Saturday, December 28, 2013

William S Burroughs' The Junky's Christmas

I'm a couple of days late posting this, but here's William S Burroughs' The Junky's Christmas, in claymation.

The Junky's Christmas (plot summary from Wikipedia)

Penniless and withdrawing from opiates, Danny emerges from a 72-hour stay in a police holding cell. Hoping to make enough money to buy his next hit of heroin, he scours the streets looking for something to steal. After an unsuccessful attempt to break into a parked car, he discovers an unattended suitcase sitting in a doorway. He makes off with the case and takes it to an abandoned park to examine its contents. There he finds that the case contains two severed human legs. Disgusted, he discards the legs and tries to find a buyer for the suitcase. He finds a buyer who gives him three dollars but also informs him that the local heroin dealer has been arrested.

Unable to find heroin anywhere Danny decides to visit a doctor with the hopes of obtaining some morphine. When he reaches the doctor’s house he pretends to be suffering from facial neuralgia. The doctor is suspicious but gives Danny a quarter of a grain of morphine free of charge.

Drugs in pocket, Danny rents a room for two dollars. As he prepares to inject the morphine, he hears groaning coming from the next room. Distracted, he follows the sound of the groaning across the hall to find a young man suffering from kidney stones. Danny offers to call an ambulance, but soon realizes that the paramedics will not come as they believe the young man is faking illness to obtain opiates. Danny selflessly administers his morphine to the young man. The morphine immediately alleviates the young man’s pain. Danny returns to his room. All of a sudden he begins feeling the effects of heroin; it appears that his good deed has been rewarded with “the immaculate fix.” Danny nods off to sleep.

Saturday, December 7, 2013

Opium Production in Afghanistan

According to a recently released report by the UN Office on Drugs and Crime, acreage dedicated to opium production in Afghanistan has reached an all time high. Every year the UN releases these reports, and they are a testament to the massive failure of global drug prohibition. While poppies grow almost anywhere, the illicit market is largely supplied from three areas: Afghanistan, Southeast Asia (mostly Myanmar) and Latin America (mostly Mexico and Colombia). Of these three, Afghanistan is by far the largest supplier, accounting for 85-90% of worldwide production. 

Opiates are popular worldwide, unfortunately the majority of consumers use the semi-synthetic derivative heroin instead of opium. There are still opium users and even markets, but worldwide the market for heroin (an estimated $55 billion) dwarfs the market for opium (an estimated $7-10 billion). Worldwide illicit consumption of opium is estimated to be around 5,000 tons annually, most of which is ultimately consumed as heroin.

The price of opium varies depending on the season and region. The price of opium is naturally reflective of supply and demand, it is lowest during times of harvest, and in regions that grow a lot of poppies. In 2013 the price per kg varied between $100-200, averaging around $150. Crop eradication has had a negligible impact. In 2010 bad weather in Afghanistan adversely affected crop productivity, causing a spike in prices toward the end of 2010. Ironically the increase in opium price enticed more farmers to grow poppies, contributing to the increase in acreage dedicated to opium production.

The price of opium is artificially high, yet still relatively cheap compared to the price of heroin on the streets of the United States. In a previous review of an Afghan heroin production yields of heroin from opium were reported to be 6%. Other sources indicate 10% is more usual, other papers report yields as high as 12-16%. The morphine content of the opium can vary and is probably the largest factor effecting the yield. According to the UN world drugs report, Afghan opium has a higher morphine content and requires 7kg of opium to produce 1 kg of heroin. At an average cost of $150 per kg, it costs a little over a thousand dollars worth of opium to produce a kg of heroin, or about a dollar a gram. Even using the more modest 6% yield, the final cost is only $2.50/gram. 

Graph from Brian Bennett's Truth: the Anti-Drug War
Heroin obtains almost all of its value near the end of the distribution chain, after it is smuggled into the consumer country. Within the United States, I previously reported costs of $500/gram at the retail level. Brian Bennet, using data from the ONDCP, reports somewhat lower costs around $400/gram (with per pure gram costs as low as $150 for those buying weight of 10+ grams).

Afterword, why the trade in opium should be legalized:

Production of opium is driven by the worldwide demand for opiates. Trying to eradicate the drug supply is not only pointless due to the balloon effect, but it leads to unintended consequences that violate human rights. Farmers have a right to live a life of dignity, even if their crop is used to manufacture politically disfavored intoxicants. Moreover it is futile to destroy the crops, as even if the price of opium increases four- or five- fold, the cost to produce a gram of heroin would only increase to $5-10. This is why the cost of production has almost no effect on the street price. When heroin is selling for $400 per pure gram on the streets of US cities it doesn't matter if the cost of opium goes up or down.

The "Iron Law of Prohibition" states that prohibition results in forms of the drug that are more concentrated, which is why the vast majority of the world's illicit opium is ultimately consumed as heroin. While opium is usually eaten or smoked, heroin is often injected. The high cost of heroin also increases the utility of injection use, which combined with laws criminalizing injection equipment brings along other health harms like HIV and Hep C.  

Instead of being able to order opium directly from the Afghan farmers over the internet, opiate users must purchase their drugs from black market suppliers who rely on criminal drug trafficking organizations to get the product to the markets. Opiates represent an illicit commodity worth an estimated $65 billion dollars, money which goes exclusively to criminal organizations. 

The high cost of opiates in the black market causes many people dependent on illicit opiates to fall into abject poverty. When addicts are able to access opiates at reasonable prices, prices close to the real cost of production, many are able to live relatively normal lives. If heroin was sold at $10/gram, there would be no black market. Addicts would no longer commit crimes to raise money for their habits. The "junkie" stereotype is a product of our drug laws, after prohibition the popular image of an opiate user will hopefully be different.

There are other arguments for why opium should be legalized, but preventing Afghanistan from becoming a narco-state is a powerful one. The only way to do that is to bring the drug trade into the legitimate economy, by legalizing opium.

Further Reading:

Just Say No (to Afghan Counternarcotic Efforts)
By Sam Kierstead

Record Opium Poppy Acreage Means Victory Is Just Around The Corner (As Usual)
By Jacob Sullum

Documents from the UN Office on Drugs and Crime:

The Global Heroin Market

Sunday, November 24, 2013

Opiates are not Highly Addictive

SAMHSA: National Survey on Drug Use and Health, 2008

In most news stories about prescription opioids or heroin, the drugs are usually described as "highly addictive." Heroin in particular is considered among the most addictive, supposedly immensely pleasurable and causing an insatiable craving for more. And yet according to data collected by SAMHSA, only 13.4% of people who first try heroin are dependent on the drug one year later. For "non-medical" users of prescription opioids, the number is only 3.1%. Interesting, based on the SAMHSA data, marijuana is almost twice as addictive as oxycodone.

One may wonder why heroin users become dependent at a rate more than four times that of pharmaceutical opioid users. This may be explained in part due to the heroin shift, users of pharmaceutical opioids switching to heroin following the nationwide crackdown on "pill mills." Secondly heroin is so demonized that that those who use it are a self-selected population. Compared to cannabis or cocaine, there just aren't as many recreational heroin users out there (people who might get high occasionally on weekends or special occasions).

Defenders of the drug war claim that drug prohibition is the only thing holding back legions of potential addicts. The truth is that the response to opioids is highly individualized, many people experience only negative effects (nausea and headaches are common) and no euphoria.

The Prescription Painkiller Experience: Less than a Third Say They Like It
by Maia Szalavitz

Many people fear that mere exposure to prescription painkillers like Vicodin or OxyContin will set them down the road to addiction. But new research on the response to opioid medication suggests that most people don’t particularly like the experience of using the drugs — a key factor in future addiction risk.

Researchers led by Dr. Martin Angst of Stanford University studied 114 pairs of identical twins aged 18 to 70, none of whom had chronic pain or addiction. Participants received intravenous infusions of either placebo or the opioid alfentanil, a drug that is approximately 10 times stronger than heroin and is used as an anesthetic during surgery. IVs are known to be the most addictive route of drug administration.

