting and highlighting drug-testing. But this was the fifth Prescription Drug Monitoring Report done by Quest. Additionally, Quest provides testing services to about half of all physicians and hospitals in the U.S. So the claim in the report, that it is “well positioned to identify trends in prescription drug monitoring and misuse” is legitimate.

Further, Dr. Grinspoon’s comments on the inaccuracy of urine testing seem overstated. Yes, there are false positives and negatives; and labs can make mistakes. But he gave the impression these errors happen so often that drug testing was a questionable, unreliable procedure. The FDA, among other sources, considers laboratory testing of urine samples to be the most reliable way to confirm drugs of abuse.

He also seems to assume the testing in the Quest report included drug users given urines as part of their treatment within drug treatment programs, which is not the case. Quest specifically stated that drug rehabilitation clinics and addiction specialists were excluded from the analysis “given the higher rates of testing and potentially higher rates of inconsistency.” There is no reason for a drug user to want to outsmart a urine test done in conjunction with their ongoing medical treatment that I can imagine.

The bottom line is that I think the Quest Prescription Drug Monitoring Report still provides helpful and valuable information on the dangerous practice of combining prescription medications. But prescription drug misuse is just one third of a kind if opioid shell game. Along with heroin and fentanyl, it keeps us trying to guess where the next opioid crisis will be.

04/4/17

CBD and the DEA

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As 2016 drew to a close, the DEA announced its decision to classify cannabis extracts separately under the federal government’s Schedule I category. As Victoria Kim reported for The Fix, the ruling sent ripples of panic through the marijuana industry, playing on fears of what is ahead as our country grew closer to a Donald Trump presidency. While the DEA sees the change as marking a clear distinction between cannabis and it extracts, the marijuana industry sees it as saying that those who sell CBD oil are in violation of federal law. However, according to the DEA, the decision was made to more closely align U.S. policy with the United Nations, which already treats cannabis and its extracts separately.

Writing for Leafly, Bruce Barcott described the DEA announcement as an attempt “to criminalize the status of cannabidiol (CBD).” Hundreds of thousands of people around the country who rely on CBD products will be forced find CBD on the black market, according to the CEO of Women Grow. She said the rule “has the potential to inflict substantial harm to a legitimate industry that has been operating legally worldwide for over a decade.”  The executive director of the Cannabis Business Alliance said it creates “unfair barriers for companies with cannabidiol in their products.”

Cloaked in the guise of a bureaucratic technicality, DEA Administrator Chuck Rosenberg made an aggressive bid to wrap CBD into the Controlled Substances Act as a federally illegal Schedule I drug.

In an article he wrote for Leafly on the day of the DEA announcement, Barcott noted where the acting administrator for the DEA said the new code would allow the DEA to track quantities of marijuana extract separately from marijuana. The changes bring U.S. regulations into compliance with international drug-control treaties and present no major change in the law. “Rather it serves to clarify and reinforce the DEA’s position on all cannabis extracts, including CBD oil.” All marijuana extracts will continue to be treated as Schedule I controlled substances.

So what is the uproar if the DEA is merely bringing U.S. regulations in line with international regulations—if marijuana extracts were already Schedule I controlled substances? Barcott said the new rule clarifies the DEA’s position after the 2014 farm bill allowed certain states to grow hemp and blocked federal law enforcement from interfering with state agencies, hemp growers and agricultural research. Hemp-derived CBD oil is available nationwide on web sites and through mail order services. “Those operations survive on the assumption that cannabidiol products below the legal threshold for THC percentage in hemp (0.3 percent or less) are technically legal.” Barcott suggested the rule now says you can grow hemp, but if you try to extract CBD oil from it, the DEA considers that a federal crime.

First, hemp-based CBD products do not have the therapeutic benefits they claim to have. Writing for High Times, Mike Adams noted in his 2014 article, “The Difference Between Hemp Oil and High-CBD Strains,” that while CBD was still illegal in most of the U.S., its rise as “the rock star of the medical marijuana industry” provided the opportunity for some hemp businesses to “market a variation of knockoff CBD treatments that they claim have the same healing power as popular strains such as Charlotte’s Web.” These so-called “knockoff CBD treatments,” while technically similar to medical marijuana strains with CBD, “do not provide the same health benefits as high-CBD cannabis strains.”

However, after patients began submitting complaints about some of these products, including “Real Scientific Hemp Oil,” claiming they were making them sick, a research firm dedicated to cannabidiol education – called Project CBD – launched a full-blown investigation into the matter. After six months, the organization emerged with a 30-page report entitled “Hemp Oil Hustlers: A Project CBD Special Report on Medical Marijuana Inc., HempMeds and Kannaway,” which began as a curious look into an umbrella penny stock company, but transformed into a dissection of the hemp oil industry and its sometimes shady business practices.

Project CBD published a report in 2014 that investigated hemp oil products. The introduction of the report said that Project CBD did not believe that industrial hemp was an optimal source of CBD. On page 13 of the report is a quote from a press release of the Hemp Industries Association. The quote clearly indicates its position:

 It is important for America farmers and processors of hemp to understand that most CBD in products mislabeled as ‘hemp oil’ is a co-product of large-scale hemp stalk and fiber processing facilities in Europe where the fiber is the primary material produced at a large scale. CBD is not a product or component of hemp seeds, and labeling to that effect is misleading and motivated by the desire to take advantage of the legal grey area under federal law. Hemp seed oil does not contain any significant quantity of CBD.

So the hue-and-cry about the DEA’s clarification means that the loophole opened by the 2014 farm bill for hemp CBD products has been closed. Retailers selling “knockoff CBD treatments” of questionable medicinal value will now have to stop selling these products or face possible federal prosecution. This is a good thing. But what about the new 7350 drug code proposed by the DEA?

In the Federal Register, vol. 81, no. 240, under “Why a New Code Number is Needed,” it was noted that U.N. conventions on international drug control treated cannabis extracts differently from marijuana and THC. So creating a new drug code for marijuana extracts would allow for more appropriate accounting of these materials consistent with existing treaty provisions. The existing schedules contained in DEA regulations include marijuana as a Schedule I drug (drug code 7360). This listing includes “any material, compound, mixture, or preparation, which contains any quantity of the substance, or which contains any of its salts, isomers, and salts of isomers that are possible within the specific chemical designation.”

Until now, the DEA has used the 7360 drug code for all marijuana extracts. The proposed rule change recommends that a new drug code, 7350, should be used for marijuana extracts. Marijuana extracts “will continue to be treated as Schedule I controlled substances.” In other words, they were always Schedule I substances.

The Single Convention on Narcotic Drugs and 1971 Convention on Psychotropic Substances are international treaties that provide for the international control of marijuana. The schedules under the Single Convention prohibit the production and supply of specific drugs as well as drugs with similar effects—except for drugs under license for specific purposes, such as medical treatment and research. Many of the provisions of the Controlled Substances Act (CSA) under which the DEA operates were drafted to comply with these Conventions. Both the CSA and the Single Convention list drugs in four schedules, but their classification schemes mean different things. For one, drugs can be in more than one schedule under the Single Convention.

