tag:theconversation.com,2011:/us/topics/naloxone-7974/articlesNaloxone – The Conversation2024-01-22T13:24:01Ztag:theconversation.com,2011:article/2193872024-01-22T13:24:01Z2024-01-22T13:24:01ZUntrained bystanders can administer drone-delivered naloxone, potentially saving lives of opioid overdose victims<figure><img src="https://images.theconversation.com/files/569922/original/file-20240117-23-cg30az.jpg?ixlib=rb-1.1.0&rect=9%2C0%2C3285%2C2198&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drone deliveries would be particularly effective in places where emergency responders can't respond quickly.</span> <span class="attribution"><a class="source" href="https://engineering.purdue.edu/AAE/Aerogram/2023-2024/articles/28-narcan-delivery-by-drone">Vincent Walter/Purdue University</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>An onlooker – even one without prior training – can successfully administer <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html">naloxone</a> to an overdose victim within about a minute of a drone delivering the lifesaving opioid reversal agent. That’s the key finding of <a href="https://doi.org/10.1177/11782218231211830">my team’s newly published study</a>.</p>
<p>Naloxone is also known by the <a href="https://theconversation.com/fda-approval-of-over-the-counter-narcan-is-an-important-step-in-the-effort-to-combat-the-us-opioid-crisis-198497**">name brand Narcan</a>.</p>
<p>The study involved 17 participants responding to a simulated overdose. Each simulation included an untrained participant who portrayed a bystander, a box of naloxone delivered by drone, a mannequin as the overdose victim, and a panicked observer. The latter added a sense of urgency by continually shouting at the bystander throughout the simulation. </p>
<p>Via a video playing on a screen carried by the drone, the bystander received instructions on how to use the naloxone, which is administered as a nasal spray. We timed each participant on how long it took them to correctly give the medication during this crisis moment.</p>
<p>Our trial revealed that the average time for someone to remove the naloxone from the drone, view the video and administer the medication was 62 seconds. </p>
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<figcaption><span class="caption">Simulation of the first demonstration flight of the drone’s delivery of naloxone to an overdose victim.</span></figcaption>
</figure>
<h2>Why it matters</h2>
<p>Such a scenario could be a lifesaver, particularly in places where an emergency medical services, or EMS, team is either not available or slower than a drone delivery. This includes not only densely populated cities with traffic congestion, but more remote areas. </p>
<p>The average response time for an ambulance in rural America is <a href="https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/access-to-ems-rural-communities.pdf">14 minutes</a>. Nationally, the average ambulance response time <a href="https://doi.org/10.1001/jamasurg.2017.2230">is seven minutes</a>. </p>
<p>Either way, it’s too late to help an opioid user who has stopped breathing. Brain damage occurs in about four minutes, and death in six. </p>
<p>But get a drone to an overdose victim within three minutes, and add one more minute for someone to remove and administer the drug, and there’s a chance to save their life and even prevent brain injury. </p>
<p>More than 75,000 people in the U.S. <a href="https://www.nytimes.com/2023/05/17/us/politics/drug-overdose-deaths.html">died in 2022 from an opioid overdose</a>. A drone network that could deliver naloxone fast enough to ensure quick administration of the drug could save thousands of lives every year.</p>
<p>The technology, although nascent, is here. Amazon is already using drones to <a href="https://www.aboutamazon.com/news/transportation/amazon-prime-air-drone-delivery-mk30-photos">deliver packages</a> in select U.S. cities and in other countries. Since 2011, drones have been <a href="https://doi.org/10.1503/cmaj.109-5541">delivering blood</a> to remote hospitals in Africa. </p>
<h2>What still isn’t known</h2>
<p>Deciding where to distribute drone stations across an area is the next step. But if emergency service planners can first determine how long it takes to dispense the medication, informed by our study and others, then they will know how much time a drone has to get to the scene. </p>
<p>Our trial provides a template for future studies – and it comes closer than other controlled trials to simulating the surprise and anxiety experienced by a bystander during an overdose incident. </p>
<p>To the best of our knowledge, there are two previous human trials from the U.S. using drones for medical intervention. But both studies <a href="https://doi.org/10.1016%2Fj.resuscitation.2020.10.006">used trained participants</a> who were <a href="https://doi.org/10.1016/j.ajem.2020.05.103">familiar with the interventions</a> and did not require in-the-moment training on how to use the device.</p>
<h2>What’s next</h2>
<p>As this technology matures, engineering teams will continue to improve the drone’s design and its methods of instruction.</p>
<p>Replicating this study with a diverse population and larger groups of people will be crucial to confirm the time needed to administer the drug after the drone lands. </p>
