The Opioid Issue: Part 4

Part Four: Taking It to the Streets

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The opioid epidemic doesn’t stay behind closed doors. It’s spilling into public life, spurring crime and homelessness.

The opioid crisis has hit hard in Macomb County, Michigan. Composed of 27 Detroit suburbs, the county has the state’s second-highest opioid-related overdose death rate, more than double the national average. District Court Judge Linda Davis has been on the bench 17 years. She sees the consequences pretty much every day. “When I look at the docket I handle, I’d say 70 percent is addiction-related,” she says, not counting low-level traffic offenses like driving on a suspended license. “We’ve definitely seen a rise in thefts with this opioid surge.”

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Although opioid addiction often starts out legally, recent years have seen a shift toward illegal opioids. It’s an all-to-familiar story: People get hooked on prescription painkillers, often moving on to heroin, which can be cheaper on the street. Since 2011, as prescription opioid overdose deaths leveled off, heroin overdoses started rising. Starting in 2014, illicit fentanyl deaths began spiking upward. Whatever the substance, the cost mounts up fast. So many users resort to theft. They’ll steal from family, friends, acquaintances or strangers. They’ll shoplift, commit fraud, rob pharmacies, break into homes or cars. Even commit armed robbery. And whether or not they’re committing those crimes themselves, their desperate dependency can feed some even worse ones.

Lethal Combination

In 2015, the nation’s homicide rate rose sharply (11 percent) after decades of decline. The uptrend continued in 2016, climbing another 8 percent. Some observers looked for racial reasons for it. There could be one, says Richard Rosenfeld, an emeritus professor of criminology and criminal justice at the University of Missouri-St. Louis. But he thinks there’s more to the story. When Rosenfeld looked into the data, he quickly saw homicides had jumped among several ethnicities—and it was very pronounced among whites.

“The increase is quite abrupt, quite recent and quite large, at levels we hadn’t seen since the early 1990s outside of 9/11,” Rosenfeld says. “The ‘Ferguson Effect’ doesn’t explain that. So what might explain it? The opioid epidemic, for one thing—which crosses racial lines, but is most concentrated among whites. Drug-related homicides rose more than 21 percent in 2015, a rate far higher than other common categories of homicide, which rose between 3 and 5 percent. Rosenfeld said it stands to reason that there’d be a connection between the spikes in opioid use and lethal violence.

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“It’s not opioid use per se that sparks violence, but the markets,” Rosenfeld says. “When disputes arise between sellers or buyers, they can’t be settled by police or courts or the Better Business Bureau. As the number of buyers expands, so does the number of disputes that turn deadly will also go up.”

Just how big a role do opioids play in driving the rise in homicides? That calls for more research, Rosenfeld says. But he sees ample evidence to sound the warning and to call for addressing the root causes. “Policymakers and law enforcement are framing this as a public-health crisis more than as a criminal-justice crisis, and I’m very much in favor of that,” he says. “The bottom line is: If we reduce demand, we reduce crime.”

“We Don’t Want Those People Here!”

Reducing demand for opioids would likely reduce other social pathologies too. Like homelessness. “For those of us who’ve been providing health care to people who are homeless, this is not a new problem,” says Barbara DiPietro, senior policy director for the National Health Care for the Homeless Council. “We’ve been seeing opioid addiction and overdoses for decades.

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“When people are in a spiral and aren’t getting the help they need, oftentimes they lose their jobs and their ability to pay rent. Before you know it, you cycle through family and friends, and you’re in a shelter or on the street.” Of course, not all people who are homeless have addiction issues, but those that do have a harder time getting into treatment once the stability of housing is gone. Living on the street could easily drive anyone to substance abuse. Maybe you started with alcohol, but once you were on the street, you found other things. It’s very hard to get well when you’re homeless.

Federally-qualified health centers provide care to 1.2 million people a year, and the Council provides technical assistance to help improve quality and access. DiPietro says homeless service providers often see clients who never expected to be in this situation. “We see a lot of clients who come from construction work or other hard-physical-labor jobs, who got hurt and got prescriptions for legitimate reasons,” she says. “We see a lot of people who’ve experienced trauma in their lives—child abuse, domestic violence, sexual assault. So they self-medicate to deal with the pain.” And on the street, their problems are much more visible than those of people who engage in their addictive behavior behind closed doors.

“They’re living their private lives in a public space,” DiPietro says. “They’re subject to public scrutiny, arrest and incarceration at a much higher rate. And once you have an incarceration history, it’s hard to get housing assistance or a job again.”

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While more medical facilities and first responders are being equipped with opioid-overdose medications like naloxone (Narcan), that’s just an emergency measure, not a solution. DiPietro says what people struggling with addiction and homelessness need most is stable housing where they can get effective treatment. Health care providers the Council works with can help, but not enough to meet the scale of the problem.

Right now, communities don’t have the capacity desperately needed to get people into treatment. Another big obstacle is the attitude known as NIMBY—Not in My Back Yard. “Everyone believes treatment is important, but no one wants the services near them,” DiPietro says. “When that’s proposed, they rise up in community meetings and say, “We don’t want those people here.”

We’ve simply got to get beyond that attitude.

A Parting Thought

I spent forty years in active addiction. It started simple enough: A case of beer and an ounce of Colombian Gold. Eighteen months later I was serving 3 to 10 in state prison. Drug and alcohol abuse continued throughout parole and into my thirties, forties and early fifties. My drug use ran the gamut, from weed to cocaine to crack to opiates. When I couldn’t get enough oxycodone through doctors, I began stealing it from friends and family. My addiction cost me plenty, yes, but it also cost my children, my two ex wives, my brothers, my sister, and my parents. I lost jobs, cars, apartments, friends and family. I blew every penny I made, bounced checks, embezzeled, fenced stolen goods. I was enslaved to addiction. Not only did my family disown me for nearly two years, my youngest son didn’t talk to me for five years.

