Friday, May 31, 2013

Exploring the Heroin Overdose Myth

Most fatal overdoses attributed to heroin are not actually the result in taking too large a dose. Heroin overdoses are largely a myth.

What causes people to overdose on heroin? The conventional wisdom states that because heroin users do not know the purity of the drug they are consuming, they misjudge the strength of the dose. If only users knew the exact dosage, they wouldn't overdose.
    This is largely a myth. The Consumers Union Report on Licit and Illicit Drugs exposed this myth back in 1972:
But alas, the two standard precautions against overdose--- warnings against taking too much and administration of an antidote--- are in fact wholly ineffective in the current crisis, for the thousands of deaths attributed to heroin overdose are not in fact due to heroin overdose at all. The evidence falls under three major rubrics.
(1) The deaths cannot be due to overdose.
(2) There has never been any evidence that they are due to overdose.
(3) There has long been a plethora of evidence demonstrating that they are not due to overdose.
Why these deaths cannot be due to overdose. The amount of morphine or heroin required to kill a human being who is not addicted to opiates remains in doubt but it is certainly many times the usual dose (10 milligrams) contained in a New York City bag. "There is little accurate information," Drs. A. J. Reynolds and Lowell. Randall report in Morphine and Allied Drugs (1967). "The figures that have been reported show wide variation." This ignorance no doubt stems from the rarity of morphine or heroin overdose deaths. The amounts of morphine or heroin needed to kill a nonaddict have been variously estimated at 120 milligrams (oral), 200 milligrams, 250 milligrams, and 350 milligrams - though it has also been noted that nonaddicts have survived much larger doses. 
The best experimental evidence comes from Drs. Lawrence Kolb and A. G. Du Mez of the United States Public Health Service; in 1931 they demonstrated that it takes seven or eight milligrams of heroin per kilogram of body weight, injected directly into a vein, to kill unaddicted monkeys. On this basis, it would take 500 milligrams or more (50 New York City bags full, administered in a single injection) to kill an unaddicted human adult.
Dr. Helpern's associate, Deputy Chief Medical Examiner Baden, went on to further discredit the already implausible overdose theory at a joint meeting of two American Medical Association drug-dependency committees held in Palo Alto, California, in February 1969.
"The majority of deaths," Dr. Baden told the AMA physicians, "are due to an acute reaction to the intravenous injection of the heroin-quinine-sugar mixture. This type of death is often referred to as an 'overdose,' which is a misnomer. Death is not due to a pharmacological overdose in the vast majority of cases."  
At the same AMA committee meeting and at a meeting of the Medical Society of the County of New York, Dr. Baden cited six separate lines of evidence overturning the "heroin overdose" theory. 
First, when the packets of heroin found near the bodies of dead addicts are examined, they do not differ from ordinary packets. "No qualitative or quantitative differences" are found. This rules out the possibility that some incredibly stupid processor may have filled a bag with pure heroin instead of the usual adulterated mix.
Second, when the syringes used by addicts immediately before dying are examined, the mixture found in them does not contain more heroin than usual.
Third, when the urine of addicts allegedly dead of overdose is analyzed, there is no evidence of overdose.
Fourth, the tissues surrounding the site of the fatal injection show no signs of high heroin concentration.
Fifth, neophytes unaccustomed to heroin rather than addicts tolerant to opiates would be expected to be susceptible to death from overdose. But "almost all of those dying" of alleged overdose, Deputy Chief Medical Examiner Baden reported, "are long-term users."
Sixth, again according to Dr. Baden, "addicts often 'shoot' in a group, all using the same heroin supply, and rarely does more than one addict die at such a time." 

So if heroin overdoses are not truly due to taking too much heroin, what is killing heroin users?

1. Mixing opiates with other central nervous system depressants, especially alcohol and benzodiazepines.

The depressant effect of opiates on breathing can be countered by conscious effort and opiates rarely result in a loss of consciousness. When combining opiates with CNS depressants, the drugs work synergistic ally to depress breathing, doses which may be well tolerated when taken alone can be fatal when combined. If an individual stops breathing in the presence of others an overdose can be avoided by waking the person up. Alcohol and benzodiazepines cause a loss of consciousness which preclude this possibility.

The combination of opiates and other CNS depressants account for at least half of all overdoses attributed to opiates, and in all probability are responsible for more than 50%. Educating people not to mix depressants with opiates would do more than any other preventative, educational campaign. It would certainly save more lives than just saying don't use heroin.