According to the findings, published in the journal Anesthesiology, 14% of participants said they disliked the opioid experience outright. About 6% found it neither pleasant nor unpleasant and 52% had mixed feelings about it; 23% of those with mixed feelings said they disliked it more than they liked it. Less than one-third (29%) of volunteers said they liked the opioid experience unreservedly. “If you would split it up, you would say about a quarter really didn’t like it and a quarter really liked it a lot,” says Angst, a professor of anesthesia at Stanford.

Researchers study drug liking as a sign of addiction risk; not surprisingly, people do not usually become addicted to drugs they don’t like. But liking alone doesn’t necessarily lead to addiction; otherwise addiction rates would be at least double what they appear to be now: research on recreational use of heroin finds, for example, that 69% of those who try the drug are not using it at all a year later, while 13% are addicted. For prescription opioids, 57% who try the drugs non-medically aren’t using them a year later; 3% are addicted.


Meanwhile, another new study published in the journal Addiction [see results and link below- Ed] reviewed the literature on addiction risk following exposure to opioid medication for pain. The data on the subject are not very strong, the review suggests, but they do show a wide range of risk: anywhere from 0% to 24% of people treated for chronic pain or cancer pain can expect to develop a new addiction. However, the average risk found in the data is less than half a percent, meaning that the studies showing extremely high percentages represent outliers.

“We have an immense problem because we don’t understand who is at risk and under what circumstances,” says Clark in reference to the rates of prescription painkiller overdose and addiction, which have been skyrocketing in recent year.

Numerous studies have been done which look at the rate of addiction in patients treated with opioids for chronic pain. Cited below are two reviews, one done by the prestigious Cochrane Review, found that iatrogenic addiction was rare, occurring in less than 1% of the patients. A more recent review published in Addiction found an average rate of 0.5% (though some studies did have unusually high numbers, up to 24%). Both studies concluded that iatrogenic addiction was rare in patients treated for chronic pain.

The irony behind this is that there exists in the public mind two groups of people who consume opioids: "legitimate" pain patients and "illegitimate" addicts. And yet the most evidence-based treatment for opioid addiction is to prescribe an opioid, usually methadone or buprenorphine, and rarely heroin. The major difference in treatment is that the addict's access to the drug is far more restricted, and there are additional requirements involving some form of psycho-social support . The result is a massive medical bureaucracy around the dispensing of narcotics, pain clinics on one end and methadone clinics on the other. Drug testing industries profit from both systems, monitoring the patients for any use of the naughty substances (but never tobacco, which has a higher burden of disease and death than all illegal drugs combined). All of this over a substance that grows naturally from the ground and has been legally traded for most of human history!


Long-term opioid management for chronic noncancer pain
The Cochrane Library
Published Online: 20 JAN 2010
DOI: 10.1002/14651858.CD006605.pub2

Main results

We reviewed 26 studies with 27 treatment groups that enrolled a total of 4893 participants. Twenty five of the studies were case series or uncontrolled long-term trial continuations, the other was an RCT comparing two opioids. Opioids were administered orally (number of study treatments groups [abbreviated as "k"] = 12, n = 3040), transdermally (k = 5, n = 1628), or intrathecally (k = 10, n = 231). Many participants discontinued due to adverse effects (oral: 22.9% [95% confidence interval (CI): 15.3% to 32.8%]; transdermal: 12.1% [95% CI: 4.9% to 27.0%]; intrathecal: 8.9% [95% CI: 4.0% to 26.1%]); or insufficient pain relief (oral: 10.3% [95% CI: 7.6% to 13.9%]; intrathecal: 7.6% [95% CI: 3.7% to 14.8%]; transdermal: 5.8% [95% CI: 4.2% to 7.9%]). Signs of opioid addiction were reported in 0.27% of participants in the studies that reported that outcome. All three modes of administration were associated with clinically significant reductions in pain, but the amount of pain relief varied among studies. Findings regarding quality of life and functional status were inconclusive due to an insufficient quantity of evidence for oral administration studies and inconclusive statistical findings for transdermal and intrathecal administration studies.

Authors' conclusions

Many patients discontinue long-term opioid therapy (especially oral opioids) due to adverse events or insufficient pain relief; however, weak evidence suggests that patients who are able to continue opioids long-term experience clinically significant pain relief. Whether quality of life or functioning improves is inconclusive. Many minor adverse events (like nausea and headache) occurred, but serious adverse events, including iatrogenic opioid addiction, were rare.

Development of dependence following treatment with opioid analgesics for pain relief: a systematic review
Addiction. Volume 108, Issue 4, pages 688–698, April 2013
DOI: 10.1111/j.1360-0443.2012.04005.x


Data were extracted from 17 studies involving a total of 88 235 participants. The studies included three systematic reviews, one randomized controlled trial, eight cross-sectional studies and four uncontrolled case series. Most studies included adult patients with chronic non-malignant pain; two also included patients with cancer pain; only one included patients with a previous history of dependence. Incidence ranged from 0 to 24% (median 0.5%); prevalence ranged from 0 to 31% (median 4.5%).


The available evidence suggests that opioid analgesics for chronic pain conditions are not associated with a major risk for developing dependence.

Saturday, November 16, 2013

A Phoney War

It seems to me that the chief problem here is that the state has taken on the role of a ‘nanny’ and is wont to issue various stern moral commandments - even though, of course, that is not the function of a (secular) state. Politicians (whose wages are paid by us) are stuck in an outdated mindset which views psychoactive drug use as immoral and they feel obliged to promote their dislike of such behaviour (apart, that is, from alcohol use, the acceptance of which is evinced by the four subsidized bars in the House of Commons). Even the word ‘drug’ has become pejorative, at least in the UK. So as soon as you mention drugs, there are negative associations.

In thinking about all this, one is reminded of the hatred and malice once meted out to gay people. Being gay was (and still is in certain quarters) proffered as some kind of moral degradation, so much so that homosexuality was criminalized and punished. As a case in point, not many people know that the grandfather of modern computing, Alan Turing, was publicly ridiculed to the point of suicide on account of his homosexuality. So you get this finger wagging and demonization, as if the ills of the world are caused by a certain subset of the population engaging in a behaviour that the state views as immoral and improper. It is oppression pure and simple and no different in kind to, say, racist oppression. You pick some behaviour (or physical attribute in the case of race) that you are afraid of, or that unsettles you in some way, or that you do not really understand, or that you know nothing whatsoever about, and then you vilify and condemn that behaviour, you drag people in front of judges, and maybe you jail them for good measure.

This is classic subjugation, a classic power game that ends up supporting a veritable industry of oppression. Think of all the police manpower used chasing drug users, all the organized dawn raids, the court costs and extortionate lawyer fees, and the privatised prisons that profit from a sizable incarcerated population from which free labour can be drawn. And that is not to mention the vast webs of organized crime that thrive the world over on the back of drug dealing. The black market trade in illicit drugs is right up there with arms sales and oil sales.

The irony here is that prohibited drugs are referred to as ‘controlled’ drugs. Yet they are well and truly out of control. There is no control over production, no control over distribution, no taxes are paid, no educational leaflets are handed out - the situation is appalling and has been so for over forty years. And yet it rolls on and on and we still hear the cry of ‘zero tolerance to drugs!’. It is an oppressive mess.

To reiterate: the central issue is health. If you are addicted to heroin you have a health problem that needs to be treated. It's the same with any other drug addiction. If, on the other hand, you don’t have health problems and you are not hurting anyone, then there is no problem (about 90% of all drug use is considered to be non-problematic). What is totally out of order and has no place in society is unwarranted oppression and demonization. Yet this is what the war on drug users entails.