It’s not only the family of addicts that can become fed up and turn their backs on their loved ones struggling with addiction; society has become rather fed up and impatient. One of our local television stations airs a nightly feature called “Talkback 16,” where viewers call to voice their grievances, pet peeves, and, yes, an occasional compliment. Several days after a news story aired about plans to build a drug and alcohol treatment center in the Pocono Mountains (Pennsylvania), a viewer called to complain about the plan, adding, “Not in my neighborhood. [Addicts and alcoholics] can’t be trusted. Besides, they did it to themselves.”

Truly, this attitude must change.

 

Ambitious Research Plan to Help Solve the Opioid Crisis

From the blog of Dr. Lora Volkow, National Institute on Drug Abuse Posted June 12, 2018

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In spring 2018 Congress added an additional $500 million to the NIH budget to invest in the search for solutions to the opioid crisis. The Helping to End Addiction Long-term (HEAL) initiative is being kicked off June 12th with the announcement of several bold projects across NIH focusing on two main areas: improving opioid addiction treatments and enhancing pain management to prevent addiction and overdose. The funding NIDA is receiving will go toward the goal of addressing addiction in new ways, and creating better delivery systems for addictions counseling for those in need.

NIH will be developing new addiction treatments and overdose-reversal tools. Three medications are currently FDA-approved to treat opioid addiction. Lofexidine—a drug initially developed to treat high blood pressure—has just been approved to treat physical symptoms of opioid withdrawal. Narcan (naloxone) is available in injectable and intranasal formulations to reverse overdose. Regardless, more options are needed. One area of need involves new formulations of existing drugs, such as longer-acting formulations of opioid agonists and longer-acting naloxone formulations more suitable for reversing fentanyl overdoses. Compounds are also needed that target different receptor systems or immunotherapies for treating symptoms of withdrawal and craving in addition to the progression of opioid use disorders.

Much research already points to the benefits of increasing the availability of treatment options for Opioid Use Disorder (“OUD”), especially among populations currently embroiled in the justice system. Justice Community Opioid Innovation Network is working to create a network of researchers who can rapidly conduct studies aimed at improving access to high-quality, evidence-based addiction treatment in justice settings. It will involve implementing a national survey of addiction treatment delivery services in local and state justice systems; studying the effectiveness and adoption of medications, interventions, and technologies in those settings; and finding ways to use existing data sources as well as developing new research methods to ensure that interventions have the maximum impact.

The National Drug Abuse Treatment Clinical Trials Network (“CTN”) facilitates collaboration between NIDA, research scientists at universities, and a myriad of treatment providers in the community, with the aim of developing, testing, and implementing addiction treatments. As part of the HEAL initiative, the CTN Opioid Research Enhancement Project will greatly expand the CTN’s capacity to conduct trials by adding new sites and new investigators. The funds will also enable the expansion of existing studies and facilitate developing and implementing new studies to improve identification of opioid misuse and OUD. Further, it will enhance engagement and retention of patients in treatment in a variety of general medical settings, including primary care, emergency departments, ob/gyn, and pediatrics.

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A great tragedy of the opioid crisis is that there are a number of effective tools not being deployed effectively in communities in need. Only a fraction of people with OUD receive any treatment, and of those less than half receive medications that are universally acknowledged to be the standard of care. Moreover, patients often receive medications for too short a duration. As part of its HEAL efforts, NIDA will launch a multi-site implementation research study called the HEALing Communities Study in partnership with the Substance Abuse and Mental Health Services Administration (SAMHSA). The HEALing Communities Study will support research in up to three communities highly affected by the opioid crisis, which should help evaluate how the implementation of an integrated set of evidence-based interventions within healthcare, behavioral health, justice systems, and community organizations can work to decrease opioid overdoses and prevent and treat OUD. Lessons learned from this study will yield best practices that can then be applied to other communities across the nation.

The HEAL Initiative is a tremendous opportunity to focus taxpayer dollars effectively where they are needed the most: in applying science to find solutions to the worst drug crisis our country has ever seen.

Find Help Near You

The following website can help you find substance abuse or other mental health services in your area: www.samhsa.gov/Treatment. If you are in an emergency situation, people at this toll-free, 24-hour hotline can help you get through this difficult time: 1-800-273-TALK. Or click on: www.suicidepreventionlifeline.org. We also have step by step guides on what to do to help yourself, a friend or a family member on our Treatment page.

Opioids

Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as Fentanyl, and pain relievers available by prescription such as codeine, oxycodone, Vicodin, morphine, and others.

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All opioids are chemically related and interact with opioid receptors on nerve cells in the brain and on the spinal column. Opioid pain relievers are generally safe when taken for a short time and as prescribed by a doctor, but because they produce euphoria in addition to pain relief, they can be misused (taken in a different way or in a larger quantity than prescribed, or taken without a doctor’s prescription). Regular use—even as prescribed by a doctor—can lead to dependence and, when misused, opioid pain relievers can lead to addiction, overdose, and death. 

An opioid overdose can be reversed with the drug naloxone (Narcan) when given right away. Improvements have been seen in some regions of the country in the form of decreasing availability of prescription opioid pain relievers and decreasing misuse among the Nation’s teens. However, since 2007, overdose deaths related to heroin have been increasing. Fortunately, effective medications exist to treat opioid use disorders including methadone, Buprenex and Vivitrol. 

A National Institute of Drug Abuse (NIDA) study found that once treatment is initiated, both a Buprenex/Vivitrol combination and an extended-release Vivitrol formulation are similarly effective in treating opioid addiction. However, Vivitrol requires full detoxification, so initiating treatment among active users is difficult. These medications help many people recover from opioid addiction.

What are Prescription Opioids?

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Opioids are a class of drugs naturally found in the opium poppy plant. Some prescription opioids are made from the plant directly, and others are made by scientists in labs using the same chemical structure. Opioids are often used as medicines because they contain chemicals that relax the body and can relieve pain. Prescription opioids are used mostly to treat moderate to severe pain, though some opioids can be used to treat coughing and diarrhea. Opioids can also make people feel very relaxed and high, which is why they are sometimes used for non-medical reasons. This can be dangerous because opioids can be highly addictive. Overdoses and death are common. Heroin is one of the world’s most dangerous opioids, and is never used as a medicine in the United States.

