Illegal Pills: An Overlooked Threat

A Joint Project by National Association of Boards of Pharmacy, National Association of Drug Diversion Investigators, and the Partnership For Safe Medicines. This Article was Originally Posted to opioidlibrary.org.

EXECUTIVE SUMMARY

For less than $500, an individual with ill intent can purchase a pill press and a counterfeit pill mold that allows them to turn cheap, readily available, unregulated ingredients into a six-figure profit. Criminals rely upon these pill presses to create dangerous counterfeit medications with toxic substances such as cheaply imported Fentanyl. Their deadly home-made products have reached 46 states in the United States. Of grave concern is the significant lack of manufacturing control utilized in the making of these counterfeit products. The inexperience of these “garage manufacturers” has killed unsuspecting Americans in 30 states.

Counterfeit medications that can kill someone with a single pill are a reality that is increasing at an alarming rate. This is a critical health issue that all three of our organizations are urgently striving to stay on top of.How do these criminals get their hands on pill presses? How are they evading customs inspections? Is possession of these presses illegal and if so, why are more people not charged with it?Recently, the National Association of Boards of Pharmacy, National Association of Drug Diversion Investigators and The Partnership for Safe Medicines joined together to research the extent of the pill press challenge for law enforcement and other first-responders. Key findings include:

  • Pill presses are broadly available for sale on the Internet and virtually untracked. These devices are successfully smuggled through customs because the enormous volume of packages makes compliance challenging. Data from Customs and Border Protection (CBP) shows pill press seizures at International Mail Facilities are increasing every year, growing 19 fold from 2011 to 2017.
  • The broad availability and sale of pill presses allow novice criminals to make millions of doses of nearly perfect-looking counterfeits that can have deadly consequences.
  • Possession of a pill press, while not well regulated, is at most a violation of a Drug Enforcement Administration (DEA) registration requirement carrying no jail time. It only becomes a crime once you add a counterfeit pill mold. However, the prosecution of individuals for possession of a pill press with a counterfeit pill mold is also a rare occurrence and does not carry a sentence high enough to be a deterrent.
  • Disrupting the availability of pill presses will be a challenging process. Our research suggests that increasing criminal penalties for the possession or non-registration of a pill press alone is not likely to provide a sufficient deterrent because it relies on a change in charging behavior by prosecutors. Note: Some law enforcement interviewed suggested adding a sentencing enhancement that increases penalties for committing a drug-related crime with a pill press and suggested exploring serialization or registration as a technique to increase the frequency of indictments for illegal possession and manufacturing operations.

METHODOLOGY

To develop this study, staff from all three of our organizations conducted many hours of interviews, studied dozens of prosecutions, and reviewed interviews with many families of victims killed by illegally pressed pills. The National Association of Boards of Pharmacy (NABP), the National Association of Drug Diversion Investigators (NADDI), and The Partnership for Safe Medicines (PSM) each bring complementary expertise in patient safety, law enforcement, and regulatory issues related to the secure pharmaceutical supply chain. The goal is to help understand why America has seen a sudden increase in domestic counterfeit production, its impact on patient safety and law enforcement, and what is required to address the problem.

INTRODUCTION TO THE PROBLEM

We are currently living through a public health emergency of unprecedented proportions: the opioid crisis. A factor that has made this crisis worse is how cheap and accessible tableting machines (often called pill presses) and counterfeit pill molds are a readily available tool to drug traffickers and organized criminal organizations. According to a 2016 Drug Enforcement Administration (DEA) brief, a small investment of $1,000 for a pill press and a pill mold, and a few thousand more for materials, including illicitly imported Fentanyl and binding agents, could yield between $5 to $20 million in salable counterfeit opioid pills. Desk-top pill presses can produce hundreds of pills per hour while easily fitting inside the trunk of a car. The demand and supply for these counterfeit pills have increased rapidly due to a multitude of varying factors. As regulators and policymakers focus on the problem of opioid over-prescribing by implementing important regulations such as prescription limits and production quota reductions, the street price of genuine diverted opioids increases.

In addition, illegal websites, many of them posing as Canadian pharmacies and/or operating on the increasingly accessible dark web have proliferated, and peddle an ever-increasing supply of counterfeit opioids to unsuspected patients. Pill presses provide an even faster and easier way to supply the increased demand. Today, pill presses, pill molds, and the ingredients to make counterfeit pills are illegally smuggled into the United States through trafficking networks, commercial cargo, and small packages with ease.

The overall number of products being shipped in small packages creates a volume so large that many things, including pill presses and molds, are easily concealed. Since Fentanyl is very potent, importing just a kilogram of illicit Fentanyl can help create a multi-million dollar operation. The pill presses themselves hide among the even larger amount of non-medical products, machine parts, industrial parts, and legitimate merchandise. Pill presses are such a poorly-recognized item that sellers can merely break them into three parts to completely obscure their nature.© March 2019 NABP, NADDI, and PSM.

Once illegal pill presses arrive in the United States, the “bootleg” product created can wreak havoc across an entire city in a single weekend. United States law enforcement has seized pill presses capable of producing thousands of counterfeits pills per hour. A single, poorly-made counterfeit containing one extra milligram of Fentanyl is deadly. As PSM’s research shows, fake pill makers both in the United States and outside the United States frequently add toxic levels of Fentanyl to counterfeit pills. More than half of the states in the United States have seen deaths due to these counterfeits containing lethal doses of synthetic opioids, especially Fentanyl.

While people struggling with substance use disorder are at the highest risk of being exposed to these dangerous counterfeits, the increased presence of deadly Fentanyl-laced counterfeits in America has seeped into every community. As these pills circulate, they find their way into the medicine cabinets of people unaware of the existence and potency of these “knockoff ” products. These “knockoffs ” are finding their way into the hands of United States residents and killing them. The existence of a counterfeit pill endangers all Americans, not just the purchaser.

HOW THESE PILLS ENTER THE MARKET

The declaration said the package contained a “hole puncher,” but upon examination, CBP concluded it was a pill press. CBP queried the DEA because it is illegal to import pill presses without prior permission from the agency.

The DEA Coordinator alerted field agents working on a case in the Long Beach, California area about the shipment and its intended destination. Multiple teams around the country were already working on investigations related to Subject Gary Resnik and his ring of drug dealers. The DEA obtained a warrant to put a GPS tracker on the pill press, and in April it was released to ship to Resnik and followed by law enforcement.It’s important to recognize when the interdiction process works. In this case, CBP caught the illegal pill press despite attempts to mislabel it to evade detection. Not only was it found, but it became a direct conduit and useful tool in uncovering a ring of counterfeiters and preventing the potential poisoning deaths of countless Americans. This is the type of story we heard over and over again as we talked to law enforcement; criminal conspiracies to make counterfeits require specific materials, and those materials are the threads you can follow to discover the crime and eradicate a criminal organization.

Based upon this data and other information gleaned during the investigation, the DEA agents working the case raided three locations used by the gang and seized six pill presses, presumably including the one shipped to them that was being monitored by law enforcement. While this case clearly outlines a success and is a great example of how the process is supposed to work, a few important lessons can be drawn from this example:

  1. Discovery of an illegal pill press’s importation is often used by law enforcement to locate illegal production sites, to uncover a counterfeiting ring, or to provide probable cause for search warrants and further investigation.
  2. This case study shows how well the interdiction and investigation teams can work, but also exemplifies how the criminal organization had already gotten their hands on five other pill presses that evaded interdiction.Seizures of pill presses are up 19-fold since 2011. In Tennessee alone, law enforcement seized 12 pill presses in 2017.

On the morning of September 18, 2017, while his parents were sleeping, ten-month-old Leo Holtz put a pretty colored pill that had fallen out of his father’s pocket into his mouth. Around 8:25 am his parents woke and found their baby blue and unresponsive. They called 9-1-1, but Leo could not be revived and was declared dead at Rady Children’s Hospital. According to The San Diego Union-Tribune, investigators believe Leo’s father, Colin, bought the pills from Melissa Scanlan, who sourced her counterfeit Oxycodone pills from a drug cartel in Mexico. How-ever, even if the counterfeit Fentanyl pills came from someone else, nothing will ever change the fact that ten-month-old Leo Holz’s life was cut short because of a counterfeit Oxycodone pill made with Fentanyl. 

