Opioid deaths in Canada during the pandemic, and what to do about it.

 Canada has a different political culture than the U.S., and attitudes towards drug abuse are one place in which that shows through clearly.

The Washington Post has the story--drug overdoses have risen during the pandemic:

Canada’s other health crisis: As overdoses surge, officials call on government to decriminalize illicit drugs

By Amanda Coletta

"a growing chorus, including top public health officials, the premier of British Columbia and the nation’s police chiefs, is calling on Prime Minister Justin Trudeau to decriminalize the possession of illicit drugs for personal use.

...

"British Columbia, the epicenter of the crisis, recorded its deadliest month in May — and then surpassed it in June. Nearly four times as many people in the province have died of a suspected overdose this year as have died of the coronavirus.

...

"Border closures have disrupted drug markets, making the street supply more unpredictable and toxic. Authorities have urged people to stay at home, pushing some to use drugs alone, without anyone nearby to help when dosages go wrong. Some supervised consumption sites and treatment centers have reduced operations, cutting people off from support networks.

...

"For the pandemic, officials have marshaled extraordinary financial resources and provided daily updates. Lawmakers have stood side-by-side with public health officials, largely deferring to their advice.

"But they’ve not always backed the remedies those same officials have offered to fight overdoses.

...

"“The most important thing we can do is make it okay for people to talk about their drug use and to seek assistance for it,” Henry said. “Labeling somebody a criminal is one of those major barriers that keeps people hiding and afraid and ashamed.”

... 

"That followed an extraordinary endorsement from the Canadian Association of Chiefs of Police, which said police resources would be better spent on cracking down on drug trafficking, illegal production and importation than on pursuing users.

"The chiefs said that arresting people for simple possession has been “ineffective” and that police should instead direct users to ­social services and health care, which could reduce recidivism and ancillary crimes."

100 years since Prohibition

An op-ed in the NY Times points out that Prohibition didn't start suddenly when the 18th Amendment went into effect in January 1920--it was a popular movement that had started with ordinary legislation.

Why Americans Supported Prohibition 100 Years Ago
Temperance crusaders weren’t crackpots. They were fighting the business of making money off addiction.  By Mark Lawrence Schrad

"The United States had already been “dry” for the previous half-year thanks to the Wartime Prohibition Act. And even before that, 32 of the 48 states had already enacted their own statewide prohibitions.

“With little that differed from normal wartime prohibition drinking habits, New York City entered at 12:01 o’clock this morning into the long dry spell,” this newspaper solemnly noted.

...

"Temperance was the longest-running, most widely supported social movement in both American and global history. Its foe wasn’t the drink in the bottle or the drunk who drank it, but the drink traffic: powerful business interests — protected by a government reliant on liquor taxes — getting men addicted to booze, and then profiting handsomely by bleeding them and their families dry.

...

"For a better understanding of temperance and prohibition, forget Bible-thumping “thou shalt nots.” Think instead about a major industry making outlandish profits by getting people hooked on an addictive substance that could kill them. Maybe that industry uses some of those profits to buy corrupt political cover by currying favor with government and oversight bodies. Let’s call this substance “opioids,” and the industry, “Big Pharma.”

"This is the same type of predatory capitalism that the temperance-cum-prohibition movement fought 100 years ago. Should big businesses be able to use addiction to reap tremendous profits from the poor? If your answer is no, and you were around 100 years ago, you likely would have joined the vast majority of Americans calling for the prohibition of liquor traffic."

Black markets for drugs in Europe: report of the European Monitoring Centre for Drugs and Drug Addiction

Here is the 2019 report from the European Monitoring Centre for Drugs and Drug Addiction (EMCDDA) and Europol, the EU's police organization:

EU Drug Markets Report 2019
EMCDDA, Europol, Lisbon, November 2019

Summary: The EU Drug Markets Report 2019 is the third comprehensive overview of illicit drug markets in the European Union by the EMCDDA and Europol. The analysis presented in this report spans numerous topics such as the links between drugs and other crimes, the licit economy and society more generally as well as the processes and players involved in the trade, from production and trafficking to distribution. Taking an evidence-based approach, the report reviews the markets for heroin, cocaine, cannabis, amphetamine, methamphetamine, MDMA and new psychoactive substances. It also provides action points to inform policy development at EU and national level. This publication is an essential reference for law enforcement professionals, policymakers, the academic community and indeed for anyone seeking up-to-date information and analysis on drug markets in Europe.