<p>Another issue for future study will be addressing community acceptance of medical drones. As they fly over houses, drones still cause <a href="https://dronesurveyservices.com/drone-statistics/">fear and uncertainty</a> in many neighborhoods. Adequate education will be needed to prepare communities for these potentially life-saving deliveries.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/219387/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Adams has received funding from the Substance Use and Mental Health Service Administration (SAMHSA), the US Department of Agriculture (USDA), the National Council of State Boards of Nursing (NCSBN), as well as internal University seed grants. </span></em></p>The study discovered that nonmedical personnel can provide the naloxone to an overdose victim in about one minute.Nicole Adams, Clinical Associate Professor of Nursing, Purdue UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1984972023-03-29T19:21:16Z2023-03-29T19:21:16ZFDA approval of over-the-counter Narcan is an important step in the effort to combat the US opioid crisis<figure><img src="https://images.theconversation.com/files/515985/original/file-20230317-22-wo4sgg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The use of naloxone administered by nasal spray can be a lifesaving drug with minimal side effects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/demonstration-of-a-drug-nebulizer-for-intranasal-royalty-free-image/1457667344?phrase=naloxone&adppopup=true">TG23/iStock via Getty Images Plus</a></span></figcaption></figure><p>On March 29, 2023, the U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray">approved Narcan</a> for <a href="https://apnews.com/article/business-medication-opioids-health-38ae986009788501bc418fe108593632">over-the-counter sale</a>. Narcan is the 4-milligram nasal spray version of naloxone, a medication that can quickly counteract an opioid overdose.</p>
<p>The FDA’s greenlighting of over-the-counter naloxone means that it will be available for purchase without a prescription at more than 60,000 pharmacies nationwide. That means that, for 90% of Americans, naloxone nasal spray will be accessible at a pharmacy <a href="https://doi.org/10.1016/j.japh.2022.07.003">within 5 miles from home</a>. It will also likely be available at gas stations, supermarkets and convenience stores. The transition from prescription to over-the-counter status is expected to take a few months.</p>
<p><a href="https://scholar.google.com/citations?user=9Np7_DYAAAAJ&hl=en">We are</a> <a href="https://scholar.google.com/citations?user=84WOMGkAAAAJ&hl=en">pharmacists</a> and <a href="https://www.pharmacy.pitt.edu/directory/profile.php?profile=99">public health experts</a> who seek to increase public acceptance of and access to naloxone. </p>
<p>We think that making naloxone available over the counter is an essential step in reducing deaths due to overdose and destigmatizing <a href="https://www.cdc.gov/dotw/opioid-use-disorder/index.html#">opioid use disorder</a>. Over-the-counter access to naloxone will permit more people to carry and administer it to help others who are overdosing. Moreover, increasing naloxone’s over-the-counter availability will convey the message that risks associated with substance use disorder warrant a pervasive intervention much as with other illnesses.</p>
<p>Deaths from opioid overdoses across the U.S. have <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">increased nearly threefold since 2015</a>.
Between October 2021 and October 2022, approximately 77,000 people died <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">from opioid overdoses in the U.S</a>. Since 2016, the synthetic opioid fentanyl has been responsible for most of the <a href="https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates">drug-involved overdose deaths in America</a>. </p>
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<figcaption><span class="caption">Naloxone can be a lifesaving intervention from opioids and other drugs that are laced with the synthetic opioid fentanyl.</span></figcaption>
</figure>
<h2>What is naloxone?</h2>
<p>Naloxone reverses overdose from prescription opioids like fentanyl, oxycodone and hydrocodone and recreational opioids like heroin. Naloxone works by competitively binding to the same receptors in the central nervous system that opioids bind to for euphoric effects. When naloxone is administered and reaches these receptors, it can block the euphoric effects of opioids and reverse respiratory depression when opioid overdose occurs. </p>
<p>There are two common ways to administer naloxone. One is through the prepackaged nasal sprays, such as <a href="https://www.narcan.com/">Narcan</a> and <a href="https://kloxxado.com/">Kloxxado</a> or generic versions of the drug. The other method is via auto-injectors, like <a href="https://zimhi.com/">ZIMHI</a>, which deliver naloxone through injection, similar to the way epinephrine is delivered by an EpiPen as an emergency treatment for life-threatening allergic reactions. </p>
