Harm reductions (fentanyl test strips) remain illegal in Texas

It's a long way from Texas to Vancouver. This recent story from the Texas Monthly caught my eye:

Fentanyl Test Strips Could Save Lives—But They’re Illegal in Texas By Jeff Winkler, July 22, 2022

"The most widely embraced method of harm reduction is offering users naloxone, known by the brand name Narcan, an easy-to-use medication capable of reversing the effects of an opioid overdose. All U.S. states, including Texas, have relaxed restrictions on access to naloxone amid the opioid epidemic’s “third wave,” which began in 2013 with the rise of fentanyl’s presence on the black market. A less-popular harm-reduction method is the creation of government-approved, supervised sites where users can get clean syringes and take drugs in the presence of a health-care worker. Just two such sites in the nation have been authorized—both in New York City.

"Fentanyl test strips fall somewhere in the middle in terms of their acceptance. The strips have become easier to access, as several states, including Tennessee and New Mexico, have recently decriminalized their possession. But they remain illegal in about half the states, including in Texas, where the strips are considered “drug paraphernalia,” meaning they fall into the same category as bongs and blunt papers. Since the passage of the 1973 Controlled Substances Act, Texas has banned any material intended for use in testing for or “analyzing” a controlled substance."

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It's based in part on this earlier report from State of Reform:

 Drug testing strips remain illegal in Texas despite recent rise in overdose deaths, by Boram Kim | May 14, 2022 

"In Harris County alone, fatal drug overdoses increased 52% from 2019 to 2021. County statistics show deaths involving fentanyl skyrocketed by 341% in the same period, from 104 to 459.

"Meanwhile, the Travis County Medical Examiner’s Office released 2021 figures that showed drug overdoses were the leading cause of accidental deaths for the first time in a decade. Approximately one-third of overdose deaths were caused by fentanyl."

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earlier:

Tuesday, May 17, 2022

Fentanyl test strips save lives. Why do Kansas and Missouri ban them?

Fentanyl by prescription: a Vancouver experiment

 Part of the problem of black markets, particularly for drugs (but not just for drugs) is that customers are dealing with criminals who are neither as honest nor as skilled as pharmacists. This means that drug buyers don't know what they are getting, and can overdose, sometimes fatally, when the mixture they have purchased contains drugs or quantities of drugs that they don't know about.  As fentanyl has started to show up mixed into heroin, and to replace it, this seems to have been one of the big causes of inadvertent overdoses.

In Vancouver, an experiment is underway to make drugs safer by having pharmacists dispense them, in prescribed dosages. (Not everyone thinks this is a good idea.)

The NYT has the story:

Fentanyl From the Government? A Vancouver Experiment Aims to Stop Overdoses. A city on the forefront of harm reduction has taken the concept to a new level in an effort to address the growing toxicity of street drugs.  By Stephanie Nolen

"the breadth of Vancouver’s services and interventions is almost unimaginable in the United States, less than an hour’s drive to the south. Supervised injection sites and biometric machines that dispense prescription hydromorphone dot the city center; naloxone kits, which reverse overdoses, are available free in every pharmacy; last year, a big downtown hospital opened a safer-use site next to the cafeteria, to keep patients who are drug users from leaving in order to stave off withdrawal.

"And since April, Chris... has received pharmaceutical-grade fentanyl through the dispensary, which sells to those who can pay and provides free drugs through the program’s operational budget to those who cannot.

"The new program aims to provide a safer alternative to the fentanyl available on the streets, where the supply is increasingly lethal and is responsible for most of the overdose epidemic that was declared a public health emergency here six years ago.

"Dr. Christy Sutherland, a board-certified addiction medicine specialist who set up the program, said its goal was, first, to keep people from dying, and, second, to help bring stability to their lives so that they may think about what they might want to change."

Drugs, drug regulation, and chemistry: the case of nicotine (following Rob Jackler)

 My Stanford colleague Dr. Rob Jackler has a longstanding interest in nicotine as an addictive drug that continues to be effectively marketed and ineffectively regulated.

Lately he's been concerned with novel delivery systems, such as the non-combustion vaping devices offered by sellers like Juul (which  has recently been on a regulatory roller coaster.)

You can find many of his papers at the Stanford Research into the Impact of Tobacco Advertising (SRITA) site.  The most recent of these papers concerns the fact that a lot of regulation is focused on "tobacco products," but that nicotine itself--the addictive chemical in tobacco--has been successfully synthesized in the lab, and so can be marketed as a "tobacco free" product.

Here's a recent NY Times article on his work:

The Loophole That’s Fueling a Return to Teenage Vaping. Sales are rising of flavored e-cigarettes using synthetic nicotine that evades regulatory oversight, a gap that lawmakers are now trying to close.  By Christina Jewett

And here's the paper:

Marketing of “Tobacco-Free” and “Synthetic Nicotine” Products. Ramamurthi D, Chau C, Lu Z, Rughoobur I, Sanaie K, Krishna P, Jackler RK. SRITA White Paper. March 8, 2022.

"Executive Summary:

• A 2009 US law assigned tobacco regulation to the FDA, created its Center for Tobacco Products, and defined a tobacco product as derived from any component of the tobacco plant.

• As the September 2020 deadline for submission of application to the for FDA authorization of novel tobacco products (PMTA) approached, major tobacco companies submitted application for their brands, but innumerable smaller companies lacked the resources needed to undertake the extensive studies required.

• In an effort to circumvent FDA tobacco regulations, and thus exempt their products from the PMTA process, numerous brands claimed to be formulated with tobacco-free and/or synthetic nicotine.