Here is the full report.

From the Executive Summary:

"The drug market is a major source of income for organised crime groups (OCGs) in the EU, with minimum estimated retail value of EUR 30 billion per year. In addition to the economic impact, drug-related deaths and other harms to public health, there are broader consequences of drug markets, such as links with wider criminal activities and terrorism; the negative impact on the legal economy; violence in communities; damage to the environment; and the increasingly important issue of how the drug market can fuel corruption and undermine governance.
...
" All data indicate that overall drug availability within Europe, for both natural and synthetic drugs,
remains very high. The European drug market is increasingly characterised by consumers having access to a wide variety of high-purity and high-potency products that, in real terms, are usually equivalent in price or cheaper than they have been over the past decade.
...
"Cannabis
Europe’s biggest drug market is for cannabis and significant production of the drug takes place within the EU. With around 25 million annual users, the retail market for cannabis was estimated to be worth at least EUR 11.6 billion in 2017. Around one in seven young adults in the EU reports having used cannabis in the past year, with prevalence rates generally stable but with early signs of possible  increases in some countries.
...
"Herbal cannabis is extensively produced within the EU, with estimates indicating that at least 20 000 cultivation sites are dismantled each year, and is a major source of income for the criminal economy. Despite efforts to counter production, the Western Balkans, and Albania in particular, appear to remain an important source of origin for seized herbal cannabis
...
"Heroin and other opioids
The use of heroin and other opioids still accounts for the largest share of drug-related harms. The retail value of the heroin market in 2017 was estimated to be at least EUR 7.4 billion. There are indications that heroin availability in the EU may increase: recent opium production estimates from Afghanistan, levels of seizures in Turkey and intelligence assessments of activity along the main trafficking routes to Europe are all high, and large consignments of heroin have been detected within the EU.
...
"Cocaine
The cocaine market is the second largest illicit drug market in the EU, with an estimated minimum retail value in 2017 of EUR 9.1 billion. Surveys estimate that about 4 million people in the EU will have used cocaine in the past year. Use is still concentrated in the west and south of Europe but appears to be becoming more common elsewhere.
...
"While Colombian and Italian OCGs have historically played a central role in the trafficking
and distribution of cocaine, increasingly other groups are becoming more significant, including Albanian-speaking, British, Dutch, French, Irish, Moroccan, Serbian, Spanish and Turkish OCGs. At the same time some European OCGs have established a presence in Latin American countries, developing a new ‘end-to-end’ business model for managing the supply chain, with large quantities of cocaine purchased near production areas at lower costs. This may be driving competition and conflict within the cocaine market and leading to increasing cocaine market-related violence and corruption within the EU.
...
" The global market for cocaine appears to be growing and a knock-on effect of this is that the EU appears to be increasingly used as a transit area for cocaine destined for other markets such as Australia, New Zealand, Russia, Turkey and countries in the Middle East and Asia. The cocaine market is increasingly enabled by digital technology, including darknet markets and the use of the surface web, social media and mobile phone apps to advertise and facilitate the delivery of cocaine to consumers. Innovation seen in the supply chain at the consumer level is suggestive of both high
availability and attempts by OCGs to increase market share.
...
"Synthetic drugs: amphetamine, MDMA and methamphetamine
Europe’s synthetic drugs market, particularly in respect to stimulants like amphetamine, MDMA and methamphetamine, is evolving rapidly. Within the stimulant market, these drugs compete for market share alongside cocaine and a number of new psychoactive substances. Of the two closely related stimulants, amphetamine continues to be more commonly used than methamphetamine in most EU countries, though there are growing signs of a gradual diffusion of methamphetamine use. The value of the EU retail market for amphetamines (amphetamine and methamphetamine combined) in 2017 is estimated to be at least EUR 1 billion, and for MDMA EUR 0.5 billion.
...
"New psychoactive substances
Policies relating to new psychoactive substances (NPS) appear to be having some impact, especially those aimed at reducing open trade in the EU as well as measures taken in source countries, such as China. There has been a slow-down in the number of first detections of NPS in Europe. Currently around 50 new substances are reported annually, giving a total of over 730 that have been reported to the EU Early Warning System."

