Opiate Users get Lobotomized

Here is some sad but completely unsurprising news regarding the "treatment" for opiate addiction in China. This procedure, surgical destruction of the "pleasure center" in the brain (ablation of the nucleus accumbens), is not new and has been used on cocaine users in South America. I'm sure the "patients" were all fully informed and not at all coerced, just like when a judge "suggests" a defendant undergo drug treatment in the US. I have reproduced some paragraphs from two articles, though I highly recommend reading them both in full.

Controversial Surgery for Addiction Burns Away Brain’s Pleasure Center by Maia Szalavitz

How far should doctors go in attempting to cure addiction? In China, some physicians are taking the most extreme measures. By destroying parts of the brain’s “pleasure centers” in heroin addicts and alcoholics, these neurosurgeons hope to stop drug cravings. But damaging the brain region involved in addictive desires risks permanently ending the entire spectrum of natural longings and emotions, including the ability to feel joy.

David Linden, professor of neuroscience at Johns Hopkins and author of a recent book about the brain’s pleasure systems calls the surgery “horribly misguided.”  He says “This treatment will almost certainly render the subjects unable to feel pleasure from a wide range of experiences, not just drugs of abuse.”

Given the available evidence, in fact, it’s hard to find a scientific justification for even studying the technique in people at all. Carl Hart, associate professor of psychology at Columbia University and author of the leading college textbook on psychoactive drugs, says animal studies suggest the approach may ultimately fail as an effective treatment for addiction; a 1984 experiment, for example, showed that destroying the nucleus accumbens in rats does not permanently stop them from taking opioids like heroin and later research found that it similarly doesn’t work for curbing cocaine cravings. Those results alone should discourage further work in humans. “These data are clear,” he says, “If you are going to take this drastic step, you damn well better know all of the animal literature.” [Disclosure:  Hart and I have worked on a book project together]. 

Moreover, in China, where addiction is so demonized that execution has been seen as an appropriate punishment, it’s highly unlikely that addicted people could give genuinely informed consent for any brain surgery, let alone one that risks losing the ability to feel pleasure. And even if all of the relevant research suggested that ablating the nucleus accumbens prevented animals from seeking drugs, it would be hard to tell from rats or even primates whether the change was due to an overall reduction in motivation and pleasure or to a beneficial reduction in desiring just the drug itself. 

There is no question that addiction can be difficult to treat, and in the most severe cases, where patients have suffered decades of relapses and failed all available treatments multiple times, it may make sense to consider treatments that carry significant risks, just as such dangers are accepted in fighting suicidal depression or cancer.  But in the ablation surgery studies, some of the participants were reportedly as young as 19 years old and had only been addicted for three years.  Addiction research strongly suggests that such patients are likely to recover even without treatment, making the risk-benefit ratio clearly unacceptable.

Pleasure Center Lobotomy: The Logical Extreme of The Brain Disease Model of Addiction by Steven Slate

You must understand that the idea of addiction, as currently conceived, holds that people use drugs because of the structure and functioning of their brain. In this view, addiction has nothing to do with thoughts, beliefs, or values. It has nothing to do with personal awareness and judgment of various life options and the pursuit of happiness – it has everything to do with the makeup of one’s brain – nothing more, nothing less. And if that is true – that you use drugs because your nucleus accumbens “wants” the dopamine triggering powers of drugs, and will push you to do anything to get more drugs, then removing it must be the simplest and most surefire solution to ending addiction. 

So all of you counselors and addiction theorists who have a history with addiction and identify as lifelong recovering addicts and alcoholics, and spread this tragic view to vulnerable troubled people, here’s your solution: put your brain and life where your mouth is, and move to China to get this procedure done. You will be cured of your disease. This is the end product of all your propaganda. Just beware of the full implications of this, as Maia lays out in her article:

Alcohol Poisonings During Prohibition

The Chemist's War The little-told story of how the U.S. government poisoned alcohol during Prohibition with deadly consequences.

Frustrated that people continued to consume so much alcohol even after it was banned, federal officials had decided to try a different kind of enforcement. They ordered the poisoning of industrial alcohols manufactured in the United States, products regularly stolen by bootleggers and resold as drinkable spirits. The idea was to scare people into giving up illicit drinking. Instead, by the time Prohibition ended in 1933, the federal poisoning program, by some estimates, had killed at least 10,000 people.

[...] 