2. Deliberate Overdosing. Suicide is a major contributor to the overdose statistics.

Poor mental health and feelings of hopelessness are associated with overdose. Opiate addicts are far more likely to attempt suicide, four times as likely for men and eleven times as women. Overdose suicides are almost certainly under reported, so this rate may be much higher.
     Unless the evidence for suicide is overwhelming most overdoses are considered accidental.  Establishing the number of suicide-overdoses is difficult.  One method involves asking persons who survived an overdose if it was intentional, then extrapolating this rate to those who died from an overdose.  Studies done in the UK indicate that up to a third of overdoses may have been intentional.  One of the few prospective studies followed British opiate and cocaine addicts notified by doctors.  The rate of confirmed suicides was 4 times higher than the general population for men and 11 times for women; 45% used an overdose of drugs as the method.  In British studies of persons on methadone deliberate, non-fatal overdose is twice as common as accidental.  A London study of opiate injectors not in treatment found that 1 in 10 overdoses is deliberate.  It is hard to determine the number of overdoses that are intentional, but it seems that somewhere around 10-30% are deliberate.

3. Fluctuations in tolerance.

Addicts are more likely to OD when their tolerance is at its lowest. Users are most at risk for an overdose when they drop out (or are kicked from) an opioid maintenance program, after a period of forced abstinence  (usually due to incarceration), or after discharge from a detoxification hospital. This is more of a risk factor than a cause, but I included it in the list.

4. Homelessness and Street Use

An oft overlooked aspect of heroin use involves the mindset of the user and the environment where he/she is using. Opiate tolerance is not a purely physiological phenomenon, tolerance is also situation specific. Most regular opiate users have a ritual of preparation prior to ingesting the drug. Situation-specific tolerance is also a piece of the opiate overdose mystery:
The fatal consequence of the heroin injection may have been caused by the failure in the action of conditioned tolerance. As the figure shows, when a conditioned place preference arises, the user has to take a bigger dose each time to achieve the same effect as the user who does not have the opportunity for secondary conditioning with environmental stimuli since he or she constantly changes the place where the drug is taken [6]. When the drug is taken in a strange environment the conditioned tolerance does not operate since the organism is not "expecting" the drug. The end result is that the otherwise accustomed dose leads to an overdose and thereby to death. This is why the term "overdose" is misleading since the quantity taken was not greater than other doses taken without fatal complications
A case report: Pavlovian conditioning as a risk factor of heroin 'overdose' death. József Gerevich1, Erika Bácskai1, Lajos Farkas and Zoltán Danics. [Link]

Heroin concentration levels in a case A after conditioning in an accustomed place (A1) and in a new place (A2), and in a case B without conditioning.

Most "overdoses" involving opiates are chalked up to the use of opiate drugs regardless of the circumstances around the death (polydrug use, ect.)  This is well documented and known among those that care about the lives of users.  Unfortunately most people simply do not care about users and medical examiners readily attribute the cause of death to opiate drugs regardless of the toxicology.

Putting these factors together it becomes clear that drug prohibition itself contributes to overdoses among opiate users. Opiate prohibition causes inflated prices, users may add other drugs to augment the expensive opiates. Without prohibition, the cycle of addicts coming in and out of jails, prisons, detoxes and rehabs would come to an end. Each time an addict has their tolerance lowered they are at increased risk for an overdose.

The constant drug war propaganda in the media portrays opiate addicts, and especially heroin addicts, in an extremely negative light. Addicts are stereotyped as dangerous criminals, out of control and in need of rehabilitation. The uniformly negative view of addicts, combined with blatant stigma and discrimination (discrimination even written into the law), causes most addicts to hide their use. The situation today is not unlike how homosexuality was treated in the early 20th century. Today most addicts remain in the closet, for very good reasons. Being constantly reminded that one is both sick and a criminal (two charges also once leveled against homosexuals), takes its toll. The rate of suicide among homosexuals was also high during the peak periods of homophobia.

The artificially high cost of black market opiates causes many addicts to fall into abject poverty. Not only does homelessness make hygiene difficult, but it contributes to "street use" (use outside of one's usual place of consumption, such as a public bathroom). This contributes to a lowering of situation specific tolerance, further putting the user at risk of an overdose.

More on this topic to come.