As far as I can see, the immediate decriminalization of all and any drug use is a no-brainer. Thereafter, we would need to address how best to properly control all drug manufacture and distribution away from the hands of unscrupulous armed cartels and the like. Society needs to take back control. The so-called ‘war on drugs’ is a scam, a pernicious folly that does not stand up to close scrutiny. The sooner ordinary people ‘come out’ and declare drug use to be a health issue and not a criminal issue, the better.

A Phoney War  by Simon G. Powell

Thursday, November 14, 2013

Wednesday, October 30, 2013

Doubts About Reported Krokodil Cases Within US

Suspected krokodil a false alarm
Negative tests lead to further skepticism
October 27, 2013|By Andy Grimm, Chicago Tribune reporter
The hunt for krokodil continues as tests conducted in recent days on a suspected sample of the so-called flesh-eating drug came back negative, federal officials said.

An announcement two weeks ago by a Joliet doctor who said he treated three patients who showed the telltale rotting flesh associated with the toxic, home-brewed opiate — made from mixing codeine tablets with solvents like gasoline or acids — has sparked media coverage. A week later, a Crystal Lake hospital reported treating a krokodil user, and reports have cropped up across the country.

In a sweep modeled after the agency's successful search for the source of deadly fentanyl-tainted heroin some six years ago, 200 DEA agents across five states have made finding krokodil a top priority, Riley said.

"We have run quite a few buys in the city and suburbs," Riley said "What the lab tells us is it's just heroin."

Some experts in law enforcement and public health say it's unlikely the drug will be widely used beyond the remote areas of Russia and eastern Europe where it became popular a decade ago.

The Tribune contacted health officials in nine states where reports of krokodil have surfaced in the media, but no agency, yet, has found conclusive proof that the drug is in use. The number of unverified cases recorded by poison control centers in states where krokodil has been reported in the media is barely into double digits.
 Most of the reported cases of krokodil use have come from people who thought they were buying heroin, public health officials said.
"For krokodil ... people think they are getting heroin, and they say, 'I was using heroin and I got these sores.'"

In the Joliet case at least, suspected krokodil victims reportedly were heroin users who began to develop sores where they injected the drugs.

And even the symptoms associated with krokodil use are not that unique, said Jane Maxwell, a researcher at the University of Texas who has studied drug trends and sits on a National Institute on Drug Abuse panel that has identified new drug variants.

Long-term users of injectable drugs like heroin can develop infections from reusing needles and exposing themselves to all sorts of bacteria, leading to staph infections or those that are resistant to methicillin, known as MRSA infections.

Maxwell said there have been outbreaks of infections among heroin users that point out a peril facing users of illegal drugs that is well known, and less insidious than a new concoction: quality control.

"In California once, there were these outbreaks of sores," she said. "It was because the heroin was coming across the border stuck up the rear ends of cows."

Desomorphine, questionably the main component of Krokodil

     I had my own doubts about the appearance of krokodil within the US. One reason krokodil is a thing in Russia is because codeine is available OTC. Combined with a high rate of opiate use and crushing poverty it's not surprising some people desperate to relieve their pain turn to this toxic, home-baked and short-acting opioid. I doubt there are very many recreational krokodil users, though I may be wrong.
     Codeine is not exactly rare in the US, but given how short-acting desomorphine is (duration around 90 minutes), it just does not seem economical. Most codeine pills are 15, 30 and 60 mg. No synthesis is 100% efficient and there is every reason to believe the amateurish attempts at synthesizing desomorphine from codeine would result in low yields. I personally have not done much in depth research on the specifics of the "krokodil" method, there are some on the opiophile forums that question whether the Russians are truly producing desomorphine. Anyway codeine is sold in Russia OTC and cheap, but that is not the case here in the US.
      So it's possible the recent krokodil-like effects seen in some heroin users may in fact be due to contaminated heroin. We have seen this before, in anthrax outbreaks in UK heroin users (caused by smuggling heroin in the stomachs of animals). You know what might stop people from sticking heroin up the rear end of cows and causing infections in users? Legalization. Drug users have rights, among them the right to the highest possible standard of health. Any regime which violates fundamental human rights is illegitimate and should be discarded. 

A Note about Krokodil Synthesis:

The Russian makers only get a low yield or an impure product BUT codeine phosphate capsules are about $1.50/50x25mg so the start material is cheap. The exact route varies from maker to maker but they all seem to do more or less this:

1-Codeine + SOCl2 ---> α-Chlorocodide + HCl + SO2

2-α-Chlorocodide + I2 ---> 7,8 diiodo α-Chlorocodide

3-7,8 diiodo α-Chlorocodide + HI ----> desomorphine

Basically steps 2 & 3 are done in 1 pot. The iodine adds across the 7,8 double-bond in the same way Br adds across a double bond. The chemist then adds P to make HI which is a reducing agent. It removes the Is. The HI also demethylates the 3-methoxy. Looking at a list of the stuff formed, 6 or 7 impurities are found in varying amounts. Yield of product is about 30% at best. Of course, the stuff is x10 morphine so about 4x heroin (the BNF directs doctors that diamorphine is x2.5 morphine in medical uses).
Now, the product has a bare phenol on it so it cannot be smoked. One can readily esterify this compound (acetyl ester, nicotinic ester and so on) so it's BP becomes sufficiently low.
I will do a full test including pictures if enough people ask me to. It's about £300 of stuff I will use and I have no interest in taking the product... or selling... or giving away.
-Borohydride on the Opiophile Forum


    It appears Russia has made codeine prescription-only. Apparently krokodil has become less common, a good thing. For people who used codeine medically, or for junkies trying to take the edge off the withdrawals, life is bound to get more difficult.
     Opiophilia was mentioned in Jacob Sullum's article on krokodil, Another Way Prohibition Makes People's Flesh Rot. I'm a huge fan of Sullum's work, he and Maia Szalavitz are two of the best writers in the mainstream press covering drugs and drug policy.


Tuesday, October 29, 2013

Thursday, October 24, 2013

Harm Reduction, the Ultimate Goal

In the United States harm reduction was followed three basic themes:
-Syringe Exchange
-"Good Samaritan" Laws which offer immunity for people who respond to overdoses by contacting emergency services (immunity may be limited and not cover those on probation, in drug court, nor possession or distribution charges)
-Naloxone (narcan) access for people who use opioids

Radley Balko has a recent post about a Wisconsin state Rep whose daughter is a heroin addict. It was her experience which motivated him to sponsor a series of bills that moved forward harm reduction in Wisconsin:
The Milwaukee Journal Sentinel has the story of Wisconsin Republican state Rep. John Nygren, who is sponsoring a series of bills aimed at addressing and minimizing the damage from heroin overdoses. Two of the policies he's pushing are somewhat controversial. The first would offer limited immunity for people who call 911 or bring overdose patients to an emergency room. The sensible theory behind the policy is that people are reluctant to report overdoses if doing so could subject them to criminal charges. The other would expand those with access to Narcan, a medication that reverses the effects of an overdose.

Nygren is sponsoring these laws after confronting his daughter's heroin habit, and her near fatal overdose in 2009. Unfortunately, that sort of brush with the drug war's collateral damage is sometimes what it takes to make politicians see the light. But good on Nygen for coming around.

The Good Samaritan policy is understandably controversial, although it's certainly a sound approach. You're sacrificing a possible low-level drug prosecution in order to save a life. You'd think that even an ardent drug warrior would find that to be a satisfactory trade.

Or perhaps not. Some drug policies over the years have reflected more of a "better dead than high" approach to addiction. Consider the Narcan policy. If there's a medication out there that can prevent heroin overdose deaths, you'd think policymakers would want it distributed far and wide. But that hasn't been the case. There's a history here in which both the federal government and state governments have tried to restrict Narcan's availability. Consider this quote from Dr. Bertha Madras, deputy director of the White House Office on National Drug Control Policy during the George W. Bush administration.
    "Sometimes having an overdose, being in an emergency room, having that contact with a health care professional is enough to make a person snap into the reality of the situation and snap into having someone give them services."
In other words, withholding lifesaving medication from overdose patients may be just what addicts need to kick the habit for good. Yes, it could also kill them. But at least at that point, they'll no longer be getting high.

