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.






Introduction

What is Kratom? [Link]

DEA "Fact" Sheet [Link]




Pharmacology


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]

Culture

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

ETHNOPHARMACOLOGY OF KRATOM AND THE MITRAGYNA ALKALOIDS. KARL L.R. JANSEN and COLIN J. PRAST. Journal of Ethnopharmacology, 23 (1988) 115-119 [Link]

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.

Sen. Joe McCarthy's Startling Morphine Source

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:

How the Prison-Industrial Complex Destroys Lives

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.

Diagnosing Addiction

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). 

THE EFFECT OF DRUG PROHIBITION ON DRUG PRICES: EVIDENCE FROM THE MARKETS FOR COCAINE AND HEROIN Jeffrey A. Miron. 2003 [Link]

Worldwide Distribution of Licit Morphine

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.

Medication

    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.