References and Further Reading:

The Consumers Union Report on Licit and Illicit Drugs by Edward M. Brecher and the Editors of Consumer Reports Magazine, 1972
Chapter 12. The "heroin overdose" mystery and other occupational hazards of addiction [Link]

The Persistent, Dangerous Myth of Heroin Overdose by Stanton Peele [Link]

Drug and Alcohol Findings Issue 4 2000. Overdosing on opiates Part I Causes by David Best et al. [Link]

Drug and Alcohol Findings Issue 5 2001.Overdosing on opiates Part II Prevention by David Best et al. [Link]

Reducing heroin ‘overdose’ death risk [Link]

Siegel S, Hinson RE, Krank MS, McCully J: Heroin "overdose" death: Contribution of drug-associated environmental cues. Science 1982, 216:436-437

Sunday, May 26, 2013

Are Psychosocial Interventions with Addicts Worthless?

It is often said that addicts require counseling in addition to maintenance drugs for the treatment of opioid dependence. This review of over 4000 patients cast doubt on that assertion. It would appear that opioid addicts simply require their drug supply. More evidence that ending drug prohibition would cause the problem of opioid addiction to cease to be a social problem.

Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence. Amato L, Minozzi S, Davoli M, Vecchi S.
Cochrane Database Syst Rev. 2011 Oct 5;(10):CD004147. doi: 10.1002/14651858.CD004147.pub4

35 studies, 4319 participants, were included. These studies considered thirteen different psychosocial interventions. Comparing any psychosocial plus any maintenance pharmacological treatment to standard maintenance treatment, results do not show benefit for retention in treatment, 27 studies, 3124 participants, RR 1.03 (95% CI 0.98 to 1.07), abstinence by opiate during the treatment, 8 studies, 1002 participants, RR 1.12 (95% CI 0.92 to 1.37), compliance, three studies, MD 0.43 (95% CI -0.05 to 0.92), psychiatric symptoms, 3 studies, MD 0.02 (-0.28 to 0.31), depression, 3 studies, MD -1.70 (95% CI -3.91 to 0.51) and results at the end of follow up as number of participants still in treatment, 3 studies, 250 participants, RR 0.90 (95% CI 0.77 to 1.07) and participants abstinent by opioid, 3 studies, 181 participants, RR 1.15 (95% CI 0.98 to 1.36). Comparing the different psychosocial approaches, results are never statistically significant for all the comparisons and outcomes.

Saturday, May 25, 2013

Ethics and Addiction Treatment

Addiction Now Defined As Brain Disorder, Not Behavior Problem, LiveScience
Addiction is a chronic brain disorder and not simply a behavior problem involving alcohol, drugs, gambling or sex, experts contend in a new definition of addiction, one that is not solely related to problematic substance abuse. 
The American Society of Addiction Medicine (ASAM) just released this new definition of addiction after a four-year process involving more than 80 experts. [...]
Two decades of advancements in neuroscience convinced ASAM officials that addiction should be redefined by what's going on in the brain. For instance, research has shown that addiction affects the brain's reward circuitry, such that memories of previous experiences with food, sex, alcohol and other drugs trigger cravings and more addictive behaviors. Brain circuitry that governs impulse control and judgment is also altered in the brains of addicts, resulting in the nonsensical pursuit of "rewards," such as alcohol and other drugs. 
A long-standing debate has roiled over whether addicts have a choice over their behaviors, said Dr. Raju Hajela, former president of the Canadian Society of Addiction Medicine and chair of the ASAM committee on addiction's new definition. 
"The disease creates distortions in thinking, feelings and perceptions, which drive people to behave in ways that are not understandable to others around them," Hajela said in a statement. "Simply put, addiction is not a choice. Addictive behaviors are a manifestation of the disease, not a cause." 
Even so, Hajela pointed out, choice does play a role in getting help
"Because there is no pill which alone can cure addiction, choosing recovery over unhealthy behaviors is necessary," Hajela said. 
This "choosing recovery" is akin to people with heart disease who may not choose the underlying genetic causes of their heart problems but do need to choose to eat healthier or begin exercising, in addition to medical or surgical interventions, the researchers said.
"So, we have to stop moralizing, blaming, controlling or smirking at the person with the disease of addiction, and start creating opportunities for individuals and families to get help and providing assistance in choosing proper treatment," Miller said.