In the Single Convention, the most stringent controls are in Schedule IV; and all Schedule IV drugs are also listed in Schedule I. So placing a drug into both Schedule I and Schedule IV “imposes the most stringent controls under the Single Convention.” Cannabis or marijuana falls into three listings within the Single Convention. Cannabis is the flowering or fruiting tops of the cannabis plant (with the resin not extracted). Cannabis resin is the separated resin, crude or purified, obtained from the cannabis plant. Then there are the extracts and tinctures of cannabis.

The Single Convention placed “cannabis” and “cannabis resin” under both Schedule I and IV of the Convention, the most stringent level of control under the Convention. While “cannabis resin” is extracted from “cannabis,” the Single Convention specifically controls “extracts” separately. Extracts of cannabis are controlled only under Schedule I of the Convention, which is a lower level of control than “cannabis resin.”

Cannabis resin and cannabis (marijuana) will continue under the drug code for marijuana (drug code 7360). The DEA changes will distinguish cannabis extracts from cannabis resin, by defining “marijuana extract” to exclude material referenced as “cannabis resin” under the Single Convention. The new code number created by the DEA is as follows:

Marihuana Extract—7350 ‘‘Meaning an extract containing one or more cannabinoids that has been derived from any plant of the genus Cannabis, other than the separated resin (whether crude or purified) obtained from the plant.’’

Not only does this distinction bring U.S., CSA regulations in line with the Single Convention, it creates a category for medicinal cannabis extracts to be scheduled differently from the recreational cannabis products that fall within the “7360” drug code. Cannabis resin products such as shatter, wax, honey, budder and others will remain classified as 7360—along with the flowering or fruiting tops of the cannabis plant that are rolled into joints or smoked in pipes. But cannabis or marijuana extracts, coded with the 7350 drug code, could be reclassified into a lower CSA Schedule. As the science of CBD research demonstrates the medicinal efficacy of CBD more clearly and consistently, this could be done without rescheduling cannabis bud and flower or cannabis resin. No wonder companies selling marijuana and hemp-based CBD products don’t like the new DEA ruling.

09/9/16

The Dragon Threat

© Linda Bucklin | 123rf.com

© Linda Bucklin | 123rf.com

The DEA released its updated “National Heroin Threat Assessment Summary” on June 27, 2016 and the news is not good. Chuck Rosenberg of the DEA called the death and destruction from heroin and opioids “unprecedented and horrific.” The number of users, treatment admissions, overdose deaths, seizures from heroin traffickers all increased since the 2015 Summary. The increased demand and use of heroin is being driven by greater availability of heroin in the U.S. and prescription opioid users switching to heroin because it’s cheaper. “The problem is enormous and growing, and all of our citizens need to wake up to these facts.”

There were three big takeaways in the 2016 Summary: 1) the number of people currently using heroin almost tripled between 2007 and 2014. 2) Deaths due to heroin more than tripled between 2010 and 2014. 3) Deaths due to synthetic opioids, like fentanyl, increased 79% between 2013 and 2014. You can access a pdf of the full report here.

In 2014, 10,574 American died from heroin-related overdoses. Geographic areas of the country particularly hard hit are in the Northeast and the Midwest. See Map 2 in the 2016 DEA Summary. Not surprisingly, availability levels are the highest in these areas as well. Possible reasons for the increase in overdoses and deaths include: more heroin users, especially those who are new to heroin, who are young and inexperienced; the higher purity of heroin found in certain areas and the use of adulterants like fentanyl.

Twenty to thirty years ago, the average retail-level purity of heroin available in the U.S. was about 10%. By 1999, the average purity was 40%. While the purity increased, the price decreased. The average price per gram in 1981 was $3,260 in 2012 US dollars. By 1999, the price for a gram of heroin had dropped to $622. Heroin prices have remained low since then. With an increase in purity, heroin can be snorted or smoked, which broadens its appeal. “Many people who would never consider injecting a drug were introduced to heroin by inhalation.”

Beginning in late 2013, several states started reporting overdose death due to fentanyl and acetyl-fentanyl. There were 5,544 reported synthetic-opioid-related deaths in 2014. But the DEA speculated it was much higher because of a lack of standardization in reporting; and because coroners and state crime labs don’t initially test for fentanyl or its analogs unless they have a reason to do so. The eastern U.S. is the area most effected by this, because white powder heroin from South America predominates. Fentanyl, also a white powder, is mixed with heroin or sold disguised as white powder heroin. The following chart is from the 2016 DEA Summary.

Heroin deathsThe Mississippi River has historically been a geographic dividing line with Mexican, “black tar” and brown powder heroin more common west of the Mississippi and white powder heroin, now supplied from South America, common east of the Mississippi. But that is changing. Mexican traffickers are making inroads into major eastern cities. Mexican organizations are now the most prominent wholesale-level traffickers of heroin in Chicago, New Jersey, Philadelphia, and Washington DC. Increased trafficking of Mexican heroin means more heroin is entering the U.S. across the Southwest border from Mexico. Black tar heroin is popping up more frequently in the Northeast, although it still comprises a small percentage of the heroin seized.

Mexican traffickers have taken a larger role in the U.S. heroin market, increasing their heroin production and pushing into eastern U.S. markets that for the past two decades were supplied by Colombian traffickers. This is notable because Mexican traffickers control established transportation and distribution infrastructures that allow them to reliably supply markets throughout the United States

The DEA also noted the increase in counterfeit prescription pills, many which contain deadly amounts of fentanyl. Small-scale local drug entrepreneurs can buy the materials and equipment to produce the counterfeit drugs online and set up their own operation, ala Breaking Bad. “Fentanyl pill press operations have been identified in the United States, Canada, and Mexico, indicating a vast expansion of the traditional illicit fentanyl market.” Oxycodone and other opioid painkillers are the main counterfeited medications, but traffickers are also packaging fentanyl as Xanax and other benzodiazepines. See “Buyer Beware Drugs” for more information.

When comparing heroin use to other drugs in the U.S., we find that the population of heroin users is slightly smaller than the estimated population of methamphetamine users and significantly smaller than individuals reporting current cocaine use. However, the number of individuals reporting current use of prescription pain relievers non-medically was about TEN TIMES the size of heroin users. So although a rather small percentage of prescription drug abusers (4%) will try heroin, this represents a significant increase in the number of heroin users because the size of the prescription drug abuse population is so much larger. See the following chart taken from the 2016 DEA Summary.

chart 7Behind all these statistics are real people, some living and some now dead. And despite all the law enforcement efforts over the past several decades, the problem seems to be getting worse. So two federal law enforcement agencies decided to combine their efforts and try a different tactic. They thought they’d try to address the problem from the demand side instead of the supply side.

Back in February the FBI and DEA released a documentary film addressing the growing epidemic of prescription drug and heroin abuse. “Chasing the Dragon: The Life of an Opiate Addict” is intended as an educational film for high school and above. Educational materials have had mixed effectiveness with decreasing drug usage. But the value of this film is in its portrayal of the real people who chased the dragon and became part of the above statistics. You can watch the film here.