Fighting addiction in Seattle, where incarceration isn't the treatment of choice

Here's Kristof in yesterday's NY Times:

Seattle Has Figured Out How to End the War on Drugs
While other cities are jailing drug users, Seattle has found another way.

"SEATTLE — On gritty streets where heroin, fentanyl and meth stride like Death Eaters, where for decades both drugs and the war on drugs have wrecked lives, the city of Seattle is pioneering a bold approach to narcotics that should be a model for America.

"Anyone caught here with a small amount of drugs — even heroin — isn’t typically prosecuted. Instead, that person is steered toward social services to get help.

"This model is becoming the consensus preference among public health experts in the U.S. and abroad. Still, it shocks many Americans to see no criminal penalty for using drugs illegally, so it takes courage and vision to adopt this approach: a partial retreat in the war on drugs coupled with a stepped-up campaign against addiction.

"The war on drugs has been one of America’s most grievous mistakes, resulting in as many citizens with arrest records as with college diplomas. At last count, an American was arrested for drug possession every 25 seconds, yet the mass incarceration this leads to has not turned the tide on narcotics.
...
"In effect, Seattle is decriminalizing the use of hard drugs. It is relying less on the criminal justice toolbox to deal with hard drugs and more on the public health toolbox.
...
"As I see it, the problem is that while Seattle has done an outstanding job halting the war on drugs, it hasn’t done well in financing the war on addiction. It closed the law enforcement toolbox without fully opening the public health toolbox.

"Local officials found that in a world of competing budget silos, money saved from jails can’t easily be reallocated to treatment. This is so even though researchers repeatedly find that drug treatment pays for itself by saving huge amounts of taxpayer money, not to mention lives. One study found that substance abuse treatment in California paid for itself seven times over in reduced crime and other savings.

Clean needle exchange programs may be both helpful and harmful

Here's a recent NBER working paper that looks at the effects of opening a place where intravenous drug users can get clean needles--it finds that this reduces blood borne disease, but may in fact increase drug use.

Are Syringe Exchange Programs Helpful or Harmful? New Evidence in the Wake of the Opioid Epidemic
by Analisa Packham
NBER Working Paper No. 26111,  July 2019

Abstract: "In light of the recent opioid crisis, many public health entities have called for an expansion in syringe exchange programs (SEPs), which provide access to sterile syringes and facilitate safe needle disposal for injection drug users. This paper investigates the effects of recent SEP openings on HIV diagnoses and drug-related overdoses in the wake of the opioid crisis. I find that SEP openings decrease HIV diagnoses by up to 18.2 percent. However, I present new evidence that SEPs increase rates of opioid-related mortality and hospitalizations, suggesting that needle exchanges alone may be less effective than other interventions at stimulating recovery."


"From an economic standpoint,SEPs have the potential to create large positive externalities by reducing the stock of used needles on the streets and preventing the spread of disease. Conversely, by providing clean needles to drug users, reducing the stigma of using drugs and/or creating a safe environment for networking with other users, SEPs may also generate untended consequences. In particular, lowering the cost of obtaining needles and other supplies incentivizes drug users to inject more frequently, potentially exacerbating rates of opioid misuse and abuse. 

"In this paper, I test the causal relationships between SEP openings and drug-related health and crime outcomes. Because no official national directory of SEPs exist, I construct a hand collected dataset on program locations and opening dates to identify areas exposed to SEPs within the last ten years. In particular, using health outcomes data from the CDC, I compare rates of HIV, drug- and opioid-related deaths, opioid-related overdoses, and drug-related crime in counties with SEP openings to other counties without SEPs before and after the initial year of implementation. I find that SEPs decrease the number of HIV cases in some areas, and that  this effect grows over time. However, estimates also indicate that SEP openings increase drug-related mortality. … Effects are largest in rural and high-poverty areas, suggesting that those with larger geographic or financial obstacles  to substance abuse treatment are most affected by such programs."