<p>The FDA will review a second over-the-counter application for <a href="https://www.fda.gov/news-events/press-announcements/fda-announces-preliminary-assessment-certain-naloxone-products-have-potential-be-safe-and-effective">naloxone auto-injectors at a later date</a>. Although no interaction with a health care provider will be needed to purchase over-the-counter naloxone, when naloxone is purchased at a pharmacy, a knowledgeable pharmacist will be able to help people choose a product and explain instructions for use.</p>
<p>Research shows that when people who are likely to witness or respond to opioid overdoses have naloxone, <a href="https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf">they can save patients’ lives</a>. This also includes bystanders as well as first responders like police officers and paramedics. </p>
<p>But until now, people in those situations could intervene only if they were carrying prescription naloxone or knew where to retrieve it quickly. Friends and family of people who use opioids are often given prescriptions for naloxone for emergency use. Over-the-counter naloxone will help make the drug more accessible to members of the general public. </p>
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<figcaption><span class="caption">Naloxone works on a variety of opioids, including fentanyl.</span></figcaption>
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<h2>Reducing stigma and saving lives</h2>
<p>Naloxone <a href="https://www.cdc.gov/drugoverdose/featured-topics/naloxone.html">is a safe medication</a> with minimal side effects. It works only for those with opioids in their system, and it’s unlikely to cause harm if given by mistake to someone who’s not actively overdosing on opioids.</p>
<p>Since approximately 40% of overdoses <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html#:">occur in the presence of someone else</a>, we believe public access to naloxone is extremely important. People may wish to have naloxone on hand if someone they know is at an <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html">increased risk for opioid overdose</a>, including people who have opioid use disorder or people who take high amounts of prescribed opioid medications.</p>
<p>Community centers and recreational facilities may also keep naloxone on hand, similar to the placement of automated external defibrillators in public spaces for emergency use when someone has a heart attack. </p>
<p>There’s a long-held public stigma that suggests addiction is a moral failing rather than a <a href="https://www.cdc.gov/stopoverdose/stigma/index.html">chronic yet treatable health condition</a>. Those who request naloxone or who have an opioid use disorder <a href="https://doi.org/10.1186/s13722-018-0116-2">experience stigma and often aren’t comfortable</a> disclosing their drug use to others, or seeking medical treatment. Removing naloxone’s prescription requirements by making it over the counter could decrease the stigma experienced by individuals since they no longer must request it from a health care provider or behind the pharmacy counter. </p>
<p>In addition, we encourage health care providers and members of the general public to <a href="https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction">use less stigmatizing language</a> when discussing addiction.</p>
<h2>Questionable accessibility</h2>
<p>Often, medications switched from prescription to over the counter are <a href="https://doi.org/10.4103/2279-042X.185706">not covered by insurance</a>. It remains unclear if this will be the case with Narcan. If so, the costs will shift to the patient, highlighting the reason continued support of <a href="https://www.samhsa.gov/find-help/harm-reduction">programs that offer naloxone free of charge</a> remains important.</p>
<p>What’s more, over-the-counter access could paradoxically cause a decrease in the drug’s availability. A rise in purchases could make it harder to buy naloxone if manufacturer supply does not keep up with increased consumer demand. The U.S. experienced such <a href="https://www.cnn.com/2022/12/28/health/flu-covid-rsv-medications-tests/index.html">shortages of over-the-counter drugs</a> in late 2022 during the nationwide surges in flu, respiratory syncytial virus and COVID-19. </p>
<p>Federal and state governments could lessen these potential barriers by subsidizing the cost of over-the-counter naloxone and working with drug manufacturers to provide production incentives to meet public demand.</p>
<p>The effects of nationwide access to over-the-counter naloxone on opioid-related deaths remain to be seen, but making this medication more widely available is an important next step in our nation’s response to the opioid crisis.</p><img src="https://counter.theconversation.com/content/198497/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucas Berenbrok is part owner of the consulting company, Embarx, LLC. </span></em></p><p class="fine-print"><em><span>Janice L. Pringle is affiliated with C4 Recovery. </span></em></p><p class="fine-print"><em><span>Joni Carroll receives grant funding from the Centers for Disease Control and Prevention Overdose Data to Action. </span></em></p>The Food and Drug Administration’s approval of Narcan will make the lifesaving drug more widely available, especially to those who might be likely to witness or respond to opioid overdoses.Lucas A. Berenbrok, Associate Professor of Pharmacy and Therapeutics, University of PittsburghJanice L. Pringle, Professor of Pharmacy and Therapeutics, University of PittsburghJoni Carroll, Assistant Professor of Pharmacy and Therapeutics, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1994822023-03-28T12:15:09Z2023-03-28T12:15:09ZWhat is xylazine? A medical toxicologist explains how it increases overdose risk, and why Narcan can still save a life<figure><img src="https://images.theconversation.com/files/517430/original/file-20230324-20-vu2ybd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5444%2C3627&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Although xylazine is not an opioid, naloxone can reverse the effects of the fentanyl and heroin it is often mixed with.