How to reduce drug overdose deaths

There is no easy way to reduce drug overdose deaths but a simple first step is to provide users with safe opioids. The hard part will take time.

 North Vancouver couple die of fentanyl-linked overdose. Image:Vancouver Sun

The grim toll of deaths –of community leaders and ordinary citizens -marches on relentlessly. In just eight months of 2017, more British Columbians died of drug overdoses than the whole year before.

Lots of things don’t work. Still, politicians persist in the tried and unproven. B.C. Solicitor-General Mike Farnworth echoed concerns that rose in meetings with federal and provincial public safety ministers:

“We strongly believe that if you’re dealing fentanyl, you’re dealing death, and you should be facing much more severe penalties such as manslaughter charges,” Farnworth said (Globe and Mail, October 19, 2017.)

Tough talk has failed in the past. The divide between pushers and users is not as clear as Farnworth might think. Provincial Health Officer Perry Kendall says there is a risk that “the policy implementation will not be able to distinguish between importers or non-user, large-scale dealers and the easier-to-apprehend street-level user/dealer.”

“Our attempts to destigmatize,” adds Kendall, “through decriminalizing the user and treating him or her as a person with an illness rather than a criminal, could be jeopardized.”

Restrictions on importation will fail as well. LifeLabs in B.C. has been testing urine samples of patients screened for fentanyl and found that these patients also tested positive for the even more powerful carfentanil. Now another synthetic opioid, U-47700, has been detected. More synthetic opioids could be on the way. Garth Graham, director for LifeLabs says:

“Are we two steps ahead? No, we’re not. In my opinion, there’s more of this coming … I think it is difficult. We’re working with provincial stakeholders . . . They mentioned another fentanyl analogue, and we are now trying to work that up so we can look for that.”

It’s a cat-and-mouse game. As soon as one variety of fentanyl is identified, another is cooked up. Testing equipment for the new analogue has to be built and laws restricting it enacted.

Naloxone kits save lives but only if someone nearby is lucid enough to administer them. Bob Hughes, Executive Director of ASK Wellness, suggests an alternative:

“We’re not going to fix this with one approach, such as providing Naloxone. That they’ve got some other option like basically pharmaceutical-grade heroin for some of those folks who just can’t seem to shake it,” Hughes told Radio NL.

Providing heroin to drug addicts may seem like a bad idea because it enables an addiction. But if we’re concerned about saving lives rather than making moral judgements on users, then legal heroin or other opioids like hydromorphone is a good first step.

However, the hard part is not the supply of safe opioids. The hard part is the destigmatization of drug users. Deaths due to drug overdose are still seen as a moral failing rather than a disease or “a person with an illness” as Dr. Kendall put it.

Open discussions about mental illness have helped destigmatize what was once thought of as lunacy or possession by evil spirits. Now the conversation needs to start around addiction; not as a weakness of character; not an embarrassment to be hidden from public view by friends and family.

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Help fentanyl labs make a safer drug

Illegal fentanyl lab operators don’t intend to kill users. They would prefer to have return customers. The problem, I suspect, is that the fentanyl used is so concentrated that it’s hard to dissolve to a uniform consistency. The resulting doses are uneven –from low to deadly. It’s a good idea to provide testing facilities for fentanyl cooks to let them know the potency of their product. Dr. Tyndall of the BC Centre for Disease Control says:

  fentanyl lab. image: Global news

“I’m still firmly of the belief that nobody’s actually trying to kill people. These manufacturers don’t know what they’re doing and they’re putting out ridiculous concentrations of these drugs.”

The BCCDC recommends an expansion of drug-checking services where anyone, including producers of illegal fentanyl, can have their drugs tested for toxicity. B.C.’s Minister of Health, Judy Darcy, endorses the expansion.

As it stands, drug policy is perverse because we tell users not to use street drugs but provide no other option when legal supplies fail.

“We strongly advise people to stop using street drugs,” says Dr. Tyndall, “and if they can’t do that, then we offer them … Suboxone or methadone, and if that doesn’t work, we basically tell them to go and find their own drugs even though there is a very real possibility of dying.”

The BCCDC suggests ten “areas of action.” If they were adopted, opioids would be essentially legalized much in the way that marijuana will be next year. Grower’s clubs and individuals would be allowed to make medical grade opiates. To clarify, opiates are derived from poppies whereas opioids include all synthetic and natural products.