• Following the late 2021denial of their PMTA applications, some brands which were ordered off the market promptly relaunched claiming that they had been reformulated with tobacco-free or synthetic nicotine.

• Brands claiming to use non-tobacco derived nicotine are offered in a wide array of youth-appealing sweet & fruity flavors – which have been systematically denied market authorization during the ongoing FDA PMTA process.

• Synthetic nicotine is currently expensive, costing approximately 4x tobacco derived nicotine. 

• While residuals from tobacco leaf derived nicotine are well known, byproducts of the chemical synthesis of nicotine have not been characterized for potential human toxicity and carcinogenicity.

• Justified by concerns for unknown safety risk, the FDA should insist upon toxicity/carcinogenicity studies of synthetic nicotine products before they are marketed.

• The FDA should also consider systematic testing of products claiming to be tobacco-free as at least a portion of them may prove to have chemical signatures indicative of tobacco origin.

• Some brands marketed as “tobacco-free” or “tobacco leaf-free” use a purified form of tobacco derived nicotine and thus are legally tobacco products under US law and thus subject to the PMTA requirements.

• Terms describing nicotine products as “tobacco-free,” “non-tobacco,” and “zero tobacco” need regulation as consumers may perceive such products as having reduced addictive potential.

• Marketing claims such as “clean,” “pure,” and “free of carcinogens” should be disallowed absent modified risk designation by the FDA.

• “Tobacco-free” nicotine brands have been allowed to post paid advertisements, and are widely sold on major online stores (e.g., Amazon, eBay, Google Shopping), which prohibit sale of all tobacco products.

• Underage sales of “tobacco-free” nicotine products are common via major online stores.

• As it is a potently addictive substance, and harmful to the developing adolescent brain, there is no justification for nicotine, regardless of its source, to be exempt from regulation.

• The synthetic nicotine regulatory loophole should be closed by designating such products as unauthorized drugs requiring pre-market authorization. "

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Congress closed the synthetic nicotine loophole in March, and since July 2022 synthetic nicotine products can only be on the market if they have been authorized by the FDA – none have been so yet.   Here's the story from the Washington Post:

Congress moves to give FDA new powers over synthetic nicotine products including a youth favorite — Puff Bar e-cigarettes By Laurie McGinley, March 8, 2022

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There have also been bans on flavored nicotine, aimed at children as well as adults. These may be doomed to be at least partly ineffective. Menthol flavored cigarettes are likely to be banned in the U.S., and have already been banned in Britain and elsewhere. But just as cocktail mixes can be sold separately from alcohol (but ready to mix), so apparently can flavorings for cigarettes and e-cigarettes... e.g. search for "menthol flavour cards for cigarettes" or "menthol crush balls" to see how to add menthol back into your smokes in England.

Here's a recent NBER working paper comparing menthol smokers to non-menthol smokers:

Are Menthol Smokers Different? An Economic Perspective, by Yu-Chun Cheng, Donald S. Kenkel, Alan D. Mathios & Hua Wang, WORKING PAPER 30286, DOI 10.3386/w30286, July 2022

 **********

And here's an old NYT story in which Rob describes himself as “an accidental tourist in the world of advertising.”

When Doctors, and Even Santa, Endorsed Tobacco, By Stuart Elliott, Oct. 6, 2008

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earlier: 

Sunday, January 30, 2022

Chemistry is replacing agriculture in the supply of black market drugs

Sunday, May 2, 2021

Repugnance as paternalism: bans on flavored tobacco products

Tuesday, February 12, 2019

The new market for (and marketing of) nicotine--Robert Jackler (followed by the CDC)

The (local) labor markets for terrorists and drug traffickers

 It's so hard to hire good help nowadays, but two papers in the latest Econometrica give us some insight into how that problem is solved in the labor markets for terrorists, and for narcotics.

First terrorism, which turns out to have a local financing element, suggesting frictions in moving money and terrorists...

TERRORISM FINANCING, RECRUITMENT, AND ATTACKS, by NICOLA LIMODIO, Econometrica, Vol. 90, No. 4 (July, 2022), 1711–1742

Abstract: This  paper  investigates  the  effect  of  terrorism  financing  and  recruitment  on  attacks. I exploit a Sharia-compliant institution in Pakistan, which induces unintended and quasi-experimental variation in the funding of terrorist groups through their religious affiliation. The results indicate that higher terrorism financing, in a given location and period, generate more attacks in the same location and period. Financing exhibits a complementarity in producing attacks with terrorist recruitment, measured through data from Jihadist-friendly online fora and machine learning. A higher supply of terror is responsible for the increase in attacks and is identified by studying groups with different affiliations operating in multiple cities. These findings are consistent with terrorist organizations facing financial frictions to their internal capital market.

"I study two aspects of the relationship between terrorism financing and attacks: (1) the correlation between the timing of financing and attacks; (2) the relation between financing and recruitment in generating attacks. To investigate the first point, I follow 1750 cities over 588 months between 1970 and 2018 containing the universe of terrorist attacks (e.g.,more than 14,000 events). I also build a panel with 29 terrorist groups operating in the same number of cities and the same period. To study the second point, I combine data from multiple online fora active in Pakistan disseminating Jihadist-friendly material with the work of two judges and a machine-learning algorithm, leveraging novel techniques from the computer science literature.

