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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Bring drug overdose plan to B.C. interior

To reduce drug overdose deaths, Vancouver Coastal Health authority plans to track patients to make sure they are taking their prescribed opioids.

image: IFL Science

I may seem odd that lives can be saved by making sure that patients take one opioid (Methadone) so that they don’t die from another (fentanyl). But that’s what statistics show. If patients stay on Methadone they’re more likely to be alive a year later.

It’s the first program of its kind in Canada and the latest effort to turn the tide on the opioid crisis that is projected to kill 1,500 British Columbians (Globe and Mail, Sept. 15, 2017). That’s up from 914 in 2016.

The problem is that patients have hectic lifestyles that make daily prescriptions difficult to take. As a result, only one-third are still on Methadone after a year. Laura Shaver, board member of the B.C. Association for People on Methadone, supports the plan:

“I would think it would be a great idea for many people that are, you know, a little bit unstable, for them to have a bit of a push behind them. With a bit of support, things could be a lot different.”

Rolando Barrios, assistant director at the Vancouver Coastal Health, sets his goal at 95 per cent Methadone compliance:

“We may not achieve that, but think about doubling the 30 per cent to 60 per cent . . . and the impact that would have.”

Tracking Methadone patients is labour intensive. The unregimented lifestyles of drug addicts make it difficult for them to make daily appointments. Starting this month, 20 teams, each comprising of three health professionals, will check on 3,000 patients to make sure they are taking their drugs.

Pharmacists will alert the teams if patients have not taken their daily dose. The team will then phone or visit the patient to check up. Participation in the program is voluntary: the teams are not policing patients.

The plan is modeled on the highly successful program to stop HIV/AIDS launched in 2010. It actively sought untreated HIV-positive people and followed up with an antiretroviral therapy. As a result, the transmission of AIDS was reduced by 96 per cent.

“With HIV,” says Dr. Barrios, “we used to wait until people had low immune systems before they started treatment . . . and then science came in and said we need to treat them earlier and faster. We learned that we needed to be aggressive.”

If the plan is so good for Vancouver, why isn’t it being applied throughout the province? Vancouver’s drug deaths may make news but the problem is worse in B.C.’s interior on a per capita basis.

Kamloops is bad -40 people died of drug overdoses in 2016- but Kelowna is worse. Kelowna led all Canada in per capita opioid poisoning hospitalizations. Vancouver was 16th. Kamloops didn’t make the top twenty but the program is needed here.

The Interior Health Authority needs to match the efforts of Vancouver Coastal Health. Users of prescription opioids need to be monitored. Only by reaching out will the death rate be brought down.

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?

Opioid use rises despite crisis

Am I the only one not surprised that the opioid crisis has worsened? Despite the widespread distribution of naloxone kits to save lives from fentanyl overdose. Despite increased prescriptions of methadone to treat addiction.

       opium den

It’s all so predictable. The fuse to the opioid bomb was lit long ago.

I just finished reading Dan Malleck’s thoroughly researched book When Good Drugs Go Bad: Opium, Medicine, and the Origins of Canada’s Drug Laws. He traces the opioid crisis that gripped young Canada at the turn of the twentieth century and led to the Opium Act of 1908.

As now, the problem wasn’t the “recreational” use of opium, but rather the prescribed and drug store concoctions of opium. Laudanum, a tincture of opium, was commonly found in medicine chests to treat toothaches and diarrhea, and as a cough suppressant.

Opium was, and still is, a powerful drug in a doctor’s medicine bag. It was especially useful to treat the illnesses of urbanization before the advent of antibiotics; diseases such as dysentery, cholera, and tuberculosis. Even today, nothing surpasses it as a pain killer.

As now, the crisis then was triggered by drugs other than opium. Cocaine had been introduced as a pain killer. The effect on users was startling different than that of opium and its sister morphine. The concept of “drug fiends” didn’t exist until cocaine came on the scene. Now the term easily applies to crystal meth addicts. Charles Heebner, Dean of the Ontario College of Pharmacy commented in 1906 that the public alarm over drug users was non-existent until “the Cocaine Monster came upon the arena . . . Cocaine proved to be a far more enslaving drug than opium or morphine (p.199 of Malleck’s book).”

The politics of the opium scare were quite different than the reality of the problem. Whereas the medical problem was opium addiction and the crazed effect of cocaine, the politics dwelt on the anti-Asian sentiment, especially in B.C.