FEDERAL LAWS AND REGULATIONS

Possession of a pill press is not illegal. Buying or selling requires notification to the DEA, but there are no known penalties failing to do so. Possession of a counterfeit pill mold with or without a pill press violates 21 United States Code, § 333, with a criminal penalty of up to one year in jail and a possible fine of $1,000. If the perpetrator intended to defraud or mislead others regarding pill manufacturing the penalty can be up to three years in prison and a fine of $10,000. Actual use of a counterfeit pill press or pill mold in commerce violates 21 United States Code, § 333, and carries a penalty of up to one year in prison and a possible fine of $1,000. Again, if the perpetrator intended to defraud or mislead others regarding the authenticity of the pill the penalty can be up to three years and a possible fine of up to $10,000.

Additionally, buying, selling, reselling, giving, importing, and exporting of pill presses is regulated by DEA. Any time a change of ownership occurs for one of these machines, the DEA requires you to file an electronic report. Importation requires this notification to be made in advance. Domestic transactions require that this notification is submitted within 15 days of the transaction. Domestic transactions also require additional verbal notification to the local DEA office or Special Agent in Charge. The electronic requirement for all transactions including domestic was added in 2017 and is outlined in this helpful presentation from the DEA’s Diversion Control Department.

STATE LAWS AND REGULATIONS

Many, but not all, states have laws that govern the practice of manufacturing prescription medications. These statutes often mirror the Federal Food, Drug, and Cosmetic Act. Illegally owning a pill press with a mold to produce counterfeit pills is a criminal violation of such state laws. It’s important to note the distinction. The possession of a mold used to make copies of a trademarked pill (with the imprint of a trademarked logo) is an illegal act under state law. Only a handful of states regulate the pill press itself. Two of these states are Texas and Florida.

Discovery of a pill press may indicate that someone is engaging in the crime of counterfeit medicine manufacturing. Following the pill press to its destination can lead investigators to members of a criminal conspiracy that they might not have known about. It can also provide reasonable cause needed to obtain a search warrant. Dan Zsido, a veteran law enforcement officer from Florida and the National Training and Education Director for NADDI, explained that there is no point bringing a charge that will be dropped. He said, “Loading up a case with charges consumes valuable, limited, court resources with charges that are just going to be dropped or merged into the more major indictment anyway. This is how narcotics prosecutions have worked for years: if you get charged with trafficking, nobody will take the time to charge you with drug paraphernalia.”

Advocates who study medicine safety detest the broadly dispersed, cottage industry of drug counterfeiters. As with the fear of small meth labs percolating throughout the country, they are concerned that hundreds of criminals are capable of producing millions of doses of perfect-looking but deadly fake medicines. It is a public health and public safety concern.Even if you could make Fentanyl in the United States disappear tomorrow, this manufacturing capacity would still exist. Criminals could turn to other substances to use as the active ingredient in their counterfeit medicines. Unfortunately, drug traffickers adapt to the “drug of the day,” so merely removing a specific controlled substance does not minimize the threat of drug activity; it’s a social behavior issue.

IN CONCLUSION

Today the volume of medical products coming across the border is enormous. FDA Com-missioner Scott Gottlieb, M.D. reported in March 2018 that less than 1% of all medical products coming into the country through International Mail Facilities are inspected. Counterfeit medicines are already extremely difficult to detect. If we legalize drug importation, it will be the same as tripling the size of that haystack (or worse). Finding the Fentanyl-type substances used to make these counterfeits products domestically with unregulated pill presses will be even more difficult and will create an even higher risk of harm to human life.

Law enforcement resources are currently stretched thin stemming the tide of synthetic opioids that are flooding our country. Many of them are presently chasing counterfeit opioids that are flooding our streets, as well as, responding to the overwhelming increases in daily overdoses. If we flood the country with suspect medications through drug importation, our first-responders’ workload would significantly increase because of the increased suspect drug supply and the resulting fallout.

Addressing the Socioeconomic Complexities of Addiction—Lessons from the Kensington Neighborhood in Philadelphia

From the Monthly Blog of Dr. Lora Volkow, Dir., National Institute on Drug Abuse
Originally Posted October 29, 2019 here.

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This September, Dr. Volkow was invited by Thomas Farley, the Health Commissioner of Philadelphia, to see firsthand how that city is responding to the opioid crisis. With other members of NIDA leadership, she toured Prevention Point, a private non-profit organization providing harm reduction services to Philadelphia and the surrounding area. The group also visited the health unit of the city’s Prisons Department, where they recently started a program that provides medications to prisoners with opioid addiction, and they met with outreach workers from Temple University who operate a mobile treatment unit that provides medications and behavioral health services for opioid addiction, as well as basic wound care.

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Philadelphia’s rate of overdose deaths skyrocketed this past decade, tripling the city’s number of homicide deaths and greatly exceeding the peak number of deaths from AIDS in 1994. With one fifth the population of Manhattan, Philadelphia still has almost as many overdose deaths. It was humbling not only to see the challenges facing a city with a longstanding opioid problem but also to see the engagement and dedication of people on the ground attempting to help, as well as the struggles of those battling their own drug addiction amidst extremely hard socioeconomic challenges.

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Prevention Point’s Wound Care Clinic offers free, specialized wound care for all people

Whenever Dr. Volkow asks people on the front lines of America’s drug crisis what more NIDA can do to support and help their work, they remind her how essential it is to address the basic needs of individuals with addiction, such as stable and safe housing, food, basic medical care, and an opportunity for employment.  In the addiction field, NIDA has recognized the importance of addressing these basic needs as part of recovery support. Yet, it is crucial to realize that these needs have to be met even before a person is in stable recovery in order to facilitate them getting to recovery at all.  People cannot recover from addiction if they are homeless, isolated, and struggling to find food and safety.

Located in Kensington, one of Philadelphia’s hardest-hit neighborhoods, Prevention Point, which began three decades ago in response to the AIDS crisis, offers medications for opioid use disorder (buprenorphine and naltrexone), distributes Narcan (Naloxone) kits for reversal of opioid overdoses, and provides sterile syringes to reduce the risk of infections. It also offers testing for HIV and HCV and treatment referral when needed, wound care (people who inject drugs frequently develop infections), and linkage to behavioral health treatment.

Additionally, the center provides temporary housing and meals, as well as case management and a wide array of other non-medical services to people experiencing homelessness and struggling with addiction, such as legal services and mail services for clients who would otherwise be unable to file and receive needed paperwork. Under the impressive leadership of Executive Director Jose Benitez and Associate Executive Director Silvana Mazzella, Prevention Point provides these services with a very limited budget (facilitated by both public and private funding), in an old church.

Man Giving Money To Beggar On Street

By visibly providing support and care for individuals with addiction, Prevention Point is embraced by some in the community but resisted by others. Some view treatment as competition for the drug market; others fear how it may affect the neighborhood’s potential for renovation and gentrification. With addiction services historically segregated from the rest of healthcare, the “not in my backyard” (“NIMB”) problem has long been a major factor in impeding access to treatment.

NIDA’s visit to Philadelphia drove home why America needs to address the stigma that still surrounds opioid addiction and its treatment. It also drove home why addressing the crisis will require a comprehensive approach—including treatment with medications along with harm-reduction (like needle exchange), as well as case management and an array of non-medical services that can attend to people’s basic needs, including helping them build meaningful social relationships.

It is crucial that drug treatment specialists do more research to find ways of effectively delivering such services and support to all communities, both urban and rural, that need them. It will require more collaborative engagement between researchers and community-level providers, volunteers, and people suffering from substance use disorders—the HEALing Communities Study, which is getting underway in four hard-hit states, is a start.

In conclusion, Dr. Volkow said, “I also strongly encourage scientists who work in other aspects of addiction research to spend time at local addiction service providers to get a firsthand understanding of the challenges faced by those on the front lines, to visit neighborhoods that have been devastated by addiction, and to speak to those afflicted. It can be a valuable reminder of how every aspect of a person’s life—from employment, to housing, to interpersonal relationships—can be either a vulnerability or an asset on the road to addiction recovery. “

U.S. Surgeon General’s Advisory: Marijuana Use and the Developing Brain

Steven Barto, B.S., Psych.

I am reposting this information from a link to the U.S. Department of Health and Human Services (HHS.gov) provided by the National Institute on Drug Abuse (NIDA) website.

I, Surgeon General Jerome Adams, am emphasizing the importance of protecting our Nation from the health risks of marijuana use in adolescence and during pregnancy. Recent increases in access to marijuana and in its potency, along with misperceptions of safety of marijuana endanger our most precious resource, our nation’s youth.

Background

Marijuana, or cannabis, is the most commonly used illicit drug in the United States. It acts by binding to cannabinoid receptors in the brain to produce a variety of effects, including euphoria, intoxication, and memory and motor impairments. These same cannabinoid receptors are also critical for brain development. They are part of the endocannabinoid system, which impacts the formation of brain circuits important for decision making, mood and responding to stress.