Daughter's Heroin Habit Moves Wisconsin Lawmaker To Sponsor Good Samaritan Law

Offering immunity for people who try to save addicts lives and expanding access to naloxone are important measures. Yet these "controversial" measures (if it was saving the lives of any other population it wouldn't be controversial) are doing little more that chipping away some of the worst aspects of the drug war. Rep Nygren's daughter went through the stereotypical junkie experience:

Cassie Nygren's parents divorced when she was 3.

As a teen, she experimented with alcohol and marijuana. She also says she was sexually abused.

At 15, she became pregnant and later gave up her daughter for adoption.

"I had just turned 16 and for her to leave me and be put into a vehicle of somebody else's and driven away was the hardest thing that I've ever had to do," she says. "I know that it was best. I know that it was a selfless thing to do. I know that she's loved and safe, and I wouldn't ask for anything more. However, it affected me, and it was never dealt with."

Months after she gave birth, she says, she started using Oxycontin, a commonly abused prescription narcotic painkiller. A friend introduced her to the drug, she says.

"I loved it right away," she says. "It gave me a feeling of being numb, no pain. It filled a void of emptiness that I had had, and right away I was hooked. The way I started was snorting....By 18, I was shooting heroin."

To feed her drug habit, she stole from her family.

"I don't think even any dollar amount could answer how much I've stolen and robbed from them," she says. "Not just in expenses or valuable things but our trust."

She cries as she recalls stealing her dad's Jaycees ring and pawning it for $150.

"It breaks my heart and to have admitted that to him was extremely hard," she says.

Cassie Nygren confessed to her father about her drug problems during a dinner at a local pizza restaurant.

"She looked terrible," he says. "Face white, pale, sunken in. And she's a pretty girl. You could basically see it on her face."

The family got her into treatment, but it didn't stick. She was in and out of several programs.

"A smart kid with a bright future ended up not graduating from high school," John Nygren says. "She got her GED later."

And she spent time in jail. The prosecutor, Marinette County Assistant District Attorney Kent Hoffmann, says his approach in Cassie Nygren's case "was to send her to prison to save her life."

After serving her prison sentence, Cassie Nygren violated her extended supervision several times. The latest was over the summer when she left town with an ex-boyfriend. They went to Texas, where she was picked up during a routine traffic stop.

She says she was trying to break away so that she could live a clean life with a friend in Texas. She says she now knows it was a mistake to leave.

John Nygren and his ex-wife worry about what will happen to their daughter. Amy Harris says she has seen encouraging changes in recent weeks.
 Marinette lawmaker confronts daughter's heroin addiction, seeks new legislation

Cassie Nygren

A traumatized girl deals with her mental pain by self-medicating with opiates. Because real drug education on how to use drugs safely is nonexistent, and only the most concentrated and therefore dangerous formulations are available to users (oxycontin and heroin instead of opium or poppy pod tea), the chance of overdosing is high. Cassie Nygren's story, the overdosing, stealing, jail, the in-and-out of ineffective treatment programs, is far from unique. It could even be called the stereotypical junkie story, but it doesn't need to be.

If Cassie Nygren was offered heroin maintenance she could have been kept from overdosing, stealing from her family and out of jail. She might even go to school and become a productive member of society. Expanding opiate maintenance beyond methadone and buprenorphine to include the full spectrum of available opioids would probably do more to lessen the problems of opiate prohibition than any other measure (short of full legalization). The black market would be dramatically reduced and users would no longer be criminalized. Because heroin is relatively harmless in and of itself, most of the health problems that are common in heroin users would disappear. The acquisitive crime and prostitution that is so common among destitute addicts would be dramatically reduced. The hard working addicts who hold down a job only to see a sizable portion of their paycheck go to supporting their habit would keep that money, improving the quality of life of their families. Accidental overdoses would be rare, and would be promptly treated by clinic staff.

The cost of pharmaceutical heroin, morphine and the other semi-synthetic opiates is negligible. The savings in criminal justice costs, crime averted and health savings more than compensates for the cost of running opiate maintenance clinics. The only real cost to society is that we would have to stop persecuting addicts and give them the drugs they want.

Opiate maintenance using the individual's opioid of choice is the form of harm reduction that has the most benefit for the individual and society. I urge all drug reformers to move the discussion beyond (but not abandon!) clean syringes, safe injection facilities and "Good Samaritan" laws and adopt maintenance prescribing as the most important harm reduction goal.

Saturday, October 19, 2013

Opium Dens and Shooting Galleries

In the 19th century when opiates were legal, consumed as opium, morphine or patent medicines containing opium among other ingredients, there were two primary types of addicts. One was predominantly white, and had been introduced to opiates from a doctor (iatrogenic addiction). They took their opiates orally, or increasing through a syringe. Women outnumbered men, middle-class housewives were typical cases.
The second type of addict was the opium smoker. Opium smoking was a Chinese custom, one they brought with them upon mass immigration to the US in the latter part of the 19th century. 

The Chinese immigrant largely isolated themselves, in part due to racism and in part by choice. Most immigrants were young men hoping to earn enough money to return home a wealthy man, a dream few actually realized. Regardless most thought of themselves as temporary workers and saw no reason to assimilate with US society. Mass influx of Chinese labor willing to work cheap was seen by some as taking away jobs from white native Americans, when combined with racism and xenophobia, contributed to the exclusion of the Chinese.

One major exception was the opium den, which attracted the more deviant members of society. The opium den was more than just a place to get high. "More formally, the opium den had become the matrix of a deviant subculture, a tightly knit group of outsiders whose primary relations were restricted to themselves." (Courtwright, 1982) The den was one of the few places where Chinese and whites, of both sexes, mixed openly. Lurid charges were leveled at proprietors, charges that Chinese perverts were using opium to seduce young white women into a life of immorality. The labor leader Samuel Gompers excelled at using hysterical rhetoric, complete with anxieties over miscegenation, to drum up popular support against the opium den:

"...tiny lost souls...forced to yield up their virgin bodies to their maniacal yellow captors...What other crimes are committed in these dark fetid places when these innocent victims of the Chinaman's wiles were under the influence of the drug opium is too horrible to imagine. There are hundreds, aye thousands, of our American girls and boys who have acquired this deathly habit and are doomed, hopelessly doomed, beyond redemption.

They carry the curse of China, opium, as their weapon. They and their poison must be rooted out before they will decimate our youth and emasculate the coming generation of Americans."
Opium Dens from around the world, some are more affluent than others but the basic accommodations for those on the hip are the same.
The reality was quite different, as the historian David Courtwright documents:

"An opium den was more than a school, however; it was also a meeting place, a sanctuary, and a vagabonds' inn. Member's of the underworld could gather in relative safety, to enjoy a smoke with their friends and associates. One addict has left us a memorable portrait of life in the New York City dens. 'The people who frequent these places,' he recounted, 'are, with very few exceptions, thieves, sharpers and sporting men, and a few bad actors; the women, without exception, are immoral.' In spite of the desperate character of clientele, fights were practically unknown. Instead, the smokers passed the time between pipes by chatting, smoking tobacco, telling stories, cracking jokes, or even singing in low voices...Within the den a rigid code of honor prevailed: smokers would not take advantage of other smokers, or tolerate those who did. 'I have seen men and women come to the joints while under the influence of liquor,' continued the New York addict, 'lie down and go to sleep with jewelry exposed and money in their pockets, but no one would ever think of disturbing anything.' 'The joint,' confirmed an experienced Denver smoker, 'is considered a sacred sanctum, and to betray...any conversation between the fiends is considered an unpardonable offense, and a fiend who commits a second offense of this character is generally debarred from all the rights and privileges of the joint.'" (Courtwright, 1982)

In many ways the opium den represented the start of the drug subculture in the United States. Language still in use today originates from the opium den culture. "Hip", which is used by drug users to distinguish themselves from non-drug users ("squares", "straights"), originates from opium smokers lying on their hip while on the pipe. The word "dope" is adapted from the Dutch, originally meant a thick, viscous sauce, probably adapted during the process of preparing the opium for smoking. Today "dope" is a generic term for any illicit drug (though where I come from if you ask for dope on the street you are referring to heroin).