"The  natural  experiment  affects  a  specific  form  of  charitable  donation  and  terrorism financing through an Islamic institution: the Zakat. During Ramadan, Muslim individuals offer this Sharia-compliant contribution to philanthropic causes. While the amount is a personal choice, the Pakistani government collects a mandatory payment through a levy on bank deposits applied immediately before Ramadan.1When the tax hits fewer people due to its unique design, there is an increase in donations. This expansion in charitable donations boosts the probability that funds reach terrorist organizations due to multiple extremist groups having a legal charity branch.2 This unintended channel through which the design of the Zakat levy promotes terrorism financing has also been acknowledged by Pakistani government officials in the past.#"

# (cited newspaper article):"Information Minister Pervaiz Rashid has advised people to pay Zakat and charity to institutions which save lives and not to those producing suicide bombers."

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And then there's narcotics production and narco-terrorism, which to some extent runs in families.  The paper begins with this quote:

"The only way to survive, to buy food, was to grow poppy and marijuana, and from the age of 15, I began to grow, harvest, and sell.– Joaquin “El Chapo” Guzman, when asked how he became the leader of the Sinaloa drug cartel"

Making a Narco: Childhood Exposure to Illegal Labor Markets and Criminal Life Paths, by Maria Micaela Sviatschi, https://doi.org/10.3982/ECTA17082, ECONOMETRICA: JUL 2022, VOLUME 90, ISSUE 4, p. 1835-1878

Abstract: This paper provides evidence that exposure to illegal labor markets during childhood leads to the formation of industry‐specific human capital at an early age, putting children on a criminal life path. Using the timing of U.S. antidrug policies, I show that when the return to illegal activities increases in coca suitable areas in Peru, parents increase the use of child labor for coca farming, putting children on a criminal life path. Using administrative records, I show that affected children are about 30% more likely to be incarcerated for violent and drug‐related crimes as adults. No effect in criminality is found for individuals that grow up working in places where the coca produced goes primarily to the legal sector, suggesting that it is the accumulation of human capital specific to the illegal industry that fosters criminal careers. However, the rollout of a conditional cash transfer program that encourages schooling mitigates the effects of exposure to illegal industries, providing further evidence on the mechanisms.

"To establish these results, I take advantage of drug enforcement policies in Colombia that shifted coca leaf production to Peru, where 90% of coca production is used to produce cocaine. In particular, in 1999, Colombia, then the world’s largest cocaine producer, implemented Plan Colombia, a U.S.-supported military-based interdiction intervention.One of the main components was the aerial spraying of coca crops in Colombia. This intervention resulted in higher prices and expanded coca production in Peru, where production doubled in districts with the optimal agroecological conditions.2 By 2012, Peru had become the largest producer of cocaine in the world.3 

"This setting yields three useful sources of variation: (i) geographic variation in coca growing  in  Peru,  (ii)  over  time  variation  in  coca  prices  induced  by  Colombian  shocks, and (iii) variation in the age of exposure, exploiting the fact that in Peru children are more  likely  to  drop  out  from  school  in  the  transition  between  primary  and  secondary education at the ages 11–14. I thus define age-specific shocks by interacting coca suitability measures and prices. Differential exposure by age arises since children within a district or village experience the changes in coca prices at different ages and due to variation in coca suitability across districts, villages, and schools."

Harm reduction for drugs: an experiment in British Columbia

 Here's a news story in the Guardian, and the policy paper from British Columbia about the new efforts on harm reduction there.

Canada to decriminalize some drugs in British Columbia for three years. Policy aims to stem record number of overdose deaths by easing a fear of arrest by those who need help

Here's the official report of the Provincial Health Officer of British Columbia. I think the choice of cover picture does a good job of capturing the tension between treating drug users as criminals or as patients.

STOPPING THE HARM. DECRIMINALIZATION OF PEOPLE WHO USE DRUGS IN BC

Fentanyl test strips save lives. Why do Kansas and Missouri ban them?

 You can imagine a world, with virtually no drug abuse, in which we would want to inhibit the recreational use of fentanyl and so might outlaw tools that might promote it.  But that isn't the world we live in, and instead simple tests for the presence of fentanyl can save lives by preventing fatal accidental overdoses.

Here's an editorial bemoaning the fact that these tests are sometimes banned.

Simple, cheap fentanyl test strips save lives. Why do Kansas and Missouri ban them? BY THE KANSAS CITY STAR EDITORIAL BOARD

 "As the Kansas and Missouri legislative sessions come to a close, there’s at least one more matter lawmakers in both states should attend to. They could save lives with tiny strips of paper that can detect the presence of fentanyl in recreational drugs. 

"Fentanyl test strips are designed to prevent people from overdosing on illegal recreational drugs that have been spiked with potentially fatal amounts of the synthetic opioid fentanyl. 

"Overdose deaths have risen to well over 100,000 a year in the United States. Synthetic opioids — primarily fentanyl — are the primary reason for the overall increase in total drug overdose deaths, according to the U.S. Drug Enforcement Administration. 

...

"But in some states, including Kansas and Missouri, the strips are considered drug paraphernalia and are not legal. Now there are proposals before both state legislatures to decriminalize them. This is not a partisan issue, and no one should oppose this move."

Beyond vaccines: Bill Gates on drug development for the next pandemic

 In the NYT:

Bill Gates: How to Develop Life-Saving Drugs Much Faster

"The Covid-19 pandemic would look very different if scientists had been able to develop a treatment sooner. The death rates are likely to have been far lower, and it may have been harder for myths and misinformation to spread the way they did.

...

"We’re lucky that scientists made Covid vaccines as quickly as they did — if they hadn’t, the death toll would be far worse. But in the event of another pandemic, even if the world is able to develop a vaccine for a new pathogen in 100 days, it will still take a long time to get the vaccine to most of the population. This is especially true if you need two or more doses for full and continued protection. If the pathogen is especially transmissible and deadly, a therapeutic drug could save tens of thousands or more.