Federal government contests safe injection facility in Philadelphia, where the overdose rate is four times the homicide rate

When will they ever learn? The Washington Post updates us on Federal efforts to prevent exploration of ways to cut down on drug overdose deaths.

Philadelphia plans to open supervised opioid injection facility despite federal lawsuit

"Though the plan for what is known as a safe injection site has garnered local support, the city now finds itself in the middle of a major legal fight with the federal government.

"The Justice Department sued the nonprofit Safehouse in February, arguing that opening the facility in Philadelphia — the first supervised consumption facility in the United States — would violate federal law. Likening the idea to a crack house, federal officials say allowing the use of illicit drugs with impunity enables and exacerbates the in­trac­table opioid problem; the U.S. attorney for the Eastern District of Pennsylvania argued that opening Safehouse would violate the Controlled Substances Act, which makes it illegal to open or run a place where illegal drugs are knowingly used.
...
"The overdose rate in Philadelphia is four times the homicide rate; were the statistics reversed “there’d be absolute citizen outcry, they’d have National Guard in the streets,” said former Pennsylvania governor Ed Rendell, who is on the Safehouse board and said the organization plans to move forward even with federal opposition."
*************

see earlier posts

Thursday, February 7, 2019

Philly and Feds at odds over reducing opioid overdoses

Sunday, September 2, 2018

The DOJ argues against harm reduction measures for drug addicts

Marijuana debate in New Hampshire

The NY Times has the story:

Legalize Pot? Amid Opioid Crisis, Some New Hampshire Leaders Say No Way

"MANCHESTER, N.H. — The push to legalize recreational marijuana is sweeping the Northeast: Massachusetts, Vermont and Maine have done it, and the governors of Rhode Island, Connecticut, New York, and New Jersey say they want their states to do it, too.

"But in New Hampshire, Gov. Chris Sununu and some other state leaders are opposed. The problem, they say, is not just about pot. It’s about opioids — drugs that have ripped across this state, devastating thousands of residents and leaving New Hampshire in recent years with one of the highest per capita death rates from opioid-related overdoses. After so many deaths, so much misery and so much state money spent fighting opioids, the opponents say, how could anyone even think about easing access to some other drug?

"There is little consensus about a relationship between marijuana use and opioid addiction, and the debate in New Hampshire, where a key vote on the issue is expected this week, is tapping into a national discussion about whether marijuana is a gateway drug or something else entirely."

Philly and Feds at odds over reducing opioid overdoses

Here's the story from NPR:

U.S. Prosecutors Sue To Stop Nation's First Supervised Injection Site For Opioids

"After months of threats, federal prosecutors in Philadelphia launched a legal challenge on Wednesday against the nonprofit Safehouse, which is hoping to open what could be the nation's first site where people with opioid addiction can use drugs under medical supervision.

"The civil lawsuit, which is jointly being pursued by Pennsylvania-based prosecutors and the Department of Justice in Washington, is the first time the federal government has intervened in the hotly debated issue of supervised injection sites. The lawsuit could become an important legal test case as about a dozen cities across the country consider similar proposals.
...
"The provision of the law in question is widely known as the crack house statute. It makes it illegal to maintain a space for the purpose of making, storing, distributing or using an illegal drug. Safehouse would not make or provide opioids to users. But it would allow people to bring in their own drugs, to use while being monitored by medical staff."

Self regulation of black markets on the dark web?

Here's an interesting story from the Guardian, about some dark-web black markets in the U.K. banning fentanyl, as too deadly and (hence) too likely to attract vigorous police attention:

Dark web dealers voluntarily ban deadly fentanyl
Suppliers, fearing police crackdown, decide opioid is too high-risk to trade

"Major dark web drug suppliers have started to voluntarily ban the synthetic opioid fentanyl because it is too dangerous, the National Crime Agency has said.

"They are “delisting” the high-strength painkiller, effectively classifying it alongside mass-casualty firearms and explosives as commodities that are considered too high-risk to trade.
...
"Vince O’Brien, one of the NCA’s leads on drugs, told the Observer that dark web marketplace operators appeared to have made a commercial decision, because selling a drug that could lead to fatalities was more likely to prompt attention from police.