Marijuana and its related products are widely available in multiple forms. These products can be eaten, drunk, smoked, and vaped. Marijuana contains varying levels of delta-9-tetrahydrocannabinol (THC), the component responsible for euphoria and intoxication, and cannabidiol (CBD). While CBD is not intoxicating and does not lead to addiction, its long-term effects are largely unknown, and most CBD products are untested and of uncertain purity.

Marijuana has changed over time. The marijuana available today is much stronger than previous versions. The THC concentration in commonly cultivated marijuana plants has increased three-fold between 1995 and 2014 (4% and 12% respectively). Marijuana available in dispensaries in some states has average concentrations of THC between 17.7% and 23.2%. Concentrated products, commonly known as dabs or waxes, are far more widely available to recreational users today and may contain between 23.7% and 75.9% THC.

The risks of physical dependence, addiction, and other negative consequences increase with exposure to high concentrations of THC and the younger the age of initiation. Higher doses of THC are more likely to produce anxiety, agitation, paranoia, and psychosis. Edible marijuana takes time to absorb and to produce its effects, increasing the risk of unintentional overdose, as well as accidental ingestion by children and adolescents. In addition, chronic users of marijuana with a high THC content are at risk for developing a condition known as cannabinoid hyperemesis syndrome, which is marked by severe cycles of nausea and vomiting.

This advisory is intended to raise awareness of the known and potential harms to developing brains, posed by the increasing availability of highly potent marijuana in multiple, concentrated forms. These harms are costly to individuals and to our society, impacting mental health and educational achievement and raising the risks of addiction and misuse of other substances.  Additionally, marijuana use remains illegal for youth under state law in all states; normalization of its use raises the potential for criminal consequences in this population. In addition to the health risks posed by marijuana use, sale or possession of marijuana remains illegal under federal law notwithstanding some state laws to the contrary.

Marijuana Use during Pregnancy

Pregnant women use marijuana more than any other illicit drug. In a national survey, marijuana use in the past month among pregnant women doubled (3.4% to 7%) between 2002 and 2017. In a study conducted in a large health system, marijuana use rose by 69% (4.2% to 7.1%) between 2009 and 2016 among pregnant women. Alarmingly, many retail dispensaries recommend marijuana to pregnant women for morning sickness.

Marijuana use during pregnancy can affect the developing fetus.

  • THC can enter the fetal brain from the mother’s bloodstream.
  • It may disrupt the endocannabinoid system, which is important for a healthy pregnancy and fetal brain development.
  • Studies have shown that marijuana use in pregnancy is associated with adverse outcomes, including lower birth weight.
  • The Colorado Pregnancy Risk Assessment Monitoring System reported that maternal marijuana use was associated with a 50% increased risk of low birth weight regardless of maternal age, race, ethnicity, education, and tobacco use.

The American College of Obstetricians and Gynecologists holds that “[w]omen who are pregnant or contemplating pregnancy should be encouraged to discontinue marijuana use. Women reporting marijuana use should be counseled about concerns regarding potential adverse health consequences of continued use during pregnancy”. In 2018, the American Academy of Pediatrics recommended that “…it is important to advise all adolescents and young women that if they become pregnant, marijuana should not be used during pregnancy.”

Maternal marijuana use may still be dangerous to the baby after birth. THC has been found in breast milk for up to six days after the last recorded use. It may affect the newborn’s brain development and result in hyperactivity, poor cognitive function, and other long-term consequences. Additionally, marijuana smoke contains many of the same harmful components as tobacco smoke. No one should smoke marijuana or tobacco around a baby.

Marijuana Use during Adolescence

Marijuana is also commonly used by adolescents, second only to alcohol. In 2017, approximately 9.2 million youth aged 12 to 25 reported marijuana use in the past month and 29% more young adults aged 18-25 started using marijuana. In addition, high school students’ perception of the harm from regular marijuana use has been steadily declining over the last decade. During this same period, a number of states have legalized adult use of marijuana for medicinal or recreational purposes, while it remains illegal under federal law. The legalization movement may be impacting youth perception of harm from marijuana. 

The human brain continues to develop from before birth into the mid-20s and is vulnerable to the effects of addictive substances. Frequent marijuana use during adolescence is associated with:

  • Changes in the areas of the brain involved in attention, memory, decision-making, and motivation. Deficits in attention and memory have been detected in marijuana-using teens even after a month of abstinence.
  • Impaired learning in adolescents. Chronic use is linked to declines in IQ, school performance that jeopardizes professional and social achievements, and life satisfaction.
  • Increased rates of school absence and drop-out, as well as suicide attempts.

Risk for and early onset of psychotic disorders, such as schizophrenia. The risk for psychotic disorders increases with frequency of use, potency of the marijuana product, and as the age at first use decreases. 

  • Other substance use. In 2017, teens 12-17 reporting frequent use of marijuana showed a 130% greater likelihood of misusing opioids.

Marijuana’s increasingly widespread availability in multiple and highly potent forms, coupled with a false and dangerous perception of safety among youth, merits a nationwide call to action. 

You Can Take Action

No amount of marijuana use during pregnancy or adolescence is known to be safe. Until and unless more is known about the long-term impact, the safest choice for pregnant women and adolescents is not to use marijuana.  Pregnant women and youth–and those who love them–need the facts and resources to support healthy decisions. It is critical to educate women and youth, as well as family members, school officials, state and local leaders, and health professionals, about the risks of marijuana, particularly as more states contemplate legalization.

Science-based messaging campaigns and targeted prevention programming are urgently needed to ensure that risks are clearly communicated and amplified by local, state, and national organizations. Clinicians can help by asking about marijuana use, informing mothers-to-be, new mothers, young people, and those vulnerable to psychotic disorders, of the risks. Clinicians can also prescribe safe, effective, and FDA-approved treatments for nausea, depression, and pain during pregnancy. Further research is needed to understand all the impacts of THC on the developing brain, but we know enough now to warrant concern and action. Everyone has a role in protecting our young people from the risks of marijuana.

Emergency Departments Can Help Prevent Opioid Overdoses

From the Blog of Dr. Nora Volkow
Executive Director, National Institute on Drug Abuse

Additional Writings by Steven Barto, B.S., Psych.

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Originally Posted at the NIDA Website on August 26, 2019

One of the biggest risk factors for overdose death from opioids is having had a previous overdose. Common sense and a growing body of research suggest that patients with Opioid Use Disorder who receive acute care in an emergency department will be at reduced risk for later overdose if they are initiated on medications to treat their Opioid Use Disorder. Unfortunately, too few Emergency Departments are making this a standard practice, and lives are being lost as a result.

According to a new report published by the Delaware Drug Overdose Fatality Review Commission, half of the people in the state of Delaware who died of an overdose in the second half of 2018 had suffered a previous nonfatal overdose, and more than half (52%) of the overdose deaths occurred within three months of a visit to the emergency room. Even when visits were not for overdose, signs of Opioid Use Disorder were apparent during the visit in most cases. The report thus recommended that patients who visit emergency rooms with obvious signs of Opioid Use Disorder should be immediately referred to rehabilitation treatment. Optimally, the initiation of medication for Opioid Use Disorder should be started before patients are discharged. This will improve their clinical outcomes.

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Even without a waiver, Emergency Department providers are permitted to administer Subcutex (buprenorphine) or methadone a limited number of times to patients under their care. In fact, several studies have now shown the benefit of initiating Subcutex in the Emergency Department rather than just referring the patient to drug treatment—it is called an “emergency” department for a reason! A recent NIDA-funded study by Yale researchers published in JAMA in 2015 showed that Subcutex treatment initiated by Emergency Department physicians was associated with decreased opioid use and improved treatment engagement in the 30-day period following discharge.

There is significant evidence that medications for Opioid Use Disorder prevent overdoses. For example, a prospective cohort study of 17,568 opioid overdose survivors in Massachusetts published last year in Annals of Internal Medicine found significant reductions in the risk of subsequent overdoses over the next 12 months in those who received treatment with methadone or Subcutex. Yet, only 30 percent of those who had overdosed received medication for Opioid Use Disorder. This statistic is extremely alarming, because the sample of patients was clearly at high risk for overdosing.