07/29/16

Be Careful of Where You’re Going

© : J�rg St�ber | 123rf.com

© : J�rg St�ber | 123rf.com

On July 9, 2015 eight Senators sent a letter to the Department of Health and Human Services (HHS), Office of National Drug Control Policy (ONDCP), and the Drug Enforcement Administration (DEA) asking for information on their efforts to facilitate scientific research into the benefits of medical marijuana. The Senators asked for answers to a series of questions, stating that relevant federal agencies had to play a leadership role in coordinating and facilitating research into medical marijuana. This began a process culminating in the administrators of the three agencies sending a detailed reply to their questions in an April 4, 2016 response … 26 pages long. And so speculation began that the DEA would decide whether or not to change the controlled substance status of marijuana “in the first half of 2016.”

This was part of the inquiry made by the Senators’ letter, in noting the need to remove “extraneous regulatory barriers for researchers who wish to perform scientific studies on the sue of marijuana for various diseases.” They pointed to the need of the federal government to make a concerted effort to understand how marijuana works and what the appropriate doses and methods of treatment are, “like any prescribed medicine.” Within Appendix C of the HHS, ONDCP, DEA response, was the following graphic and text delineating the process to schedule or re-schedule any drug.

DEAThe Controlled Substance Act requires eight factors as part of its scientific review: 1) the actual or relative potential for abuse; 2) the scientific evidence of its pharmacological effect; 3) the state of current scientific knowledge regarding the substance; 4) the history and current pattern of abuse; 5) the scope, duration and significance of abuse; 6) the risk to the public health; 7) the psychic or physiological dependence liability; and 8) the immediate precursor of a substance already controlled.

Writing for the Huffington Post in April 2016, Matt Ferner noted the FDA completed its review of the medical evidence of the safety and effectiveness of marijuana, and forwarded it to the DEA. But the FDA recommendations are still not public. In the Washington Post, Christopher Ingraham interviewed John Hudak of the Brookings Institution, who said the small amount of researchers currently working with marijuana is not due to the government turning down applications to do the research. Rather, it is a function of the application process itself. “People just aren’t applying because of all the headaches involved. . . . It’s a huge disincentive for the academic community.”

The bureaucratic hurdles also mean that colleges and universities are often hesitant to fund marijuana research for fear of running afoul of complex federal regulations. One ongoing study on the use of marijuana to treat veterans with PTSD has been struggling to get off the ground for more than five years, for instance.

There was an unconfirmed rumor by an “anonymous” DEA attorney that the DEA planned to reschedule marijuana as a Schedule II controlled substance and make medical marijuana legal with a doctor’s prescription in all 50 states. This is simply not true. Rescheduling would merely make it easier to get permission to do research with marijuana, not make it legal for doctors in all 50 states to prescribe marijuana. If that were the case, why can’t doctors prescribe cocaine legally? It is a Schedule II Controlled Subtance. Writing for The Fix, McCarton Ackerman noted the skepticism about the validity of the source.

In response to the rumors, DEA staff coordinator Russ Baer would not confirm the rumored rescheduling by August 1st in an interview with aNewDomain. Baer pointed out the complexity of what is referred to as “medical marijuana.” While THC and CBD are the two main cannabinoids, there are an estimated 480 compounds in cannabis. “What is under-reported right now is how complex the marijuana plant is.”

Baer said the DEA wants to remove the roadblocks to further research into the effectiveness of medical marijuana. However, he said the DEA doesn’t support decisions made on anecdotal evidence.

We want there to be research on marijuana and its component parts, there needs to be (more) studies about both the benefits and the adverse effects about marijuana. . . . We want to know more about cannabis— we need rigorous scientific research — the DEA stands behind the scientific process.

He added that safe medical cannabis requires rigorous peer-reviewed studies. He singled out current research into the benefits of cannabinol (CBD). “We are told by NIDA, also, that there are medical studies out there also preliminarily indicate CBD is beneficial.” But the opioid crisis has captured most of the DEA’s attention. “Marijuana is important, but our efforts are mainly focused on the nation’s growing opioid crisis. . . . We’re focusing on fentanyl, fentanyl compounds and on preventing the deaths caused by opioid addiction.”

A June 24th article by Kate O’Keeffe for the Wall Street Journal said Baer didn’t expect an answer by June 30th, but the agency was in the final stages of deciding whether to reschedule marijuana. He added that a decision is expected sometime soon.

On July 13, 2016 Dr. Douglas Throckmorton of the FDA appeared before the Judiciary Subcommittee on Crime and Terrorism. In his written statement to the committee, he reiterated its standing 2006 recommendation that marijuana remain as a Schedule I controlled substance because of a high potential for abuse; no currently-accepted medical use; and that it lacks accepted safety for use under medical supervision. However, “DEA is currently in the process of evaluating a number of other Citizen Petitions regarding the scheduling of marijuana.”

He noted there are three drugs approved for human use that contain active ingredients present in or similar to those in botanical marijuana: Marinol Capsules, Syndros and Cesamet Capsules. These products have undergone the FDA’s approval process and have been determined to be safe and effective for their respective indications. The future of medical marijuana lies in “classical drug development.”

If there is any future for marijuana as a medicine, it lies in its isolated components, the cannabinoids and their synthetic derivatives. Isolated cannabinoids will provide more reliable effects than crude plant mixtures. Therefore, the purpose of clinical trials of smoked marijuana would not be to develop marijuana as a licensed drug but rather to serve as a first step toward the development of nonsmoked rapid-onset cannabinoid delivery systems.

Throckmorton pointed to three Fast Track designations for Savitex (April 2014), Epidiolex (June 2014) and a CBD formulation of Insys Therapeutics to treat Dravet syndrome (February 2015). All three are drugs derived from marijuana.He said the FDA is working with researchers who are conducting studies on the development of potential new drugs derived from marijuana.

FDA encourages and supports medical research into the safety and effectiveness of marijuana products through adequate and well-controlled clinical trials conducted under an IND [Investigational New Drug] and consistent with DEA requirements for research on Schedule I substances. FDA has provided scientific advice to representatives from several states considering support for medical research of marijuana and its derivatives, including CBD, to help ensure that their research is rigorous and appropriate.

Another date floated on the rumor pond for a DEA decision on rescheduling marijuana was August 1st, which is fast approaching. Will there be an answer? Who knows? According to Russ Baer, the DEA is not bound to give its answer within some artificially determined timeframe. So I suggest those anxious for an announcement by the DEA (senators and marijuana activists alike) apply a mash up of a famous Yogi-ism here: “Marijuana ain’t re-scheduled till it’s rescheduled.” Perhaps the DEA is just trying to be careful in its decision making process about the rescheduling. Yogi Berra has some further words of wisdom to apply there: “You’ve got to be very careful if you don’t know where you are going, because you might not get there.”

06/7/16

Buyer Beware Drugs

© Yurly Kirsanov | 123rf.com

© Yurly Kirsanov | 123rf.com

At the end of March in 2016, detectives with the Onondaga County Sheriff’s Office executed a search warrant at a split level home in quiet suburban neighborhood about 8 miles north of Syracuse, New York. They discovered a fentanyl processing operation where six people were mixing and packaging fentanyl for street-level sales. Detectives found an estimated 5,866 doses of fentanyl, 2 ounces of A-PVP (flakka), a loaded 12-gauge shotgun, a replica sub machine gun, drug paraphernalia and $3,571. The total street value of the drugs was $60,000.