"Even once there is a vaccine, we’ll still need good therapeutics. As we’ve seen with Covid, not everyone who can take a vaccine will choose to do so. And, along with non-pharmaceutical interventions, therapeutics can reduce the strain on hospitals, which would prevent the overcrowding that ultimately means that some patients die who otherwise wouldn’t.

...

"All of which is to say: Therapeutics are fundamentally important in an outbreak. To understand what caused the delay in drugs and how we can avoid such delays in the future, we need to take a tour through the world of therapeutics: what they are, how they get from the lab to the market, why they didn’t fare better early in this pandemic and how innovation can set the stage for a better response in the future.

...

"One of the keys to ensuring that health care workers have better treatment options in the next big outbreak than they did for Covid will be investing in large libraries of drug compounds that researchers can quickly scan to see whether existing therapies work against new pathogens. Some of these libraries exist already, but the world needs more. We need libraries that cover many types of drugs, but the most promising, in my view, are those known as pan-family and broad-spectrum therapies — either antibodies or drugs that can treat a wide range of viral infections, especially those that are likely to cause a pandemic."

Opioid prescription reductions and suicides

 Addictive drugs are repugnant, but painkillers are essential pharmaceuticals.  In an effort to reduce addiction, guidelines have been formulated that reduce prescription, and these sometimes backfire when applied to patients with unbearable pain.

The NY Times has the story:

What the Opioid Crisis Took From People in Pain  By Maia Szalavitz

"Though even some doctors are confused on this issue, addiction and physical dependence are not the same thing. Addiction, according to the National Institute on Drug Abuse, is compulsive drug seeking and use that occurs despite negative consequences. But pain patients like Mr. Slone are not considered addicted when medication improves their quality of life and the risks of side effects like withdrawal are outweighed by the relief medication offers.

"For people with chronic pain, research is only beginning to show how widespread the damage from opioid prescription cuts is. One study examined the medical records of nearly 15,000 Medicaid patients in Oregon who were taking long-term, high doses of opioids. Those whose medications were stopped were three and a half to four and a half times as likely to die by suicide compared to those whose doses were stable or increased. Another study, which included the medical records of over 100,000 people, found that drastically reducing a patient’s opioid dosage increased the risk of overdose by 28 percent and increased the risk of mental health crisis requiring hospitalization by 78 percent.

"Many opioid prescribing cuts were made under the auspices of guidelines published by the Centers for Disease Control and Prevention in 2016 to fight the overdose crisis. These guidelines recommend avoiding opioid prescriptions if at all possible and, when prescribing them for chronic pain, generally keeping the dosage below 90 morphine milligram equivalents, or M.M.E., per day 

...

"The C.D.C. is now updating those recommendations, admitting that the result has too often been unsafe changes in care.

...

"By 2019, the authors of the original guidelines warned in The New England Journal of Medicine that they were being misused, saying, “Unfortunately, some policies and practices purportedly derived from the guideline have in fact been inconsistent with, and often go beyond, its recommendations.” That year, the Food and Drug Administration cautioned that it had “received reports of serious harm,” including suicides, associated with patients who suddenly had their medication discontinued or abruptly reduced.

"But by then, states had passed legislation giving some of the recommendations the force of law. The National Committee for Quality Assurance, which provides standards for insurers, government agencies and medical organizations, made keeping doses within the guidelines into a metric — incentivizing doctors to taper or stop seeing high-dose patients. Insurers, pharmacy chains and government agencies also use the guidelines to inform restrictions, and law enforcement uses them when prosecuting physicians for running “pill mills.”

"If these policies had reduced the death toll, some might argue that they are warranted. But they have not. Measured by the number of prescriptions written per capita, medical opioid use rates in 2020 were down to levels last seen in 1993, before OxyContin marketing helped spark the crisis. However, overdose deaths are still increasing dramatically, driven by illegally manufactured synthetic opioids and many who formerly got pharmaceuticals from doctors and now resort to dealers."

The future pandemic that has already started making an appearance

I never expected the Covid pandemic: I was expecting a different one, coming not from a virus but from an antibiotic-resistant bacteria.  That one is still in our future, but here's an article that indicates that there are many bacterial candidates that could start something big, and taken together they are already starting to loom on the horizon.

In the Lancet (Available online 19 January 2022, In Press, Corrected Proof):

Global burden of bacterial antimicrobial resistance in 2019: a systematic analysis  By the  Antimicrobial Resistance Collaborators 

"Background: Antimicrobial resistance (AMR) poses a major threat to human health around the world. Previous publications have estimated the effect of AMR on incidence, deaths, hospital length of stay, and health-care costs for specific pathogen–drug combinations in select locations. To our knowledge, this study presents the most comprehensive estimates of AMR burden to date.

...

"Findings: On the basis of our predictive statistical models, there were an estimated 4·95 million (3·62–6·57) deaths associated with bacterial AMR in 2019, including 1·27 million (95% UI 0·911–1·71) deaths attributable to bacterial AMR. At the regional level, we estimated the all-age death rate attributable to resistance to be highest in western sub-Saharan Africa, at 27·3 deaths per 100 000 (20·9–35·3), and lowest in Australasia, at 6·5 deaths (4·3–9·4) per 100 000. Lower respiratory infections accounted for more than 1·5 million deaths associated with resistance in 2019, making it the most burdensome infectious syndrome. The six leading pathogens for deaths associated with resistance (Escherichia coli, followed by Staphylococcus aureus, Klebsiella pneumoniae, Streptococcus pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa) were responsible for 929 000 (660 000–1 270 000) deaths attributable to AMR and 3·57 million (2·62–4·78) deaths associated with AMR in 2019. One pathogen–drug combination, meticillin-resistant S aureus, caused more than 100 000 deaths attributable to AMR in 2019, while six more each caused 50 000–100 000 deaths: multidrug-resistant excluding extensively drug-resistant tuberculosis, third-generation cephalosporin-resistant E coli, carbapenem-resistant A baumannii, fluoroquinolone-resistant E coli, carbapenem-resistant K pneumoniae, and third-generation cephalosporin-resistant K pneumoniae.