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/PhotoEssayFentanylsScourge/6b522b7eb85b4bf3aca36ae6cb30ed2a">AP Photo/Jae C. Hong</a></span></figcaption></figure><p>The White House officially designated fentanyl adulterated with xylazine as an <a href="https://www.whitehouse.gov/ondcp/briefing-room/2023/04/12/biden-harris-administration-designates-fentanyl-combined-with-xylazine-as-an-emerging-threat-to-the-united-states/">emerging threat to the U.S.</a> on Apr. 12, 2023. Earlier, the U.S. Drug Enforcement Administration <a href="https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine">issued a warning</a> on Mar. 21, 2023, about an increase in trafficking of fentanyl adulterated with xylazine, which can increase the risk of overdosing on an <a href="https://theconversation.com/what-is-fentanyl-and-why-is-it-behind-the-deadly-surge-in-us-drug-overdoses-a-medical-toxicologist-explains-182629">already deadly drug</a>. Xylazine is <a href="https://doi.org/10.1016/j.drugalcdep.2022.109380">increasingly appearing</a> within the U.S. supply of illicit opioids like fentanyl and heroin. The agency noted that it has seized mixtures of xylazine and fentanyl in 48 of 50 states.</p>
<p>Xylazine, commonly referred to as <a href="https://khn.org/news/article/xylazine-tranq-drugs-dangerous/">tranq</a>, is a <a href="https://www.drugsandalcohol.ie/13119/">drug adulterant</a> – a substance intentionally added to a drug product to <a href="https://theconversation.com/rat-poison-is-just-one-of-the-potentially-dangerous-substances-likely-to-be-mixed-into-illicit-drugs-163568">enhance its effects</a>. Illicit drugmakers may include xylazine to <a href="https://doi.org/10.1016/j.drugalcdep.2022.109380">prolong opioid highs</a> or prevent withdrawal symptoms. </p>
<p>As a <a href="https://scholar.google.com/citations?user=X55PT8EAAAAJ&hl=en">physician who cares for people who use fentanyl</a>, I worry about the ways xylazine increases their risk for overdose. I worry even more that misunderstandings about xylazine can make bystanders less likely to <a href="https://umasstox.com/narcan/">administer the lifesaving drug naloxone (Narcan)</a> during an overdose. If you suspect an overdose, calling emergency medical services and administering naloxone are still the critical first steps to saving a life.</p>
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<figcaption><span class="caption">Learning what to do when someone overdoses can help save a life.</span></figcaption>
</figure>
<h2>Tranq overdoses and fentanyl</h2>
<p>Xylazine was originally developed as a veterinary anesthesia. It was first identified as an adulterant in heroin supplies <a href="https://doi.org/10.1186/1747-597X-6-7">in the early 2000s</a>. Although xylazine is not an opioid, it induces opioidlike effects, including sedation, slowed heart rate and small pupils, similar to the effects produced in people by its pharmaceutical cousin clonidine. Xylazine use is also associated with <a href="https://doi.org/10.1007%2Fs11524-011-9662-6">serious skin and soft tissue ulcers and infections</a>.</p>
<p>The use of opioids with sedating medications like xylazine increases the risk of fatal overdose. Historically, people who use drugs <a href="https://doi.org/10.1007%2Fs11524-011-9662-6">have been unaware</a> that xylazine is in the drug supply and are <a href="https://theconversation.com/rat-poison-is-just-one-of-the-potentially-dangerous-substances-likely-to-be-mixed-into-illicit-drugs-163568">unable to tell</a> whether they have been exposed to it. Routine hospital drug testing does not detect xylazine, further complicating surveillance.</p>
<p>Xylazine overdoses rarely occur in isolation. Xylazine detection in heroin- and fentanyl-associated deaths in Philadelphia has grown from less than 2% before 2015 to <a href="http://dx.doi.org/10.1136/injuryprev-2020-043968">more than 31% in 2019</a>. Similarly, one study of 210 xylazine-associated deaths in Chicago from 2017 to 2021 found that fentanyl or a chemically similar substance was detected in <a href="http://dx.doi.org/10.15585/mmwr.mm7113a3">99.1% of overdoses</a>. This data underscores the key role that fentanyl plays in causing fatal overdoses in cases where xylazine is found, and anecdotal evidence suggests the problem is only increasing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/517435/original/file-20230324-1164-oqro8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of hands holding pieces of fentanyl" src="https://images.theconversation.com/files/517435/original/file-20230324-1164-oqro8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/517435/original/file-20230324-1164-oqro8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/517435/original/file-20230324-1164-oqro8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/517435/original/file-20230324-1164-oqro8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/517435/original/file-20230324-1164-oqro8m.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/517435/original/file-20230324-1164-oqro8m.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/517435/original/file-20230324-1164-oqro8m.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Xylazine overdoses often occur in the presence of fentanyl or heroin.</span>