Nineteen hundred and eight was a federal election year and Prime Minister Laurier was looking for his fourth majority in a row. In response to “race riots” in Vancouver, Laurier sent his minister of labour, William Lyon Mackenzie King, to Vancouver to investigate.

King found that Chinese workers had been brought to British Columbia to build the railway and there now 16,000 Chinese immigrants and their decedents which amounted to eight per cent of the population of B.C. White Canadians claimed they were taking jobs away. Chinese Canadians were demonized for leading good, white, Canadian women astray in “opium dens.” The Chinese were perfect scapegoats: too many, too shady. Laurier played the race card and was returned to power in 1908.

One hundred and eight years later, nothing much has changed. The opioid problem is characterized by sensational news coverage of ordinary Canadians, many of them in the prime of their lives, being killed in alarming numbers by overdosing on fentanyl.

However, the root of the problem is not the recreational use of opioids but the prescription of opioids by doctors. “Prescriptions for hydromorphone have soared 57 per cent over the past five years (Globe and Mail, March 27, 2017).”

And predictably, the more opioids that are prescribed, the more Canadians get hooked. The problem is compounded as users get habituated and require increased dosages for them to work. So they turn to multiple doctors to get them. Failing that, they turn to the streets and the deadly fentanyl.

The problem is not recent -it’s been going on for generations according to the Globe and Mail. “The problem is particularly challenging for new doctors who have inherited patients on high-dose opioids from a colleague who has retired.”

It feels like 1908 all over again.

 

Legalize heroin and save lives

Legal opiates are being use to adulterate illegal ones with tragic consequences. More than 800 British Columbians were killed in fentanyl-related overdoses last year. Many of them were ordinary Canadians you might find living next door. One of them was my nephew who died a few years ago.

Calgary Herald

Calgary Herald

They injected what they thought was heroin, or some other illegal drug. If they had injected legal heroin, of known purity and strength, they would still be alive. I’m not naive; they would still be addicted but their quest for bliss would not have ended in death.

It’s a question of harm prevention. Legalization of heroin may seem like a radical idea but not long ago so did giving drug addicts clean needles and a safe place to inject.

Like the prohibition of alcohol, the prohibition of drugs has been a dismal failure. Prohibition simply pushes the drug trade underground. When a trade is unregulated, who knows what junk users will end up taking? Drug manufacturers don’t intend to kill users: it’s bad for business to kill your customers. They just want to maximize profits.

Fentanyl is perfectly legal. It’s prescribed by doctors for controlling pain. Fentanyl is just one the opium family. It turns out that all of them are addictive.

A brief history of legal opiates is a guide to the intersection of illegal ones. Opium from Persian poppies has been used for pain control since the fourth century. Researchers discovered the active components of opium -morphine, codeine and theobain- in the 1800s. In an attempt to find a non-additive painkiller, heroin was derived from morphine. The manufacturer of heroin, Bayer, pulled it from shelves in 1913 once it was found to be addictive.

In the quest for a non-addictive pain killer, Perdue Canada filed a patent in 1992 for OxyContin, a pill that would treat pain “without unacceptable side effects (Globe and Mail, Dec. 30, 2016).” Perdue encouraged doctors to prescribe the pill and soon it was a blockbuster hit with billions of dollars being made.

But OxyContin turned out to have terrible side effects and thousands of were hooked. Canadians consume more prescription opiates on a per-capita basis than any other country in the world according to a United Nations report.

As in all opiates, those hooked on OxyContin become habituated so that they needed more pills to control pain. Purdue attempted to control the problem with the replacement OxyNEO in 2012, a tamper-resistant alternative that is difficult to crush, snort or inject. And that same year, the provinces stopped paying for both opiates.

Both factors drove addicts to the streets to find a fix. Illegal drug manufacturers care not how their clients get hooked, whether it be from the pursuit of bliss or the relief of pain.

Fentanyl is now the universal opiate. Manufactured in China in concentrated form, it can be ordered on the internet and sent through the mail. From there, it is pressed into pills to mimic OxyContin and other opiates.

Making fentanyl illegal is not the solution. Drug abuse is a medical problem, not a criminal one. All opiates should be legalized and safe doses prescribed. Education, as in tobacco and alcohol abuse, is the only solution.