I did, however, remember the U.S. government's controversial decision in the 1970s to spray Mexican marijuana fields with Paraquat, an herbicide. Its use was primarily intended to destroy crops, but government officials also insisted that awareness of the toxin would deter marijuana smokers. They echoed the official position of the 1920s—if some citizens ended up poisoned, well, they'd brought it upon themselves. Although Paraquat wasn't really all that toxic, the outcry forced the government to drop the plan. Still, the incident created an unsurprising lack of trust in government motives, which reveals itself in the occasional rumors circulating today that federal agencies, such as the CIA, mix poison into the illegal drug supply. 

During Prohibition, however, an official sense of higher purpose kept the poisoning program in place. As the Chicago Tribune editorialized in 1927: "Normally, no American government would engage in such business. … It is only in the curious fanaticism of Prohibition that any means, however barbarous, are considered justified." Others, however, accused lawmakers opposed to the poisoning plan of being in cahoots with criminals and argued that bootleggers and their law-breaking alcoholic customers deserved no sympathy. "Must Uncle Sam guarantee safety first for souses?" asked Nebraska's Omaha Bee.

This is an interesting article about how the federal government poisoned industrial alcohol during alcohol prohibition.  To this day there are calls for the government to infiltrate drug trafficking organizations to poison supplies, thereby murdering thousands of users. It is only when these proposals are put into the proper historical context that the motivations of the authors become clear. These people want to kill drug users. They don't care who you are, if you are a good person, have children or others depending on you or whatever. If you use the "wrong" drugs you deserve to die, that's it. The following quotes were taken from a debate over alcohol prohibition in 1926. I wonder how many people would defend Wheeler today. In 100 years, how many people will still advocate poisoning the supply of opiates?


"The government is under no obligation to furnish the people with alcohol that is drinkable, when the constitution prohibits it. The person who drinks this alcohol is a deliberate suicide." Wayne Wheeler.

"Any man who takes a drink of alcohol today may be poisoned without a trial by jury, without anything, just be poisoned because he dared take it!" Clarence Darrow responding to Wheeler.

The Economic Case for Decriminalizing Heroin

The Economic Case for Decriminalizing Heroin by Dylan Matthews
From the Washington Post Wonk Blog

The University of Chicago’s Gary Becker and Kevin Murphy, who generally lean right on matters of public finance, made some waves by calling for the full decriminalization of drugs in the Wall Street Journal. They don’t want to just, say, decriminalize the use of marijuana while still banning its sale, as Massachusetts does. They want to decriminalize the sale and use of heroin, and meth, and crack, and other hard drugs. 

Becker and Murphy have been making this argument for a while. Indeed, they first broached the subject back in the 1980s when they argued that many drug addicts are perfectly rational consumers. They, like the savviest grocery shopper, use the resources they have to get what they want in a cost-effective manner. It’s just that what they want happens to be drugs.
But the most relevant paper for understanding the Becker/Murphy critique is one they coauthored with CUNY’s Michael Grossman, who was last seen in these parts arguing for a tax on junk food. The paper attempts to describe the economics of the drug market in the broadest sense. In particular, the authors want to combat the idea that legalizing drugs would lead to more addictions. 

Becker, Murphy and Grossman think this view is dramatically mistaken and they build a model to show why. They put together an equation that outputs the benefits to society of a drug prohibition regime, taking into account the social cost of drugs but also the cost of enforcement, and the enjoyment that drugs provide to their consumers. They then used that equation to determine the regime that maximizes social welfare and determined what the cost of drugs would be under that regime. 

Here’s the kicker: if drugs sold for that price after taxes in an environment where drugs are legalized, they’d still be cheaper than drugs sold on the black market. So the legal market would drive illegal producers out of business, there wouldn’t be any of the enforcement costs — including huge social costs like mass incarceration — that come with drug prohibition, the government would gain considerable new tax revenue, and because the price is the same, consumption of drugs wouldn’t be any different than under prohibition. In short, the best form of prohibition is still worse than legalize-and-tax.

"In short, the best form of prohibition is still worse than legalize-and-tax"

The idea behind Becker, Murphy and Grossman's proposal to legalize and regulate (despite the headline they mean the L and R words) the sale of heroin is to keep the price similar to that of the current black market.  They hypothesize that the high price will keep use down.