<span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/PhotoEssayFentanylsScourge/4e185189ef7e4b35b1c5fad7d66c75d9">AP Photo/Jae C. Hong</a></span>
</figcaption>
</figure>
<h2>Naloxone and xylazine</h2>
<p>Unfortunately, increasing awareness of xylazine has contributed to the myth of <a href="https://www.changingthenarrative.news/naloxone-resistant-fentanyl">“naloxone-resistant” overdoses</a>. Unlike overdoses with opioids only, patients experiencing xylazine-associated overdoses may not immediately wake up after naloxone administration. While naloxone may not reverse the effects of xylazine, it is still able to reverse the effects of the fentanyl it is often mixed with and should be used in all suspected opioid overdoses. </p>
<p>The critical goal of administering naloxone is to prevent patients from dying of dangerously low breathing rates. Bystanders who suspect an overdose <a href="https://www.youtube.com/watch?v=HzAvzNoUERE">should always call 911</a> to bring in experts in case treatment is required.</p>
<p><em>Article updated to include a White House announcement on Apr. 12, 2023</em></p><img src="https://counter.theconversation.com/content/199482/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kavita Babu receives funding from the National Institute on Drug Abuse, the MA Department of Public Health/ Bureau of Substance Addiction Services, the Centers for Disease Control and Prevention, and the National Highway Traffic Safety Administration. All opinions here are hers and do not represent the position of these organizations. </span></em></p>Xylazine, or tranq, is increasingly being mixed with drugs like fentanyl or heroin and can be difficult to detect. Most people who use drugs are unable to tell if they have been exposed to it.Kavita Babu, Professor of Emergency Medicine, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1826292022-05-10T12:06:06Z2022-05-10T12:06:06ZWhat is fentanyl and why is it behind the deadly surge in US drug overdoses? A medical toxicologist explains<figure><img src="https://images.theconversation.com/files/462077/original/file-20220509-18-ruua59.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1024%2C683&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Only a small amount of fentanyl is enough to be lethal.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/OverdosesLosAngeles/9b9e2555c6654b1094d2be9f3ef43226">AP Photo/Jacquelyn Martin</a></span></figcaption></figure><p>Buying drugs on the street is a game of Russian roulette. From Xanax to cocaine, drugs or counterfeit pills purchased in nonmedical settings may contain life-threatening amounts of fentanyl.</p>
<p>Physicians like me have seen a rise in unintentional fentanyl use from people buying prescription opioids and other drugs <a href="https://doi.org/10.1016/j.drugalcdep.2022.109398">laced, or adulterated, with fentanyl</a>. Heroin users in my community in Massachusetts came to realize that fentanyl had entered the drug supply when <a href="https://www.bostonindicators.org/reports/report-website-pages/opioids-2018">overdose numbers exploded</a>. In 2016, my colleagues and I found that patients who came to the emergency department reporting a heroin overdose often <a href="https://doi.org/10.1080/15563650.2017.1339889">only had fentanyl present in their drug test results</a>.</p>
<p>As the Chief of Medical Toxicology at UMass Chan Medical School, I have <a href="https://scholar.google.com/citations?user=X55PT8EAAAAJ&hl=en">studied fentanyl and its analogs</a> for years. As fentanyl has become ubiquitous across the U.S., it has transformed the illicit drug market and raised the risk of overdose.</p>
<h2>Fentanyl and its analogs</h2>
<p><a href="https://doi.org/10.1016/j.jpain.2014.08.010">Fentanyl</a> is a synthetic opioid that was originally developed as an analgesic – or painkiller – for surgery. It has a specific chemical structure with multiple areas that can be modified, often illicitly, to form related compounds with marked differences in potency.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Diagram depicting various functional groups that can be substituted in fentanyl." src="https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=435&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=435&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=435&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=546&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=546&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462058/original/file-20220509-19-b5q65.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=546&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Fentanyl’s chemical backbone (the structure in the center) has multiple areas (the colored circles) that can be substituted with different functional groups (the colored boxes around the edges) to change its potency.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1002/cpt.1418">Christopher Ellis et al.</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>For example, <a href="https://pubchem.ncbi.nlm.nih.gov/compound/Carfentanil">carfentanil</a>, a fentanyl analog formed by substituting one chemical group for another, is 100 times more potent than its parent structure. Another analog, <a href="https://doi.org/10.1097/ADM.0000000000000324">acetylfentanyl</a>, is approximately three times less potent than fentanyl, but has still led to <a href="https://dx.doi.org/10.15585%2Fmmwr.mm6643e1">clusters of overdoses in several states</a>. </p>