"Interpretation: To our knowledge, this study provides the first comprehensive assessment of the global burden of AMR, as well as an evaluation of the availability of data. AMR is a leading cause of death around the world, with the highest burdens in low-resource settings. Understanding the burden of AMR and the leading pathogen–drug combinations contributing to it is crucial to making informed and location-specific policy decisions, particularly about infection prevention and control programmes, access to essential antibiotics, and research and development of new vaccines and antibiotics. There are serious data gaps in many low-income settings, emphasising the need to expand microbiology laboratory capacity and data collection systems to improve our understanding of this important human health threat."

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Earlier:

Wednesday, July 15, 2020

The economics of antibiotics

Forbidden Transactions and Black Markets

 Here's a paper that was just published early online. (Only now do I see that I left out the middle initial I always use, but I'm one of the coauthors...)  

The idea of the paper is to understand when a repugnant transaction can be effectively banned, versus when a ban will lack sufficient social support to succeed. We present a simple to state (but tricky to analyze) model of conditions in which banning a market is likely to lead to a difficult to extinguish black market.

Two prominent examples are narcotic drugs (big black market) and hired killers (not so much, at least in the U.S.).  So we could have called the paper Heroin and Hitmen. (Hitmen were little more than a metaphor in this paper, but I expect to say a bit more about the actual market for hitmen in tomorrow's post.)

 Chenlin Gu, Alvin Roth, Qingyun Wu (2022) Forbidden Transactions and Black Markets. Mathematics of Operations Research  Published online in Articles in Advance 28 Jan 2022  . https://doi.org/10.1287/moor.2021.1236  (It's an open access article, so you can read the full paper: here's the pdf.)

 Abstract: "Repugnant transactions are sometimes banned, but legal bans sometimes give rise to active black markets that are difficult if not impossible to extinguish. We explore a model in which the probability of extinguishing a black market depends on the extent to which its transactions are regarded as repugnant, as measured by the proportion of the population that disapproves of them, and the intensity of that repugnance, as measured by willingness to punish. Sufficiently repugnant markets can be extinguished with even mild punishments, while others are insufficiently repugnant for this, and become exponentially more difficult to extinguish the larger they become, and the longer they survive."

Here are the first two paragraphs of the introduction:

"Why are drug dealers plentiful but hitmen scarce? That is, why is it relatively easy for a newcomer to the market to buy illegal drugs but hard to hire a killer? Both of those transactions come with harsh criminal penalties, vigorously enforced: in the United States, almost half of federal prisoners have drug convictions,1 and murder for hire2 is treated as a federal crime for both the buyer and the hitman.3

More generally, many transactions are repugnant, in the specific sense that they meet two criteria: some people want to engage in them, and others think that they should not be allowed to do so (Roth [48]). But only some repugnances become enacted into laws that criminalize those transactions, and only some of those banned markets give rise to active, illegal black markets. Only some of those black markets are so active yet so difficult to suppress that the laws banning them are eventually changed so as to allow the transactions that cannot be suppressed to be regulated. Laws that exact harsh punishments but are ineffective at curbing the transactions that they punish may come to be seen as causing harm themselves. Some well-known examples include Prohibition era laws against selling alcohol in the United States or laws in much of the world that once banned homosexual sex (and, in some places, still do)."

Chemistry is replacing agriculture in the supply of black market drugs

 The war on drugs is getting more complicated, as chemistry replaces agriculture as a primary source.  This calls for changes in both law enforcement and harm reduction.

Here's a balanced view from the WSJ:

The Once and Future Drug War. During the 50 years the U.S. has battled the narcotics trade, illegal drugs have become more available and potent. But that’s no reason to give up. Governments must adapt and find answers beyond law enforcement  By James Marson, Julie Wernau  and David Luhnow 

"America’s longest war isn’t the 20-year fight in Afghanistan. That struggle is dwarfed by the War on Drugs, started by President Richard Nixon more than 50 years ago and still raging.

"The drug war—which has relied on both law enforcement and the military, at a cost of untold lives and hundreds of billions of dollars—has fared little better than the Afghan campaign. Since Nixon’s declaration of war in 1971, drug use has soared in the U.S. and globally, the range and potency of available drugs has expanded and the power of criminal narcotics gangs has exploded.

...

"The global spread of synthetic drugs like methamphetamine, fentanyl and synthetic opioids is complicating interdiction—the core of America’s strategy for 50 years.

...

"Fentanyl has now killed far more Americans than all U.S. conflicts since World War II combined. In the past decade, it has claimed more than a half million lives, a toll that is growing swiftly. The nation was reporting fewer than 50,000 fatal overdoses as recently as 2014. 

...

"The Biden administration is the first to name “harm reduction” a priority. The White House Office on National Drug Control Policy, which was often run in the past by former generals and law-enforcement officials, is now led, for the first time, by a physician, Dr. Rahul Gupta.

...

