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Overdose crisis? Or, addiction crisis?

British Columbia has long been cited as a model for North American drug policy and harm reduction implementation.

BC has established a Death Review Panel in response to the overdose crisis. The panel recently issued a report with 3 recommendations. The first recommendation to regulate recovery homes, which currently require only a simple inspection of the facility. (The other 2 were for more maintenance treatments and more harm reduction.)

The chair of the panel cited the abstinence orientation of houses as a concern.

A columnist at the Vancouver Sun pushes back against the argument that BC is suffering from insufficient harm reduction:

This is, after all, a city and a province that for nearly 20 years has been at the forefront of harm-reduction with needle exchange programs, safe injection sites, methadone and suboxone treatment programs, a prescription heroin program and, more recently, free naloxone kits, free-standing naloxone stations and training for first-responders and even teachers in how to use it as an antidote for fentanyl overdoses.

We’ve gone from crisis to crisis, each one sucking up incredible resources. Currently, a quarter of a million dollars a day goes into the Downtown Eastside alone for methadone treatment. This year, the B.C. government expects the number of British Columbians receiving replacement drug therapy to rise to 30,000 and then nearly double to 58,000 by 2020-21.

In 2006 when Vancouver updated its four pillars approach, it noted that there were 8,319 British Columbians being treated with methadone.

By 2020-21, the province also expects to be supplying 55,000 “free” take-home naloxone kits, up from 45,000 this year.

We keep hearing about an overdose crisis, but what we have is an addictions crisis. Solving it will require a lot more than simply reducing harm.

What’s needed is a recovery orientation. (Which does not rule out harm reduction.)

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“safely discharged”?

hand drowningFrom a press release about newly published research. The title of the press release is Fentanyl overdose survivors require little if any hospital treatment

“Our protocol should give emergency physicians and nurses the confidence to allocate the appropriate resources to the patients who truly need them, especially when there is a wave of fentanyl overdoses that threaten to overwhelm the hospital,” Scheuermeyer said. “If the patients meet our definition of low-risk, physicians and nurses should also feel comfortable letting patients leave if they want to.”

Number of times the following words appear:

  • referral = 0
  • continuing care = 0
  • linkage = 0
  • treatment = 2 (the context is as follows)
    • “don’t need prolonged hospital treatment”
    • ” leading to unnecessary treatment that strains hospital resources”

The only reference to trying to address the disorder that nearly killed the patient is this:

Patients also received visits from a social worker who asked them about their need for housing and detoxification programs.


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Exhibit A

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Pharma, Pharma, Pharma

MedPage Today reports on a recent NIH, NIDA, HHS press briefing.

HHS Secretary Alex Azar, JD, NIH Director Francis Collins, MD, PhD, and Nora Volkow, MD, director of the National Institute on Drug Abuse (NIDA) pitched the president’s opioid initiative to reporters during a press briefing on Wednesday afternoon.

So, how did they describe their priorities?

  • Improve understanding of the “neurobiology of pain and to locate new drug targets.” (They note that Collins said “private industry is eager to leverage” this knowledge.
  • Testing for biomarkers for pain that would guide treatment.
  • To “create public-private partnerships and incentivize industry to come up with medications for opioid use disorder that don’t need to be taken every day” because “half of all patients relapse in 6 months.”
  • “partnering with pharmaceuticals for the development of alternative formulation devices… of naloxone or another antagonists”
  • Developing opioid vaccines.

Industry dollars part of the plan

That sounds like a lot of opportunities for new patents.

Is the industry interested in this plan?

At least 33 companies have shown interest in partnering with the NIH, said Collins, and a “scientific work plan” that involves an “unprecedented” level of information sharing is underway.

He also spoke of efforts to set up a clinical trial network, so that new treatments could be quickly tested.

“All of that seems to have received wide enthusiasm from both the public and the private sectors. It is now a matter of figuring out how we would put the funding and the governance together,” Collins said.

This prompted Keith Humphreys to tweet:


And the head of the Academy of Integrative Pain Management to tweet this:

Best practices (“best” for who?)

The story added this:

Azar reiterated President Trump’s goal of cutting legal opioid prescriptions by one-third in three years, and ensuring that all federal programs operate according to best practices when it comes to opioids.

Of course, this begs questions about the role of industry dollars shaping those “best” practices.

These concerns are heightened by the recent coverage of NIAAA and NIH offering the beverage alcohol industry an opportunity to invest in research on the grounds that the findings would benefit the industry before the research began.

The death penalty

The president’s inclusion of the death penalty for big drug dealers came up in the briefing.

Asked about the president’s repeated mentions of capital punishment for drug traffickers, Azar called it one piece of a “comprehensive plan.”

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Buying an evidence-base?

The Breakers Palm Beach

From the New York Times:

It was going to be a study that could change the American diet, a huge clinical trial that might well deliver all the medical evidence needed to recommend a daily alcoholic drink as part of a healthy lifestyle.

That was how two prominent scientists and a senior federal health official pitched the project during a presentation at the luxurious Breakers Hotel in Palm Beach, Fla., in 2014. And the audience members who were being asked to help pay for the $100 million study seemed receptive: They were all liquor company executives.

The 10-year government trial is now underway, and Anheuser Busch InBev, Heineken and other alcohol companies are picking up most of the tab, through donations to a private foundation that raises money for the National Institutes of Health.

. . .

The alcohol study is overseen by the National Institute on Alcohol Abuse and Alcoholism, one of 27 centers under the N.I.H. The lead investigator and N.I.H. officials have said repeatedly that they never discussed the planning of the study with the industry. But a different picture emerges from emails and travel vouchers obtained by The New York Times under the Freedom of Information Act, as well as from interviews with former federal officials.