If the opium dens were left alone, perhaps by today they would be legitimate. People would be able to choose whether to frequent an alcohol bar, cannabis cafe or opium den. Because opium is smoked slowly, overdosing is more difficult than taking concentrated derivatives. Proprietors would be on hand to treat any cases of overdose.
"Needle Park" in Zurich, Switzerland (prior to heroin maintenance)

Unfortunately the War on (the people who use certain) Drugs has perverted this possible scenario. Opium smoking is almost unknown in the US, almost all the opium produced for the illicit market is manufactured into heroin. Because of prohibition, the cost of this inexpensive to produce, plant-based medicine is astronomical. This encourages methods of ingestion that maximize the effect: intravenous injection.

So instead of opium dens, we have shooting galleries. A shooting gallery is a place where addicts can inject together in relative safety, they are also synonymous with disease and degradation. In contrast to the opium den described by Courtwright, if someone nodded out in a shooting gallery their money and jewelery would almost certainly be stolen.

By ending the drug war and bringing back the opium den, the problems of accidental overdoses will be reduced. Diseases associated with injecting drugs of unknown purity and subject to no quality control (meaning they may be adulterated with other drugs or diluted with substances never meant to be injected), in addition to blood born infections from sharing syringes, will be reduced or eliminated altogether. Crime brought about by the poverty resulting from being dependent on an (artificially) expensive drug will disappear. Drug dealers and criminal cartels will be replaced by taxpaying opium den proprietors.

Further Reading and References:

Courtwright, David T. (1982) Dark Paradise Opiate Addiction in America before 1940. Cambridge, MA: Harvard University Press

Sunday, September 29, 2013

Krokodil Makes its Appearance in the US

The first case of krokodil use in the US has just appeared in Arizona. Another product of our idealistic drug laws, krokodil is made from codeine in a matter similar to illicit methamphetamine production. However even the most rudimentary meth cooks will recrystallize the final product, separating out the toxic solvents and catalysts used in the reaction. Krokodil users inject the final solution straight. While pure desomorphine is probably no more toxic than morphine, the solvents and chemicals used in the reaction cause sores at the site of injection, necrosis of flesh and turns the skin scaly (hence the name "crocodile")...

 A powerful heroin-like drug that rots flesh and bone has made its first reported appearance in the United States, an Arizona health official says.

Known on the street as "krokodil," the caustic homemade opiate is made from over-the-counter codeine-based headache pills mixed with iodine, gasoline, paint thinner or alcohol. When it's injected, the concoction destroys a user's tissue, turning the skin scaly and green like a crocodile. Festering sores, abscesses and blood poisoning are common.

Frank LoVecchio, the co-medical director at the Banner Good Samaritan Poison & Drug Information Center, told KPHO-TV that Arizona health officials have seen two cases during the past week.

"As far as I know, these are the first cases in the United States that are reported," he said. "So we're extremely frightened."

Flesh-rotting 'krokodil' drug emerges in USA

Just more collateral damage caused by the war on drugs.

Saturday, September 21, 2013

The Frozen Addicts: A Cautionary Tale

MPPP is structurally similar to meperidine, in MPPP the ester is the inverted (red arrow) 
This is a cautionary tale for those who dream of home-baking their own drugs. In 1976 a 23-year old graduate student by the name of Barry Kidston began researching opioid drugs that were not scheduled, nor used precursor chemicals watched by the authorities. He came across MPPP, which at the time was an untested, obscure synthetic opioid related to Demerol (meperidine). Relative to Demerol, the ester in MPPP is inverted (red arrow in figure). MPPP is slightly less potent than morphine, and has a shorter duration of action. 

Unfortunately the synthesis is sensitive to both temperature and acidity, if the conditions are not kept perfect a monsterous impurity is formed,  MPTP. MPTP readily crosses into the brain and in uptaken into neurons by the dopamine transporter. It is then converted to the ion MPP+ by the enzyme mono amide oxidase B. From there MPP+ enters the mitochondria where it wrecks absolute havok, setting off a chain reaction that ultimately ends in cell death. The damage done by MPP+ is localized to a region of the brain known as the substantia nigra. Destruction of this brain region results in symptoms of Parkinson's Disease.
Parkinson's usually progresses slowly, symptoms include tremor while at rest, movements are slow, and muscles rigid. In the latter stages patients have reduced facial expressions, inability to move from fixed postures and aphonia (reduced or absent speech). Senses and the intellect are unaffected. For the victims of MPTP induced Parkinson's this must truly have been a traumatic experience; it is must have been terrifying to wake up one day unable to move or speak and then to experience withdrawal on top of this is almost too terrible to imagine. 
Parkinson's Disease in a 23-year-old was unheard of, and Kidston was originally misdiagnosed with catatonic schizophrenia. Treatment for Parkinson's Disease involves administration of the drug L-Dopa,which is converted to dopamine in the body replacing the dopamine usually produced by the cells. It was only after a neurologist administered the drug L-Dopa that Kidston was able to speak again. After telling the doctors about his recent home chemistry work, scientists at the National Institute of Mental Health recovered some samples of Kidston's synthesis from his glassware and discovered the MPTP impurity. 

Drug manufacture should not be attempted without less than a BS degree in chemistry or a related field. A master's degree in organic chemistry is even better. For example I was reading a forum where the synthesis of fentanyl was being discussed. Someone posted a comment asking, what is an SN2 reaction? If you do not know that SN2 refers to a 2nd order nucleophilic substitution, something that is covered in the first semester of a college level organic chemistry course, you have no business trying to synthesize fentanyl. Even Barry Kidston was a graduate student and he made a serious error (if he had access to GC-MS equipment he might have detected the impurity, but since such machines run into the tens of thousands of dollars few clandestine labs are such equipped). 

Unless you are an experienced chemist with a well-equipped laboratory, you should not attempt to synthesize opioids. Instead buy the book Opium for the Masses by Jim Hogshire and try growing your own poppies. Poppy cultivation and opium harvesting is comparatively easy, and not likely to result in devastating errors. 

I wish that I could say that the damage from MPTP was limited to Barry Kidston, unfortunately it has reared its ugly head again in 1982 in San Jose, California. Apparently these chemists' technique was no better than Kidston's and samples confiscated by authorities were found to be contaminated by MPTP.  

Advice for Opiate Users (Harm Reduction)

If you are buying dope that the dealers claims to be "synthetic heroin" it is possible that the drug is MPPP. MPPP does not have as long a duration as heroin, nor will it appear on a standard drug screen. Moreover mixtures of MPPP-MPTP causes a severe burning at the site of injection, blurred vision, tremors, a metallic taste in the mouth, jerking of the arms and legs followed by tightness and stiffness in the muscles. 

If you think that you have been exposed to MPTP, there are things you can do to prevent the onset of Parkinson's symptoms. It takes 3-4 days for MPTP to do its damage, and it is actually the metabolite MPP+ that does the damage. Taking an MAO-B inhibitor may prevent the conversion of MPTP to MPP+, and thus prevent the onset of symptoms. MPTP can remain in the body for over 2-weeks, so administration of the MAO-B inhibitor may need to continue for several weeks.