"Europe is also pursuing harm reduction. The U.K., the Netherlands, Austria and others have offered drug testing, often at music events, to reduce the risk of overdosing or poisoning. Switzerland, the U.K., Germany and the Netherlands prescribe heroin to dependent users to cut fatal overdoses and needle sharing.

"Portugal has gone further. It decriminalized all drugs in 2001 amid a surge in heroin use and drug-dependent prisoners. Anyone caught with less than a 10-day supply of any drug is sent to a local commission that includes a doctor, lawyer and social worker for treatment. Overdose deaths have fallen from about 360 a year to 63 in 2019.

...

"Growing social and legal tolerance of drugs dismays people like Mike Vigil, who had a 31-year career in the DEA, including chief of international operations. He acknowledges that interdiction and law enforcement have not solved the problem. But he says that the U.S. has failed to develop a comprehensive strategy, including investing in down-and-out communities where drug use flourishes and trying to reduce future demand through massive, sustained education programs.

...

“We aren’t going to be able to arrest our way out of this,” says Mr. Vigil. His frustration is widely shared. “The U.S. has never taken the demand side of things seriously,” says former Mexican President Felipe Calderón."

Decriminalizing personal drug use

 The WSJ has the story

Some Cities Turn to Decriminalizing Drugs as Overdoses Climb. Toronto follows Vancouver and the state of Oregon in seeking to make it legal to carry small amounts of heroin, fentanyl and other drugs for personal use.  By Vipal Monga

"Canada’s largest city is the latest jurisdiction aiming to decriminalize drug possession as it faces a surging overdose epidemic.

"Toronto’s board of health this month said it would seek permission from Canada’s federal government to allow drug users to carry small amounts of drugs for personal use, including heroin, fentanyl and cocaine, without fear of prosecution. The exemption wouldn’t cover drug trafficking, which would remain a criminal offense.

"City officials hope that decriminalization will make it easier for people to get help. They say it could also make it easier for drug users to get jobs and stable housing because they won’t have criminal records.

...

"The new policies and proposals come as officials say they are seeking ways of handling an overdose epidemic that has swept across North America. Drug users are dying in record numbers as an increasingly toxic drug supply overwhelms the black market.

“The current approaches to drug policy and regulation are not working,” said Dr. Eileen de Villa, medical officer for Toronto, during a presentation to the city’s board of health on Dec. 6."

Supervised drug injection sites open in NYC

 The NY Times has the story:

Nation’s First Supervised Drug-Injection Sites Open in New York. During the first official day in operation at the two Manhattan facilities, trained staff reversed two overdoses, officials said.  By Jeffery C. Mays and Andy Newman

"New York, the country’s most populous city, became the first U.S. city to open officially authorized injection sites — facilities that opponents view as magnets for drug abuse but proponents praise as providing a less punitive and more effective approach to addressing addiction.

"Other cities including Philadelphia, San Francisco, Boston and Seattle have taken steps toward supervised injection but have yet to open sites amid debate over the legal and moral implications of sanctioning illegal drug use.

...

"Mayor Bill de Blasio began championing safe injection sites in 2018, citing their use and success in European and Canadian cities. The decision to officially allow the sites to open comes during the mayor’s last few weeks in office and as he considers a run for governor. He said in a statement that the decision will show other cities that “after decades of failure, a smarter approach is possible.”

"The mayor also sent a letter to the providers promising “not to take enforcement action” against their operations. Four of the city’s five district attorneys — excluding only the Staten Island district attorney, Michael McMahon — support supervised drug sites."

Can it be made safe for drug users to call for help when a friend overdoses?

There are lots of ways that drug laws contribute to the design of the black market for drugs, and the behavior of its participants. Here's a recent post from the blog Bill of Health:

New Data Highlights Complexity of Good Samaritan Overdose Law Landscape, By David Momjian

 "To combat the rising death toll from drug overdoses, 47 state legislatures and the District of Columbia have passed Good Samaritan laws (GSLs) to protect bystanders from criminal prosecution if they call for medical assistance during a drug overdose. Bystanders to a drug overdose are often worried that by calling for help, they could be arrested for drug possession or evicted by the police, who often arrive first at the scene of a 911 call, even if it is a medical emergency.

A new dataset built by the Center for Public Health Law Research at Temple University’s Beasley School of Law and funded by Vital Strategies, covers the evolution of GSLs in the United States from January 1, 2007, to June 1, 2021."

Drug overdose deaths between April 2020 and 2021 reach 100,000

 The Washington Post has the story:

100,000 Americans died of drug overdoses in 12 months during the pandemic  By Dan Keating and Lenny Bernstein

"The U.S. drug epidemic reached another terrible milestone Wednesday when the government announced that more than 100,000 people had died of overdoses between April 2020 and April 2021. It is the first time that drug-related deaths have reached six figures in any 12-month period.

...

"The new data shows there are now more overdose deaths from the illegal synthetic opioid fentanyl than there were overdose deaths from all drugs in 2016."

We should be thinking about harm reduction...

Marijuana black markets are coexisting with (poorly designed, over-regulated, highly taxed) legal markets in California

 The Guardian has the story:

California legalized weed five years ago. Why is the illicit market still thriving? by Amanda Chicago Lewis

"Voters passed a law in November 2016 making recreational marijuana legal. But today, the vast majority of the market remains underground – about 80-90% of it, according to experts.

"Because that 2016 law, known as Proposition 64, gave municipalities the power to ban weed as they see fit, the majority of cities and counties still don’t allow the sale of cannabis, inhibiting the growth of the legal market.

"In the places that do allow pot shops and grows, business owners say high taxes, the limited availability of licenses, and expensive regulatory costs have put the legal market out of reach. 