The individuals arrested were considerate enough to warn the arresting officers not to touch the fentanyl without gloves. The drug is potent enough to be absorbed through the skin if you touch it without gloves. I guess they were concerned about a possible felony murder charge on top of the drug charges. Although the source of the drug was not known at the time of the drug bust, it typically comes from international sources in Mexico and increasingly from China.

A similar arrest took place near Los Angeles, where four men were operating a pill lab in Baldwin Park. Police found several pill presses and large quantities of variously colored powders, among them acetyl-fentanyl and methamphetamine. DEA Agent David Dowling said: “Fentanyl and its analogues pose a serious public health risk. Even small doses absorbed through the skin or accidentally inhaled can be fatal.” They were getting their drug supply from China. The Southern California lab was just one of four by law enforcement in the U.S. and Canada in March of 2016.

David Armstrong reported for STAT News on both of the above incidents as well as a lab in a custom car business in British Columbia that was shipping 100,000 fentanyl pills monthly to nearby Calgary, Alberta. Police reported that the equipment used to press the pills had come from China. Recently a quarter-ton pill press was intercepted before it was transported to a suburban Los Angeles drug lab. It had been labeled as a “Hole Puncher.”

In an affidavit, DEA agent Lindsey Bellomy said that based on wire transfers and other evidence, she “strongly believes” the Southern California group acquired its fentanyl from China. The affidavit lists a dozen deliveries from China to members of the group in January and February.

The China connection is allowing local drug dealers in North America to mass produce fentanyl in pill form, in some cases producing tablets that look identical to an oft-abused version of the prescription painkiller OxyContin. It also has been added to Xanax pills.

The emergence of decentralized drug labs, using materials obtained from China, makes it difficult to police fentanyl sold as a street drug. A report from the Department of State’s Bureau for International Narcotics and Law Enforcement Affairs indicated China is still a major producer and exporter of fentanyl and other drugs for illicit international markets. Lax regulation, low production costs, and government corruption, mixed in with the country’s large chemical and pharmaceutical industries, makes China a perfect supply source for the materials needed for the illicit drug labs.

Fentanyl pills masquerading as hydrocodone were recently blamed for a wave of overdoses and 11 deaths in the Sacramento California area. The Sacramento Bee reported on April 13, 2016 there had been 51 fentanyl-linked overdoses since late Mach of 2016. By April 27th, the death toll was up to 14. The pills were exact replicas of a medium-strength opioid painkiller, Norco. The CDC discussed this outbreak in detail in one of their Morbidity and Mortality Weekly Reports (MMWR).

Analysis of the fake Norco pulls showed they contained fentanyl, promethazine, acetaminophen and trace amounts of cocaine. Normally used to treat nausea vomiting and motion sickness, promethazine is used here to boost the high of the opioid. Reporting for the Digital Journal, Karn Graham said the pills were exact replicas for the real ones. It was only pure luck that health officials were able to get one of the fake pills from an overdose patient in order to analyze its ingredients.  Keri Blakinger, writing for The Fix, said in Canada, British Columbia has declared a public health emergency from the increase of fentanyl overdose deaths in the province.

Lookalike oxycodone pills containing fentanyl have also appeared in Tennessee and Ohio. In testimony before the Committee on Homeland Security and Government Affairs in the U.S. Senate, Carole Rendon, the Acting U.S. Attorney for Northeastern Ohio said the overdose deaths from heroin and fentanyl had risen until they began to see an average of two overdose deaths per day in March of 2016.  She said: “Opioid addiction knows no boundaries. It is an equal opportunity killer of old and young, men and women, urban, suburban, and rural, rich and poor, black, white, and Hispanic. We are all at risk.”

In February, Tennessee officials warned about the availability of counterfeit drugs, specifically pills being sold as Percocet that actually contained fentanyl. David Reagan, the Chief Medical Officer of the Tennessee Department of Health said: “When people sell fake pills appearing to be oxycodone but actually containing the more powerful pain medicine fentanyl, lives are at risk.” During a traffic stop in May of 2015 a police officer discovered several 30 mg pills of what appeared to be oxycodone, with its signature A/215 stamp characteristic. Lab analysis showed they were fentanyl. In January of 2016, 300 pills stamped with the characteristic markings for Percocet were found to be fentanyl.

Even worse, counterfeit Xanax pills that contain fentanyl are appearing. In October of 2015 at least three people died from ingesting the combination drug in San Franciso. Saint Petersburg Florida reported that nine people died in Pinellas County from what was being sold as Xanax on the street. The pills were actually a combination of fentanyl and Xanax. The Daily Mail said the combination is sold as “Super Pill” on the street for as little as $5 a pill.

Last, and probably worst, there is another synthetic opioid coming onto the illicit drug market, W-18. It is 100 times more powerful than fentanyl; 10,000 times more powerful than morphine. And again, the likely source for the drug is China. Alan Hudson, an associate professor with the department of pharmacology at the University of Alberta, said W-18 is one of the most dangerous drugs in the whole spectrum of analogs. A tiny speck can cause respiratory failure and kill you.

Global News reported that the drug comes from a “W-series” of opioid compounds first discovered at the University of Alberta in Canada in 1982. Of the 32 compounds, W-1 to W-32, W-18 was the most toxic. As little as four kilograms of the drug is enough to produce millions of tablets. An Edmonton-area drug bust in December 2015 netted four kilograms of W-18.

Because of its potency, W-18 exponentially raises the stakes for potential overdoses. “It’s just too potent to even consider using.”  It was never listed as a controlled substance; never tested on humans. So it is technically legal and for sale online—typically from China. “Obviously somebody in China has picked up on the fact that W-18 is quite easy to make in large quantities and they’re trying to sell it to the North American market.”

If you are having trouble understanding why the practices above persist, think about basic branding, marketing and salesmanship. Established brands in the drug market include “heroin” and various pills like: “OxyContin”, “Percocet”, “Xanax”, and even “MDMA.” A significant segment of the drug market has a negative view of heroin, so they prefer to use pharmaceutical versions of opiates/opioids. So they seek out “OxyContin”, “Percocet”, and others. There is also a higher production cost for pills due to their stricter regulation. Pharmaceuticals are legally produced; heroin is not.

Over the past 100 years or so, the government has developed a regulatory process to give consumers some assurance that when they buy pharmaceuticals, they are getting what they paid for. Even with all the problems in the existing regulatory procedures, the modern pharmaceutical consumer is better protected today than they were during the time of patent medicines. THERE IS NO REGULATORY PROCESS FOR ILLICITLY PRODUCED DRUGS.

So if drug dealers and manufacturers want to increase their profits, they produce knockoffs of the more popular drug brands (like Percocet or heroin) by substituting cheaper products for the known brands. Since there is no regulatory process, they can and do sell knockoffs to their customers as the real thing with relative impunity. Illicit drugs today are truly a “buyer beware” market. The consumer/user is risking their health and their life as they seek out the newest, best high.