Thanks to prohibition, opiates are far more expensive than they would be in a free marketplace. It is not surprising then to see people attempting to manufacture their own drugs. Some simply want to self-medicate without having to spend a small fortune doing so, others undoubtedly dream of being like Walter White (Breaking Bad) and running a drug empire. If it were not for prohibition, this would not be an issue. Users would have access to drugs produced by pharmaceutical firms with quality control, and make purchases from pharmacies instead of street corners. 

MPTP induced Parkinson's Disease is another unintended consequence of our War On (the people who use certain) Drugs. During the days of alcohol prohibition, tens of thousands of alcohol users were poisoned by contaminated booze. Opiate users who are poisoned by contaminated drugs are more collateral damage in this futile war. Few people today would suggest that alcohol consumers deserve to contract horrible diseases simply because they choose to consume alcohol (and alcohol is certainly a "hard" drug if the hard/soft distinction is to have any meaning whatsoever).

We are not collateral damage, we are people. It is time to admit that drugs have won the drug war, and  well past time to make peace with drugs.

Further Reading:

Restak, Richard M. (1994) Receptors New York, NY. Bantam Books

MPTP, mitochondrial Complex I, and William Gibson's Necromancer

The Frozen Addicts

The Case of the Frozen Addicts [Book - Amazon Link]

Lee, J.; Ziering, A.; Heineman, S. D.; Berger, L. (1947). "Piperidine Derivatives. Part II. 2-Phenyl- and 2-Phenylalkyl-Piperidines". Journal of Organic Chemistry 12 (6): 885–893. doi:10.1021/jo01170a021

Wednesday, September 4, 2013

I Need Help...Acquiring Drugs

While this Onion article is meant as a parody, there is truth in this article. Many of the problems caused by opiate dependence could be solved if users could access their drugs in a legal marketplace at reasonable prices. 

I Admit It, I Need Help Acquiring More Drugs
COMMENTARY • Opinion • ISSUE 49•32 • Aug 8, 2013
By Ray Patton

As any longtime drug user can attest, there comes a time in your life when you have to admit that you have a problem. A time when things get so bad that the only thing left to do is open your eyes and admit you need help. It’s about acceptance, about acknowledging that something is wrong and that you can’t fix it alone. And for me, that moment of acceptance happens now. So here it is: I admit that I am a serious drug abuser and that I need help acquiring more drugs.
I have a problem, and my problem is that I don’t have any drugs right now and I need you to help me find more drugs.
This is not an easy thing for me to admit, as you can imagine. Hell, it took me a long time before I could even admit to myself that I have a problem obtaining illicit drugs. And then once I did finally admit this to myself, I felt a great deal of shame about my drug-acquiring problem, and I spent many long, sleepless nights wondering, “Damn it, why can’t I beat this thing? Why can’t I just find a dude in the park who’s willing to give me a solid discount on some rock or blow, no hassle?”
That’s when I realized I couldn’t do this alone, and that I don’t have to do this alone. On the contrary, I have to be able to trust in the kindness, understanding, and generosity of loved ones to guide me through this challenging, drugless time by helping me secure a new connection and maybe lending me a little extra scratch if they have any. Whatever they can spare.
And the thing I’ve come to accept is that it’s okay to ask for help, ya know? There’s no shame in it. It’s okay to turn to a close friend or family member and say to them, from the bottom of your heart, “Yo, your neighbor likes to party, right? Can you call him up and see who his delivery guy is? Come on, man, I really need this. I’ll make it up to you, I fucking swear.” Once you take that first crucial step toward accepting help for your drug-finding—as difficult as it is for someone who’s completed hundreds if not thousands of drug transactions before with no assistance whatsoever—then you’re on the road to being a regular user again, enjoying a normal life of hard drug abuse.
Now, it goes without saying that acquiring more drugs isn’t going to be easy, and I know that. I know I’ve got a tough road ahead of me, as does my family, and especially my friends, whose help I’m going to need every day if I’m ever going to find another dealer and pay upfront for my shit so I don’t start owing people and getting a bad rap on the street. It’s humbling, sure, but with patience and the support of others, I can make it out the other side of this struggle.
Preferably sooner rather than later, too, because if I don’t score in the next few hours I’m going to be crawling up the fucking walls.
And for those who doubt me, let me promise you this: I am deeply, deeply committed to finding more drugs. I’m not just going through the motions here to please others. This is not an empty promise. This is something that I desperately want to do for myself so that I can get high constantly each and every day. Hell, just hearing myself make that promise to exploit close relations for drugs makes me truly believe I can conquer this thing. This not-having-drugs thing.
And when you think about it, I’ve already come a long way. A week ago I never would have admitted that I needed anyone’s help finding drugs. At that point I would have just probably stolen from a sibling or old college buddy and lied about it. But now I’m coming right out and saying, “Hey, buy me drugs, I need them real fucking bad, okay? What kind of monster are you? If I don’t get a hit I’ll die, man. Do you want me to die?” That’s a huge step. And you know what? I’m proud of myself. I’ve really come a long way.
So, that being said, may I please have $50 and a ride to the Safeway parking lot on Brentwood? I really need your help.

Monday, August 12, 2013

Charging Dealers with Murder Following an Overdose Death

Drug selling and buying are considered consensual crimes.  Two people come to an agreement about quantity and price and make an exchange. There is no victim. A merchant who deals in tobacco or alcohol does not belong in a different logical category than a merchant of cocaine, cannabis or opiates. With alcohol or tobacco, after the purchase the responsibility to then use the substance lies with the purchaser, not the seller. If the individual chooses to use the drug in an irresponsible manner, such as operating machinery while intoxicated or otherwise putting others in harm's way, the consequences should lie with the individual. We don't hold liquor stores responsible for drunk drivers or cases of alcohol poisoning, neither should heroin sellers be responsible for overdoses resulting from use of their product.

Similarly the individual should educate themselves about the pharmacological effects of the drug prior to consumption. Just as one should not attempt to drive a car without first learning how to operate an automobile, one should not use drugs without first becoming familiar with their effects. Of course society has put in place regulations on the operating of automobiles, since they can be dangerous in the wrong hands. Unfortunately with illicit drugs it is a free-for-all. Far from drug control, the current system is completely uncontrolled. There are no age restrictions or any prerequisites at all in the illicit drug marketplace outside of cold hard cash. On the supply side there is no standards or quality control. The drug purchased may be something else entirely, or an inert substance. Substances oft injected are not sterile.

Accidental drug overdoses are often tragic, and probably largely avoidable if our drug policies were guided by science instead of hysteria. Nevertheless the drug war machine rolls on, and the bodies continue to stack up. As the crackdown on prescription opioids continues, heroin has been strong comeback, and with it an increase in overdoses.

To respond to the increase in overdoses law enforcement has been moving to charge dealers with additional penalties when a particular sale results in death. The additional penalties are substantial, not that the penalties for selling heroin are anything to laugh at.    

Dealers now being charged in drug overdose deaths

TOMS RIVER, N.J. (AP) — With the number of heroin overdoses skyrocketing nationwide, a growing number of law enforcement agencies are dusting off strict, rarely used drug laws, changing investigatory techniques and relying on technology to prosecute drug dealers for causing overdose deaths.

The aggressive change in tactics comes as more people turn to heroin because of crackdowns on powerful prescription opiate painkillers that make them more expensive and inaccessible. The popular prescription drug OxyContin has also been reformulated to make it difficult to crush and snort, making it less desirable on the street, law enforcement officials said.

Nationwide, the number of people who said they have used heroin in the past year skyrocketed by 66 percent between 2007 and 2011, according to the Substance Abuse and Mental Health Services Administration. The number of people who died of overdoses and had heroin present in their system jumped 55 percent from 2000 to 2010, according to the Centers for Disease Control and Prevention.

Rather than going after lower-level users of heroin, prosecutors are looking to take out dealers and members of the supply chain by connecting them and the drugs they sold to overdose deaths and charging them with laws that carry stiff penalties.