How Do People Misuse Opioids?

Prescription opioids used for pain relief are generally safe when taken for a short time and as directed by a doctor, but they can be misused. People misuse prescription opioids by:

  • taking the medicine in a way or dose other than prescribed
  • taking someone else’s prescription medicine
  • taking the medicine for the effect it causes—getting high

How Do Prescription Opioids Affect the Brain?

Opioids bind to and activate opioid receptors on cells located in many areas of the brain, spinal cord, and other organs in the body, especially those involved in feelings of pain and pleasure. When opioids attach to these receptors, they block pain signals sent from the brain to the body and release large amounts of dopamine throughout the body. This release can strongly reinforce the act of taking the drug, making the user want to repeat the experience.

Opioid misuse can cause slowed breathing, which can cause hypoxia, a condition that results when too little oxygen reaches the brain. Hypoxia can have short- and long-term psychological and neurological effects, including coma, permanent brain damage, or death. Researchers are also investigating the long-term effects of opioid addiction on the brain, including whether damage can be reversed.

What are Other Health Effects of Opioid Medications?

Older adults are at higher risk of accidental misuse or abuse because they typically have multiple prescriptions and chronic diseases, increasing the risk of drug-drug and drug-disease interactions, as well as a slowed metabolism that affects the breakdown of drugs. Sharing drug injection equipment and having impaired judgment from drug use can increase the risk of contracting infectious diseases such as HIV.

Prescription Opioids and Heroin

Prescription opioids and heroin are chemically similar and can produce a similar high. Heroin is typically cheaper and easier to get than prescription opioids, so some people switch to using heroin instead. Nearly 80 percent of Americans using heroin (including those in treatment) reported misusing prescription opioids prior to using heroin. However, while prescription opioid misuse is a risk factor for starting heroin use, only a small fraction of people who misuse pain relievers switch to heroin. This suggests that prescription opioid misuse is just one factor leading to heroin use.

The Numbers

More than 64,000 Americans died from drug overdoses in 2016, including illicit drugs and prescription opioids. This number has nearly doubled over the past ten years. 2015 was the worst year for drug overdoses in U.S. history. Then 2016 came along. In that year alone, drug overdoses killed more people than the entire Vietnam War did.

A chart of US drug overdoses going back to 1999.

The Opioid Epidemic Explained

This latest drug epidemic is not solely about illegal drugs. It began, in fact, with a legal drug. Back in the 1990s, doctors were persuaded to treat pain as a serious medical issue. There’s a good reason for that: About 100 million U. S. adults suffer from chronic pain, according to a report from the Institute of Medicine.

Chronic Pain The Silent Condition

Pharmaceutical companies took advantage of this concern. Through a big marketing campaign they got doctors to prescribe products like OxyContin and Percocet in droves — even though the evidence for opioids treating long-term non-cancer related chronic pain is very weak despite their effectiveness for severe short-term, acute pain—while the evidence that opioids cause harm in the long term is very strong. So painkillers inundated society, landing in the hands of not just patients but also teens rummaging through their parents’ medicine cabinets, other family members and friends of patients, and the black market.

As a result, opioid overdose deaths trended up — sometimes involving opioids alone, other times involving drugs like alcohol and benzodiazepines (Xanax, Ativan, Valium) typically prescribed to relieve anxiety. By 2015, opioid overdose deaths totaled more than 33,000 — close to two-thirds of all drug overdose deaths. The numbers have grown exponentially over the past three years.

What Can We Do?

Seeing the rise in opioid misuse and deaths, officials have cracked down on prescription painkillers. Law enforcement, for instance, now threaten doctors with incarceration and loss of their medical licenses if they prescribed the drugs unscrupulously. Ideally, doctors should still be able to get painkillers to patients who truly need them — after, for example, evaluating whether the patient has a history of drug addiction. But doctors, who weren’t conducting even such basic checks, are now being instructed to give more thought to their prescriptions.

Yet many people who lost access to painkillers are still addicted. So some who could no longer obtain prescribed painkillers turned to cheaper, more potent opioids bought off the street, such as heroin and Fentanyl. Not all painkiller users went this direction, and not all opioid users started with painkillers. But statistics suggest many did. A 2014 study in JAMA Psychiatry found many painkiller users were moving on to heroin, and a 2015 analysis by the Centers for Disease Control and Prevention (CDC) found that people who are addicted to prescription painkillers are 40 times more likely to be addicted to heroin.

So other types of opioid overdoses, excluding painkillers, also rose. That doesn’t mean cracking down on painkillers was a mistake. It appears to have slowed the rise in painkiller deaths, and it may have prevented doctors from prescribing the drugs to new generations of people with drug use disorders. But the likely solution is to get opioid users into treatment. According to a 2016 report by the Surgeon General of the United States, just 10 percent of Americans with a drug use disorder obtain specialty treatment. The report found that the low rate was largely explained by a shortage of treatment options. Given the exorbitant cost of health care in America today, that is simply unacceptable. Federal and state officials have pushed for more treatment funding, including medication-assisted treatment like methadone and Buprenex.

Source: National Institute on Drug Abuse; National Institutes of Health; U. S. Department of Health and Human Services.

COUNTERFEIT OXYCODONE WARNING!

COUNTERFEIT PAIN PILLS CONTAINING DANGEROUS SYNTHETIC OPIOIDS!

Originally posted July 18, 2017
National Institute of Drug Abuse
https://www.drugabuse.gov/

Health and safety agencies in Iowa have issued an advisory to warn Iowans of counterfeit pain pills containing dangerous synthetic opioids. The Iowa Division of Criminal Investigation’s (DCI) laboratory analyzed pills made to resemble the prescription pain reliever oxycodone, finding them to contain more powerful and illicit synthetic fentanyl and U-47700, putting users at higher risk of opioid overdose. U-47700, also known as “Pink” or “U4” on the streets, is a synthetic opioid pain medication currently being distributed as a dangerous designer drug. Since 2015, reports have surfaced of numerous deaths due to street use of U-47700. Law enforcement agencies have traced illegal importation into the United States primarily from clandestine chemical labs in China. It is available through the Dark Web.