<p>Despite the number and diversity of its analogs, fentanyl itself continues to <a href="http://dx.doi.org/10.15585/mmwr.mm6910a4">dominate the illicit opioid supply</a>. Milligram per milligram, fentanyl is roughly <a href="https://www.cdc.gov/stopoverdose/fentanyl/index.html">50 times more potent than heroin and 100 times more potent than morphine</a>.</p>
<h2>Lacing or replacing drugs with fentanyl</h2>
<p>Drug dealers have used fentanyl analogs as an adulterant in illicit drug supplies <a href="https://doi.org/10.1021/ac00235a790">since 1979</a>, with fentanyl-related overdoses clustered in <a href="https://doi.org/10.1111/j.1556-4029.2008.00669.x">individual cities</a>. </p>
<p>The modern epidemic of fentanyl adulteration is far broader in its geographic distribution, production and number of deaths. Overdose deaths <a href="https://dx.doi.org/10.15585%2Fmmwr.mm6634a2">roughly quadrupled</a>, going from 8,050 in 1999 to 33,091 in 2015. From May 2020 to April 2021, <a href="http://dx.doi.org/10.15585/mmwr.mm7050e3">more than 100,000 Americans</a> died from a drug overdose, with over 64% of these deaths due to synthetic opioids like fentanyl and its analogs.</p>
<p>Illicitly manufactured fentanyl is <a href="https://www.dea.gov/documents/2020/2020-03/2020-03-06/fentanyl-flow-united-states">internationally synthesized</a> in China, Mexico and India, then exported to the United States as powder or pressed pills. China also exports many of the precursor chemicals needed to synthesize fentanyl.</p>
<p>Additionally, the emergence of the <a href="https://doi.org/10.2196/24486">dark web</a>, an encrypted and anonymous corner of the internet that’s a haven for criminal activity, has facilitated the sale of fentanyl and other opioids shipped through <a href="https://www.npr.org/2018/05/24/613762721/deadly-delivery-opioids-by-mail">traditional delivery services</a>, including the U.S. Postal Service.</p>
<p>During the 2023 Asia-Pacific Economic Cooperation summit, U.S. President Joe Biden and Chinese President Xi Jinping reached an agreement to <a href="https://apnews.com/article/biden-xi-apec-san-francisco-58d11e7e3902955302182c2bc41430e0">combat fentanyl trafficking</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/01QYV8nbHs0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Fentanyl is driving an increasing number of opioid overdose deaths.</span></figcaption>
</figure>
<p>Fentanyl is both sold alone and often <a href="https://theconversation.com/rat-poison-is-just-one-of-the-potentially-dangerous-substances-likely-to-be-mixed-into-illicit-drugs-163568">used as an adulterant</a> because its high potency allows dealers to traffic smaller quantities but maintain the drug effects buyers expect. Manufacturers may also add bulking agents, like flour or baking soda, to fentanyl to increase supply without adding costs. As a result, it is much more profitable to cut a kilogram of fentanyl compared to a kilogram of heroin. </p>
<p>Unfortunately, fentanyl’s high potency also means that even just a small amount can prove deadly. If the end user isn’t aware that the drug they bought has been adulterated, this could easily lead to an overdose.</p>
<h2>Preventing fentanyl deaths</h2>
<p>As an emergency physician, I give fentanyl as an analgesic, or painkiller, to <a href="https://www.mayoclinic.org/drugs-supplements/fentanyl-injection-route/description/drg-20075614">relieve severe pain</a> in an acute care setting. My colleagues and I choose fentanyl when patients need immediate pain relief or sedation, such as anesthesia for surgery. </p>
<p>But even in the controlled conditions of a hospital, there is still a risk that using fentanyl can <a href="https://doi.org/10.1073/pnas.2022134118">reduce breathing rates</a> to dangerously low levels, the main cause of opioid overdose deaths. For those taking fentanyl in nonmedical settings, there is no medical team available to monitor someone’s breathing rate in real time to ensure their safety. </p>
<p>One measure to prevent fentanyl overdose is <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html">distributing naloxone to bystanders</a>. Naloxone can reverse an overdose as it occurs by blocking the effects of opioids.</p>