There has been a move to treat addiction as a health problem. On the surface this may seem like an improvement, but drug users may find themselves out of the frying pan and into the fire. The Livescience article I quoted from is unremarkable from other articles in the mainstream media. However I do find the choice of language telling. First we are told that addicts are not in control of their behavior, the disease robs them of the ability to make rational choices, except when they choose "recovery". So when addicts choose to enter drug treatment it is of their own volition, but when they engage in addictive behavior they are powerless. How do the addictionologists explain this rather convenient (for the addictionologist's paycheck) paradox?

Dr. Raju Hajela then compares addiction to heart disease, yet addiction is not treated like heart disease. Patients with heart disease may or may not act on their doctor's recommendation, they don't need to do anything they don't want to. If the patient does not implement lifestyle changes, the proper course is to reduce the harm of the disease. And yet with addiction, the individual is expected to cede control of much of their life to the care of the doctor. This is unethical and antithetical to the proper role of a healer.

Further Reading:

The ethics and effectiveness of coerced treatment of people who use drugs by Alex Stevens, PhD. Human Rights and Drugs, Volume 2, No. 1, 2012

Should we have bailiff and judge at weight watchers DPA Blog

Out of the frting pan and into the fire

Kratom Archive

Kratom (Mitragyna speciosa) is the only opium substitute that really is a substitute. The pharmacological effects are mainly due to two alkaloids, Mitragynine and 7-hydroxymitragynine. Both are active at the mu-opioid receptor, and thus have morphine like effects. Below are links to papers for further reading. Will be updated as I read more.


What is Kratom? [Link]

DEA "Fact" Sheet [Link]


Chemistry and Pharmacology of Analgesic Indole Alkaloids from the Rubiaceous Plant, Mitragyna speciosa. Chem. Pharm. Bull. 52(8) 916—928 (2004) Hiromitsu Takayama [Link]

Comparison to Morphine

Of the two alkaloids with opioid effects, mitragynine and 7-hydroxymitragynine, the latter is more potent than morphine.

Pharmacological Studies on 7-Hydroxymitragynine, Isolated from the Thai Herbal Medicine Mitragyna speciosa: Discovery of an Orally Active Opioid Analgesic. Kenjiro Matsumoto 2006 [Link]

Antinociception, tolerance and withdrawal symptoms induced by 7-hydroxymitragynine, an alkaloid from the Thai medicinal herb Mitragyna speciosa. Kenjiro Matsumoto, Syunji Horie, Hiromitsu Takayama, Hayato Ishikawa, Norio Aimi, Dhavadee Ponglux, Toshihiko Murayama, Kazuo Watanabe [Link]

(Note if someone can find a free pdf of this document leave me the URL in the comments)

See Also:

Antinociceptive effect of 7-hydroxymitragynine in mice: Discovery of an orally active opioid analgesic from the Thai medicinal herb Mitragyna speciosa. Kenjiro Matsumotoa, Syunji Horiea, Hayato Ishikawab, Hiromitsu Takayamab, Norio Aimib, Dhavadee Pongluxc, Kazuo Watanabea. Life Sciences 74 (2004) 2143 – 2155 [Link]


Kratom in Thailand Decriminalisation and Community Control? By Pascal Tanguay. Series on Legislative Reform of Drug Policies Nr. 13. April 2011 [Link]


Friday, May 24, 2013

Opiates in the News

Last Friday the Organization of American States released two groundbreaking reports on the future of drug policy in the Americas. Good coverage from CATO and Transform (links below). The Canadian Drug Policy Coalition, headquartered at Simon Fraser University, released a report calling for the legalization of marijuana and decriminalization of "hard" drugs heroin, cocaine and methamphetamine. Meanwhile also in Canada drug users are suing the city of Abbotsford for preventing the implementation of harm reduction services. In Australia, syringe vending machines could offer 24 hour access to harm reduction equipment.
Ibogaine is in the news again. More news on Senator Joseph McCarthy, a lifelong opiate addict, and his source of morphine. Finally I included an interview with two heroin dependent sex workers from Russia. The article is hard to read, the women are regularly raped, beaten, robbed and degraded. The worst offenders are the police.