Bottles of Opiate Prescriptions

More alarmingly, 34 percent of those who had been treated for overdose received additional opioid pain prescriptions during the subsequent 12 months, despite their overdose history, and 26 percent received benzodiazepines, which as respiratory depressants further increase risk of overdose in those who misuse opioid drugs or who are being treated with high doses of opioid medications for pain management. [From my personal experience, benzodiazepines were hightly addictive and I tended to abuse them along with oxycodone. Family members noted my complete lack of sadness or empathy during my father’s funeral in December 2014. I stared at the floor and did not shed a tear. This is solely based on the fact that I was high on oxycodone and benzodiazepines at that time.]

It is crucial that acute care physicians, and the health care systems in which they practice, become aware of the importance of ensuring that patients be screened for Opioid Use Disorder and, if same is detected, that they receive treatment, ideally by initiating them on Subcutex before they are released.  Additionally, patients who visit an Emergency Department because of an overdose, or who otherwise show signs of Opioid Use Disorder, should be sent home with Narcan (naloxone)  and given instructions on how to use it to reverse an opioid-induced overdose. This was another recommendation of the Delaware report.

Naloxone kit

Four out of five fatal overdoses reviewed by the Delaware state commission occurred in a private residence were Narcan was unavailable in nearly 93% of the cases. Abundant research has shown the life-saving benefits of distributing Narcan not only to people who are addicted to opioids or misusing them but also to pain patients being treated with high doses of opioid medications and their families and friends. After all, patients taking opiates for severe chronic pain are at risk of becoming dependent on the narcotic, and could suffer an accidental opiate overdose. It is simply a matter of brain neurochemistry that has no true moral component, and can impact patients of any socioeconomic class.

Making Emergency Department physicians more responsive to the opioid epidemic often means educating colleagues and changing hospital culture. Many emergency physicians do not feel adequately prepared to treat with Subcutex—there are real or perceived logistical impediments like obtaining prior authorization from insurers. Emergency physicians should be encouraged to complete the training necessary to get a waiver to prescribe Subcutext, which greatly enhances their confidence and ability to respond to patients with Opioid Use Disorder.

The NIDA-MED website includes firsthand stories from physicians implementing emergency department overdose treatment with buphrenorphine and prescribed Suboxone to patients suffering from Opioid Use Disorder. Gail D’Onofrio, the lead researcher of the 2015 JAMA study, translated the study findings into practical videos for Emergency Room clinicians now posted on NIDA-MED. NIDA has also developed a companion, comprehensive set of resources to help emergency physicians initiate buprenorphine. In fact, initiating buprenorphine treatment in the emergency room includes step-by-step guidance on buprenorphine treatment, discharge instructions, instructional videos for clinicians on interacting with Opioid Use Disorder patients, and other useful materials.

[PLEASE NOTE: I have added the following sections to Dr. Volkow’s blog post.

Let’s Take a Look at Opioid Use Disorder

DSM 5

The American Psychiatric Association¹ included a comprehensive explanation of Opioid Use Disorder in their Diagnostic and Statistical Manual of Mental Disorders, Fifth Ed. (DSM-5), beginning at page 541. Essentially, Opioid Use Disorder (OUD) is a problematic pattern of opioid use leading to clinically-significant impairment or distress, as manifested by at least two of the following, occurring within a 12-month period:

  1. Opioids are often taken in larger amounts or over a longer period than was intended [by the prescribing physician].
  2. There is a persistent desire or unsuccessful effort to cut down or control opioid use.
  3. A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or recover from its effects.
  4. Craving or a strong desire or urge to use opioids.
  5. Recurrent opioid use resulting in a failure to fulfill major role obligations at work, school, or home.
  6. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of opioids.
  7. Important social, occupational, or recreational activities are given up or reduced because of opioid use.
  8. Recurrent opioid use in situations in which it is physically hazardous.
  9. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.
  10. Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of opioids to achieve intoxication or desired effect; (b) a markedly diminished effect with continued use of the same amount of an opioid. NOTE: This criterion is not considered to be met for those taking opioids solely under appropriate medical supervision.
  11. Withdrawal, as manifested by either of the following: (a) the characteristic opioid withdrawal syndrome (refer to Criteria A and B of the criteria set for opioid withdraw in the DMS-5, p. 547-548; (b) opioids (or a closely-related substance) are taken to relieve or avoid withdrawal symptoms. NOTE: This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.

Healthcare is not yet doing enough to avail itself of an effective referral system in the opioid crisis: using visits to emergency rooms to get patients with Opioid Use Disrder on medication and provide them with Naloxone. Intervening in these simple ways would greatly help reduce the shocking numbers of deaths from opioids in this country.

Are You Struggling?

I was obsessed with alcohol and drugs for nearly four decades of my life, which caused horrific and lasting consequences. I ended up serving three years in a state prison around the time I turned 20 years old. My history of using had started in early summer of 1977 shortly after graduating high school. I enjoyed the escape these mind-altering (numbing?) substances provided. Admittedly, it was quite fun at first. Within months, I became dependent on drugs and alcohol in order to function and to feel any degree of release from the demons of my past and the obsessive thoughts in my brain. I couldn’t laugh, relax, enjoy sex or food, or sleep unless I first got high or drunk. Sadly, I struggled with active addiction from shortly after my 18th birthday in 1977 to June 8, 2019.

I had started smoking cannabis and popping oxycodone pills during early Spring of 2018 in an attempt to self-medicate my depression, anxiety, and severe back pain secondary to a construction-related injury several years ago. Looking at the above description of Opioid Use Disorder established by the DSM-5, when in active opiate addiction I exhibit ten out of eleven of the criteria needed for a definitive diagnosis! I am sixty years old now, and I am finally looking at who I am in Christ. I am clean from opiates and cannabis for nearly 120 days, and I no longer dwell on the decades of constant failure. I should mention that I nearly took my own life several times during  my long history of active addiction. My struggle with opiates is fairly recent, and has taken me to places that I did not wish to go. Thankfully, I am confronting this issue with confidence in the power of the Name of Jesus and my unmitigated committment to change, never to be the same.

I work extensively today with a drug and alcohol counselor who is a believer in Christ. The ability to focus on Christ in therapy sessions provides an opportunity to examine the “spiritual malady” of addiction. I am constantly in contact with several elders at my home church who have become mentors. I am “coachable” today. I have started speaking regularly with Duche Bradley on the phone. He has a nationwide ministry of speaking in prisons and high schools about addiction and who we are in Christ Jesus. You can hear his “white chair” testimony here. He has led me through renouncing pharmacia and all nature of flesh-bound habits and addictions, and has encouraged my growth in Christ in order to move forward with my own ministry. Duche said to me, “Brother, if you do these things, you will be blown away about the many permanent changes in your character and your life.”

Nowadays, after having submited to Jesus Christ as my “higher power”—indeed, as my Savior and my Lord and Teacher—the obsession to use chemicals is gone. Likewise, the physical compulsion or craving has been defeated. I could never accomplish this under my own power. The Big Book of Alcoholics Anonymous tells us that alcohol is cunning, baffling, and powerful! No human power can relieve our alcoholism, but God can and will if we seek Him. The same applies to drug addiction. After all, a drug is a drug whether you drink it, snort it, or shoot it into your veins.

It is only through admitting my weaknesses and deciding to work with those who have risen above the evil and failure in their lives that I can get on with my life: studying theology on the master’s degree level, teaching weekly Bible study lessons at a local homeless shelter, and reaching out to newcomers at 12-Step meetings that are presently on a rapid decent into the living hell of active addiction. By accepting God’s “call” on my life, I can move toward a ministry of evangelism, applied apologetics, and lecturing, writing about, and teaching about Christianity and the release we all can have through Jesus. This is my life (as it was always meant to be), and I am happy to finally get on with living it!

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Given the near impossibility of quitting a mind-altering substance on your own, I highly suggest you reach out to someone who’s been there. Check your local government phone number pages in the phone book or, better, yet, do a Google search for A.A. or N.A. If, however, you are in the middle of a psychological or physical life-threatening crisis secondary to substance abuse, Please Call 911.

With suicides on the rise, the federal government wants to make the National Crisis Hotline easier and quicker to use. A proposed three-digit number — 988 — could replace the National Suicide Prevention Lifeline, 1-800-273-TALK (8255). The FCC presented the idea to Congress in a report earlier this month and is expected to release more information and seek public comment about the proposal in the coming months. PLEASE REMEMBER: You are not alone.

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¹ American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, fifth ed. (DSM-5). Arlington, VA: American Psychiatric Publishing (2013), pp. 547-548.