Heroin and a Handgun

U-47700 has been seized by law enforcement on the street in powder form and as tablets. Typically, it appears as a white or light pinkish, chalky powder. It may be sold in glassine bags stamped with logos imitating heroin, in envelopes and inside knotted corners of plastic bags. In Ohio, authorities seized 500 pills resembling a manufacturer’s oxycodone immediate-release tablets, but they were confirmed by chemical analysis to contain “Pink.” U-47770 has also been identified and sold on the Internet misleadingly as a “research chemical” at roughly $30 per gram.

Pink is very toxic or deadly in even small doses. Labels on the packaging may state NOT FOR HUMAN CONSUMPTION or FOR RESEARCH PURPOSES ONLY, most likely to avoid legal detection. Fatalities due to U-47770 in the United States join the growing incidents of drug overdose deaths from opioid pain medication. Those who abuse U-47770 may be at high risk of addiction and substance abuse disorder, overdose and death. Fatalities have been reported in New York, New Hampshire, Ohio, Texas, Wisconsin and North Carolina.

In July 2016, a toxicology case report was published in the Annals of Emergency Medicine that detailed events in which fentanyl and U-47700 were being sold misleadingly as the prescription opioid pain medication Norco or Vicodin (acetaminophen and hydrocodone) on the streets of Northern and Central California. In one patient who presented to the emergency room, nalaxone (Narcan) was administered which reversed respiratory depression and pinpoint pupils. After additional chemical analysis, it was found the Norco contained hydrocodone, fentanyl, and U-47700.

Reports indicated that Pink and prescription fentanyl may have been contained in the drug cocktail that led to the death of pop star legend Prince in April 2016. In Utah, two 13-year old boys died in September 2016 reportedly due to use of U-47770 purchased from an Internet website. U-47700 (“Pink”) is a novel synthetic opioid agonist with selective action at the mu-opioid receptors in the brain and on the spinal column. It was originally developed by chemists at Upjohn Pharmaceuticals in the 1970’s as a potent pain reliever for use with cancer patients, post-operative patients with intractable pain, or extremely painful trauma injuries. Although it was never commercially made available, the patent and chemical details remained available, and have been produced on the black market.

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U-47700 has a similar chemical profile as morphine and other mu-opioid receptor agonists; however, it has been reported by the National Institute of Drug Abuse (NIDA) that Pink is “far more potent than morphine” –  possibly by seven to eight times. Unfortunately, the strength of the product can never be assured, and may be much stronger, especially when manufactured overseas in illicit labs as a designer drug. On November 14, 2016, the DEA placed U-47700, as well as its related isomers, esters, ethers, and salts into Schedule I of the Controlled Substances Act due to an imminent hazard to public safety and health. Substances in Schedule I have a high potential for abuse, no currently accepted medical use, and a lack of accepted safety for use under medical supervision.

Temporary emergency scheduling of dangerous illicit drugs is one tool the DEA uses to help restrict potentially fatal and new street drugs. Scheduling will last at least 24 months, with a possible 12-month extension if the DEA needs more time to determine whether the chemical should remain permanently as a Schedule I drug. According to the Federal Register, there are no current experimental or approved new drug applications for U-47700, which can typically hinder its permanent placement in Schedule I if approved. DEA’s Final Order is available in the Federal Register with details on threats to public safety. Prior to DEA’s scheduling, several states had already outlawed the drug under emergency orders, including Florida, Ohio, Wyoming and Georgia.

BOTTOM LINE

U-47700, known on the streets as “Pink” or “U4”, is a dangerous designer drug exported from illegal labs in China to the U.S. It is a strong opioid analgesic, reportedly 7 to 8 times more potent than morphine. Authorities in many U.S. cities have reported that Pink is sold on the streets or over the Internet, often falsely promoted as a prescription opioid like Norco or Percocet, or as heroin. In fact, many of these products have contained the potent designer drug Pink, as well as fentanyl. U-47700 is now illegal in all forms, and the DEA has temporarily placed the substance into Schedule I of the Controlled Substances Act, pending further review, due to an imminent hazard to public safety and health. It is considered not safe for human consumption, and has no acceptable medical use.

Clusters of overdoses and deaths of Pink were reported in U.S. cities in 2015 and 2016. Some of these deaths involved children. According to one case report, the use of naloxone (Narcan) in an emergency setting reversed the effects of U-47700, but this may not always be the case. Emergency physicians should contact their local poison control center, medical toxicologist or public health department in cases where there is a reasonable suspicion of ingestion of designer drugs to help protect the surrounding community. Special lab analysis is typically needed to identify drugs like “Pink,” leaving communities at risk.

The public should be aware that drugs obtained on the street, even though they look like an authentic prescription medication, may be fake and deadly. Don’t take any prescription drug, legal or otherwise, unless it is prescribed specifically for you by a doctor and is dispensed by a reliable pharmacy.

Fentanyl Becomes Deadly Force

Some Excerpts taken from an article By Eric Scicchitano
The Daily Item
July 10, 2017

Fentanyl

The deadly heroin and opioid epidemic is expected to become even deadlier with the increasing presence of Fentanyl in America. According to the DEA, Fentanyl is 50 to 100 times more powerful than morphine, and substantially more potent than heroin. As little as 2 grams of Fentanyl can be deadly. Alarmingly, it is fast becoming the most prevalent active ingredient in counterfeit drugs like Adderall, Xanax, and OxyContin being sold on the streets. During the first quarter of 2017, heroin combined with Fentanyl was detected in 61% of opioids seized for evidence and inspected in DEA labs. It is also frequently laced into marijuana and smoked.

The DEA’s Philadelphia Division warns that Fentanyl is on the rise, with seizures of shipments more than doubling from 167 kilos in 2015 to 365 kilos in 2016. Investigators are trying to determine if an outbreak of Fentanyl is responsible for 51 overdoses which occurred in Williamsport (Pennsylvania) in forty-eight hours. [See my post 51 overdoses in 48 hours] Three of those cases ended in death. According to the National Institute on Drug Abuse (NIDA), heroin and opioids killed an estimated 280,000 people nationwide between 2002 and 2015. Based upon preliminary figures put together through state coroners, more than 4,800 people died of an overdose in Pennsylvania last year. Experts are concerned that the next chapter in the opioid crisis could dwarf what we’ve seen so far. Their concern is based on the proliferation of Fentanyl.