Here's the links:

A Look at the OAS Report on Drug Policy in the Americas from CATO

Organization of American States launches groundbreaking report exploring alternatives to the war on drugs from the Transform Drug Policy Foundation

A Public Vote Shouldn't Decide Drug Users' Access to Health Care

Imagine if your city government decided to take a public vote to determine whether you and your family members should have access to health care. Based on what the public decides about your mother and her illness, and not what her doctors, your city government says it will pass a bylaw that prevents her and others in her situation from receiving that treatment in their home community. Maybe they decide that your mother is not entitled to receive the insulin she needs to manage her diabetes. Preposterous and unreasonable? Absolutely. But, this is exactly what happens when municipal governments decide to ban harm reduction services based on public opinion and stigma about drugs and the people who use them.

Decriminalize heroin, cocaine and methamphetamines to fight addiction, B.C. report says

“While countries all around the world are adopting forward-thinking, evidence-based drug policies, Canada is taking a step backwards and strengthening punitive policies that have been proven to fail,” states a summary of the 112-page report from the Canadian Drug Policy Coalition, headquartered at Simon Fraser University’s Centre for Applied Research in Mental Health and Addiction.[snip] 
But by far the most controversial recommendation calls for the end to prohibition of not only “soft” drugs like marijuana, but also products like heroin, cocaine and methamphetamines.
The report notes that at least 25 jurisdictions around the world have moved to decriminalize at least some drugs, with Portugal in 2001 and the Czech Republic in 2010 ending prohibition for all drugs. 
“After decriminalization and similar to Portugal, drug use (among Czechs) has not increased significantly but the social harms of drug use have declined,” the report stated.
“In Portugal decriminalization has had the effect of decreasing the numbers of people injecting drugs, decreasing the number of people using drugs problematically, and decreasing trends of drug use among 15 to 24 year olds.”
VICE on HBO: Can an Obscure -- and Illegal -- African Plant Help Cure Heroin and Opiate Addiction?
Ibogaine is a psychoactive alkaloid naturally occurring in the West African shrub iboga. While it is a mild stimulant in small doses, in larger doses it induces a profound psychedelic state. Historically, it has been used in healing ceremonies and initiations by members of the Bwiti religion in various parts of West Africa. People with problematic substance use have found that larger doses of ibogaine can significantly reduce withdrawal from opiates and temporarily eliminate substance-related cravings.
According to the country’s first de-facto drug czar, Harry Anslinger, McCarthy’s addiction was enabled by the federal government. Anslinger, who served as chief of the Federal Bureau of Narcotics from 1930 to 1962, is credited with successfully demonizing “marijuana” as causing addiction and insanity, murder and mayhem. More than any other political figure, Anslinger was responsible for criminalizing opiates and its users. And his word was gospel when it came to the country’s nascent war on drugs. 
In his 1961 memoir, The Murderers, Anslinger wrote about finding out, in the 1950s, that a prominent senator (whom he left unnamed) was addicted to morphine. When confronted by Anslinger, the politician refused to stop, even daring Anslinger to reveal his addiction, saying it would cause irreparable harm to the “Free World.”  Anslinger responded to this gambit by securing the lawmaker a steady supply of dope from a Washington, DC, pharmacy. (Morphine taken by prescription was, then as now, legal.) 
Anslinger’s acquiescence was a testament to just how feared McCarthy was in his heyday. Few dared to speak above a whisper about his evident alcoholism. “[He] went on for some time, guaranteed his morphine because it was underwritten by the Bureau," Anslinger wrote. "On the day he died I thanked God for relieving me of my burden."
“Who’s going to believe us? We’re not people, we’re animals”

The war on drugs has been going on for the last 50 years.  And yet, there is just as much drugs in the world and just as many drug users.  The war on drugs hasn’t made treatment and care any more accessible.  Its only achievement is that it’s profited the ones in power at the expense of other people’s misfortunes, while filling the lives of the sick and impoverished drug users with even more humiliation and suffering. 
 One of the outcomes of the war is that drug users are treated as outcasts who are denied their basic rights.  They have nowhere to turn for help. And those who are supposed to be protecting them–our so-called “law enforcement” officers–rape, abuse and kill them. The most vulnerable, powerless, and disparaged victims of this war are women.

Assorted Links:

Syringe Vending Machines Proposed in Australia

The Importance of Good Samaritan Laws: Jon Bon Jovi recalls his sadness when his daughter suffered a heroin overdose

American Teens Are Being Trapped in Abusive 'Drug Rehab Centres'

Is the INCB Dangerous to Your Health? 5 Ways the UN’s Drug Watchdog Fails on Health and Human Rights

From Twitter:

OpPoppyField ‏@BobD1984
Fed Govt is the drunken step-dad nobody asked for. Willing to beat and imprison you for using "drugs".I have a father. I don't need a daddy.