Let's start with the positives with such a regime:
Decriminalization
There would be enormous savings from police time spent enforcing prohibition, incarceration costs (including the opportunity cost of locking up citizens who would otherwise be working and paying taxes), court costs and all the expenditures of fighting the drug war.
Legalization
The loss of a customer base would decimate the black market.  Drug cartels may not disappear, but their major source of revenue would dry up. Prostitution, human smuggling and other areas organized crime traditionally deals in require far more work and are not nearly as profitable.  Without drug trafficking these cartels would be significantly weakened.  The term "Narco-state" would become obsolete.
Regulation
Users would presumably be getting pure drugs with labeled dosages. Sterile ampules of heroin suitable for injection could be made available along with clean syringes. Heroin could also be formulated in smokable or
insufflatable (snortable) formulations. Naloxone and naltrexone could also be made available or given along with every purchase. Blood-born disease transmission among IV users and overdoses would both decrease. Funds currently directed toward ineffective (indeed some say counter-productive) public information campaigns demonizing heroin could instead be used to educate users about using opiates safely.

Unfortunately for users who have a habit, this regime will not significantly improve their lives. It is the high cost alone which prevents those dependent on black market opiates from having normal lives. Furthermore heroin is not a particularly expensive drug, at least at first until tolerance develops.

According to Brian Bennett's excellent site, the per gram cost of heroin has been decreasing quite a bit since the 1980's. The last entry in his data set is the year 2003, in which the cost of a gram of heroin at the retail level (sales of less than a gram) was $372, or 37 cents per milligram. For the regime discussed in the Washington Post article to work, the cost would have to be below the black market prices. For the purposes of discussion, let's say the government set the price at 25 cents per milligram. It is also entirely possible that the black market could take a significant price reduction and still be profitable, but I will leave out that factor for the purposes of this discussion.

For the occasional user, or chipper, heroin is not particularly expensive. A dose of 10-20 mg of pure heroin, for an individual with no opiate tolerance, would get them feeling quite nice. For these individuals the cost of a dose would probably cost $5-10, and not exceed $20. Heavy users often reminisce over the days when they could get a buzz off a couple bags or a few percocets.  

For individuals who are physically dependent the benefits of the proposed regime are far more modest. Contrary to the popular mythology surrounding opiate (opioid), tolerance does not continue to develop indefinitely, every individual eventually reaches a plateau beyond which the returns rapidly diminish. We know from authors like de Quincey and Burroughs that extraordinarily high doses of opiates are not pleasurable, but rather cause some adverse symptoms. From reviewing the results of the Swiss heroin prescription trials, and other trials done in Vancouver, we know that the average daily dose (the plateau or therapeutic dose) is about 500mg. Therefore dependent users are still going to have to come up with over $100 a day to support their habit. As I said before it is the high cost alone which prevents even heavy heroin users from having otherwise normal, functional lives. The purposed regime will do nothing to end drug dependent prostitution or the acquisitive property crime that has become characteristic of heroin dependence in the 20th century.

Best Comment Ever left on WSJ Article on Drug War

Have We Lost the War on Drugs?

Even God could not enforce prohibition and He only had two people to watch. We will always eat the apple.
Norman Gooding

Drug User Unity

I don't usually just post a link to an article, but the following is worth reading.  The author is Tony Newman, of the Drug Policy Alliance.

Drug Users of the World Unite

How Heroin is Made

This review of a heroin manufacturing process uses images from Afghanistan, though opium poppies grow all over the world and the process of making heroin destined for the black market is the same.  It all starts here with the harvesting of opium from the poppy.  The pods are lightly scored with a blade and the raw opium collected.  The opium is collected into balls and transferred to a makeshift "laboratory" where the morphine will then be extracted and processed into heroin.

Upon arrival at the site the opium is unpacked and placed into tubs.  It is then crushed and divided into portions for each batch.  The crushed opium was then placed into barrels and hot (not boiling) water is added.  At this point the pH is around 8.  The barrel is then stirred and any solids that float to the surface, pieces of plastic or plant matter, are removed.  Hot water with lime (Calcium Oxide, CaO) is added until all the opium has dissolved and the pH reaches 10-12.  The barrels are then filled with water, covered and left to sit overnight.  The following day the insoluble oils and resins will be floating on the surface, the opium solution containing the morphine is then siphoned out into separate containers.  

The dark brown opium solution which contains the morphine is siphoned off from the insoluble oils and residues in the opium.  The solution may then be filtered again through cloth or sacks to further remove insoluble particles.  The filtrate (liquid portion) is then poured back into a barrel.  

At this point the morphine is ready to be precipitated (solid morphine comes out of the liquid)  by the addition of Ammonium Chloride (NH4Cl) while stirring continuously.  After all the ammonium chloride is added, the barrel is covered and left to stand overnight.