Fentanyl Deaths Map

Let’s take a few moments to discuss Fentanyl. It is a man-made (synthetic) opioid, meaning it is manufactured in a laboratory, but it acts on the mu-opioid receptors in our brain and spinal column in the same manner as the morphine molecule found naturally in opium. Typically, these receptor sites are meant for naturally-occurring endorphins, our “feel good” chemical released by the pituitary gland. Fentanyl is usually prescribed to patients suffering from intractable cancer-related pain and, in some cases, debilitating back pain. My father was given Fentanyl patches for compression fractures near the end of this life. Initially, it was believed Fentanyl would not be abused. Unfortunately, addicts decided to start opening the patch in order to scrape out the medicine and abuse it.

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As if that were not enough, Fentanyl is being illegally manufactured in labs (primarily in China). It is produced in powder form, and is also pressed into pills, and smuggled into the United States. These knock-off pills are catching users off guard. Fentanyl is 50 to 100 times more powerful than morphine. DEA and border patrol seized more than 10,000 counterfeit pills containing Fentanyl in 2015. An amount as small as 2 milligrams can be deadly. First responders and ER physicians have to use extreme caution in order to avoid accidental exposure. According to the article in The Daily Item, an Ohio police officer accidentally overdosed in May of this year after brushing Fentanyl powder from his uniform during an arrest.

After the recent overdose surge in Lycoming County (Pennsylvania), Todd Owens, Mount Carmel police chief and head of the Northumberland County Drug Task Force, advised first responders to take measures to protect themselves. Chief Owens said his own department stocks medical masks, coveralls and heavy-grade gloves in their cruisers to be worn in the event they encounter heroin.

Heroin Fentanyl and Carfentanil Pics

The above is an illustration of potency betwen heroin, Fentanyl, and Carfentanil.

Carfentanil

Carfentanil is an extremely powerful derivative of Fentanyl. While Fentanyl is up to 100 times more potent than morphine, Carfentanil is 100 times more powerul than Fentanyl. In other words, it is 10,000 times more powerful than morphine. It is not approved for use in humans; rather, it is used in veterinary medicine to sedate large animals, primarily elephants. Yes, elephants! Carfentanil is so powerful that when veterinarians handle it, they use protective gear to avoid breathing it in or absorbing it through their skin. The amount of Carfentanil that can be safely administered to a human is 0.1 mg., compared to 13 mg. needed to sedate an elephant. It is obviously rather easy for an addict to accidentally take too much Carfentanil.

Interestinly, there are no statistics showing Carfentanil leading to addiction. That’s because even in the case of a seasoned addict a dose the size of a grain of salt can rapidly lead to an overdose and death. Frighteningly, drug dealers have begun cutting heroin with Carfentanil because it is extremely cheap to acquire. Even more disturbing is the fact that addicts in search of the ultimate high are deliberately trying this deadly drug. Rangers at Yellowstone National Park have recently begun issuing warnings to avoid eating the meat of bison killed in the park because the bison might have been sedated with Carfentanil for tagging or medical treatment. The drug can easily enter the bloodstream of those who eat the bison meat. It is most chilling to note that Carfentanil rapidly latches on to the mu-opioid receptors in humans, causing overdose almost immediately.

Moving Forward

Fentanyl moved up the rankings, from the 9th most common drug involved in overdose deaths in 2013, to the 5th most common drug involved in overdose deaths in 2014. The singer-songwriter Prince died of an overdose of Fentanyl in April 2016, according to officials in Minnesota. Philip Seymour Hoffman, a very successful indie film star (and one of my favorites), died of a heroin overdose on February 2, 2014. Although he had a drug problem while in college, he was clean for twenty years. No doubt his system was not able to handle the strength of today’s heroin.

Reports from the Centers for Disease Control (CDC) and the Food and Drug Administration (FDA) showed that deaths from heroin more than tripled during a five-year period, from 3,020 deaths in 2010, to 10,863 deaths in 2014. These deaths are yet another symptom of the broader epidemic of opioid addiction. Just as deaths from AIDS are due to untreated HIV, deaths from overdose are frequently due to untreated addiction. I know of many addicts attending 12-step meetings who are positive for hepatitis-C secondary to sharing needles while injecting heroin. Prince’s death is a reminder that opioid addiction is a disease that can and does affect people from all economic classes and all walks of life.

References

Scicchitano, E. (July 10, 2017). Fentanyl Becomes Deadly Force. Daily Item. Sunbury, PA.

Wakeman, S. (Aug. 5, 2016). Fentanyl: The Dangers of this Potent “Man-Made” Opioid. [Web Blog Comment.] Retrieved from: http://www.health.harvard.edu/blog/fentanyl-dangers-potent-man-made-opioid-2016080510141

Rettner, R. (Dec. 20, 2016). Deaths From Fentanyl Overdoses Double in a Single Year. LiveScience.com. Retrieved from: https://www.livescience.com/57268-fentanyl-overdose-deaths-double.html

 

Opioid Use Disorders and Suicide

The following is a guest blog taken verbatim from the monthly blog post of Dr. Nora Volkow, director, National Institute of Drug Abuse published April 20, 2017.

“At a Congressional briefing on April 6, the President of the American Psychiatric Association, Dr. Maria Oquendo, presented startling data about the opioid overdose epidemic and the role suicide is playing in many of these deaths. I invited her to write a blog on this important topic. More research needs to be done on this hidden aspect of the crisis, including whether there may be a link between pain and suicide.” – Nora

In 2015, over 33,000 Americans died from opioids—either prescription drugs or heroin or, in many cases, more powerful synthetic opioids like Fentanyl. Hidden behind the terrible epidemic of opioid overdose deaths looms the fact that many of these deaths are far from accidental. They are suicides. Let me share with you some chilling data from three recent studies that have investigated the issue.