"It is the first known instance of these types of operators moving to effectively ban a drug.
...
"O’Brien said that the NCA is working with US law enforcement agencies to prevent the UK from having a similar fentanyl epidemic, though the number of people dependent on opioids in the UK compared to America means it has a much smaller market."

The DOJ may not get the last word on supervised injection sites

The WP has the story:
Cities defiant after Justice Department’s threat on ‘supervised injection sites

"Cities seeking to open sites where illegal drug users are monitored to prevent overdoses responded defiantly Tuesday to a Justice Department threat to take “swift and aggressive action” against that approach to the nationwide opioid epidemic.

"Plans for those “supervised injection sites” — under consideration in San Francisco, Philadelphia, New York City, Seattle and elsewhere — collided with a stern Justice Department warning issued last week, threatening to create a standoff between federal and local authorities like the confrontation over “sanctuary cities.”

As they have before, some liberal-leaning cities trying to cope with conditions on their streets find themselves at odds with more-restrictive Trump-era policy and enforcement.
...
More than 72,000 people died of drug overdoses in 2017, led by more than 49,000 deaths from opioids, according to preliminary statistics released last month by the Centers for Disease Control and Prevention."
************
Earlier related post:

Sunday, September 2, 2018

The DOJ argues against harm reduction measures for drug addicts

The perils of (too) sharply reducing opioid prescriptions

The ongoing opioid epidemic in the U.S. (and elsewhere) has at least some of its origins in the over-prescription of opioid painkillers. So there is a lot of interest in how, and how much, to cut back on prescribing these drugs.  The two articles below raise some flags about cutting back too sharply, and warn of the long road ahead in any event (partly because people in chronic pain and people who have become addicted to prescription painkillers sometimes enter the market for illegal narcotics when they lose their prescriptions).

Sally Satel directs my attention to this article in Politico:

How the opioid crackdown is backfiring
Hundreds of chronic pain patients responding to a POLITICO survey describe being refused opioid prescriptions they had relied on for years with sometimes devastating consequences.

"Many of POLITICO’s respondents described being tapered off narcotics too quickly, or worse, turned away by doctors and left to navigate on their own. Some said they coped by using medical marijuana or CBD oil, an extract from marijuana or hemp plants; others turned to illicit street drugs despite the fear of buying fentanyl-laced heroin linked to soaring overdose death numbers. A few, like Fowlkes, contemplated suicide."
************

And here is an article by some of my Stanford colleagues that explores a model to make some predictions. It is forthcoming in The American Journal of Public Health (AJPH) (and published online first):

Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic
Allison L. Pitt, MS, Keith Humphreys, PhD, and Margaret L. Brandeau, PhD

"Objectives.To estimate health outcomes of policies to mitigate the opioid epidemic.

Methods.We used dynamic compartmental modeling of US adults, in various pain,opioid use, and opioid addiction health states, to project addiction-related deaths, lifeyears, and quality-adjusted life years from 2016 to 2025 for 11 policy responses tothe opioid epidemic.

Results.Over 5 years, increasing naloxone availability, promoting needle exchange,expanding medication-assisted addiction treatment, and increasing psychosocial treatment increased life years and quality-adjusted life years and reduced deaths. Other policies reduced opioid prescription supply and related deaths but led some addicted prescription users to switch to heroin use, which increased heroin-related deaths. Over a longer horizon, some such policies may avert enough new addiction to outweigh the harms. No single policy is likely to substantially reduce deaths over 5 to 10 years.

Conclusions.Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation. (Am J Public Health.Published online ahead of print August 23,2018: e1–e7. doi:10.2105/AJPH.2018.304590)"
******

Note the contrast between these views and those of the Department of Justice as expressed by Deputy Attorney General Rod Rosenstein in yesterday's post.