The following morning the contents of the barrel are poured into a bucket lined with cloth soaked in warm water.  After being poured through the bucket the morphine base is wrapped in the filtering cloth and squeezed to remove remaining liquid.  The brownish-grey morphine base is then spread out on a cloth to air-dry in the sun.  The dried morphine base is then weighed in preparation for the acetylation reaction to convert the morphine to heroin.  This crude morphine base is about 50% morphine, 20% narcotine and 30% other compounds.

The crude morphine base is placed in an aluminum pot and a slight excess of acetic anhydride is added to the pot.  The pot is stirred until all the morphine has dissolved and then left for 45 minutes.  A fire is built during this time and after the 45 minutes have passed the pot is heated for 30 minutes.  

The reaction mixture is then poured into a bowl with warm water and the solution is filtered again into another barrel.  A solution of sodium bicarbonate (baking soda) is poured into the barrel, carbon dioxide gas is given off as the base reacts with the acid.[1]  When the solution no longer gives off gas and the pH reaches 10 the crude heroin base will be precipitated out of the solution.

The solution is then filtered again through a cloth.  The brownish colored crude heroin is then poured into a bowl to be prepared for the final purification step.  

The brown heroin base is then dissolved in dilute hydrochloric acid until the pH reaches 7-8.  Activated carbon is added to the solution and left to sit for 30 minutes.  The solution is then filtered again through a cloth, and a second time through a filter paper.  After the impurities are removed, the heroin base is precipitated out by addition of a dilute ammonia solution until the pH reaches 12.  The solution is filtered again, leaving a relatively pure, white heroin base.

The final step involves dissolving the heroin base in a hydrochloric acid and acetone solution. The solution is filtered through a filter paper into a metal bowl.  The liquid is evaporated leaving off-white heroin hydrochloride.  This final product is about 75% pure, see Table 4 below.  The yield of heroin from raw opium, is about 6% by weight.  

The process of making heroin from opium is a simple one and can be done anywhere in the world.  The following two tables list the needed equipment and chemicals needed for the process.  Calling these laboratories is generous, and truly an insult to real chemical labs.  For these reasons it should be obvious that there will never be a victory in the war against heroin by attempting to stop the supply at its source.  Opium poppies grow all over the world and the chemical reaction requires only the most primitive equipment.  Electricity and running water is not even needed.  The only chemical that would be difficult in any way to procure is the acetic anhydride.  

UN Intercepts Taliban's Heroin Chemical in Rare Afghan Victory

The intensified effort to block the Taliban's access to acetic anhydride comes as the Afghan war turns deadlier, with a record 236 U.S. and allied troops killed so far this year, according to icasualties.org, a Web site that tracks coalition fatalities. U.S. Army General John Craddock, supreme allied commander for Europe, is pushing to increase military involvement in countering the narcotics trade. 

The chemical allows Afghanistan's drug lords to dramatically increase revenue by producing heroin in their own laboratories instead of shipping out raw opium to be processed elsewhere. According to Craddock, a kilo of opium fetches about $100, compared with $3,500 for heroin.

This article is from 2008, so apparently that "rare" victory was short-lived.  Given the 6% yield of heroin from opium, it would take 16.7 kg of opium to produce 1 kg of heroin.  Using the figures provided by Craddock, to produce a kilogram of heroin requires $1,670 worth of opium to produce a product worth $3,500, more than doubling the value.  Additionally the final product is only 6% the weight, making it easier to smuggle to destination countries.  Compared to the logistics of smuggling thousands of tons of opium out of the country to be processed elsewhere, it is far easier to smuggle the acetic anhydride into the country than opium out.  

 

[1] Sodium bicarbonate is better known as baking soda and acetic acid as vinegar.  Remember in grade school the model volcanoes made by mixing vinegar and baking soda to simulate an explosion?  As the basic soium bicarbonate reacts with the acetic acid carbon dioxide gas is released.  Commercial vinegar used in cooking is only between 4-8% acid, the rest being water.  Acetic Anhydride is like two molecules of acetic acid stuck together, but does not have water added.  Water can degrade the acetic anhydride.  Due to its use in the production of heroin, acetic anhydride is "watched" by the DEA.