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In a study of nearly 5 million veterans recently published in Addiction, scientists reported that presence of a diagnosis of any substance use disorder and specifically diagnoses of opioid use disorders (OUD) led to increased risk of suicide for both males and females.  The risk for suicide death was over 2-fold for men with OUD.  For women, it was more than 8-fold.  Interestingly, when the researchers controlled the statistical analyses for other factors, including co-morbid psychiatric diagnoses, greater suicide risk for females with opioid use disorder remained quite elevated, still more than two times greater than that for unaffected women.  For men, it was 30 percent greater.  The researchers also calculated that the suicide rate among those with OUD was 86.9/100,000.  Compare that with already alarming rate of 14/100,000 in the general US population.

You may be tempted to think that these shocking findings about the effects of OUD on suicide risk are true for this very special population.  But that turns out not to be the case. 

Another US study, published last month in the Journal of Psychiatric Research, focused on 41,053 participants from the 2014 National Survey of Drug Use and Health.  This survey uses a sample specifically designed to be representative of the entire US population.  After controlling for overall health and psychiatric conditions, the researchers found that prescription opioid misuse was associated with anywhere between a 40 and 60 percent increased risk for suicidal ideation (thoughts of suicide).  Those reporting at least weekly opioid misuse were at much greater risk for suicide planning and attempts than those who used less often.  They were about 75 percent more likely to make plans for a suicide, and made suicide attempts at a rate 200 percent greater than those unaffected.

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Using a different strategy, a review of the literature in the journal Drug and Alcohol Dependence estimated standardized mortality ratios for suicide.  This is a way of comparing the risk of death in individuals with a given condition compared to individuals from the general population.  The researchers found that for people with OUD, the standardized mortality ratio was 1,351 and for injection drug use it was 1,373.  This means that compared to the general population, OUD and injection drug use are both associated with a more than 13-fold increased risk for suicide death. These are stunning numbers and should be a strong call to action.

Persons who suffer from OUD are highly stigmatized. They often talk about their experience that others view them as “not deserving” treatment or “not deserving” to be rescued if they overdose because they are perceived as a scourge on society.  The devastating impact of this brain disorder needs to be addressed.  People who could be productive members of society and contribute to their families, their communities, and the general economy deserve treatment and attention.

As a country, we desperately need to overcome stigmatizing attitudes and confront the problem. We need to understand what causes some individuals to become addicted when exposed to opioids and thus study the biological basis of the disease of opioid addiction. We desperately need to know what the best treatments are for a given individual, and for that too, we need research to identify biomarkers for treatment response. Given the fact that effective medications exist but are drastically underutilized, we need to overcome institutional and attitudinal barriers to these treatments and deliver them to the 24 million people who could benefit. It can prevent not only the suffering of addiction and the danger of unintentional overdose but also help prevent the tragic outcome of opioid-related suicide.

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America’s Fentanyl Crisis

Every day 91 Americans fatally overdose on an opioid drug. It may be a prescription analgesic or heroin–4 to 8 percent of people who misuse painkillers transition to heroin–but increasingly it is likely to be heroin’s much more potent synthetic cousin fentanyl. In the space of only two years, fentanyl has tragically escalated the opioid crisis. This drug is 50 to 100 times more potent than morphine and able to enter the brain especially quickly because of its high fat solubility; just 2 milligrams can kill a person, and emergency personnel who touch or breathe it may even be put in danger. Unfortunately, many people addicted to opioids as well as other drugs like cocaine are accidentally being poisoned by fentanyl-laced products.

Although fentanyl is a medicine prescribed for post-surgical pain and palliative care, most of the fentanyl responsible for this surge of deaths is made illicitly in China and imported to the United States via the mail or Mexican drug cartels. Its high potency and ease of manufacture make it enormously profitable to produce and sell. According to the Drug Enforcement Agency (DEA), one kilogram of fentanyl can be purchased in China for $3,000 to $5,000 and then generate over $1.5 million in revenue through illicit sales in America. Thus, distributors of illicit drugs are eager to adulterate heroin or cocaine powder with fentanyl or put it in counterfeit prescription drugs, such as pills made to look like prescription pain relievers or sedatives. Last month, for example, a wave of deaths in Florida was linked to fake Xanax pills containing fentanyl.

Deaths from fentanyl and a handful of other synthetic opioids tripled from 3,105 in 2013 to 9,580 in 2015, and those numbers are likely underestimates; some medical examiners do not test for fentanyl and many overdose death certificates do not list specific drugs involved. Thus far, New Hampshire has recorded the most fentanyl overdoses per capita; an NIDA-funded study found that in 2015, almost two-thirds of the 439 drug deaths in that state involved fentanyl. Although most who fatally overdose on fentanyl are unaware of what they have taken, news of such fatalities has unbelievably driven some people with severe opioid addictions to seek it out. Part of the cycle of an opioid use disorder is increased tolerance, causing diminished response to the drug, which leads users to seek products with higher potency so they can experience the euphoria they initially felt. Roughly one-third of opioid users interviewed as part of the study in New Hampshire knowingly sought fentanyl.

The fentanyl problem is already a high priority for policymakers. Last month, NIDA’s Deputy Director Wilson Compton testified before Congress on the science of fentanyl, accompanied by representatives from the DEA, the Office of National Drug Control Policy (ONDCP), the CDC, and other agencies. Diplomatic and law enforcement efforts to cut off the supply of illicit fentanyl and the chemicals needed to manufacture it will be important, but the emergence of very high potency opioids–which can be transported in smaller volumes–will make addressing supply increasingly difficult. Thus, a public health strategy to address the opioid crisis and overdose epidemic is more important than ever.

First, we must improve pain management and minimize our reliance on existing opioid pain medications. Second, treatment centers and healthcare systems must make much wider use of available, effective medications for opioid addiction (Buprenorphine, Methadone, and extended-release Vivitrol). Third, the opioid-overdose reversing drug naloxone needs to be made as widely available as possible, both to emergency first responders as well as to opioid users and other laypeople who may find themselves in a position to save a life. In cases of fentanyl overdose, multiple doses of naloxone may be needed to reverse an overdose, and additional hospital care may be needed. All individuals who overdose on opioids need to be linked to a treatment program to prevent it from happening again.