 The Colbert Report ‏@ColbertReport
"I'm no fan of drugs, they're immoral. Hey, drug mules, swallow that heroin without a condom. Family values."

 The House I Live In ‏@DrugWarMovie
"There's so much Orwelian euphemism in new laws which are being created. Politician are making laws to feed the monster of profiteering" EJ

 jess cochrane ‏@jkcochrane
"There's nothing about my pee that tells you how I parent." - @LynnPaltrow of @NAPW #warofthewomb #criminalizingparents

 Erowid Center ‏@erowid
Thoughts are free and are subject to no rule.”
— Paracelsus (1493–1541)

Follow me on Twitter @opiophilia for regular updates on articles of interest.

Friday, May 17, 2013

Heroin in the United States: Where does it come from, how much does it cost and how pure is it?

I recently read an interesting paper on the US heroin market. Ever wondered where does the heroin in the US come from, how pure it is or how much it costs? This paper answers those questions. I summarize the salient points in this post. The paper with a link to the pdf can be found here:

The Entry of Colombian Heroin into the US Market: The Relationship between Competition, Price, and Purity. Daniel Rosenblum , Jay Unick†, Daniel Ciccarone‡ April 8, 2013 [Link]

Where Does it Come From?
In the US heroin is largely supplied from two source countries, Mexico and Colombia. Colombian heroin made its way onto the US market in the early 1990's, and has since dominated the east coast. The introduction of Colombian heroin also coincided with a significant drop in price.
How Pure is it?

Heroin is usually found as a hydrochloride salt or free base (HCL/B - 82% samples), a grey or white powder sometimes called "china white". Occasionally it comes in other forms such as "black tar", in this paper these samples were labeled salt undetermined (HSU - 16% samples). Purity estimates are for retail amounts from 0.1 to 1.0 grams. Generally the HSU heroin is less pure with the majority of samples below 40% pure. Though more pure on average than HSU heroin, HCL/B heroin has a very evenly distributed purity. Samples range from high to low purity, I guess it depends on where you buy. 

How much does it cost?

Heroin is sold either as individual doses, usually in $10 "bags", or by weight. When sold by weight retail amounts are in fractions of a gram, 1/2 grams, 1/4 grams and 1/10th of a gram (a "point"). Visit a blog devoted to dope bags here. Pictured are several "bags" of heroin, which is an individual dose packaged in wax paper stamped with a logo. The stamp name often comes from popular culture and allows dealers to develop a brand. Also pictured is HCL/B powder, and HSU "black tar" heroin. 
As expected there is some variation in the price of a non-pure gram of heroin. However from the distribution we can see that most heroin costs less than $200 per non-pure gram, and the vast majority below $400. HCL heroin is more expensive, which is consistent with its higher quality. 

Price per pure gram.

The price of heroin has been steadily declining since the 1990's. Nationally the price per pure gram for HCL/ B heroin (the most common type) is about $500. There is significant variation regionally as the final graph demonstrates. It is safe to say that most users are paying about 50 cents per milligram for heavily adulterated diacetylmorphine. 
Heroin Price by Region

Price Inflation Due to Prohibition

The following two tables list the cost of opium necessary to produce a gram of heroin. The price varies, but at most the opium costs $6 and may be as cheap as 11 cents. By the time that gram of opium is converted into heroin, smuggled into the destination country, repackaged and sold in retail units the cost jumps to over $800 (paper from 2003 so may not reflect the price drop discussed above)! For the sake of argument, let us assume the price of opium needed for a gram of heroin is $3. Now let's also say the price doubles at each step in the distribution, so the heroin produced now costs $6 per gram. Transit to consumer countries raises the price to $12 per gram, and finally after repackaging and retail distribution the cost to the user is $24 per gram. As I noted above the national average cost of heroin is $500 per gram. Based on this estimate prohibition raises the price by a factor of nearly 21, in other words heroin is 21 times as expensive as it would be if not illegal. 