Overcoming Temptation (The Jesus Way)

“Let no one say when he is tempted, ‘I am tempted by God;’ for God cannot be tempted with evil and he himself tempts no one; but each person is tempted when he is lured and enticed by his own desire. Then desire when it has conceived gives birth to sin; and sin when it is full-grown brings forth death” (James 1:13-15, RSV).

By Steven Barto, B.S. Psych.

PERHAPS YOU’VE HEARD IT SAID “sow a thought, reap an action; sow an action, reap a habit; sow a habit, reap a character; sow a character, reap a destiny.” There is a basic concept at work here which involves obsession and compulsion. Watchman Nee (1903-1972) was a Christian leader and teacher who worked in China during the 20th century, helping to establish numerous churches in that region of the world. Nee wrote, “It is a pitiful and tragic thing to be obsessed. Those who are obsessed are in a very abnormal condition.” He said obsession encompasses lying and deception. The obsessed Christian lies to himself, pretending there is no problem with his behavior. This self-deception becomes thick like fog, making it nearly impossible to see beyond obsessive thought and habitual action.

What is Obsession?

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I have been prone to obsessions throughout my life. Psychology teaches us that obsessions are “recurring thoughts, urges, or images that are experienced as intrusive and unwanted and, for most people, cause anxiety or distress. The individual tries to ignore them, suppress them, or neutralize them with a different thought or action.” The specific details of obsessions can vary widely. For example, they might include thoughts about contamination, a desire for order, taboo thoughts related to sex or religion, or a compulsion to harm oneself or others. Obsessions can revolve around activities that provide pleasure or escape, especially relative to alcohol, drugs, gambling, shopping, watching pornography, or eating.

At this stage, the brain is typically focused on the so-called benefits of a particular action or habit rather than the negative consequences. One hallmark of an obsession involves what some addictions counselors refer to as euphoric recall. At first blush, this might sound “warm and fuzzy.” Relative to substance abuse, however, this is associated with remembering past drinking and drugging experiences in a positive light, while overlooking negative experiences associated with it. I heard someone at a 12-step meeting say, “Play the tape all the way through.” Huh? He expounded: “Look past the high and the fun and the escape, seeing the eventual consequences of taking that first drink or drug.” In other words, remember the ugly results. 

What is Compulsion?

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Compulsions are “repetitive behaviors or mental acts that one feels compelled to do in response to an obsession or based on strict rules.” Typically, such behaviors are meant to counter anxiety or distress or to prevent a feared event or situation, but they are not realistically connected to these outcomes, or they are excessive. Although rare, obsessive thoughts and compulsive actions can lead to Obsessive-Compulsive Disorder (OCD), as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). A person suffering from OCD is often plagued by obsessions or compulsions that take up more than one hour a day or cause clinically significant distress or impairment for the individual. In order for this diagnosis to stand, all other potential disorders involving similar symptoms must be ruled out. Psychiatrists and psychologists call this procedure differential diagnosis.

The Book of James

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James 1:13-15 explains the process of obsessive thoughts in the believer that lead to temptation and sin. The apostle gives us a few key points to think about.  We must remember that James said when we’re tempted, not if we’re tempted. It is inevitable that we’ll be coaxed or seduced (essentially “baited”) to disobey God’s Word. The foundation of such temptation can be demonic or fleshly. It can have physical or psychological roots, or, frankly, both. For example, the enticement to take a drug or to watch pornography has a physical component of pleasure and escape, but it might also have an emotional or psychological component. Depending on your circumstances, such as severe physical pain, the enticement can be nearly impossible to resist. From a psychological viewpoint, the inducement can be pride, anxiety, depression, or boredom. In my experience, both physical and psychological enticement can be equally compelling. The perfect storm, especially for me, is when both mechanisms are at play!

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James is quick to tell us that temptation is a solicitation from the devil to do wrong, and is never directed by God (1:13). Satan doesn’t want us to think about the how of our temptation. Instead, he wants us to obsess over the temporary pleasure to be gained when we give in to what is baiting us. The devil will deceive us about the results of taking the bait. Perhaps we’ll buy into this action as having some type of relief or benefit. That’s why deception is his “go-to” device. Our habitual sin is rooted in automatic (compulsive) behavior, focused only on temporary pleasure or escape. Hand-in-hand with the thought that God does not tempt us to sin is the fact that temptation is strictly an individual matter (1:14).

Eugene Peterson places verses 2 through 18 under the heading “Faith Under Pressure.” In his translation The Message, he writes, “Don’t let anyone under pressure to give in to evil say, ‘God is trying to trip me up.’ God is impervious to evil, and puts evil in no one’s way. The temptation to give in to evil comes from us and only us. We have no one to blame but the leering, seducing flare-up of our own lust. Lust gets us pregnant, and has a baby: sin! Sin grows up to adulthood, and becomes a real killer.” It’s critical that we see what James is teaching us on temptation. He is saying we are lured away from God in the midst of trials by our own desires. It is my experience that temptation is specific to that which I personally find pleasurable. Not everyone is prone to finding relief at the bottom of a bottle or from a handful of opiate painkillers, as I have been. Not all men or women are enticed by pornography. These wiles are specific to each of us, which makes them harder to resist.

On one level, we simply want to sin. Paul taught us this in the seventh chapter of Romans. He says, “But sin, seizing the opportunity afforded by the commandment, produced in me every kind of coveting. For apart from the law, sin was dead” (7:8, NIV) [italics mine]. He reminds us that the law is spiritual, but at our core, that is in the flesh, we are not spiritual. We’re sold as a slave to sin (7:14). Prior to giving his life to the Way of Jesus, Paul was a “Pharisee among Pharisees,” well-educated at the feet of the renowned rabbi Gamaliel. He knew the Law front-to-back. He felt justified in persecuting and murdering Christians as members of a heretical sect of Judaism. No doubt he believed he was helping to protect Israel from the wrath of God.

It is important to note that Paul, a highly-educated Jew who was called to preach the Good News to the Gentiles, and had undergone spiritual conversion on the road to Damascus, still recognized his struggle in the flesh. Exasperated, he said, “I do not understand what I do. For what I want to do I do not do, but what I hate I do. And if I do what I do not want to do, I agree that the law is good. As it is, it is no longer I myself who do it, but it is sin living in me. For I know that good itself does not dwell in me, that is, in my sinful nature. For I have the desire to do what is good, but I cannot carry it out” (7:15-18, NIV).

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Be careful, though, for it is possible to allow Paul’s struggle to become a loophole with which you will excuse your own wilful sin. I’ve been there, thinking, If even Paul can’t resist the flesh, then how can I? (See my blog article Do You Look for Loopholes as a Christian?) Wilful sin, however, is anathema to repentance, which literally means “to turn away from.” To repent is to do a 180 and never look back.

So Now What?

Repentance involves having the will to change; to never be the same again. If temptation is so difficult to resist, then what is its purpose in the life of the Christian? We know that sin occurs when we yield to enticement and make a wrong decision regarding our behavior. The dynamics of that mental and emotional process is complex. Although we’ve been freed from being a slave to sin (see Romans 6), we haven’t completely lost our taste for sin. Desires will remain in our flesh for as long as we live in a physical body. What we cannot excuse, however, is the practice of sin. Paul notes this problem in Romans 1:32, using the Greek word prasso to describe wilful sin. This refers to performing sin repeatedly or habitually. One definition specifically states, “to exercise, practice, to be busy with, carry on.”

If we are aware of a particular desire personal to us that entices or lures us into sinful behavior, we are responsible for addressing that behavior. Instead, many of us (me included) agree to be tempted, and we get on with practicing the sin. Looking at it this closely truly exposes the mechanism (the “come-on” if you will) and the chronic, repeated behavior associated with that temptation. Let’s be real: We simply “give in” once again and fail to resist the devil.

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Temptation that leads to sin always follows the same process.  There are four steps involved in giving in to temptation:  (1) the bait is dropped, (2) our inner desire is attracted to the bait, (3) sin occurs when we yield to temptation, and (4) sin results in tragic consequences.  To be aware of these principles is to be armed in the face of struggling with temptation. But can a true Christian habitually sin? Many believers wrestle with this question, and often give up and give in, thinking they must not be saved if they cannot stop sinning. Some will even teach that if you have habitual sin in your life you are not really a Christian. One pastor put it to me this way a few years ago: “You don’t have God in your heart.” Ouch! But unfortunately we can have head knowledge about God and Jesus, yet not have the required heart knowledge needed to act according to our beliefs or our intention to do that which is right.