From the blog of Dr. Nora Volkow, Dir., National Institute on Drug Abuse
April 6, 2017

Through All of It

As most of my followers know, I struggled for nearly four decades with addiction. I was able to put down the drink and the pot pipe in 2008, but I held on to one thing. One “ace up my sleeve.” One exception. One excuse. Opioid painkillers. This latest struggle has taken me through some ugly places. Despite legitimate severe pain, I cannot responsibly use such medicines as Vicodin, Percocet, or Ultram. During my last bout, I fell down the rabbit hole after taking 90 Vicodin in 4 days.

My opioid binges remind me of the example of the jaywalker in the Big Book of Alcoholics Anonymous. At first, he makes it across the street. But then he gets hit by a car and suffers some bumps and bruises. He’s not phased, though, and continues to jaywalk. The next time, he suffers a broken wrist. Again, he decides to try jaywalking, only to sustain a broken leg. This continues without end. He is actually showing behavior that demonstrates the true definition of insanity: trying the same thing over and over, expecting different results. So was I.

For me, what always follows is withdrawal symptoms that include irritability, anger, lying, denial, loss of appetite, sleeplessness, and severe diarrhea. Once I level out, I get my appetite back. I see the sun shining again. I get back out the door. I return to my usual outgoing, polite self. I do my laundry. I wash my car. My problem with drugs and alcohol began at age 18 when I drank a Miller Lite and smoked a joint. I was an addict from the start. (I don’t remember ever drinking “just one.”) My regret has always been the terrible ways I’ve treated people. Used and manipulated them. Two wives. My mother. My children. My siblings. My friends.

Today, I am more determined than ever to stand against my addiction. My mantra now is to tell my addiction (whose name is Satan) that I am an ambassador of Christ, and that my body is an embassy. It is “foreign soil.” I tell the devil he is not permitted to enter. I rebuke him in the Name of Jesus, refusing to even open the gate. I have taken a totally different approach to pain management over the last two weeks. I am using modalities I’ve only “considered” in the past: chiropractic; stretching 3 times a day; walking about a half a mile every day; hydrotherapy; laying hands on painful spots and asking God to send relief to those exact areas; meditation; weight loss.

I have definitively decided, after years of struggle and denial, that I cannot safely use narcotic pain medication. I’ve put all of my physicians on notice, saying they are not to give me anything, even if it’s a year from now, or I beg them. I stay away from friends who routinely use such medications. I attend regular NA meetings, and I see a Christian psychotherapist who went to seminary and post-graduate studies. I have stepped up my interaction with fellow believers, listen exclusively to contemporary Christian music, and began classes online  at Colorado Christian University in 2015. I attend weekly individual and group outpatient drug and alcohol treatment. And, finally, I have an NA sponsor rather than an AA sponsor. This works best for me. I recently spent over an hour on my knees crying and seeking God’s face, realizing just how out of touch I’ve been. How much I’ve missed. How much sorrow I’ve spread.

This contemporary  Christian song hits me hard every time I hear it. I changed one phrase to suit my situation. (See the brackets.) This song, by Colton Dixon, can help all of us, but it has become especially inspiring for me. I am reprinting the lyrics below.

There are days of taking more than I can give
And there are choices that I made that I wouldn’t make again
I’ve had my share of laughter
Of tears and troubled times
This has been the story of my life

I have won
And I have lost
I got it right sometimes, but [most] times I did not
Life’s been a journey
I’ve seen joy, I’ve seen regret
Oh, and You have been my God through all of it

You were there when it all came down on me
When I was blinded by my fear and I struggled to believe
But in those unclear moments You were the one keeping me strong
This is how my story’s always gone

I have won
And I have lost
I got it right sometimes, but [most] times I did not
Life’s been a journey
I’ve seen joy, I’ve seen regret
Oh, and You have been my God through all of it
Oh, through all of it

And this is who You are, more constant than the stars
Up in the sky, all these years, all my life
I, I look back and I see You
Right now I still do
And I’m always going to

I have won
And I have lost
I got it right sometimes, but sometimes I did not
Life’s been a journey
I’ve seen joy, I’ve seen regret
Oh, and You have been my God through all of it

If you want to listen to it, click here.

Me Included

I recently took the time to read President Obama’s report Epidemic: Responding to America’s Prescription Drug Abuse Crisis (2011), published on the monthly blog of Dr. Nora Volkow, director of the National Institute on Drug Abuse. (Sept. 14, 2016) According to the president’s report, prescription drug abuse is the nation’s fastest-growing drug problem. While there has been a marked decrease in the use of such illegal drugs as cocaine, data from the National Survey on Drug Use and Health (NSDUH) show that nearly one-third of people aged 12 and older who used drugs for the first time in 2009 began by using a prescription drug non-medically. The survey found that over 70 percent of people who abused prescription pain relievers got them from friends or relatives, me included.

I started taking opioid pain medication for severe low back pain in 2004. The pain became debilitating, and I was approved for Social Security Disability Income in 2009. Being an addict and an alcoholic, I should have realized that one pill was too many and a hundred was not enough. At one point, I was seeing three different doctors and going to several different pharmacies in order to avoid suspicion. I could not keep up with my cravings. When I could no longer get enough pain meds through doctors and  ERs, I started stealing medication from everyone in my family. I realized just the other day that I have been taking medication from loved ones since 1984 when I started helping myself to my mother-in-law’s Tylenol with Codeine. Although there have been periods where I was able to stop taking opiates, it started all over again about a year before my father died. Following a family intervention, I went to a rehab center for 21 days. I relapsed ten months after I left the rehab. I managed to get clean again until August 20 of this year when I stole oxycodone tablets from my mother. It appears I may have done irreparable damage to my relationship with her. Ironically, that was my greatest fear.