11/23/15

Cocaine’s Secret Ingredient

© lldipapp | Dreamstime.com

© lldipapp | Dreamstime.com

Writing for Time back in 2010, Maia Szalavitz described how the connection between levamisole and cocaine first came to light. In the summer of 2008, a man and a woman in their twenties were both admitted to a Canadian hospital with fevers, flu-like symptoms and dangerously low white blood cell counts. Although the symptoms were consistent with agranulocytosis, at the time it was only known as rare disease found in chemotherapy patients and others taking certain antipsychotic medications. Neither of the Canadian patients fit that profile. But they had one thing in common: they used cocaine. A search of the medical literature at the time didn’t find any studies linking agranulocytosis with cocaine.

But in April of 2008, a New Mexico lab had notified the New Mexico Department of Health (NMDOH) of a cluster of unexplained agranulocytosis cases in the preceding two months. The NMDOH launched their own investigation and “identified cocaine use as a common exposure in 11 cases of otherwise unexplained agranulocytosis.” In November of 2008, the NMDOH investigation and the Canadian public health officials connected with one another. In January of 2009 the NMDOH posted a notification of its findings on the CDC’s Epidemic Information Exchange. In a still separate investigation, public health officials in Seattle Washington identified 10 cases of agranulocytosis among persons with a history of cocaine use between April and November of 2009.

In the midst of this growing public health mystery, two high profile overdose deaths occurred. Celebrity disk jockey Adam Goldstein, better known as DJ AM, died of an overdose of cocaine and prescription drugs in September of 2009. Among the drugs found in his system was levamisole. Goldstein had been a fixture on the A-list party circuit and was a well-known cocaine user. Ted Koppel’s son Andrew accidentally overdosed in June of 2010. The medical examiner found a combination of drugs in his system at the time of death, including cocaine and levamisole. It was likely that neither men knew they had been snoorting any levamisole.

SAMHSA, the Substance Abuse and Mental Health Administration, posted a public health alert the same month of Adam’s death warning of the dangers of levamisole. Citing information from the DEA, the report said the percentage of cocaine specimens containing levamisole tested in its labs has steadily risen since 2002. In July of 2009, 70% of the illicit cocaine tested contained levamisole. They said there had been around 20 cases agranulocytosis, including two deaths associated with cocaine adulterated with levamisole.

Levamisole is used in veterinary medicine as a deworming agent for cattle, sheep and pigs. In the past, it was approved for use with humans to treat autoimmune diseases and cancer. It’s been increasingly found as an additive to cocaine in samples tested worldwide. It has some serious side effects like a weakened immune system, painful sores and wounds that don’t heal—the above noted condition called agranulocytosis. Left untreated, it could lead to death. Here is a short video on Adam’s death and some pictures of individuals with agranulocytosis from cocaine use. Don’t watch it if you have a weak stomach.

A recent case report in the British Medical Journal described a 42 year-old woman who came to an outpatient clinic in Britain suffering from vasculitis, an inflammation of the blood vessels. She had severe joint pain, muscle pain, intermittent abdominal pain and lesions. Initially, she repeatedly denied any cocaine use, but eventually admitted using it in the past. Hair testing done was positive for her recent use of levamisole-contaminated cocaine.

Erowid, a pro-drug website cautioned its readers to be honest with healthcare providers about their illicit substance use when they seek treatment for conditions like high fever that could be from levamisole to improve their chances of proper diagnosis and quick recovery. In other words, don’t do what the woman in the BMJ case report did. There was an informative article there on levamisole that noted how widespread levamisole-tainted cocaine is: Australia, Canada, Colombia, France, Guyana, Italy, Jamaica, the Netherlands, Spain, Switzerland, the United Kingdom, and the United States. Speculating why cocaine is adulterated with levamisole, Erowid said:

According to the DEA, levamisole–as well as other adulterants–is apparently present in some shipments of cocaine intercepted before they are broken up for further distribution to consumers. Considering that, in one batch, only 6% by weight of the total product sold as cocaine was levamisole, it seems possible it is more than simply a bulking agent. One theory is that levamisole or other adulterants boost the effects of cocaine, permitting material to pass for higher-quality product despite additional cuts made down the line. Another theory is that levamisole or other adulterants are added as chemical signatures used to track distribution of material.It may be that levamisole has been used because it has similar solubility properties to cocaine and therefore is difficult to remove and has not previously been considered a serious health hazard. As of October 1, 2009, there is no definitive answer as to why it is used as a cocaine adulterant.

Kim Gosmer, a chemist specializing in narcotic samples at the Department of Forensic Medicine as Aarhus University in Denmark speculated that levamisole-tainted cocaine originated from South America. Cited in a Vice article, he said that forensic chemists are finding levamisole-tainted cocaine all over world, increasingly from every level of distribution. Gosmer believed this suggested the adulterant is added to the cocaine in South America before it is exported. “So the question is: Why bother diluting high-grade cocaine that costs almost nothing to produce (compared to street prices) with a compound that’s more expensive than other adulterants and diluents?”

He went on to say that the amount of levamisole found in cocaine is typically not very large. So it’s not added strictly to cut the cocaine. But one of its metabolites called aminorex has amphetamine-like properties. Another possibility is that levasimole increases the amount of dopamine released by glutamate levels in the brain. “Levasimole could potentially increase the effect of cocaine through its release of dopamine.”

Casual cocaine users purportedly don’t have to worry; but habitual users should worry. With upwards of 70% of the cocaine from around the world testing positive for levamisole, the typical cocaine user will snort some levamisole sooner or later. SAMHSA warned levamisole was a dangerous substance and that agranulocytosis was a very serious illness that needed to be treated at a hospital. Remember the similar warning given by Erowid. So if you use cocaine, watch out for:

  • high fever, chills, or weakness
  • swollen glands
  • painful sores (mouth, anal)
  • any infection that won’t go away or gets worse very fast, including sore throat or mouth sores -skin infections, abscesses -thrush (white coating of the mouth, tongue, or throat) -pneumonia (fever, cough, shortness of breath).”

It used to be that you could trust drug dealers to only cut their cocaine and heroin with inert ingredients. It seems that the cost of snorting cocaine is going up in more ways than one.

10/12/15

“Shake and Bake” Meth Labs

© Mikko Lemola | 123rf.com

© Mikko Lemola | 123rf.com

The DEA posted maps of the total number of meth lab incidents from 2004 through 2014. There were 23,829 total incidents in 2004; 6,858 in 2007; 13,432 in 2012; and 9,306 in 2014. Missouri, Tennessee and Iowa were the state with the highest amounts of reported meth lab accidents in 2004; Indiana, Missouri, and Tennessee for 2014. Many states throughout the US had dramatic decreases in reported accidents. That’s the good news. The bad news is that a CDC study indicates injuries from methamphetamine-related incidents are on the rise in some parts of the country.

The CDC report noted there was an increase of reported incidents from 2001 through 2004; followed by decreases through 2007; with increases again through 2012. In 7% of the meth-related incidents, 162 people were injured, including 26 children (16%).  Among the injured, 136 (84%) were treated at a hospital, including 19 of the injured children. There were also two reported deaths: one probable meth cook and one law enforcement official.

The percentage of incidents with injured persons increased from less than 5% during 2001-2004 and 2005-2007 to 10% during 2008-2012. Most of the injuries were to members of the general public (97) and law enforcement officials (42). The most frequently reported injuries overall were: respiratory irritation, burns and eye irritation. Burn injuries were almost exclusively experienced by the general public, with 42 of the 44 reported injuries.