Thankfully, the Bible takes no steps in hiding the sins of key Old Testament figures. Abraham, Isaac, Moses, and David were not super heroes. They were normal men who sinned as Adam did. There is no question that David is one of the Bible’s more prominent figures. Jesus Christ came from the House of David. We are easily inspired by his youthful willingness to fight Goliath, his tender friendship with Jonathan, his worshipful Psalms, and his enduring patience under wicked King Saul. It’s almost hard to believe that this beloved character who’s spoken so highly of in more than half of the Bible’s books would also be guilty of breaking half of God’s commandments. David coveted Uriah’s wife, Bathsheba (2 Samuel 11:2-3), committed adultery with her (11:4) effectively stealing her from Uriah (12:9), lying to him (11:12–13), and eventually having him murdered (12:9).

Others come to mind as well. Noah was a drunk (Genesis 9:20-21). Sarah doubted God and allowed Abraham to have sex with her maidservant in order to help fulfill God’s promise of a son (Genesis 16). Jacob was a pathological liar (Genesis 25, 27, 30). Moses had a bad temper (Exodus 2, 32:19; Numbers 20:11) and killed an Egyptian. Solomon was said to be the wisest man in the world, but he was a sex addict who took over 1,000 sexual partners (1 Kings 11). The prophets, even as they spoke for God, struggled with impurity, depression, unfaithful spouses and broken families. Looking to the New Testament men of God, we see Peter’s denial of Christ (John 18:13-27). Paul persecuted Christians, often sending them to death, before God chose him to lead the Gentile world to Christ (Acts 22:1-5).

Handling Temptation the Jesus Way

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Paul said God intends for us to work out our salvation daily with fear and trembling (Philippians 2:12). Unfortunately, the importance of this verse is lost on many Christians today. It is often used by certain teachers and preachers to instill fear into people, wrongly warning them that they can lose their salvation. (I am working on a blog article on this subject, which will be based on diligent exegesis, to be published at a later date.) Paul was certainly not encouraging believers to live in a continuous condition of nervousness and anxiety. That would contradict his many other exhortations of peace of mind, courage, and confidence in Jesus, the author of our salvation. The answer lies in the Greek word phobou (from phebomai) which Paul uses for the word fear, meaning “to be put to flight.” Paul was likely telling the believers at Philippi to work out their deliverance (salvation) from sin by fleeing from it or, in the alternative, by telling it to flee. This dovetails nicely with James’s admonition, “Submit yourselves, then, to God. Resist the devil, and he will flee from you” (James 4:7, NIV).

The Greek verb for “work out” (katergazesthe) refers to continually working to bring something to completion or fruition. This sounds a lot like the ongoing process of sanctification by which we are “set apart” from our sinful nature for God. Paul describes himself as straining and pressing on toward the goal of becoming like Christ (Philippians 3:13-14).  He teaches that the very essence of salvation is holiness—what he calls sanctification of the spirit. He says good works find their only root in salvation and sanctification. In other words, we are not saved by our good works, but rather we are saved for our good works. It is true that genuine Christians are identified by their fruits. Jesus reminds us that He is the Vine, and God is the Vinedresser (John 15:1). The Vinedresser cuts off every branch that bears no fruit, while pruning the ones that do, making them more fruitful (15:2). This is a great description of the process of sanctification through being pruned and made fruitful.

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The means by which we are able to work out our salvation and resist temptation is grounded in Jesus. If we want to participate in the salvation and restoration of the world, we must live in a manner that works toward that end. We follow Jesus. This includes coming to understand the power in the Name of Jesus: power to break chains, heal minds and bodies, build the Body of Christ, and rely on the Holy Spirit to clarify the truth of the Gospel. Accordingly, we must not cherry-pick the Gospel. We cannot decide to follow Jesus in some aspects of our lives, but go our own way (or, worse, the way of the devil) in others. If we are going to follow Jesus, we must learn the ways in which He leads. Moreover, we need to examine His relationship with the Father. We have to lock on to these methods and follow them with consistency and completeness. Paul reminds us that this is not easy, and James tells us it can only be accomplished by resisting Satan.

Concluding Remarks

The ways and the means promoted and carried out in the world today are designed to take God completely out of the equation. It is no coincidence that America is suffering at the hands of gun violence, murder, terrorism, hatred, bigotry, increased rates of abortion, brokenness (especially regarding the home), addiction, deception, selfishness, illness, and heartache. Surely, wars are fought and won, wealth is accumulated, elections are won, diseases are cured, and victories are posted, but at what cost? The means by which these ends are achieved leaves a hole in the soul of our country. Many people are killed, others are impoverished, marriages are failing apart, addicts are dying at an alarming rate, our schools and other venues have become soft targets for violence, children are being abandoned and neglected, and worldly churches are hawking their watered-down message in the name of Christ. As a result, we’re not moving toward spiritual maturity.

Simply stated, Jesus said, “I am.” He is the way, the truth, and the life. He is the Word in the flesh. The salvation of the world. The Head of the Body of Christ. He said we must repent, believe, and follow Him. We repent by making a decision to turn away from everything we were in the flesh and walk toward Jesus. This must include a change of heart and mind, which is the first step in becoming a new creation in Him. This requires a personal, trusting participation in the reordering of our reality. Lastly, we must follow the Way of Jesus. This involves every aspect of our daily lives, including what we think, how we speak, the manner in which we behave, and how we pray and interact with Christ. To follow the Way of Jesus implies that we enter into a brand new reality that necessarily shapes our character. We cannot separate what Jesus says from what Jesus does and the manner by which He does it, nor can we fail to walk in that same manner.

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA: American Psychiatric Publishing, 2013.

Nee, Watchman. The Holy Spirit and Reality. Hatfield, South Africa: Van Schaik Publishers, 2001.

Peterson, Eugene. The Jesus Way: A Conversation on the Ways That Jesus is the Way. Grand Rapids, MI: Wm. B. Eeardmans Publishing, 2007.

 

Secret Opioid Memo

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A confidential government document containing evidence so critical it had the potential to change the course of an American tragedy was kept in the dark for more than a decade. The document, known as a “prosecution memo,” details how government lawyers believed that Purdue Pharma, the maker of the powerful opioid, OxyContin, knew early on that the drug was fueling a rise in abuse and addiction. They also gathered evidence indicating that the company’s executives had misled the public and Congress.

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There has been a recent wave of lawsuits against opioid makers and members of the Sackler family, which owns Purdue Pharma. Opioid abuse has ravaged America over the past two decades. According to the Centers for Disease Control and Prevention (CDC), from 1999 to 2017 more than 700,000 Americans have died from a drug overdose. Approximately 68% of the more than 70,200 drug overdose deaths in 2017 involved an opioid. In 2017, the number of overdose deaths involving opioids (including prescription opioids and illegal opioids like heroin and illicitly manufactured fentanyl) was 6 times higher than in 1999. On average, 130 Americans die every day from an opioid overdose.

The confidential Justice Department “prosecution memo” represents a missed opportunity that might have changed the course of the opioid epidemic. It also suggests that Purdue Pharma and members of the Sackler family knew far earlier than they admitted that OxyContin was being abused. The memo had the potential to change the course of the opioid crisis but was kept from circulation for more than a decade. The report states that Purdue Pharma executives were implicated in the crisis.

The Department of Justice chose not to pursue felony charges against those executives, paving the way for a settlement that ended a four-year investigation. The settlement did not produce any vital changes to industry behavior regarding the prescribing of narcotic painkillers. Secrecy surrounding the memo is emblematic of a legal process that favors the suppression of corporate information. If disclosed, this information could benefit the public’s health and safety. It is truly extraordinary to see after all these years that the opioid industry is finally being held to account.

Analysis of the DEA database obtained by the Washington Post reveals that a relatively small number of pharmacies—15 percent—distributed roughly half of prescription opioids nationwide from 2006 to 2012. It seems the DEA wasn’t paying attention to its own data, instead relying on drug companies and pharmacies to police themselves. In one engaging multimedia story, the Post took a close look at a southwestern Virginia area that was flooded with 74 million opioid pills over seven years—enough for 106 pills per resident every year. Journalists from over 30 states have now published over 90 separate articles based on the previously undisclosed DEA data.

It’s unbelievable that millions of oxycodone and hydrocodone pills flooded poor communities in Appalachia as pharmaceutical companies and the DEA failed to heed signs of large-scale inappropriate prescribing. Yet there is a certain liberation in being able to point to specific data, which might help assign responsibility for what may be U.S. health care’s most fateful systemic failure in recent history.