Many of the images and information in this post were taken from the following document:

Documentation of a heroin manufacturing process in Afghanistan. U. Zerell, B. Ahrens and P. Gerz. Federal Criminal Police Office, Wiesbaden, Germany [Link]

Conflating the Harms of Heroin with the Harms of Prohibition

I have a problem with this graph, from a 2007 Lancet article by David Nutt. I actually like David Nutt, he was fired from his position in the UK government for criticizing the decision to reclassify cannabis to Class B from C. That's right, a scientist who was working for the UK equivalent of the NIDA actually bucked the orthodoxy of "drugs are bad, mmkay," of course he was sacked for it. You will notice that heroin scores the highest on both dependence and physical harm. This the criteria used to evaluate physical harms in the lancet article:

Assessment of the propensity of a drug to cause physical harm—ie, damage to organs or systems—involves a systematic consideration of the safety margin of the drug in terms of its acute toxicity, as well as its likelihood to produce health problems in the long term. The effect of a drug on physiological functions—eg, respiratory and cardiac—is a major determinant of physical harm. The route of administration is also relevant to the assessment of harm. Drugs that can be taken intravenously—eg, heroin—carry a high risk of causing sudden death from respiratory depression, and therefore score highly on any metric of acute harm. Tobacco and alcohol have a high propensity to cause illness and death as a result of chronic use. Recently published evidence shows that long-term cigarette smoking reduces life expectancy, on average, by 10 years.9 Tobacco and alcohol together account for about 90% of all drug-related deaths in the UK.

     My main problem with the lancet article is they compare legal drugs, alcohol and tobacco, with illegal ones like heroin. Black market heroin is a dangerous drug because of its unknown purity and possibility of being adulterated with any number of substances, assuming you're even getting heroin and some some obscure fentanyl analog. Some basic information would go a long way to making heroin a less dangerous drug. For one combining opiates with CNS depressants dramatically increases the chance of overdose. Easy access to naloxone (narcan) nasal sprays could save countless lives, without having to call 911 and risk arrest in states without "good samaritan" laws. Disseminating information on safe injecting practices would go a long way to improving users health. Instead we get PSAs with a teenage girl destroying her kitchen in an apparently heroin-fueled rage. Furthermore due to the social stigma of using heroin, most users hide their drug use making it more likely no one will be around to save their life should they OD.
     This is comparing apples to oranges. To compare apples to apples one would have to look at a quasi-legal system. One option would be to compare the physical harms of individuals on heroin prescriptions or physician opiate users. Both use pharmaceutically pure opiates and sterile injecting equipment. In the heroin assisted therapy trials in Vancouver there were ODs, but medical staff quickly revived them. Most importantly there were no opiate-related fatalities. Putting aside the potential for an opiate overdose, just how bad for the body is heroin? Dr. Arnold Trebach, writing in "The Heroin Solution," informs us that "putting aside the problem of addiction, the chemical heroin seems almost a neutral or benign substance. Taken in stable, moderate doses, it does not seem to cause organic injury, as does alcoholism over time." Interesting, so if heroin were administered in an environment where the chance of ODs were minimized, and with a readily available narcotic antagonist (antidote), heroin would score below alcohol and tobacco, probably just above cannabis. Heroin is the poster child for prohibition making drug use far more dangerous than it would be in a legal, regulated market.

Rob Arthur writing in his article, "Heroin Is Harmless?" breaks it down the harms further:

Three aspects of an ingestible substance that can be considered harmful are (1) its potential to debilitate, (2) its effects on one’s health, and (3) its potential to kill via an overdose.

(1) Like the stimulants, caffeine and cocaine, heroin is not a debilitating drug. That is, moderate usage does not interfere with one’s functioning, e.g. driving ability. This is in contrast to alcohol, in which one’s performance is directly hampered. Extreme usage can interfere just like with caffeine and cocaine, e.g. too much of a stimulant can make it difficult to focus and even cause hallucinations. However, even heroin addicts can moderate their usage so that they can work unimpaired and avoid withdrawal symptoms. For this reason, heroin addicts can and do have successful professional lives in such diverse fields as surgery and law enforcement.

(2) Long-term heroin addiction is relatively harmless to one’s health. Like caffeine addicts who “need” their coffee in the morning, the side-effects are minimal. Heroin’s long-term side-effects can include constipation and impotency. This is in contrast to alcohol and tobacco which destroy the liver and the lungs respectively.

(3) Like caffeine, it is difficult to fatally overdose on heroin by itself. (It is easy to overdose when using heroin and alcohol in combination.) The popular image of a dead heroin user with the needle still in his or her arm is misleading. A fatal heroin overdose is usually a long process that takes over an hour and it can be countered within minutes by an antidote.