The researchers speculated that the initial declines in injuries were related to state and federal restrictions on the retail sales of common meth precursor drugs, ephedrine and pseudoephedrine. This was reversed in 2008 when meth cooks adapted by buying permitted quantities from multiple locations, often with false identification. Additionally, a new method for making meth became popular, one called “shake-and-bake.” This involves shaking smaller amounts of the precursor chemicals in a 2 liter plastic bottle. Unfortunately, the bottles frequently burst, causing burns and environmental contamination. “Burn injuries increased during this time, particularly to members of the public, who might have been meth cooks or household residents.”

Children who are present during the production of meth face many hazards. The Horton et al. study cited below reported that half the events with injured children occurred between midnight and 6 am, when most children are asleep. The authors speculated that sleeping children have an even higher risk of acute injury during an emergency event. “This is particularly true if the parents/care givers are in another part of the house and/or are under the influence of meth.” Several states have enacted laws to protect children from meth-related injuries.

A 2003 study by Horton et al. examined data from Hazardous Substances Emergency Events Surveillance (HSEES Events) identified eight children injured in meth events. “Five of the meth events with children occurred in private residences: three of which occurred in houses, one in an apartment building, and one in a duplex.” One of the children injured was 8 years-old. They concluded:

The HSEES data appear to indicate that the numbers of meth labs and associated emergency events will continue to increase, putting more children and other unsuspecting individuals at risk for hazardous substance(s) exposure. More action is needed to remove children from these dangerous environments and to educate innocent bystanders, as well as the substance abusers themselves, about the risks involved with meth and its illicit production.

A 2009 study by Thrasher et al., using case reports from the Washington State Poison Control Center found that a large proportion of meth lab exposures occurred in private households. Of the 198 exposed persons, 10.6% were meth cooks, 15.7% were law enforcement personnel, 35.4% were residents and 38.3% were classified as other. Twenty-eight of the reported exposures (19.2%) were children. “A subject’s own residence was the predominant site of exposure for cooks (71%), other adults (41%), and children (66%).”

Although the CDC study indicated recent increases in an increase in meth-related injuries, there is distinct likelihood the true incidence is significantly under reported. One limitation of the CDC study was that only five states were included. Now this was because those five states (Louisiana, Oregon, Utah, New York, and Wisconsin) were the only ones with complete information available for the time period 2001-2012. Another limitation was that meth incidents in homes were not included in the original data from the National Toxic Substance Incidents Program (NTSIP) unless there was a public health action, such as an evacuation.

Total Meth Incidents 2004 Total Meth Incidents 2014
Oregon 632 1
Utah 107 1
Wisconsin 109 14
Louisiana 176 11
New York 136 197
Missouri 2,913 1,034
Tennessee 2,341 958
Iowa; Ohio (2014) 1,666 919
Illinois; Michigan (2014) 1,576 750
Indiana 1,377 1,471

One illustration of this under reporting can be seen by examining the incidents reported in the DEA maps for those five states included in the CDC study to the incidents in the five states with the highest reported incidents in 2004 and 2014. The five states included in the CDC study were: Oregon, Utah, Wisconsin, Louisiana, and New York. The five states with the highest reported incidents in 2004 were: Missouri, Tennessee, Iowa, Illinois, and Indiana. The five states with the highest reported incidents in 2014 were: Missouri, Tennessee, Indiana, Michigan, and Ohio. The total meth incidents for the five states in the CDC study, for 2004 AND 2014 were less than the incidents for just one of the top five states—for both 2004 and 2012. Another readily noticeable fact is that the highest incident states for both 2004 and 2014 cluster in the Midwest, with the border states of Tennessee and Kentucky thrown in for good measure.

We can say there was an increase for the five states included in the CDC study, but can’t assume that increase holds throughout the US. It is likely the real total is much higher, especially in the selected states from the DEA map noted here.

The Department of Justice has produced a handy pamphlet of “Fast Facts” about meth labs. It described signs to look for if you suspect the presence of a meth lab. These signs include: unusual odors; excessive trash, especially chemical containers, coffee filters, red stained pieces of cloth, and duct tape rolls. Other indications are secretive, unfriendly occupants; frequent visitors, esp. at unusual hours; curtained or blackened windows; extensive security measures or attempts to ensure privacy, such as “no trespassing” or “beware of dog” signs.

Meth labs come in all sizes. Super labs produce 10 pounds or more of meth at a time; smaller “box” labs produce as little as an ounce and can fit in a box or backpack. They can be located almost anywhere: private homes, hotels and motels, automobiles, boats and luggage. They can also be found in commercial and industrial districts; or nestled away in a secluded rural area.

The chemical used to produce methamphetamine are extremely dangerous. Some are very volatile and could ignite if not handled properly, as apparently was the case in the motel video mentioned below. Even if there is not fire or explosion, meth production is dangerous. Exposure to the chemical can pose a series of health risks, including respiratory problems, severe chemical burns, pulmonary edema, and more. Look at a table in the pamphlet listing various chemicals used in meth labs and the hazards associated with them.

Health Research Funding posting some facts about meth lab explosions and also had two embedded videos of meth lab explosions. One video shows a mobile home in a rural setting going up in smoke. The other captured an explosion in a motel room on a security camera. Seven burn units have shut down over the last six years because of the unreimbursed costs of treating burn victims in meth lab explosions. One pound of meth results in six pounds of toxic waste. Eighty percent of the meth labs found and dismantled by authorities used the “shake and bake” method.

The simplified “shake and bake” method and smaller size of these labs means that rolling meth labs in cars, trailers or mobile homes can be easily moved to a secluded location where the manufacturing fumes can’t be detected and the toxic waste discarded. In 2002, Interstate 24 in southwest Kentucky was temporarily shut down when a car containing anhydrous ammonia exploded. It was a rolling meth lab. “Trucking down the highway allows them to disperse the rotten egg smell the labs produce and keep the waste out of their own homes.” Of the 2,000 chemicals that could be used to make meth, at least half are explosive.

Illustrating how meth labs can be found anywhere, here is an article about an explosion that occurred at a federal facility in Gaithersburg, MD. The explosion happened on the main campus of the National Institute of Standards and Technology (NIST) on June 19th, 2015. Federal law enforcement officials found pseudoephedrine, drain opener and a recipe for making methamphetamine in the lab. Representative Lamar Smith wrote in a letter to the Commerce Secretary said: “I am troubled by the allegations that such dangerous and illicit activity went undetected at a federal research facility.”

04/13/15

The Economics of Heroin

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© Berna Namoglu | 123RF.com

I live in the suburbs of Pittsburgh. At least nine times each week I drive past a retail store where someone I know once told me they shot up heroin in the store’s parking lot. The store sits on a busy street. This incident was a few years ago, but I’m pretty sure that wasn’t the only time someone used heroin in my neighborhood, because it’s happening all around me.

A teacher from the Montour School District was recently charged with two counts of possession with intent to deliver. Police said he was selling heroin out of his home. The school district suspended him immediately. The school district’s solicitor said there was no evidence that the man possessed or sold drugs on school property. The accused has been a math teacher for at least a decade. The ironic twist is that he rented his home from the Robinson Township police chief, who said he’s never had any problems with the accused … until now.