Although a number of classes of prescription drugs are currently being abused, the president’s 2011 action plan primarily focuses on the growing and often deadly problem of prescription opioid abuse. The number of prescriptions filled for opioid pain relievers (some of the most powerful medications available) has increased dramatically in recent years. From 1997 to 2007, the milligram-per-person use of prescription opioids in the U.S. increased from 74 milligrams to 369 milligrams, which amounts to 402 percent. In 2000, retail pharmacies dispensed 174 million prescriptions for opioids. By 2009, 257 million prescriptions were dispensed, which is an increase of 48 percent. Opiate overdoses, once almost always due to heroin use, are now increasingly due to the abuse of prescription painkillers.

A crucial first step in tackling the problem of prescription drug abuse is to raise awareness through the education of parents, youth, patients, and healthcare providers. Although there have been great strides in raising awareness about the dangers of using illegal drugs, many people are still not aware that the misuse or abuse of prescription drugs can be as dangerous as the use of illegal drugs, leading to addiction and even death. In addition, prescribers and dispensers, including physicians, dentists, and pharmacists, all have a role to play in reducing prescription drug misuse and abuse. Most receive little training on the importance of appropriate prescribing and dispensing of opioids to prevent adverse effects, diversion, and addiction.

Outside of specialty addiction treatment programs, most healthcare providers receive minimal training in how to recognize substance abuse in their patients. Most medical, dental, pharmacy, and other health professional schools do not provide in-depth training on substance abuse; often, substance abuse education is limited to classroom or clinical electives. Moreover, students in these schools only receive limited training on treating pain. A national survey of medical residency programs in 2000 found that, of the programs studied, only 56 percent required substance use disorder training, and the number of curricular hours in the required programs varied between 3 to 12 hours. A 2008 follow-up survey found that some progress has been made to improve medical school, residency, and post-residency substance abuse education; however, efforts have not been uniformly applied in all residency programs or medical schools.

Educating prescribers on substance abuse is critically important, because even brief interventions by primary care providers have proven effective in reducing or eliminating substance abuse in people who abuse drugs but are not yet addicted to them. In addition, educating healthcare providers about prescription drug abuse will promote awareness of this growing problem among prescribers, so they will not over-prescribe the medication necessary to treat minor conditions. This, in turn, will reduce the amount of unused medication sitting in medicine cabinets in homes across the country.

The president’s report indicates that all of this will take tracking and monitoring. Forty-three states have authorized prescription drug monitoring programs (PDMPs). PDMPs aim to detect and prevent the diversion and abuse of prescription drugs at the retail level, where no other automated information collection system exists, and to allow for the collection and analysis of prescription data more efficiently than states without such a program can accomplish. However, only 35 states have operational PDMPs. These programs are established by state legislation, and are paid for by a combination of state and Federal funds. PDMPs track controlled substances prescribed by authorized practitioners and dispensed by pharmacies. PDMPs can and should serve a multitude of functions, including assisting in patient care, providing early warning of drug abuse epidemics (especially when combined with other data), evaluating interventions, and investigating drug diversion and insurance fraud.

In summary, the president’s report states that research and medicine have provided a vast array of medications to cure disease, ease suffering and pain, improve the quality of life, and save lives. This is no more evident than in the field of pain management. As with many new scientific discoveries and new uses for existing compounds, the potential for diversion, abuse, morbidity, and mortality are significant. Prescription drug misuse and abuse is a major public health and public safety crisis. As a nation, we must take urgent action to ensure the appropriate balance between the benefits these medications offer in improving lives and the risks they pose. No one agency, system, or profession is solely responsible for this undertaking. We must address this issue as partners in public health and public safety. Therefore, ONDCP will convene a Federal Council on Prescription Drug Abuse, comprised of Federal agencies, to coordinate implementation of this prescription drug abuse prevention plan and will engage private parties as necessary to reach the goals established by the plan.

Substance Abuse Concerns: Heroin and Prescription Drug Use on the Rise Among Teens

Curriculum Review,  Jan. 2016, Vol. 55 Issue 5, p6-7. 2p.

It seems as though some teenagers have always dabbled in drugs, but with increasing access to dangerous prescription opioids and cheap heroin, the problem is especially acute. For some students, drug experimentation will lead to addiction. According to the National Institute on Drug Abuse (NIDA), after marijuana and alcohol, prescription and over-the-counter drugs are the most commonly abused drugs for Americans aged 14 years and older. In 2012, nearly 20 percent of American 12th graders said they had abused prescription pills at some point in their lives.

NIDA reports that heroin use has been rising since 2007. Though use among 8th, 10th, and 12th graders is at less than one percent, NIDA emphasizes that heroin use is reported as the biggest drug abuse issue in rural and urban areas. The rate of teens using heroin soared by 80 percent between 1999 and 2009. Twenty-three percent of those who try heroin will become addicted. The New York Times collected statistics about the heroin epidemic that has garnering attention from concerned citizens, politicians, and the media. There has been a 39% increase in heroin related deaths from 2012 to 2013. Ninety percent of first-time users are white. Increasing numbers of first-time users are middle or upper class. Seventy-five percent of heroin users used prescription painkillers before using heroin, with 40 percent of those individuals abusing opioid painkillers.

NIDA has found that some teenagers start taking heroin because it is much cheaper than prescription pills. Serious health problems involved with heroin include infectious diseases like HIV and hepatitis, collapsed veins and infection of the heart lining and valves, death by overdose, and liver and kidney disease. Signs that a teen could be addicted to heroin include acting slow and sedated, then intensely hyperactive, extreme sleepiness, cold and clammy skin, runny nose, pin-sized pupils, disinterest in extracurricular activities and academics, inattention to cleanliness, nausea, unexplained changes in friends, hangouts, and hobbies, weight loss, and an inability to pay attention or problem solve.

Drug overdoses cause more deaths every day than car accidents. Forty-four people per day die of opioid medication overdose. Approximately 1,600 teens begin abusing prescription drugs each day. Children and teens age 1 2 to 1 7 abuse prescription pills more than ecstasy, heroin, crack cocaine, and methamphetamines combined. Twenty percent of teens who abuse prescription pills did so before they turned 14. These statistics are obviously very alarming.