The other way we can observe the effect of prohibition on heroin prices is by looking at the cost of legal morphine. Heroin is easily made from morphine, while this step might slightly raise the cost, heroin also weighs more so I doubt this would dramatically increase the cost. Mallinkrodt sells morphine at a per gram cost of $10.61 per gram, in a legal marketplace heroin should sell for a similar amount ($0.01061/milligram). Therefore we can estimate than prohibition inflates the price of heroin by a factor of 50 (ie under legalization heroin would be 50 times cheaper or about $10 per pure gram). 


Worldwide Distribution of Licit Morphine

Tuesday, May 7, 2013

After the War on Drugs, Opioids in a Free Marketplace

    What would a legal market for opioids look like after the end of prohibition? An ideal situation would respect people's rights to use opioids for recreation or self-medication while also seeking to minimize harms. The major risks due to recreational use is mainly an acute overdose, chronic administration also includes a risk of acute overdose as well as dependence (tolerance and withdrawal).

In the case of opioids, there are many factors at play in determining the overall safety of the drugs. The only serious risk with opioids is the acute risk of toxicity. Aside from this, opioids cause no organic tissue damage to the organs or otherwise, even taken over years. The sole mechanism behind acute opioid toxicity is respiratory depression - via a reduction in brain responsiveness/sensitivity to increasing CO2 levels.
Respiratory depression is mediated via the mu-2 receptor subtype, whereas analgesia and euphoria is mediated via the mu-1 receptor type. Therefore, we can conclude that the rate at which tolerance develops (if even at all) may not be consistent between these two distinctly mediated effects.
-Project Narco

    Traditional opiates such as morphine act on both mu receptor subtypes. As the dosage increases to provide additional analgesic or euphorigenic effect there is a corresponding increase in respiratory depression. At a high enough dose breathing stops altogether and the individual may die without administration of an opioid antagonist (naloxone) or artificial respiration. 
A synthetic opioid that has a higher affinity for the mu-1 receptor subtype than the mu-2 subtype would be significantly safer. The synthetic opioid sufentanil, a fentanyl analog, appears to do just that. It has a therapeutic index of approximately 25,000, the highest among the commercially available opioids. Sufentanil is highly lipophilic and easily absorbed through mucosal tissues. For recreational uses it could be formulated similar to "bresh freshener" strips that dissolve under the tongue. A variety of dosages (such light, medium, heavy) could be made available to age appropriate consumers depending on the experience desired. A drug delivery mechanism similar to electronic cigarettes could offer an alternative, fast acting delivery mechanism. 
    Further research could provide a number of synthetic opioids with different pharmacokinetics. Opioids with short half-lives would allow someone to get high during their lunch break and be sober by the time they return to work. The important point is that the large therapeutic index of sufentanil puts it squarely at the top of the safest recreational drugs, in the same ballpark as cannabis and LSD. Cannabis users love to point out that no one has ever died from smoking cannabis, if opioids were as safe a major objection to their recreational use would be removed.
    Opium itself is also a relatively safe drug, certainly no more dangerous than alcohol (and arguably quite a bit less so.) Establishments for smoking opium (opium dens) would be available for those who prefer a "natural" experience. Proprietors would be both trained and equipped to handle an accidental overdose, though there is little evidence that overdoses would be any more common in an opium den than an alcohol bar.


    Low doses of opioids would be available over the counter much like codeine is some countries. For highly concentrated formulations greater restrictions may be necessary. Ampules for IV use of concentrated and potent opioids such as diamorphine (heroin) or hydromorphone (dilaudid) do have some risk in the hands of ignorant and reckless users. For this reason I suggest two restrictions on distribution. The first is the current prescription system where a qualified medical practitioner could provide some quantity of the medication with detailed instructions on its use. 
    The second restriction would be a licensing system akin to driver's licenses. It is generally conceded that an automobile can be a dangerous machine in the wrong hands. Their use is limited to adults who must also demonstrate a certain level of competency. I propose a similar licensing system for the purchase and use of the more dangerous drugs. To receive a license to purchase and use such drugs, an individual would first have to demonstrate competency. A basic knowledge of pharmacokinetics, safe injection practices, overdosing symptoms and treatment and safe disposal of syringes would be required before a license is issued.
    With the proper license, the individual may then purchase sterile ampules of the opioid of their choice and the knowledge to use it safely. Recreational users would have less choices, but far safer one's. Far fewer people would die from acute overdoses or diseases not specifically caused by opiate use, but a result of our misguided drug policies.