"We're going to be ruthless," said prosecutor Joseph Coronato of Ocean County, N.J., where 75 overdose deaths have occurred this year. "We're looking for long-term prison sentences."

Coronato and other New Jersey prosecutors are employing the state's little-used "strict liability for drug death" statute, a first-degree crime that holds dealers and producers responsible for a user's death and has a 20-year maximum sentence.

He and other prosecutors nationwide are changing the way they investigate overdoses, which were once looked upon as accidents. Detectives are being immediately dispatched when word of an overdose comes in. Paramedics are being told to treat overdoses like crimes. And coroners are being asked to order autopsies and preserve forensic evidence, as proving that a death was caused solely by heroin can be difficult when other opiates, drugs or alcohol are present in a person's system.

"When you go to an overdose death, treat it like a crime scene. Don't treat it like an accident," said Kerry Harvey, the U.S. attorney for eastern Kentucky. He has started prosecuting people who sold both prescription opiates and heroin under a federal law that prohibits the distribution of illicit substances and allows additional penalties for a death.

Technology is another boon to such cases. Prosecutors said cellphones have been instrumental in helping gather enough evidence because people leave behind a trail of text messages and calls.

"People text their dealer and say, 'Get me some horse,'" said Hennepin County, Minn., attorney Mike Freeman, using slang for heroin. "They text back and say, 'Meet me at McDonald's, I have some really good horse.' The guy is dead three hours later."


Some wonder whether the enforcement efforts are actually going to curtail drug sales. Douglas Husak, a lawyer and professor of philosophy at Rutgers University, said he doesn't think the stricter enforcement will stop people from dealing heroin.

"Heroin distributors are not murderers, and they're not murderers when their customers die from an overdose," said Husak, who has called for decriminalizing drugs.

In New Jersey, officials say heroin has become a scourge across the entire state, prompting Gov. Chris Christie to create a task force on heroin and other opiates. Forty-five percent of the primary drug treatment admissions in 2011 were for heroin, according to the White House Office of National Drug Control Policy.

Mariann Farino's son Raymond died of a heroin overdose in January. Coronato's office charged the man they say sold her son heroin in June.

"Did he stick the needle in my son's arm? No. Did he sell him stuff that was crazy? Yes," she said. "Should he be held partially responsible? Yes."

Ocean County Prosecutor Joseph D. Coronato with packets of confiscated heroin
So let’s put aside the morality or logic of holding dealers responsible for overdoses, there are some very good reasons why this is a bad idea. For one it is doubtful that there will be any deterrent effect from the increase in penalties. The penalty for selling heroin or other opiates is already severe enough to deter most people who might enter the market if prohibition was repealed. There is a point of diminishing returns where additional penalties will have no further deterrent effect. Dealers do not operate on a daily basis expecting to be caught, nor do they expect their clientele to die from their product (it would be bad business to kill your repeat customers). 
Many dealers are dealers in name only. Often they are addicts who support their habit in part by acquiring drugs for others, plus a modest fee. Such people are driven by forces more powerful than criminal law can hope to influence.

How much will the increased penalties cost taxpayers? An added 10 years to a sentence can run into the hundreds of thousands of dollars. As in all aspects of the drug war, this will undoubtedly fall heaviest on the poor and minority communities, exacerbating the already unconscionable racial bias in the US prison system.

Treating overdoses as crime scenes is likely to make the problem of fatal overdoses more likely. Since the increased penalties will have little to no deterrent effect, we can expect the frequency of overdoses to remain unchanged. However people will be less likely to call for help if they are aware that they will be criminally liable, especially if they sold the drugs themselves. This is where "Good Samaritan" laws come into play, where immunity is given in cases of overdoses. Specifics differ and some laws do not grant immunity for selling or for those on probation or in drug court.

What is more important, saving lives or punishing people for using opiates? History has taught us that we cannot do both. Short of a complete repeal of opiate prohibition, methadone, buprenorphine and heroin maintenance has a proven track record of saving lives, improving the health of addicts and the community in general. Naloxone access should be dramatically expanded to get OD kits in the hands of opiate users, and should also be available over-the-counter (OTC). If we are truly serious about ending the "epidemic" of opioid overdoses, this is the way forward (opiates are not infectious particles, this is a metaphorical epidemic).

Thursday, August 1, 2013

Saturday, July 27, 2013

"Glee" Star Cory Monteith

According to the British Columbia Coroner, Cory Monteith, the star of the TV show "Glee", died after taking a toxic combination of heroin and alcohol.

This is another example of how dangerous it is to combine opiates with other CNS depressants (sedatives). Opiates, by themselves, are generally safe, as are most sedatives. It is the combination that is particularly risky.

Still, others speculate that Mr. Monteith was more vulnerable to overdose after recently going through a detox program, because his body was no longer able to tolerate high doses of heroin. There is no evidence indicating he used high doses of heroin in the past or at the time of his death, making this conjecture less plausible. In addition, while it is theoretically possible to die from an overdose of heroin alone, in practical terms this is rare. Only about a quarter of the thousands of heroin-related deaths each year occur as a result of heroin alone. The vast majority of heroin-related deaths -- a whopping 70 percent or more -- are caused by combining heroin with another sedative, usually alcohol. Regrettably, Mr. Monteith too was a victim of this combination. [emphasis added - Ed] 
As a neuropsychopharmacologist who specializes in substance abuse, I find the focus on factors other than this drug combination distracting and irresponsible. Too often in these tragic cases some "experts" emphasize the failures of rehab, rather than providing the drug-using population with practical information that could prevent countless overdose deaths. We are missing an important public health education opportunity to decrease drug-related accidents. 
The Coroner concluded, "there is no evidence to suggest Mr. Monteith's death was anything other than a most-tragic accident." What was not said is that this horrible accident, and the thousands of others that occur each year, could have been prevented if our public health education message clearly focused on the potential dangers associated with the alcohol-heroin combination instead of being preoccupied with blaming rehab and vilifying heroin. 
"Glee" Star Cory Monteith's Death Proves Heroin (Alone) Is Not the Problem by Dr. Carl Hart
I agree with Dr. Hart about educating drug users in overdose prevention, but he is wrong about blaming rehab. While it is absurd to claim Monteith's death was a direct result of his going to rehab, it was almost certainly a contributing factor. 

First Monteith was coerced into rehab by his employer in an "intervention." Apparently his employer found out that Monteith was "using" again and that was sufficient evidence, not whether Monteith's work was actually impaired (which as with tobacco or alcohol should be the standard used, it matters not what drugs an individual consumes but how they behave). Second, the rehab chosen did not use evidence-based practices, but focused on abstinence and the 12-step model. Maia Szalavitz fills us in on the details:
Apparently, these “experts” suggested Eric Clapton’s Crossroads rehab in Antigua, an old-school program that does not “believe in” using medications to treat opioid addiction, despite all the data favoring them as lifesaving for people whose problems involve heroin or painkillers. Murphy implies that Monteith was in another rehab (reportedly Betty Ford) that “didn’t work”—but that after the second program, “all indications were that he’d gone through the Steps.” 
We all know what happened next. Although the intervention did get him into treatment—unlike the one conducted on [Kurt] Cobain, which was followed directly by his suicide—Monteith followed the pattern of the 90 percent of opioid addicts who are coerced into 12-step recovery and denied an adequate period of maintenance treatment: He relapsed.  
He also followed two other predictable and dangerous patterns. 
First, the risk of overdose is highest in the initial few months after being in rehab or any other situation where a period of abstinence has occurred. After a complete detoxification, a person’s tolerance drops precipitously—meaning that the dose they took before treatment without even getting very high may now be potentially fatal. The first two weeks following prison, for example, were shown by one study to carry a greater than 120-fold increased risk of overdose death; that extreme risk elevation holds for whenever the person first uses again after a period without opioids. 
Second, the vast majority of “opioid overdoses”—overdoses involving drugs like heroin or Vicodin—are not accurately characterized by that name. Instead, they are really “opioid mixture overdoses,” typically including an opioid and other depressants like alcohol and/or benzodiazepines like Xanax and Valium. Opioids are the drug that most often makes these mixes turn deadly—but only one third or fewer of so-called opioid overdoses involve those drugs by themselves. 
Monteith took the deadliest possible combination—alcohol and heroin, whose actions to slow breathing are not additive but multiple—at the deadliest possible time. He was likely not informed about the risk because abstinence-focused rehabs typically don’t provide harm reduction advice. He certainly was not provided with maintenance medication like methadone or buprenorphine that can dramatically reduce that risk; he may not even have know that maintenance was an option—just as Cobain was told he could not take any more opioids, even for his chronic pain. Nor, apparently, were Monteith or his loved ones given naloxone, which can reverse opioid overdose, or instructed on how to use it. 
How Addiction Treatment Killed Cory Monteith by Maia Szalavitz
Cory Monteith's death was due to his own actions to be sure. But that does not mean that we, as a society, have not contributed to it with our drug policies. Had heroin been legal and pure, and accurate drug information was covered in grade school in place of counterproductive anti-drug "education", perhaps it would be widely known not to mix opiates with sedatives.