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It is bad enough that many doctors and pharmacies were little more than “pill mills” supplying untreated addicts with their drug of choice rather than treating legitimate pain patients. It is quite another to know that nearly 35 billion opioids — about half of all distributed pills — were handled by just 15 percent of the nation’s pharmacies between 2006 and 2012. A single drugstore in tiny Albany, Kentucky purchased nearly 6.8 million hydrocodone and oxycodone pills during that period, equivalent to 96 a year for all 10,000 or so men, women and children in surrounding Clinton County. This was the most on a per capita, per county basis in the United States.

There is always a tension between discretion and disclosure—between keeping the public informed about the workings of large medical treatment systems and permitting specialists who operate them to handle delicate matters in private. Nowhere is that tension more relevant than in health care, where medical expertise, proprietary information and patient privacy are all at a premium. Like all good things, however, those may be taken to an extreme or turned into excuses for unwarranted concealment.

Any ordinary person who learned that a single pharmacy in small-town Kentucky was handling millions of potentially addictive pills over a seven-year period might have sounded an alarm, even if government bureaucracy, industry leaders, and doctors did not. Unfortunately, no ordinary person could know—until now.

For more information, click here: OxyKills.com

What It Feels Like to do Nothing

By Steven Barto, B.S. Psych.
Excerpts from The Demon in the Freezer written by Richard Preston.

I feel like I’m hiding from responsibility. Or, more specifically, my calling. I feel stuck. Stymied. Like a deer caught in the frickin’ headlights. The more of nothing I do, the less I feel like there’s anything I can do. This hit me hard last evening while reading a chapter in Richard Preston’s book The Demon in the Freezer. Preston also wrote the best-selling book The Hot Zone, which was recently a featured mini-series on National Geographic starring Juilanna Margulies.

The Demon in the Freezer is Preston’s true account of the inside story on virus outbreaks and the history of biological weapons. [You can order a copy of the book at Amazon.com] In the chapter called “Strange Trip,” he takes us on a wild ride that begins with Dr. Lawrence Brilliant (his real name) and Wavy Gravy, who met at Woodstock, and ends with participation in the Eradication Program for smallpox started by the World Health Organization in New Delhi. As I read this chapter, I saw strange but convincing parallels to my own life. Like Dr. Brilliant did initially, I have been postponing the fulfillment of God’s call on my life. Not unlike Dr. Brilliant and Wavy Gravy, much of this hindrance has been fueled by chronic drug and alcohol use that became what the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) calls Substance Use Disorder (SUD).

I will provide a complete account of “Strange Trip” in this blog article, and will jump in here and there to describe how this tale mimics my sloth-like approach to life and to my mission. I’ll comment on the terrible danger of allowing your journey to be interrupted; explaining what it’s like to tune God out and concentrate on assuaging emotional and physical pain as if my life depended on it. I don’t intend to go easy on myself. This is an important story that will hopefully inspire someone else to get off their rump and begin the trip that God has laid out before them. Failure to do so will haunt you. A Christian friend of mine recently told me, “God wants you to know that if you don’t do what He has called you to do, He will get someone else to do it!”

LET’S GET STARTED

There is no other way to do life but to do it the right way.

IN THE SUMMER OF 1970, a twenty-six-year-old medical doctor named Lawrence Brilliant finished his internship at Presbyterian Hospital in San Francisco. He had been diagnosed with a tumor of the parathyroid gland and was recovering from an operation, so he was not able to go on with this residency. He was living on Alcatraz Island in San Fransisco Bay, where he was giving medical help to a group of Native Americans who had occupied Alcatraz in a protest. He ended up doing some interviews on television from the island, and a producer from Warner Bros. saw one of them and offered him a role in a movie. The movie was Medicine Ball Caravan, about hippies who go to England and end up at a Pink Floyd concert. Larry Brilliant played a doctor… The movie also featured Wavy Gravy, one of the founders of the Hog Farm commune in Llano, New Mexico. The Hog Farm commune had recently become famous for running the food kitchen at the Woodstock festival, where they also provivded security…

Medicine Ball Caravan was shot first in San Francisco and then in England, and during the shooting Brilliant and Gravy became friends… In England, Brilliant and his wife, Girija, and Wavy and his wife, Jahanara Gravy—she’s from Minnesota and is said to have been Bob Dylan’s girlfriend and perhaps even the model for the “Girl of the North Country”—pondered what to do next in life. A terrible cyclone had hit the delta of the Ganges River in the Bay of Bengal, in what was then East Pakistan (now Bangladesh), and the eye of the cyclone had passed over an island named Bhota. A hundred and fifty thousand people had drowned when a tidal surge had covered the entire island. The Brilliants and the Gravys hit on the idea of buying a bus and carrying food and medicines to the devastated islanders.

“Wavy and I and our wives—who, remarkably, are still our wives—drove to Kathmandu,” Brilliant said. They started with a rotten old British Leyland bus that they bought cheap in London. They painted it in psychedelic colors and filled the bus with medicine and food and a bunch of hippie friends. They bought a second bus in Germany and equipped it similarly, and the Brilliant-Gravy bus entourage made its way slowly through Turkey and Iran. The buses wandered around Afghanistan for months, and they made it over the Khyber Pass, following the same road that Peter Los and his friends had driven a little more than a year earlier in their Volkswagen bus.

The Brilliant-Gravy expedition wound slowly through Pakistan and crossed into India. Civil war had broken out between East and West Pakistan—this was the independence war of Bangladesh—and the border of Bangladesh had been closed, so they couldn’t get their buses into the country. They turned northward into Nepal, and eventually the buses pulled into Kathmandu. “Wavy got sick and ended up going back to the U.S. weighing about eighty pounds,” Brilliant says. The Brilliants abandoned their bus in Kathmandu and went to New Delhi, India. It seems that the Brilliants were pondering what to do next in life, and nothing was coming along.

Like the Brilliants, many of us tend to get derailed from our plans by difficulties and choose indecision. For me, I’ve had plans to serve the LORD in some capacity at numerous times during my life. I remember telling my grandmother many decades ago that every time I ignore God’s call on my life I end up failing miserably at whatever I decide to do instead. Invariably, that has always led to rather troublesome developments. It’s as if God pulled back on His blessings and waited for me to return to Him ready to serve. Dr. Brilliant and his wife stumbled around India for some time not sure what to do. One day they were in an American Express office in New Delhi collecting their mail, when they met Baba Ram Dass. Baba had recently been Professor Richard Alpert of Harvard University, but he and a colleague, Professor Timothy Leary, had been kicked out of Harvard for advocating the use of LSD.

Richard Preston’s book continues.

Baba Ram Dass spoke glowingly of a holy man named Neem Karoli Baba, who was the head of an ashram at the foot of the Himalayas in a remote district in northern India where the borders of China, India, and Nepal come together. Girija Brilliant was captivated by Baba Ram Dass’s talk of the holy man, and she wanted to meet him, though Larry was not interested. Girija insisted, and so they went. They ended up living in the ashram and becoming devotees of Neem Karoli Baba… He was a famous guru in India, and the people sometimes called him Blanket Baba. The Brilliants learned Hindi, meditated, and read the Bhagavad Gita. Meanwhile, Larry ran an informal clinic in the ashram, giving out medicines that he’d taken off the bus when they’d left it in Kathmandu. One day, he was outdoors at the ashram, singing Sanskrit songs with a group of students, watching them sing. He fixed his eye on Brilliant.

Preston reports that the guru wanted to know how much money Brilliant had. When Brilliant told him he had five-hundred dollars, Blanket Baba asked how much money Brilliant had back home in America. The answer was the same—five hundred dollars. The conversation got quite interesting at this point.

Blanket Baba got a sly grin and started chanting, in Hindi, “You have no money… you are no doctor… you have no money,” and he reached forward and tugged on Brilliant’s beard. Brilliant didn’t know how to answer. Neem Karoli Baba switched to English and kept on chanting. “You are no doctor… UNO doctor… UNO doctor.” UNO can stand for United Nations Organization.

The guru was saying to his student (or so the student now thinks) that his duty and destiny—his dharma—was to become a doctor with the United Nations. “He made this funny gesture, looking up at the sky,” Brilliant recalled, “and he said in Hindi, ‘You are going to go into villages. You are going to eradicate smallpox. Because this is a terrible disease. But with God’s grace, smallpox will be unmulum.'” The guru used a formal old Sanskrit word that means “to be torn up by the roots.” Eradicated. The word “unmulum” comes from an Indo-European root that is at least ten thousand years old—the word is probably older than smallpox.