Legal opioids are not likely to happen any time soon. I started lobbying for legalization of cannabis 40 years ago and look how long that took. Optimistically, with the model of legalized marijuana to be established soon, it won’t take another 40 years for the legalization of opioids.

Even without legalization, off-label uses of opioids are allowed. The BCCDC suggest dispensing take-home opioids such as oral hydromorphone which users could take home, grind up, and inject without supervision.

If the above recommendations only seem radical, it’s only because of a false sense of what criminalization can achieve. Criminal law can’t accomplish societal goals. If we want to stop people from using harmful drugs, criminalization has been a dismal failure. Instead, make drugs legal and educate people of the unhealthy consequences of use. It works with tobacco. If the goal is harm reduction, the recommendations don’t seem so radical.

Imagine that we are talking about baby strollers instead of drugs, and that some early models collapsed resulting in injury or death. An irrational solution would be to make strollers illegal. The sensible solution would be to regulate manufacture of the strollers to make them safe.

Prohibition of opioids isn’t working. It didn’t work for coffee, cigarettes or alcohol.

If the current trend continues, the death rate will continue to climb. More than 1,500 will die in British Columbia this year -ordinary people like friends, family and neighbours. Forget the stereotype of street people overdosing in alleys: 90 per cent of deaths are indoors. Isn’t it time to abandon prohibition and give harm-reduction a chance?

It’s too late to decriminalize pot

Decriminalization of marijuana should have happened decades ago. Now it would only add to the confusion.

Marijuana users are caught in a legal limbo. The government intends to legalize marijuana before Canada Day, 2018, but until then it’s illegal. Then, like a light being switched on, what was once a criminal offence will not be.

Alberta Legalization of Cannabis Committee

Government intentions aside, police are going about their business. They arrested activists Mark Emery (the “Prince of Pot”) and his wife Jodie as reported by CFJC Today.

The Liberals have been dithering over decriminalization for decades and this Trudeau is no different. Pierre Trudeau could have decriminalized marijuana in 1979. Then Justice Minister Marc Lalonde was playing politics when he said that he would decriminalize it before the upcoming election if opposition parties would just fast track the legislation. He was doubtful that they would. “I’m not optimistic,” Lalonde said (Calgary Herald, Feb. 22, 1979).

The opposition parties took Lalonde up on his challenge, agreeing to fast tracking.  Both opposition leaders Joe Clark and Ed Broadbent sent me letters of approval for decriminalization. They were responding to letters I sent on behalf of the Alberta Legalization of Cannabis Committee. I helped organize the group in 1977.

Prime Minister Pierre Trudeau wrote me to explain how his government was trying to decriminalize marijuana. His government had initiated a bill in the Senate, Bill S-19, in 1974.”The Commons, however, was unable to find the time to give the bill further attention; so it died on the order paper when the last session of Parliament ended (January 17, 1978),” Trudeau explained.

In my letter to the Calgary Herald, I complained about Lalonde’s tardy pace: “Why does the government seem so reluctant to do what all agree must be done? If Lalonde wants us to believe that this is a demonstration of his government in haste, then it’s time to see what a new government in action; a government that will not fiddle while Canadians get burned (April 14, 1979).”

Lalonde had teased Canadians long enough with his promises of decriminalization. His government was defeated by Joe Clark’s Progressive Conservative Party in June 11, 1979.

Executive Assistant to Clark’s Minister of Justice wrote me: “Mr. Clark’s government is currently reviewing this and other issues with a view to formulating policies and setting priorities.” “Be assured, Mr. Charbonneau, that your comments will be given serious consideration by the Government as it continues its study of this important matter (Aug. 3, 1979).” However, Clark’s government didn’t last long enough to decriminalize marijuana.

A Globe and Mail editorial argues that the government should decriminalize marijuana before legalizing it because users are in legal purgatory: “Besides, there is no viable interim regulatory regime that could accommodate a quasi-legal retail market. But there is when it comes to personal possession. It’s called decriminalization.”

It’s too late for decriminalization. More legislation would only add to confusion. There is a simple solution –what the Dutch call “gedogen.” Police simply don’t enforce marijuana laws. Unlike the Netherlands, where the law has been ignored for 30 years, police only have to turn a blind eye for another year.