...

"The story of California’s legal weed chaos dates back to 1996, when voters passed a law allowing medical marijuana. At the time, Bay Area Aids activists saw the way pot relieved pain and stimulated hunger among their emaciated and desperately ill friends. That led to a grassroots campaign to get Proposition 215, a measure legalizing the medical use of cannabis, on the California ballot.

"However, Prop 215 only allowed doctors to recommend that patients and their caregivers grow their own weed. Essentially, it legalized a commodity without legalizing the business side of it.

"For the next 20 years, a laissez-faire, gray market for medical marijuana flourished and became entrenched. With doctors’ recommendations for medical marijuana easy and cheap to come by, cannabis entrepreneurs practiced a lucrative form of civil disobedience, opening dispensaries, manufacturing edibles and growing acres of plants that brought in enough money to offset intermittent law enforcement crackdowns. The industry developed protocols to get a business back up and running right after a raid, such as keeping cash offsite and obscuring ownership through a series of management companies.

"If you could withstand the legal uncertainty, it was a good time to make money in marijuana. By 2010, the city of Los Angeles had about 2,000 pot shops illegally selling cannabis. Statewide, the total illicit market surged, causing Mexican cartels to either stop growing weed or to relocate their grows to California.

...

"For a marijuana enterprise today, becoming legal has often meant sacrificing a good deal of profit. Businesses frequently pay an effective tax rate of 70%, in part because they are breaking federal law and therefore aren’t able to take tax deductions, but also because politicians see the industry as a source of tax revenue and set higher rates.

...

"But the longer we allow cannabis to remain state-legal and federally illegal, the harder it will be to fix. Though botching weed legalization sounds like a trivial issue, it intersects with many of the issues that are fundamental to our lives, from criminal justice to public health, gang violence to economic inequality, the opioid crisis to the wellness craze. Cannabis is the second-most-valuable crop in the country, after corn and ahead of soybeans. It’s the most common reason for arrest in America. And despite marijuana’s dubious reputation, research has shown the plant “may have therapeutic potential in almost all diseases affecting humans”.

Luxembourg combats cannabis black markets by legalizing home cultivation

 Luxembourg is combatting cannabis black markets by ending the prohibition on home cultivation.

The Guardian has the story:

Luxembourg first in Europe to legalise growing and using cannabis. Relaxation is part of government rethink designed to keep users away from illegal market

"Adults in Luxembourg will be permitted to grow up to four cannabis plants in their homes or gardens under laws that will make it the first country in Europe to legalise production and consumption of the drug.

"The announcement on Friday by Luxembourg’s government was said to deliver fundamental changes in the country’s approach to recreational cannabis use and cultivation in light of the failure of prohibition to deter use.

...

"Justice minister Sam Tanson described the change to the law on domestic production and consumption as a first step.

...

“We want to start by allowing people to grow it at home. The idea is that a consumer is not in an illegal situation if he consumes cannabis and that we don’t support the whole illegal chain from production to transportation to selling where there is a lot of misery attached. We want to do everything we can to get more and more away from the illegal black market.”

Opioid prescription and curtailment are associated with increased rates of suicide among rural veterans:

 Chronic pain, followed by prescription of opioid pain medicines, is sometimes followed by opioid addiction.  A recent NBER working paper shows that policies to reduce prescriptions are associated with increased rates of suicide, particularly among rural military veterans.  Presumably some of these are related to addiction, and some are related to pain.

The Opioid Safety Initiative and Veteran Suicides by Joshua C. Tibbitts & Benjamin W. Cowan WORKING PAPER 29139, DOI 10.3386/w29139,  August 2021

"We investigate the relationship between opioid diverting policy and suicides among the veteran population. The opioid epidemic of the past two decades has had devastating health consequences among U.S. veterans and military personnel. In 2013, the Veterans Health Administration (VA) implemented the Opioid Safety Initiative (OSI) with the goal of discouraging prescription opioid dependence among VA patients. Between 2012 and 2017, prescription opioids dispensed by the VA fell 41% (VA, 2018). Because this involved the aggressive curtailing of opioid prescriptions for many VA patients, OSI may have had a detrimental effect on veterans’ mental health leading to suicide in extreme cases. In addition, because rural veterans have much higher rates of VA enrollment, more prescription opioid use and abuse, and lower rates of substance abuse and mental health treatment utilization, we expect any effect of OSI on veteran suicides to be concentrated in rural areas. We find that OSI raised the veteran suicide rate relative to the non-veteran (“civilian”) rate with rural veterans suffering the lion’s share of the increase. We estimate that OSI raised the rural veteran suicide rate by a little over one-third between 2013 and 2018."

A lottery for antibody treatment, with slots reserved for vulnerable patients

 It's always good to see a collaboration between physicians and economists on allocating scarce resources, and here's a case report of allocating monoclonal antibodies in Boston (with some resemblance to school choice), forthcoming in the journal CHEST.

A novel approach to equitable distribution of scarce therapeutics: institutional experience implementing a reserve system for allocation of Covid-19 monoclonal antibodies  Emily Rubin, MD JD MSHP, Scott L. Dryden-Peterson, MD, Sarah P. Hammond, MD, Inga Lennes, MD MBA MPH, Alyssa R. Letourneau, MD MPH, Parag Pathak, PhD, Tayfun Sonmez, PhD, M. Utku Ünver, PhD.