Five approaches to the opioid crisis, by pharmacologists, doctors, insurers, prosecutors, and legislators

Five very different approaches to the opioid crisis--by
1. pharmacologists/biologists, 2. physicians, 3. payers,  4. prosecutors, and 5.legislators:

1. From PNAS:
Safer opioids may be on the horizon, but mitigating addiction is a long shot, by Jyoti Madhusoodanan

2. From Science:
Opioid prescribing decreases after learning of a patient’s fatal overdose, by
Jason N. Doctor, Andy Nguyen, Roneet Lev, Jonathan Lucas, Tara Knight, Henu Zhao, Michael Menchine

3. From the Chicago Trib, and from Stat:
Chicago limits opioid prescriptions for city employees

Tapered to zero: In radical move, Oregon’s Medicaid program weighs cutting off chronic pain patients from opioids

4. From Reuters:
New York sues OxyContin maker Purdue Pharma over opioids

5. From the NY Times
Congress Is Writing Lots of Opioid Bills. But Which Ones Will Actually Help?


******************
And here's an article from the NY Times on the magnitude of the crisis:

Bleak New Estimates in Drug Epidemic: A Record 72,000 Overdose Deaths in 2017: Fentanyl is a big culprit, but there are also encouraging signs from states that have prioritized public health campaigns and addiction treatment.

"Strong synthetic opioids like fentanyl and its analogues have become mixed into black-market supplies of heroin, cocaine, methamphetamine and the class of anti-anxiety medicines known as benzodiazepines."

Safe injection sites in New York City? Learning from Canada...

The NY Times has two recent stories, one perhaps a reaction to the other.  First this:
De Blasio Moves to Bring Safe Injection Sites to New York City

"Mayor Bill de Blasio is championing a plan that would make New York City a pioneer in creating supervised injection sites for illegal drug users, part of a novel but contentious strategy to combat the epidemic of fatal overdoses caused by the use of heroin and other opioids.

"Safe injection sites have been considered successful in cities in Canadaand Europe, but do not yet exist in the United States. Leaders in San Francisco, Philadelphia and Seattle have declared their intention to create supervised sites, although none have yet done so because of daunting obstacles. Among them: The sites would seem to violate federal law.

"The endorsement of the strategy by New York, the largest city in the country, which last year saw 1,441 overdose deaths, may give the movement behind it impetus.

"For the sites to open, New York City must still clear some significant hurdles. At minimum, the plan calls for the support of several district attorneys, and, more critically, the State Department of Health, which answers to Gov. Andrew M. Cuomo. The city sent a letter on Thursday to the state, asserting its intention to open four injection centers.

 ...
"The most serious obstacle to the safe injection sites may be the federal government. A section of federal law known as the crack house statute makes it illegal to own, rent or operate a location for the purpose of unlawfully using a controlled substance.

The enforcement of the statute in the case of safe injection sites, however, would be up to the discretion of federal authorities. While it is unclear how the Trump Justice Department will respond to the city’s proposal, the attorney general, Jeff Sessions, has taken a hard line on drug policy.

“We don’t believe a president who has routinely voiced concern about the national opioid epidemic will use finite federal law enforcement resources to prevent New York City from saving lives,” Eric F. Phillips, the mayor’s press secretary, said in a written statement.

Advocates for the sites point out that needle exchanges were considered illegal when they began, and they are now commonplace; in 2015, for example, when Mike Pence was governor of Indiana, he put aside his moral opposition to needle exchanges and allowed a program to stem the flood of H.I.V. cases."

************

And, today, this:

Opioid Crisis Compels New York to Look North for Answers
Supervised injection sites for heroin users have prevented overdose deaths in Canada. But is New York City ready for the scenes that come with them?

"As Mayor Bill de Blasio has come out in support of supervised injection centers in New York, his stance has been shaped by Canada’s lead.

The country has been a pioneer; its first supervised injection facility, where heroin can be used under supervision, opened in Vancouver in 2003. A decade of political and legal wrangling followed, culminating with the Canadian Supreme Court ruling in favor of the approach in 2011."

Harm reduction (for opioids) in Canada

Here's a story from the Washington Post:
At the heart of Canada’s fentanyl crisis, extreme efforts that U.S. cities may follow

"the Overdose Prevention Society, took over a vacant building next door, giving users a clean indoor place to inject drugs. There are 29 similar sites in British Columbia, the epicenter of Canada’s drug crisis, and more across the country.