The Pittsburgh Post-Gazette reported at the end of February 2015 that three people from Armstrong County were charged in connection with an overdose death linked to fentanyl-laced heroin known as “theraflu.” I work part time at an outpatient treatment center in Pittsburgh and remember when the theraflu scare was going on in January last year. Seventeen people from around Pittsburgh died of overdoses in a week. A local medical examiner at the time said it was  “major public health crisis.”

An ongoing investigation of drug trafficking in Homewood and other communities in the Pittsburgh metro area recently added 14 new defendants to the 40 who were originally indicted in October of 2014. US Attorney David Hickton said they were “important cogs” in a multi-state drug distribution ring. “They would be the Pittsburgh connection to this organization that has reach far beyond out state.” The trafficking involved heroin, cocaine and crack cocaine coming from Los Angles to Homewood via Cleveland. Harold Hayes of KDKA said: “The FBI says the long-term investigation has led to the indictment of more than 100 people and the seizure of more than $1 million.”

The 2014 National Drug Threat Assessment Summary (NDTS) published by the DEA stated that the threat posed by heroin in the US has been increasing across the country, particularly in the Northeast and North Central regions. The two major geographic areas for heroin supply in the US are Mexico and South America. Together they account for 96% of the heroin analyzed by the DEA in 2012. The NDTS reported that heroin seizures increased 87 percent in five years, from 2009 to 2013.

The observed increase in demand for and abuse of heroin is said to be the result of individuals who used to abuse prescription opioids switching to heroin. Reasons given for the switch include: the relatively lower cost of heroin than prescription opioids; the decreasing availability of prescription opioids versus the increasing availability of heroin; the reformulation of OxyContin, making it more difficult to abuse. My own experience with people abusing heroin is that the switch is mostly market driven, by the cost differential and the availability of heroin.

In 2013 and 2014, the Northeast and Midwest reported a spike in overdose deaths from fentanyl being sold as heroin. Fentanyl is 30 to 50 times stronger than heroin. The overdoses include both new and experienced users. Thinking they are buying heroin, the users typically don’t realize they are buying fentanyl or a fentanyl-heroin mixture. Between 2005 and 2007 over 1,000 overdose deaths were traced back to a single laboratory in Mexico. The lab was seized and destroyed. The recent outbreak, noted above, covered a wider geographic area than in 2005-2007 and involved both fentanyl and fentanyl analogs.

In Mexican states like Sinaloa and Guerrero, poor farmers living in wood-plank, tin-roofed shacks with no indoor plumbing are growing the poppies that eventually become the heroin sold in American cities like Pittsburgh. Jake Bergman, reporting for the PBS show Frontline, noted how Sinaloa has been the breadbasket for Mexico for decades. Now it a drug-rich area, “the cradle of the biggest traffickers Mexico has ever known.” They even have their own “patron saint”—Jesus Malverde. Malverde’s legend says he robbed from the rich and gave to the poor. Nevertheless, he was hung by the governor of Sinaloa in 1909. His “sainthood” is not recognized by the Roman Catholic church. Father Antonio Ramirez said: “Nobody has become a saint robbing and killing, he was a bandito.”

Nick Miroff reported last year for the Washington Post that the drug trade in Sinaloa has been going through a transition lately. Farmers who used to grow cannabis are now planting opium poppies. Rodrigo Silla, a lifelong cannabis farmer, said it’s not worth it anymore. The wholesale price for a kilogram of cannabis dropped from $100 to less than $25. “I wish the Americans would stop with this legalization. . . . There’s no other way to make a living here.” The Silla family consists of three generations of drug farmers.

A kilo of the raw, sticky opium sap that is used to make heroin sells wholesale for $1,500 in the northern Sierra Madre, nearly double its 2012 price, according to growers. With fertilizer and favorable weather, a well-tended poppy field can yield eight kilos of sap per acre, nearly enough to make a kilo of raw heroin.

David Shirk, a researcher at the University of California at San Diego said that the farmers are simply diversifying because they have a product losing its value. “The wave of opium poppies we’re seeing is at least partly driven by changes we’re making in marijuana drug policy.”

Sinaloa has grown opium poppies since the time of the arrival of Chinese settlers in the last half of the 19th century. But large-scale production did not begin until World War II. Japan controlled the Asian opium market and the US military needed morphine for its soldiers. During this time, many Sinaloans made a fortune. Everyone was growing it. Even some government officials got into the opium export trade. After Japan was defeated, the US no longer wanted the inferior Sinaloan opium. “But many farmers continued to produce opium and heroin; operations became more clandestine, and a smuggling network was set up.”

Writing for the Associated Press, Mark Stevenson reported that farmers in Guerrero don’t like growing opium poppies, but it’s the only thing that will guarantee them a cash income. Humberto Nava Reyna, the head of a group promoting development projects in the region said: “They can’t stop planting poppies as long as there is demand, and the government doesn’t provide any help.” Residents say there are no local users. “It all goes for export, a lucrative business mostly run by the Sinaloa Cartel.”

So it’s sounding like the war on drugs needs to begin changing tactics. Instead of spending so much time and energy on chocking off the supply routes, there should spend more time and energy on drug treatment and prevention to dry up the demand. And there should be some funds given to Humberto Reyna and others like him to help the multi generational drug farmers transition to non-drug crops. And I think I’ll start praying for the Silla family and other drug farmers when I pass by that retail store in my neighborhood.

11/3/14

Strange Bedfellows: Terrorists and Drugs

© Hurricanehank | Dreamstime.com - Terrorist In Mask With A Gun Photo

© Hurricanehank | Dreamstime.com – Terrorist In Mask With A Gun Photo

This past May, the DEA raided a Birmingham Alabama warehouse as a part of Project Synergy. Inside, agents found hundreds of thousands of “Scooby Snax” baggies containing spice (synthetic marijuana). Sales of the product were also linked to $40 million in wire transfers to Yemen. Yemen is the home base for Al-Qa‘ida in the Arabian Peninsula (AQAP). While not able to directly link the money to a particular group or organization, DEA spokesperson Rusty Payne said: “It doesn’t take a rocket scientist to figure out that people aren’t sending $40 million to their struggling relatives overseas.”

Derek Maltz, the director of the Special Operations Division of the DEA said: “There’s a significant, long history between drug trafficking and terror organizations.” More than 50 percent of the State Department’s designated foreign terrorist organizations (FTOs) are involved with the drug trade. While the Obama administration has been successful in cutting off state-sponsored funding for terrorist organizations, they have looked for other sources of revenue. The $400 billion annual international drug trade is the most lucrative illicit business in the world and a tempting “investment opportunity” for terrorists.

Maltz went on to say that the synthetic drug market is a “two-for-one deal” for terrorists—they undermine Western countries with the drugs and make millions in the process. We’ve put a bull’s-eye on our back, he said. “When you see a designer synthetic drug industry as lucrative as this in the U.S., it would only be natural that it would be a huge target for those trying to finance their terrorists.”