DOI: https://doi.org/10.1016/j.chest.2021.08.003, To appear in: CHEST

"Background. In fall 2020, the Food and Drug Administration issued emergency use authorization for monoclonal antibody therapies (mAbs) for outpatients with Covid-19.  The Commonwealth of Massachusetts issued guidance outlining the use of a reserve system with a lottery for allocation of mAbs in the event of scarcity that would prioritize socially vulnerable patients for 20% of the infusion slots. The Mass General Brigham (“MGB”) health system subsequently implemented such a reserve system.

"Research Question. Can a reserve system be successfully deployed in a large health system in a way that promotes equitable access to mAb therapy among socially vulnerable patients with Covid-19?

...

"Results: Notwithstanding multiple operational challenges, the reserve system for allocation of mAb therapy worked as intended to enhance the number of socially vulnerable patients who were offered and received mAb therapy. A significantly higher proportion of patients offered mAb therapy were socially vulnerable (27.0%) than would have been the case if the infusion appointments had been allocated using a pure lottery system without a vulnerable reserve (19.8%) and a significantly higher proportion of patient who received infusions were socially vulnerable (25.3%) than would have been the case if the infusion appointments had been allocated using a pure lottery system (17.6%)

...

"The reserve for vulnerable patients was a “soft” reserve, meaning that if there were not enough patients in either the high SVI or high incidence town categories to fill the vulnerable slots, those slots were allocated to patients who were next in line by overall lottery number. This was done in order to avoid unused capacity for a therapy that is time sensitive and requires significant infrastructure to provide. Once the lottery had been run, dedicated, primarily multilingual clinicians who had been trained to discuss the therapies with patients called patients to verify eligibility and engage in a shared-decision making conversation to determine whether the patient would like to receive an infusion.

Early experience with running the lottery prior to patient engagement revealed that a large number of patients declined the therapy once offered, were deemed ineligible once contacted, or wished to discuss the therapy with a trusted clinician. The process subsequently was changed to allow clinicians to enter referrals for their own patients once they established patient interest (“manual referrals”). 

...

"All of the 274 patients who were guaranteed slots and 206 of 368 patients on the wait list were called, for a total of 480 patients called. The number of wait list patients called on a given day was a function of both how many of the guaranteed slots were not filled and how much capacity there was in the system to make phone calls on any given day. Of those patients who were called, 132 (27.5%) declined, 33 (6.9%) were deemed ineligible by virtue of being asymptomatic, 19 (4.0%) were deemed ineligible by virtue of having severe symptoms, 11 (2.3%) had been or were planning to be infused elsewhere, 61 (12.7%) could not be reached, and 191 were infused (39.8% of those called and 9.7% of total referred patients).

...

"Had we operated a pure lottery with no reserve for socially vulnerable patients, and all other factors had remained constant, 19.8% of patients offered therapy (88) would have been in the top SVI quartile as opposed to 27.0% (120) in our actual population, and 17.6% of infused patients (32) would have been in the top SVI quartile as opposed to 25.3% (46) in our actual population.

...

"The system we describe is to our knowledge the first instance of a reserve system being used to allocate scarce resources at the individual level during a pandemic.

"A reserve system with lottery for tiebreaking within categories can be straightforward to operate if there are few or no steps between the assignment of lottery spots and the distribution of the good. This could be true, for example, of allocation of antiviral medications to inpatients with Covid-19. In the case of monoclonal antibody therapies, there were multiple factors that could and often did interrupt the trajectory between allocation and distribution. These included the complexity of administering infusion therapy, the time sensitive nature of the therapy, the relative paucity of evidence for the therapy at the time the mAb program started, and the dynamic nature of Covid-19. The conversations with patients about a therapy that held promise but did not yet have strong evidence to support its efficacy and had not been formally FDA approved were often challenging and time consuming. Many patients identified for allocation were difficult or impossible to reach. Others declined therapy once it was offered and discussed, or had become either too well or too sick to be candidates for the therapy once they were reached.

...

"Notwithstanding significant challenges, the reserve system implemented in our health system for allocation of mAb therapy worked as intended to enhance the number of socially vulnerable patients who were offered the therapy. A significantly higher proportion of socially vulnerable patients were offered mAb therapy than would have been if the infusion appointments had been allocated using a pure lottery system without a vulnerable reserve. The intended enhancement of the pool of vulnerable patients who actually received monoclonal antibody therapy was counterbalanced to some extent by the disproportionate number of vulnerable patients who declined therapy, but even fewer socially vulnerable patients would have received the therapy if the lottery system had not included a vulnerable reserve. 

Does legal marijuana lead to the use of more dangerous drugs, or increase crime?

 It appears that the short answer is "No," according to this recent NBER working paper

Is Recreational Marijuana a Gateway to Harder Drug Use and Crime?  by Joseph J. Sabia, Dhaval M. Dave, Fawaz Alotaibi & Daniel I. Rees

WORKING PAPER 29038, DOI 10.3386/w29038,  July 2021

Recreational marijuana laws (RMLs), which legalize the possession of small quantities of marijuana for recreational use, have been adopted by 18 states and the District of Columbia. Opponents argue that RML-induced increases in marijuana consumption will serve as a “gateway” to harder drug use and crime. Using data covering the period 2000-2019 from a variety of national sources (the National Survey of Drug Use and Health, the Uniform Crime Reports, the National Vital Statistics System, and the Treatment Episode Data Set) this study is the first to comprehensively examine the effects of legalizing recreational marijuana on hard drug use, arrests, drug overdose deaths, suicides, and treatment admissions. Our analyses show that RMLs increase adult marijuana use and reduce drug-related arrests over an average post-legalization window of three to four years. There is little evidence to suggest that RML-induced increases in marijuana consumption encourage the use of harder substances or violent criminal activity.