“So I said, ‘What do I do?’ And he said, ‘Go to New Delhi. Go to the office of the World Health Organization. Go get your job. Jao, jao, jao.’ That means, ‘Go, go go.'” Brilliant packed a few things and left the ashram that night—the guru seemed to be in a rush to “unmulate” smallpox. The trip to New Delhi took seventeen hours by rickshaw and bus. When Brilliant walked into the office of the WHO, it was nearly empty. It had just been set up, and almost no one was working there. The government of India was then headed by Indira Gandhi, and she was skeptical of the Eradication Program and had not yet approved it. The first person Brilliant met was the head of the office, Dr. Nicole Grasset.

“I was wearing a white dress and sandals,” Brilliant says, “I’m five feet nine, and my beard was something like five feet eleven, and my hair was in a ponytail down my back.” Grasset had no job to offer him, so Brilliant returned to the monastery and, having not slept in at least thirty-six hours, reported back to the guru. “Did you get your job?” “No.” “Go back and get it.”

A PERSONAL MISSION

The guru was convinced Brilliant would get his job eradicating smallpox. It was, after all, his dharma—his “calling.” Brilliant returned to New Delhi. Dr. Grasset was quite shocked to see him again, but nothing had changed. There was no job. Brilliant went back and forth between New Delhi and the ashram at least a dozen times. I’m not sure if this indicated Brilliant was like a dog with a bone, determined to get his job, or that God had called him to this task, which would ultimately materialize. Each time he returned, the guru would say, “Don’t worry, you’ll get your job. Smallpox will be unmulum, uprooted.” Brilliant returned to the WHO in New Delhi.

“On one of my trips, there was this tall guy sitting in the lobby of the WHO office. He looked up and said, ‘Who are you? What are you doing here?'” “I’ve come to work for the smallpox program,” Brilliant replied. “There isn’t much of a program here.” “My guru says it will be eradicated. Who are you?” “I’m D.A. Henderson. I’m the head of the program.”

Henderson, for his part, was a little put off by Brilliant’s white dress and his talk of a guru predicting a wipeout of smallpox. That day, Henderson wrote a note in the employment record, “Nice guy, sincere. Appears to have gone a little native…” Indira Gandhi was herself a devotee of Neem Karoli Baba, and she had visited him at the monastery, where she had bowed down to him and touched his feet and asked for his advice. Blanket Baba wanted smallpox pulled up by the roots, and he was annoyed at Mrs. Gandhi for resisting the efforts of the World Health Organization to get on with the job…

Brilliant thought he’d increase his chances of getting a job if he looked more Western, so every time he returned to New Delhi he trimmed off some of his beard and shortened his ponytail, and he began to replace articles of clothing. He ended up with medium-long hair and a short beard, and he was dressed in a checkered polyester suit with extra-wide lapels, a thick polyester tie, and a lime green Dacron shirt. He had made himself unnoticeable, for the seventies. By that time, Nicole Grasset had decided to hire him, and D.A. Henderson agreed that he might have some potential as an eradicator. He started as a typist.

At this point, it is obvious Brilliant was determined to get the job he’d been called to do. He remained obstinate and did not take no for an answer. Moreover, he made the necessary changes to accomplish his goal, especially his outward appearance that was distracting people from seeing him for who he truly was: a man destined to help eradicate smallpox from the world. Interestingly, as we’ll see later, the simple decision to learn to speak Hindi allowed Brilliant to get through to the native Hindi people to get vaccinated. Had he known only English, or had to speak through an interpreter, I don’t believe he would have been as well received. Fulfilling our calling often revolves around similar commitments and changes.

I’m sure most of us can see ourselves in the example of Dr. Brilliant. When we feel compelled—indeed, called—to do something, we invariably go through stages of action and inaction, assurance and doubt, but if we believe in the call on our life we will remain tenacious. Unfortunately, on many occasions the devil throws every possible obstacle in our path to stop us from answering that call. For me, it was a number of things, ranging from materialism to pride, but the toughest hurdle has been my struggle with active addiction. In fact, the longest time I have remained at a job in my life was three years. I have a friend who’s had two jobs since high school, and both are in the same industry! Moreover, I have finally completed the first step in answering God’s call: I’ve obtained my B.S. in Psychology at age 59, and I am starting my Master’s in Theology in August.

Preston’s chapter continues.

Eventually, they sent Brilliant to a nearby district to handle smallpox outbreaks, where if he got into trouble they could pull him out quickly. He saw his first cases of variola major. “You can’t see smallpox and not be impressed,” he said. He began to organize vaccination campaigns in villages. He would go into a village where there was smallpox, rent an elephant, and ride through the village telling people in Hindi that they should get vaccinated. People didn’t want to be vaccinated. They felt that smallpox was an emanation of the goddess of smallpox, Shitala Ma, and that therefore the disease was part of the sacred order of the world; it was the dharma of the people to have visitations from the disease.

Brilliant traveled all over India with Henderson and the other leaders of the Eradication, and they came to know one another intimately. “D.A. read nothing but war novels and books about Patton and other great generals in history,” Brilliant said. “Nicole Grasset read nothing except scientific things. Bill Foege was reading philosophy and Christian literature—he’s a devout Lutheran. I was reading mystical literature.” They ran a fleet of five hundred jeeps. They had a hundred and fifty thousand people working for the program, mostly on very small salaries. For a year and a half, at the peak of the campaign, every house in India was called on once a month by a health worker to see if anyone there had smallpox. There were a hundred and twenty million houses in India, and Brilliant estimates that the program made almost two billion house calls during that year and a half.

After he helped eradicate smallpox—his “calling”—Larry Brilliant did other things. He became one of Jerry Garcia’s physicians. He became the founder and co-owner of the Well, a famous early Internet operation. He was the CEO of SoftNet, a software company that reached three billion dollars in value on the stock market during the wild years of the Internet. He and his wife had three children. He eventually obtained the position of professor of epidemiology at the University of Michigan, and, along with Wavy Gravy and Baba Ram Dass, he established a medical foundation called the Seva Foundation. Today, that operation has cured two million people of blindness in India and Nepal.

“I’ve done a lot of things in life,” Brilliant said, “but I’ve never encountered people as smart, as dedicated, as hardworking, as kind, or as noble as the people who worked on smallpox. Everything about them—D.A. Henderson, Nicole Grasset, Zdenek Jezek, Steve Jones, Bill Foege, Isao Arita, the other leaders—everything about them as people was secondary to the work of eradicating smallpox. We hated smallpox.”

There were numerous setbacks during the World Health Organization’s campaign to eradicate smallpox. In fact, there were two false conclusions that the virus had been wiped out. Each time, the eradicators implemented known procedures, creating vaccination “rings” around the outbreaks. On October 27, 1977, a hospital cook in Somalia named Ali Maow Maalin broke out with the world’s final natural case of variola. They vaccinated fifty-seven thousand people around him, and the final ring tightened, and the life cycle of the smallpox virus stopped.

CONCLUDING REMARKS

God calls upon believers and non-believers alike to do His work. Although I am a theist of Christian belief, I take nothing away from the actions and the determination of Baba Ram Dass and Neem Karoli Baba. It is important to note, for the record, that I believe such brave and dedicated non-believers have not earned their salvation in spite of their paramount accomplishments. Salvation comes from Christ alone through faith in Christ alone. I can only hope individuals such as these brave warriors against smallpox come to know the truth during their mortal lifetime and make a conscious decision to accept the saving grace of God through the shedding of the blood of Jesus on the cross.

I will say, however, that these people we’ve read about today convicted me to stop making excuses for my long periods of inactivity, disobedience, and selfishness. I am sure the conviction I felt when reading the chapter “Strange Trip” in Preston’s book, and, moreover, while writing this blog post, came from the Holy Spirit. It is, after all, through the worldview I hold as a Christian that I receive and believe in such guidance and conviction. It is my responsibility to listen to that small voice and take steps to stop the practice of habitual sin. To cease walking in and serving the flesh and begin to walk in the Spirit of God.

Only by coming to grips with our humanity—our total lack of inability to conquer the flesh and discontinue all sinning—can we hope to stop the practice of sin. Furthermore, the flesh and its myriad distractions will drown out the voice of God. We will fail to hear Him tell us who we are in His Son, Christ Jesus. We will miss the calling on our lives. How will we know if our failure to step up and listen to God’s plans for us will result in, for example, the deaths of millions of people because we did not become the “eradicator” He needs us to be. To wipe out whatever we’re called to wipe out, whether it be smallpox, addiction, human trafficking, terrorism, violence, or mental illness?

We don’t know unless we surrender and start listening to God.

References

American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Preston, R. (2002). The Demon in the Freezer: A True Story. New York, NY: Random House.