Had opiates been legal, I highly doubt his employer would have been able to coerce Monteith into rehab. The very notion of staging an "intervention" over non-problematic opiate use would seem as absurd as staging an intervention over occasional alcohol drinking. If Monteith's opiate use did indeed become problematic and interfere with his work, he should have at least have been given the option of maintenance medicines. Szalavitz also addresses this in the same article cited above:
In no other type of treatment are FDA-approved medications seen as appropriate to withhold—without even informing the patient of their existence. No cancer center in the US provides only chemo while refusing to inform patients about radiation treatment or putting it down as something “we don’t believe in here” because it is “cheating” rather than “real recovery.” But the equivalent is done in addiction treatment—even for celebrities—every day. If we don’t want to keep losing patients, we’ve got to actually treat addiction like a disease, by providing evidence-based treatment, not just repeating faith-based philosophies.
Monteith's death, like thousands of others, could have been prevented if our drug policies approached drugs in a rational way. Instead we get vilification of drugs and the people who use them. Meanwhile the body count grows ever higher.

Saturday, July 20, 2013

Opioid Antagonists: Naloxone and Naltrexone

The effects of opioids are primarily due to their action on the mu opioid receptor. Molecules that interact with this receptor can be classified into three primary types, full agonists, partial agonists and antagonists. Full agonists such as morphine or methadone activate the receptor in a dose dependent manner. Partial agonists also activate the receptor, but the activation reaches a plateau and will not respond to increases in dosage. Finally antagonists such as naloxone bind to the receptor, but do not activate it at all.

The two most commonly used opioid antagonists are naloxone and naltrexone. Both are competitive antagonists, which means they work by competing for the receptor's binding site. The strength of the bond between the ligand (drug) and the receptor is known as the affinity. Molecules with higher affinity for the receptor will replace those with lower affinity. Naloxone has a higher affinity for the mu opioid receptor than morphine, when administered it will replace the morphine bound to the receptor. Because naloxone is an antagonist, the receptor will deactivate completely reversing the effects of the morphine.

Both naltrexone and naloxone can be described as substituted derivatives of oxymorphone. The tertiary amine methyl-substituent is replaced with a longer chain of carbon atoms (an allyl group). With naloxone the N-methyl group of oxymorphone is substituted with an N-prop-2-enyl group, with naltrexone this substitution is with an N-cyclopropylmethyl group. The name naloxone has been derived from N-allyl and oxymorphone.

While both antagonists have high oral bioavailability, they both undergo extensive first-pass metabolism. Up to 98% of naloxone is metabolized to an inactive metabolite, and for this reason it must be administered as an injection or intranasal spray. Naltrexone is metabolized to 6-β-naltrexol, which is an active metabolite also acting as an antagonist at the mu receptor. While naloxone is used primarily as an emergency antidote to opioid overdoses, naltrexone has been used as a medication to treat alcoholism and opioid addiction.


"When naloxone hydrochloride is administered intravenously the onset of action is generally apparent within two minutes; the onset of action is only slightly less rapid when it is administered subcutaneously or intramuscularly. The duration of action is dependent upon the dose and route of administration of naloxone hydrochloride. Intramuscular administration produces a more prolonged effect than intravenous administration. The requirement for repeat doses of naloxone hydrochloride, however, will also be dependent upon the amount, type and route of administration of the narcotic being antagonised. Following parenteral administration naloxone hydrochloride is rapidly distributed in the body. It is metabolised in the liver, primarily by glucuronide conjugation and excreted in the urine. In one study the serum half-life in adults ranged from 30 to 81 minutes (mean 64 ± 12 minutes). In a neonatal study the mean plasma half-life was observed to be 3.1 ± 0.5 hours."
-Naloxone Data Sheet (New Zealand)

"Naltrexone Hydrochloride is a pure opioid receptor antagonist. Although well absorbed orally, naltrexone is subject to significant first pass metabolism with oral bioavailability estimates ranging from 5 to 40%. The activity of naltrexone is believed to be due to both parent and the 6-β-naltrexol metabolite. Both parent drug and metabolites are excreted primarily by the kidney (53% to 79% of the dose), however, urinary excretion of unchanged naltrexone accounts for less than 2% of an oral dose and faecal excretion is a minor elimination pathway. The mean elimination half-life (T-1/2) values for naltrexone and 6-β-naltrexol are 4 hours and 13  hours, respectively. The elimination half-life and time to maximum concentration are dose-independent.  Naltrexone and 6-β-naltrexol are dose proportional in terms of AUC and Cmax over the range of 50 to 200 mg and there is no significant accumulation after 100 mg daily doses."
-Naltrexone Data Sheet (New Zealand)

Responding to an opiate overdose

Most overdoses are the result of mixing opiates with central nervous system depressants. Although naloxone only works on opioids, it is the synergism of the drug combo that causes the overdose. Removing the opioid component only will usually restore respiratory function. Opiate users should practice assembling the naloxone kit so as to be efficient in case of an emergency. If someone has stopped breathing every minute matters, combined with the stress and adrenaline of the emergency you don't want to have to take time out to read an instruction manual. Since naloxone overdose kits have been introduced in the US, over 10,000 lives have been saved by non-emergency persons (the friends and family of drug users).

If the individual has stopped breathing:

Do rescue breathing for a few quick breaths, then administer the naloxone. Depending on if the naloxone is administered as an injection or intranasally, it may take a few minutes to take effect. If there is no effect after 3-5 minutes, administer another dose of naloxone.

If the naloxone does not work after the second application, something is wrong. Naloxone may not work if:

1. The overdose is not due to opioids.
2. The opioid causing the overdose has a higher affinity for the mu receptor than naloxone, which can happen with some synthetic opioids (such as buprenorphine or fentanyl and its analogs).
3. Too much time has lapsed and the heart has stopped.

"Naloxone only lasts between 30 – 90 minutes, while the effects of the opioids may last much longer. It is possible that after the naloxone wears off the overdose could recur. It is very important that someone stay with the person and wait out the risk period just in case another dose of naloxone is necessary. Also, naloxone can cause uncomfortable withdrawal feelings since it blocks the action of opioids in the brain. Sometimes people want to use again immediately to stop the withdrawal feelings. This could result in another overdose. Try to support the person during this time period and encourage him or her not to use for a couple of hours."
Administer Naloxone Overdose Response from Harm Reduction Coalition 

Further Reading:

Community-Based Opioid Overdose Prevention Programs Providing Naloxone — United States, 2010
Morbidity and Mortality Weekly Report (MMWR)
February 17, 2012 / 61(06);101-105 [Link]

Understanding Naloxone, Harm Reduction Coalition