<p>Another measure is increasing the availability of <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">opioid agonists</a> like methadone and buprenorphine that reduce opioid withdrawal symptoms and cravings, helping people stay in treatment and decrease illicit drug use. Despite the lifesaving track records of these medications, their availability is limited by <a href="https://www.statnews.com/2021/12/22/inflexible-methadone-regulations-impede-efforts-reduce-overdose-deaths/">restrictions on where and how they can be used</a> and <a href="https://www.npr.org/sections/health-shots/2021/11/08/1053579556/dea-suboxone-subutex-pharmacies-addiction">inadequate numbers of prescribers</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/zWe_lPniEq4?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Naloxone can rapidly reverse an opioid overdose.</span></figcaption>
</figure>
<p>Other strategies to prevent overdose deaths include <a href="https://doi.org/10.1097/adm.0000000000000555">lowering the entry barrier</a> to addiction treatment, <a href="https://www.cnn.com/2021/12/01/health/fentanyl-test-strip/index.html">fentanyl test strips</a>, <a href="https://doi.org/10.1007/s11904-017-0363-y">supervised consumption sites</a> and even <a href="https://doi.org/10.1192/bjp.bp.114.149195">prescription diamorphine (heroin)</a>. </p>
<p>Despite the evidence supporting these measures, however, <a href="https://www.ncbi.nlm.nih.gov/books/NBK541389/">local politics and funding priorities</a> often limit whether communities are able to give them a try. Bold strategies are needed to interrupt the ever-increasing number of fentanyl-related deaths.</p>
<p><em>This article was updated on Nov. 16, 2023 to note developments regarding fentanyl at the Asia-Pacific Economic Cooperation summit.</em></p><img src="https://counter.theconversation.com/content/182629/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kavita Babu receives research support from the National Institutes of Health, Centers for Disease Control and Prevention, the National Highway Traffic Safety Administration, the Massachusetts Department of Health Bureau of Substance Abuse Services and royalties from UptoDate.</span></em></p>Fentanyl’s wide availability in the drug supply has led to an increase in unintentional overdoses. While prevention strategies are available, limited availability stymies their use.Kavita Babu, Professor of Emergency Medicine, UMass Chan Medical SchoolLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1642862021-08-11T19:29:30Z2021-08-11T19:29:30Z‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids<figure><img src="https://images.theconversation.com/files/415383/original/file-20210810-13-9vnesq.jpg?ixlib=rb-1.1.0&rect=92%2C29%2C3140%2C2004&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naloxone can prevent deaths from opioid overdose, but there is no way to reverse the effects of benzodiazepine overdose without risk.</span> <span class="attribution"><span class="source">(THE CANADIAN PRESS/Jonathan Hayward)</span></span></figcaption></figure><p>Canada has seen a drastic shift in the unregulated drug supply with the emergence of benzodiazepine-adulterated opioids (also known as “benzo-dope”). Benzodiazepines have been detected in as many as <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">60 per cent of overdose deaths in British Columbia</a>.</p>
<p>Recent data from B.C. has observed a steady rise in opioids testing positive for benzodiazepines between August 2020 and April 2021, <a href="https://drugcheckingbc.ca/monthly-reports/">from a low of five per cent to a high of 25 per cent</a>.</p>
<p>British Columbia is not alone in seeing this trend: data from Toronto has shown that this issue is even more prominent. During the same time period, there was an increase from <a href="https://drugchecking.cdpe.org/">45 per cent to 57 per cent</a> in samples containing etizolam, a specific benzodiazepine-like compound.</p>
<p>Commonly prescribed benzodiazepines include drugs like Xanax and Valium. These medications treat a variety of conditions such as anxiety and insomnia and have been used since the 1960s. </p>
<p>However, what is being detected in opioids in Canada are not pharmaceutical drugs. They are drugs from the benzodiazepine class that are neither prescribed nor used in medicine in Canada, meaning they may possess unknown strengths or side-effects. Since benzodiazepines are sedatives, combining them with another type of depressant, like opioids, significantly increases the risk of overdose.</p>
<p>As researchers in substance use, we questioned whether the increasing supply of benzo-dope in the unregulated drug market would saturate the opioid supply in a similar way fentanyl did to heroin years ago. The data seem to suggest we should be prepared for the unregulated drug supply to adjust to a new normal.</p>
<p>In this context, there are significant public health issues that need to be considered. </p>
<h2>Emergence of ‘benzo-dope’</h2>
<p>The increasing availability of benzo-dope is cause for concern given that when taken together, the combined effects of benzodiazepines and opioids can result in overdose and death. According to the B.C. Coroner’s Service, there has been a substantial increase in benzodiazepines detected in illicit drug toxicity deaths, <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">from 15 per cent in July 2020 to 60 per cent in May 2021</a>. </p>