Your microbiome and cancer

Lab studies indicate that the composition of your microbiome can help fight cancer. Your microbiome is the unique set of bacteria you carry around with you, or it might be more accurately said that they carry you around since they outnumber body cells ten to one.

Checkpoint inhibitors prevent T-cells from recognizing cancer as friend.

Checkpoint inhibitors prevent T-cells from recognizing cancer as friend.

Your microbiome can affect immune response, which in turn can fight cancer. Unfortunately, your immune system doesn’t always recognize cancer as a threat. Solid tumors are especially hard to target. Skin and lung cancers form solid masses that are hard to penetrate compared to liquid tumors in the blood.

Cancer cells hide by fooling immune cells into thinking they are not foreign at all. To determine friend or foe, immune cells check for a protein. If they find it on cancer cells, they appear as friends.

One innovative cancer treatment involves an immunotherapy drug called checkpoint inhibitors which do just what the name suggests –they block the checkpoint that looks for friend or foe. Seeing no friend because they are blocked, immune cells mount a defense.

This is where the microbiome comes in. Gut bacteria affect our immune system’s inflammatory response. Scientists at the University of Chicago found that mice responded to cancer invasion in varying degrees according to the type of bacteria in their guts (Scientific American, April, 2016).

Mice that were fed a particular strain of bacteria were able to fight skin cancer better than those who weren’t. When poop from the cancer-fighters was transferred to others, tumor growth slowed.

Remarkably, when checkpoint inhibitors were given to both the mice with the particular bacteria and those with the fecal transplant, tumors disappeared completely in the former and was reduced in the other. Then, when the mice with the fecal transplant were also given the bacteria, they were cured completely.

French scientists had similar results in which both the checkpoint inhibitor and a different bacteria were given. Next, the scientists gave antibiotics to the mice which killed bacteria, including the beneficial ones. The conclusion is obvious: doctors need to be cautious in prescribing antibiotics to cancer patients.

Not any bacteria will do. The Chicago team used either Bifidobacterium longum or Bifidobacterium breve. The French used Bacteroides. Yogurt contains Bifidobacterium lactis or Bifidobacterium bifidum remains untested.

Fine-tuning the immune system is a tricky business. The wrong kind of bacteria could cause the immune system to become too active and attack normal tissue. Autoimmune diseases include type-1 diabetes, inflammatory bowel disease, psoriasis, and rheumatoid arthritis. The effect of general bacteria on fine-tuning the immune system still needs to be investigated.

“Obviously we need to categorize the bacteria in the human microbiome and their potential antitumor effects more completely before we can recommend any treatments in people,” cautions the Chicago team.

Legalize all drugs

Don’t use drugs. If these two statements seem contradictory, it’s understandable. Legalization is approval. And since drug abuse is a problem, why approve drug use?

The flaw in this argument is that drug abuse in not a legal problem, it’s a medical and social problem. It wastes lives and is a burden on our health care system; it destroys families; it consumes the time and resources of law enforcement agencies.

we want beer

Prohibition is a well-intentioned initiative but it doesn’t work. As we discovered in the case of alcohol prohibition, booze was simply driven into the hands of criminals and organized crime who waged war against rivals.

Warring cartels and gangs in Mexico alone killed 120,000 in the years 2006 to 2013. That’s forty per cent more deaths than all the deaths due to illegal drug use in the U.S. according to data from the Center for Disease Control.

Guns in Canada are a serious problem. In the same period (2006 – 2013) there were approximately 1500 gun homicides in Canada. Not exactly the carnage that Mexico is experiencing  but that’s not the point: just because guns result in death and injury, no sensible person would suggest making them illegal.

What does make sense is the regulation of guns. Gun owners must obtain a Possession and Acquisition Licence and renew it every five years. Education makes sense. As a general rule, applicants must have passed the Canadian Firearms Safety Course.

Tobacco in Canada is a serious problem. In the same period, 259,000 Canadians died due to tobacco-related diseases according to the Canadian Cancer Agency. Education has reduced the number of Canadians who smoke from fifty to less than fifteen per cent.

Politicians have agreed for decades that education is key to harm reduction. As one of the founding members of the Calgary chapter of the Alberta Legalization of Cannabis Committee in 1976, I received letters from all leaders.