The world of narcoterrorism has some diversity in its investers. The Taliban in Afghanistan distribute heroin; FARC in Columbia deals in cocaine; and al Shabab in West Africa is alleged to sell khat. While the association of al Shabab and khat may be questionable (here and here), the links between the Taliban and heroin as well as FARC and cocaine are well documented.

While Afghanistan and growing opium have been linked for thousands of years, it has only been in the last three decades that it has become the center for worldwide opium cultivation. Since 2001, opium production in Afghanistan has increased from 70 percent of the overall global opium production to 92 percent. To give you a sense of the size of this, the 2013 World Drug Report indicated that in 2011, Afghanistan produced 5,800 tons of opium, down from 7,400 tons in 2007. The next largest opium producer in 2011 was Myanmar with 610 tons of opium.

The World Bank estimated that the opium GDP of Afghanistan is between $2.6 and $2.7 billion. This amounts to 27 percent of the country’s total GDP, both licit and illicit. And yet, only 3 percent of the natural agricultural land in Afghanistan is used for its production. Poverty is widespread in Afghanistan and many of farmers are compelled by economics and force to grow opium. “Opium is valued at over $4,500 per hectare, as opposed to only $266 for wheat.” Because of this potential profit, many farmers are pressured to cultivate opium by various organizations, warlords and landowners.

The provinces of Helmand and Kandahar, which were regularly in the news during the war in Afghanistan, are also the primary opium producing provinces in the country. As former Afghan president Hamid Karzia said: “The question of drugs . . . is one that will determine Afghanistan’s future. . . . [I]f we fail, we will fail as a state eventually, and we will fall back in the hands of terrorism.”

According to sources in Spanish intelligence, the Islamic State and other jihadist groups are using their connections in the illegal drug market to finance their operations in Iraq and Syria. Jihadists use their knowledge of drug smuggling routes to export arms, contraband and new recruits from Europe to Iraq and Syria. Ironically, the pressure to dry up legal fundraising for terrorist organizations has contributed to their increased trade with illegal arms and drugs.

According to reports from Spain’s recently established government intelligence and counter-terrorism unit CITCO, 20% percent of those detained in Spain under suspicion of working with Islamic State and other jihadist groups have previously served prison sentences for offences such as drug trafficking or document counterfeiting.

FARC rebels control over 60 percent of Columbia’s drug trade, including overseas trafficking. The Revolutionary Armed Forces of Columbia (FARC) earns about $1 billion annually from the production and sale of cocaine in Columbia. According to General Jose Roberto Leon, the head of the Columbian national police force, “We have information found on computers after operations that have captured or killed FARC leaders, and it’s involvement in drug trafficking is evident.” The Columbian anti-narcotics police chief, General Ricardo Restrepo, said that officials fear that if a peace deal with FARC is successfully negotiated, thus cutting into cocaine production, that new gangs producing synthetic drugs will emerge. “It will be our next battle.”

The connection between terrorism and drug trafficking does not currently get much attention in the news media, in part, because the connections are difficult to make. But it does exist and seems to be a growing trend. Spanish intelligence sources have reported that European jihadist groups are using drug smuggling routes to export drug contraband and new recruits from Europe to Iraq and Syria. And most of the cocaine entering Europe is reportedly going through territories controlled by the Islamic State.

The Birmingham bust discussed above is particularly disturbing to me as it connects the making and distribution of the newest addictive danger, new psychoactive substances (NPS), with terrorism. This combination truly is a two-for-one threat. But we can have a two-for-one response to that threat. Both the war on drugs and the war on terrorism can be fought by social policies as well as drug treatment and education that aim for the reduction of drug use.  Who would have thought that the slogan in the war on drugs would someday be: Fight Terrorism by Becoming Drug Free.

09/29/14

Psychoactive Science or Sideshow

© Randomshots | Dreamstime.com - Medicine Wagon Photo

© Randomshots | Dreamstime.com – Medicine Wagon Photo

There is a growing call to permit research into the therapeutic benefits of a variety of psychoactive drugs currently classified by the DEA as Schedule 1 controlled substances. The editors of Scientific American called for the U.S. government to move LSD, ecstasy, marijuana and others into Schedule 2, with cocaine, methamphetamine, fentanyl and Ritalin. They point out that such a move would not lead to decriminalization, “but it would make it much easier for clinical researchers to study their effects.”

Schedule 1 controlled substances are “drugs with no currently accepted medical use and a high potential for abuse.” They are seen as the most dangerous drugs, “with potentially severe psychological or physical dependence.” Schedule 2 controlled substances are “drugs with a high potential for abuse, less abuse potential than Schedule 1 drugs, with use potentially leading to severe psychological or physical dependence.”

British researchers have also called for greater access to “classical hallucinogens” such as psilocybin (magic mushrooms, another Schedule 1 drug) and LSD for research into treating depression.

Classical hallucinogens alter the functioning of this system [serotonergic], but not in the same way current medications do: whilst there are identified receptors and neurotransmitter pathways through which hallucinogens could therein produce therapeutic effects, the neurobiology of this remains speculative at this time.

These drugs are all caught in a catch-22, de facto ban on their use in medical research because of their Schedule 1 placement. “These drugs are banned because they have no accepted medical use, but researchers cannot explore their therapeutic potential because they are banned.” Three United Nations treaties extend similar prohibitions to rest of the globe, further complicating their reclassification as Schedule 2 drugs.

British psychiatrist David Nutt has argued that the U.N. charters are outdated and restrict doctors and scientists from studying hundreds of drugs.  He likened this “research censorship” to the Catholic Church banning Galileo from teaching or defending heliocentric ideas in the 1600s. Nutt suggested the Catholic Church banned the telescope, but the ban was actually on books that taught Copernican beliefs.

Nevertheless, he called the laws, which do not discriminate between research and recreational drug use relics of another age. “These laws serve no safety value. . . . The licenses and bureaucracy surrounding them can increase the costs of research tenfold, further limiting what is done.”  Dr. Nutt commented on how LSD and other hallucinogens like psilocybin had potential to explore and treat the brain. “Other therapeutic targets for psychedelics are cluster headaches, OCD and addiction.”

The argument for reclassifying psychoactive substances like marijuana, LSD, ecstasy and psilocybin from Schedule 1 to Schedule 2 has its pros and cons for me. The above discussion presents the case for reclassification, permitting future research into these substances. IF the ideal of rigorous, methodical research into the therapeutic potential of these drugs is followed, all is well.

But we are now in the midst of an epidemic of prescription drug abuse that came through the very same gauntlet of review and approval that these known recreational drugs would pass through to become medicinal agents once they were reclassified. And while there are potential therapeutic applications for marijuana, the current state of medical marijuana looks more like the older sideshow of patent medicines, where you could get cocaine toothache drops, heroin for cough relief, and Mrs. Winslow’s Soothing Syrup (which contained morphine) for teething discomfort.

UntitledIf special interest groups can be held off from bringing about a new age of snake oil salesmanship, then reclassifying these substances and permitting legitimate scientific research makes sense. Done correctly, it might even demonstrate that some of the existing curative claims for medical marijuana and other substances were false. But if these psychoactives achieve FDA approval for any reason, they could be prescribed “off label” as is currently the case with other FDA approved drugs.

Do you think these Schedule 1 drugs should be reclassified as Schedule 2 drugs?