“To save lives, you need a table, chairs and some volunteers,” said Sarah Blyth, the manager here.
...
"As fentanyl rampages across North America, several U.S. cities have announced that they will open the first supervised drug-consumption sites like those in Canada. Their plans illustrate the gulf between the two nations: While Justin Trudeau’s government is doubling down on its “harm reduction” approach, any U.S. organization that tries to follow suit would be violating federal law and risking a confrontation with the Justice Department.
************
See also this academic paper
Addressing the Nation’s Opioid Epidemic: Lessons from an Unsanctioned Supervised Injection Site in the U.S.
Alex H. Kral and Peter J. Davidson
American Journal of Preventive Medicine, 53, 6, 2017, 919 - 922

and this January 2017 news story
Awash in overdoses, Seattle creates safe sites for addicts to inject illegal drugs

Opioids and pharma sales

Prescription pain medicines have played a significant role in the opioid epidemic.  Recently, the makers of OxyContin have decided to stop direct marketing it to doctors. Stat has the story:
End of an era: Purdue to stop marketing opioids to doctors

"Purdue Pharmaceuticals, the maker of the opioid painkiller OxyContin, said it would no longer actively market opioid products — a major about-face for a company increasingly viewed as a principal culprit in the country’s addiction and overdose crisis.

The company said it is reducing its sales staff by more than half, and that its remaining salespeople will no longer visit doctor’s offices to push their product. Instead, the company said it will direct prescribers to materials published by the Centers for Disease Control and Prevention and the office of the U.S. surgeon general.

...

"The health insurer Cigna also announced in October it would no longer cover OxyContin through employer-based plans, shortly after the pharmaceutical industry lobby group PhRMA broadly endorsed policies that limit opioid prescriptions to seven days."

Drug trafficking via the U.S. mail

A recent Senate report (which I haven't seen) has generated a lot of news coverage to the effect that fentanyl, a Schedule II controlled substance (i.e. a drug that may not be legally sold without a prescription in the U.S.) that is implicated in the current opioid crisis in the U.S., is widely available from internet sites that will send it to you in the mail.

Here's the WSJ story:

Stamp Out Easy Mail Access to Deadly Fentanyl, Senate Report Urges


"A U.S. Senate report raises fresh concerns about how easy it is to buy illicit, mail-order opioids from China, a source federal authorities say has fueled a nationwide addiction crisis claiming tens of thousands of lives.

The new Senate report, issued ahead of a hearing Thursday, is the latest to focus on how international mail has become a major conduit for these drugs.

Investigators for the Senate’s Permanent Subcommittee on Investigations posed as would-be online buyers, entering terms like “fentanyl for sale” into Google..."

***********

Try it yourself: https://www.google.com/search?q=fentanyl+for+sale

Peter Singer on the undersupply of opiods in the developing world

There's been a lot of discussion of the oversupply of opioids in the U.S.  Here's a discussion of the undersupply in the developing world.
Prisoners of Pain

"Whereas the quantity of available opioids in the United States is more than three times what patients in need of palliative care require, in India, the supply is just 4% of the required quantity, and just 0.2% in Nigeria. The reason is a misplaced fear that clinical use of opioids will fuel addiction and crime in the community.

He refers us to the Lancet report;
Alleviating the access abyss in palliative care and pain relief—an imperative of universal health coverage: the Lancet Commission report

"Executive Summary
The lack of global access to pain relief and palliative care throughout the life cycle constitutes a global crisis, and action to close this divide between rich and poor is a moral, health, and ethical imperative. The need for palliative care and pain relief has been largely ignored. Yet, palliative care and pain relief are essential elements of universal health coverage (UHC).

This Lancet Commission aims to (1) quantify the heavy burden of serious health-related suffering associated with a need for palliative care and pain relief; (2) identify and cost an essential package of palliative care and pain relief health services that would alleviate this burden; (3) measure the unmet need of an indispensable component of the package—off patent, oral, and injectable morphine; and (4) outline national and global health-systems strategies to expand access to palliative care and pain relief as an integral component of UHC while minimising the risk of diversion and non-medical use."