In his letter, then leader of the opposition Progressive Conservative party Joe Clark wrote: “In my view, a drug education programme would be far more beneficial and economical in attacking the problem than using law enforcement agencies and the courts.”

NDP leader Ed Broadbent thought that marijuana should be removed from the Criminal Code and placed under the Food and Drug Act and added: “I would agree with your statement that it does not appear to have any worse impact than alcohol.”

Prime Minster Trudeau wrote that his Bill S-19, one that would remove marijuana from the Food and Drug Act, died on the order paper but his government was pursuing the bill. “[My government] is working to make certain the legislation we introduce strikes a proper balance between concerns over the personal and social effects of penal laws aimed at discouraging its use.”

Time has stood still for the last four decades. Regressive Canadian governments have preferred to pander to misconceptions such as the “war on drugs,” or “prohibition works.”

Meanwhile the U.S., a place we think of a bastion of conservative thought, has leapt ahead of Canada. Now some states, such as Washington, have legalized the sale of marijuana. I just returned from Seattle and didn’t notice any reefer madness in the streets.

Government’s solution to pot ‘problem’ doesn’t go far enough

Marijuana was made illegal 80 years ago in a puritanical panic.  The federal government’s solution is to decriminalize marijuana but leave it illegal.  It would be wrong to possess marijuana but not as wrong as before.  Seem confusing?

janeycanuk

There is a better way. Canada’s law courts already have a good start in changing our arcane marijuana laws.

For instance, it’s already legal to possess less than 30 grams of marijuana in Ontario.  The recent ruling of the Ontario Superior Court has “effectively erased the criminal prohibition on marijuana possession from the law books in Ontario,” said the lawyer who challenged the law on behalf of a 17-year-old client.

Canadians in Ontario can possess small amounts of marijuana without any legal sanctions – – not even fear of a ticket.

The Ontario court ruling is consistent with other court rulings over the last 3 years.  It all started with the case of epileptic Terry Parker.  First the court ruled that the Canada’s law violated the constitutional rights of sick people to possess marijuana for medical reasons.  Later, other courts ruled that if sick people could possess marijuana then so could all Ontarians.

The Supreme Court of Canada is also very interested in the proposed bill.  They suspended hearing a constitutional challenge of Canada’s marijuana laws pending the outcome of new laws.

The federal bill has been hastily constructed as a response to the court challenges.  And even if passed, the proposed bill may not withstand subsequent court challenges.

The bill is flawed because it doesn’t address fundamental problems with the old law.  For example the new law would criminalize the growing of just one plant but make the possession of marijuana a minor offence.  The difference growing and possession could hinge on whether the plant is growing or dead.  If the plant is growing you are a criminal and if it is dead, you’ll get a ticket.  I see it all now -dramatic court debates determining when a plant ceases to live.

If the Ontario court ruling became the law of the land, then possession of less than 30 grams would have no legal status.  Possession would not be criminal or illegal.  You could possess it for medical, recreational, or contemplative purposes.

Marijuana has been used for centuries to alter consciousness and achieve spiritual insights. Scientist Dr. Carl Sagan writes  “I do not consider myself a religious person in the usual sense, but there is a religious aspect to some highs. The heightened sensitivity in all areas gives me a feeling of communion with my surroundings, both animate and inanimate (1969).”

The religious right in the U.S. Bush administration has a different view of marijuana use.  They don’t see it as a gateway to enlightenment but as a gateway to hell.  They imagine one toke as being the corruption of our youth and ruin of society.

These kinds of puritanical views from the U.S. got us in the predicament that we are in today.  After California enacted anti-marijuana laws in 1915, an epidemic of moral outrage gripped Canadians.

Emily Murphy, the otherwise rational champion of women’s rights in Canada, took her cues from a Los Angles police chief.  The chief  said that marijuana use drives users “completely insane.”

In 1922, writing under the name “Janey Canuk”  for Maclean’s magazine and in a book called “The Black Candle,”  she said that users become  “raving maniacs and are liable to kill or indulge in any form of violence to other persons, using the most savage methods of cruelty without, as said before, any sense of moral responsibility.”   A year later,  marijuana was criminalized.