The documents and interviews show that the institute waged a vigorous campaign to court the alcohol industry, paying for scientists to travel to meetings with executives, where they gave talks strongly suggesting that the study’s results would endorse moderate drinking as healthy.

It can be argued that we are facing a crisis of faith in institutions.

It’s going to be hard to maintain or restore faith if researchers and institutions behave in untrustworthy ways.

On the one hand, there is nothing surprising in this story.

On the other hand, it appears that the findings were determined and before the research began and they raised money on the basis of these predetermined findings.

That’s shocking.

It also invites all sorts of other musings.

  • What other evidence was decided upon before the research began?
  • What other interests are invited to invest in research that will benefit them financially?
  • What would have happened to this research if the findings were not satisfactory to the alcohol lobby?
  • Many of us have been puzzled by the failure to integrate NIAAA and NIDA. Have ties between the alcohol lobby and NIAAA contributed to this? (Because they don’t want alcohol treated as a drug? Or, because those ties would become more complicated in a merged agency?)
  • Are there similar problems at NIDA?


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Naloxone a moral hazard?

From Stat:

. . . a controversial new working paper has raised the question of whether the urgent push to expand naloxone access may be doing more harm than good.

The paper, published online last week, aimed to estimate the changes in behavior resulting from expanded naloxone access. Researchers found that after states passed naloxone access laws, opioid-related emergency room visits and opioid-related theft both rose, and no decrease was observed in opioid-related mortality. Their most troubling results came in the Midwest, where the researchers measured a 14 percent increase in opioid-related mortality attributable to expanded naloxone access.

It would not surprise me at all to learn that naloxone distribution has less impact on mortality than public health professionals hoped.

Why might it not be as effective as hoped?

I don’t know that it’s not, but I’ll explain why it wouldn’t surprise me.

Here’s what happens when someone has a heart attack41KSA2GA12L._SX300_

  1. A person has a heart attack at the grocery store and . . .
  2. . . . thank goodness, the store has an automatic defibrillator.
  3. Someone has been trained to use the defibrillator and performs the rescue.
  4. Someone else calls 911 to make sure the patient gets all the care they need.
  5. The patient is taken to the emergency department and medically stabilized.
  6. Once stabilized, the patient gets transferred to care that will address the cause of the heart attack and/or care that will prevent future heart attacks.
  7. The patient’s treatment plan will generally include lifestyle changes. (Diet, exercise, etc.)
  8. Then, the patient gets follow-up care that might include:
    • follow up appointments with specialists,
    • periodic tests to monitor for indicators of a recurrence,
    • self-monitoring (blood pressure), and
    • monitoring by the patient’ primary care physician.
  9. If problems recur or there are indications of a potential recurrence, the care plan will be re-evaluated and the patient will get whatever care they need.

Here’s what happens when someone ODs and is rescuednarcan

  1. A person overdoses and . . .
  2. . . . thank goodness, the someone has naloxone.
  3. The person has been trained to use naloxone and performs the rescue.

Maybe, if they are lucky, these steps happen.

  1. Someone else calls 911 to make sure the patient gets all the care they need.
  2. The patient is taken to the emergency department and medically stabilized.

If they are REALLY lucky . . .

  1. The get a passive referral to treatment.

Naloxone is not enough.

We’d never tolerate cardiac patients being sent home without the proper care. Why should people with an addiction be treated any differently?

Without adequate follow-up care, it’s like saving cardiac patients so they can die of untreated heart disease another day.

A moral hazard?

The working paper speculates the following:

Naloxone access reduces the risk of death for each use of a given quantity of opioids, but it also appears to increase the number of uses (and/or the potency of each use) – consistent with the idea that moral hazard leads users to “seek higher highs” that increase their risk of an overdose.

This seems like an academic-ized rehash of the Lazarus party hype and it’s just as absurd. (BTW, I did not begin my social work career at the age of 6.)

Shared assumptions?

To me, harm reduction advocates often seem to overestimate the capacity of active addicts to engage in rational and organized behavior change in the direction of health and wellness.

The writers of the working paper seem to make a similar error—that there’s some calculation of risk, followed by rational and organized behavior change in the direction of maximum pleasure.

Where they diverge

Many people have observed that addicts often resemble Dr. Jekyll and Mr. Hyde. Bill White pointed out that every professional helper needs to determine who they believe the real person is.

Is Mr. Hyde the real person? Is the real person revealed in their alcohol and drug use through inhibition and intoxication?

Or . . .

Is Dr. Jekyll the real person? Is the real person the sober self? Does addiction distort addicts true character in awful ways? Is addiction is about goodness corrupted by sickness?

The authors of this working paper seem to see Hyde as the real person.

For all my questions about the assumptions of some harm reduction efforts, at least they seem to assume the best about the addict.


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“The correlation you found is very powerful”

For doctors more opioid prescriptions bring more money CNN

From CNN:

The CNN/Harvard analysis looked at 2014 and 2015, during which time more than 811,000 doctors wrote prescriptions to Medicare patients. Of those, nearly half wrote at least one prescription for opioids.

Fifty-four percent of those doctors — more than 200,000 physicians — received a payment from pharmaceutical companies that make opioids.

Doctors were more likely to get paid by drug companies if they prescribed a lot of opioids — and they were more likely to get paid a lot of money.

Among doctors in the top 25th percentile of opioid prescribers by volume, 72% received payments. Among those in the top fifth percentile, 84% received payments. Among the very biggest prescribers — those in the top 10th of 1% — 95% received payments.

On average, doctors whose opioid prescription volume ranked among the top 5% nationally received twice as much money from the opioid manufacturers, compared with doctors whose prescription volume was in the median. Doctors in the top 1% of opioid prescribers received on average four times as much money as the typical doctor. Doctors in the top 10th of 1%, on average, received nine times more money than the typical doctor.

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