Supervised injection facilities for opioids

From Statnews:
As a doctor, I was opposed to supervised injection facilities. Now I’m ready to give them a try  By Henry L. Dorkin (the president of the Massachusetts Medical Society).

"Over the last few years, I have watched with a blend of amazement and grave concern as an odd phenomenon has unfolded against the backdrop of our nation’s opioid crisis: Despite the clear need to battle this ongoing epidemic with all of the tools at our disposal, one evidence-proven option — supervised injection facilities — is being overlooked, and even disparaged.
...
"A supervised injection facility is a safe, clean space where individuals can inject drugs they already possess under the supervision of trained medical staff. The facilities also offer sterile injection equipment. The advantage is that medical expertise is immediately present in case an emergency occurs. At the same time, these on-site clinicians can facilitate pathways to treatment and rehabilitation from the chronic disease of opioid abuse disorder.
...
"As a physician and president of the Massachusetts Medical Society, I was initially inclined to oppose the concept of supervised injection facilities. How, I thought, could a health care professional, someone grounded in ethics and an oath to “do no harm,” stand by and watch as individuals inject street drugs into their veins?
...
"The concept of supervised injection facilities fits well with the overarching and proven public health philosophy of harm reduction: meeting patients where they are in their disease to eliminate existing barriers to rehabilitation.

With lives being lost each day from all segments of our society, dealing in theoretical solutions can be counterproductive. Fortunately, supervised injection facilities operating in other parts of the world have yielded substantial and evidence-backed reductions of death, disease, and expenditures.

"To better understand the utility of these facilities, the Massachusetts Medical Society created a task force to examine the evidence for and against supervised injection facilities. This group produced a report that reviewed all available data regarding the use of supervised injection facilities around the world.

"The report clearly showed that these facilities save lives. For example, after the Insite facility opened in Vancouver, British Columbia — the first supervised injection facility in North America — researchers reported a 35 percent decrease in the number of lethal overdoses in that area.

...

"Shortly after our medical society overwhelmingly voted to adopt a policy in support of a pilot supervised injection facility program in Massachusetts, the American Medical Association adopted a similar policy.

...

"As we continue to look for ways to increase access to recovery programs for those with opioid use disorder, we must remember that in order to get people into recovery, they must first stay alive."

Supervised drug injection sites--Harm reduction

One of the problems with intravenous drug addition is that addicts can overdose and die. A number of North American cities are trying to combat this by opening supervised drug injection sites, meant to be safe places to shoot up, staffed with one or more healthcare workers and social workers.

From the Globe and Mail:
Montreal gets federal approval for two supervised injection sites

"Supervised injection sites provide a safe space for addicts and provide them with the necessary equipment — sterile syringes, gauze pads and the like — for safe injections.

"The users themselves bring their drugs, the sites pride themselves on being anonymous and confidential, and the users are accompanied on site by nurses and community and psycho-social workers.

...
"The Montreal sites are modelled after Vancouver-based Insite, which was the first city in North America to have a legal, supervised injection site beginning in 2003.

"While critics say the sites encourage drug use, experience has shown they reduce the number of overdose deaths and transmission of hepatitis C and HIV."
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Here's a 2010 article from the Canadian Medical Association Journal:
Vancouver’s supervised injection facility challenges Canada’s drug laws
Kathleen Dooling, MD MPH and Michael Rachlis, MD LLD

Here's a 2008 article in the British Columbia Medical Journal by a former Vancouver Chief of Police (he would prefer strict enforcement rather than harm reduction):
Supervised injection sites—a view from law enforcement
Issue: BCMJ, Vol. 50, No. 3, April 2008, page(s) 132-134
Jamie Graham

Here's a 1995 Editorial in the American Journal of Public Health
Editorial: Harm Reduction-A Framework for Incorporating Science into Drug Policy by Don C. Des Jarlais

And of course, all this is made topical by the opioid epidemic:
Why opioid deaths are this generation’s Aids crisis
"The soaring numbers of deaths from overdoses in the US and UK requires a radical and fast rethink of drugs policy"