The guardians of North American morals are now in Washington, D.C.  They don’t worry about the ruinous effects that legalized booze has on society or carnage on our highways caused by drunk drivers.  For the good ol’ boys in the halls of power, “white lightning’s still the biggest thrill of all (Merle Haggard, 1969)”

I hope that the government of Canada’s proposed bill to decriminalize marijuana fails.  But even if it passes, I doubt that it will withstand legal challenges any better than the old law did.

The Constitution of Canada would bring a rational resolution to decades old half-baked misconceptions borrowed from the U.S.  And not even keepers of North American morality in Washington could criticize a defence of our constitution.

In the case of acne, the cure is sometimes worse than the ailment   

On January 5 of this year, fifteen year old Charles Bishop stole an airplane and crashed it into a Florida office.  He killed himself but no on else was hurt.

In light of September 11, it looked like the act of a pathetic copy-cat.  Newspapers reported the contents of a suicide note left behind.  In it, Bishop claimed that Afghanistan’s al-Qaida had tried to recruit him.

accutane

What most newspapers didn’t report was that Bishop had been taking the powerful prescription drug Accutane.  Used in the treatment of skin acne, Accutane has dangerous side effects including depression, suicide and psychosis, according to the U.S. Food and Drug Administration.

The suicidal side effects are significant enough that the maker of the drug, Roche, had to retract claims that Accutane was useful in treating “psychological trauma” and “emotional suffering” associated with acne.

Accutane is one of many prescription drugs being marketed directly to the general public.   Direct marketing is illegal in Canada but legal in the U.S.   As a result Canadians see the ads that pour over the U.S. border on television and in magazines.  Canadian media, anxious to get advertising dollars, have been dodging the law.

The law is there for a good reason.  Direct marketing bypasses the expertise of the doctor by appealing directly to consumers.   Canadians who view the ads innocently diagnose their real or imaginary problems and insist that doctors write out prescriptions.  Unfortunately, those who diagnose themselves have a fool for a patient.

Drug companies have convinced governments to look the other way.  Governments are told to get out of the way of big business and reduce regulations.  And isn’t consumer choice the saviour of us all?

Not that acne doesn’t cause “emotional suffering.”  I know because as a teen, I suffered through the “psychological trauma” of acne.  In desperation, I would have bought any drug I thought might work.  But the cure is sometimes worse than the ailment.  Direct marketing preys on the vulnerable.

Along with suicidal tendencies, another known side effect of Accutane is a risk of severe birth defects if taken during pregnancy.  They include mental disabilities, missing ears and heart problems.  Despite warnings from doctors, by 1988 there had been over 500 children worldwide had been born of Accutane users with such defects.

The tragic birth of deformed babies prompted calls for Health Canada to ban the drug.  Instead of banning the drug, with the regulators’ approval, the manufacturer set up this pregnancy prevention programme.   But it didn’t happen.

Doctor Gideon Koren  at Toronto’s Hospital For Sick Children reports four women became pregnant while taking Accutane in a six month period alone.  All had been warned of the risk, but only one had been given the pregnancy prevention programme.

The pressure on doctors to prescribe drugs is great when patients insist on getting them, convinced of the drug manufacturers claims.  Doctors are only human and give in to this pressure, despite misgivings.

Accutane is not alone in the flogging of prescription drugs directly to consumers.  A smiling woman beckons you to ask your doctor for Sarafem to treat the world’s newest disease, Premenstrual Dysphoric Disorder.  Ex-NHL great Guy LaFleur is pushing Viagra in his battle against erectile dysfunction.  The ads appeal to vanity, hypochondria, and human frailty.

The cost of drugs to our health care system is enormous.  We already spent more money on drugs than we do on doctors wages.   But that fact sometimes gets buried in the health care debate. The reason is purely political.

It’s easy for the B.C. Liberal government, for example, to moan at the recent wage increases for doctors.  But you don’t see them trying to regulate the obscene profits of drug manufactures.   Health care workers are fair game for this government.

Beware of governments who offer choice in health care.  In this case, they advocate the urge of consumers to choose potentially dangerous, inappropriate, and expensive treatments.

On a recent visit to Canada, Dr. Peter Mansfield from Australia urged Canada to start enforcing its law against U.S. style direct-to-consumer advertising.  Only the U.S. and New Zealand have not yet banned the practice. “The drugs are the newest, and often most expensive drugs, but not necessarily the best,” he says.  Such advertising distracts doctors and patients from safer, cost effective therapies.