<p>Most people do not intend to consume benzodiazepines with their opioids. As a consequence, people wanting to use opioids may unknowingly increase their risk of overdose from benzodiazepine adulteration. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A test strip in a paper cup" src="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drug checking services can provide people with timely information about the contents of their unregulated drugs using things like the fentanyl test strip shown here. However, benzodiazepine test strips may miss detecting the drug.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Benzodiazepines are also slower to take effect compared to opioids, meaning someone can experience delayed overdose symptoms. Thefts and sexual assaults have also been reported after people were given benzodiazepine-adulterated opioids without their knowledge and consequently knocked into an unresponsive state.</p>
<p>The reason behind the adulteration of benzodiazepines in opioids is unclear. Some suggest they may be added to opioids to produce similar effects at a lower total cost to drug suppliers, or intentionally used to prolong or enhance the desirable effects of opioids. Regardless, there is growing evidence that co-use and dependence on opioids and benzodiazepines is occurring in parallel to the rising supply of these drugs. </p>
<p>Deaths from opioid overdose can be prevented with <a href="https://towardtheheart.com/naloxone">naloxone, which counteracts the effects of opioids</a>. However, there is no evidence-based antidote to reverse the effects of benzodiazepines without potential consequences such as withdrawal or seizures.</p>
<p>Additionally, due to the complications of benzodiazepine withdrawal, many addiction treatment providers will not admit individuals who test positive for benzodiazepines. As a result, people may not be able to access substance use treatment because of an imposed adulterant to their drugs.</p>
<h2>Challenges detecting benzo-dope</h2>
<p><a href="https://drugcheckingbc.ca/">Drug checking services</a> have been implemented across Canada to monitor the unregulated drug supply and provide people with timely information about the contents of their drugs. In many settings in B.C., benzodiazepine test strips are used alongside a technology called <a href="https://drugcheckingbc.ca/what-is-drug-checking/overview-of-technologies/">Fourier-transform infrared</a> spectroscopy to detect the presence of benzodiazepines. However, limitations of these technologies sometimes cause benzodiazepines to be missed when present in small concentrations. </p>
<p>Etizolam, the most common benzodiazepine-like compound found in opioids, is particularly difficult to detect using point-of-care drug-checking technologies because of its chemical structure. Thus, there may be an under-reporting of how pervasive this issue really is in B.C. and elsewhere in Canada. </p>
<h2>A new wave of the overdose epidemic?</h2>
<p>There have been a number of crucial life-saving responses to address the fentanyl-driven overdose epidemic, such as <a href="http://www.bccdc.ca/our-services/programs/harm-reduction">supervised consumption sites and expanded distribution of naloxone</a>. However, less attention has been paid to the growing issue of benzo-dope and its associated health harms. As this public health emergency worsens, it is important that we incorporate a broader understanding of overdose risk that goes beyond opioids in our efforts to prevent, treat and respond.</p>
<p>It’s too soon to know whether benzo-dope will saturate the unregulated opioid market. As long as there remains a lack of any legal framework to promote a safer supply of drugs (safe supply and <a href="https://theconversation.com/decriminalizing-drug-use-as-we-contain-the-coronavirus-is-the-humane-thing-to-do-136165">decriminalization</a>), there will always be a level of unpredictability in the unregulated opioid supply that can harm people’s health.</p><img src="https://counter.theconversation.com/content/164286/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lianping Ti receives funding for her research from the Michael Smith Foundation for Health Research and Health Canada.</span></em></p><p class="fine-print"><em><span>Samuel Tobias does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fentanyl adulteration led to the replacement of heroin in the unregulated drug supply of British Columbia. Now that benzodiazepines are present in many opioids, are we headed towards a ‘new normal?’Lianping Ti, Assistant Professor, Department of Medicine, University of British ColumbiaSamuel Tobias, Research Data Coordinator, British Columbia Centre on Substance Use, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1585142021-04-28T15:51:58Z2021-04-28T15:51:58ZOverdose crisis: The COVID-19 pandemic has laid bare decades of drug policy failures<p>A <a href="https://doi.org/10.15288/jsad.2020.81.556">syndemic</a> occurs when multiple public health emergencies interact to make each other worse. This past year clearly fits the label: the global COVID-19 pandemic has indisputably <a href="https://www.ctvnews.ca/health/pandemic-aggravates-opioid-crisis-as-overdoses-rise-and-services-fall-out-of-reach-1.5189677?">intensified the existing drug overdose crisis</a> in Canada. </p>
<p>For over a year now, there has been non-stop coverage of COVID-19, while a number of other issues continue to be neglected as “newsworthy.” For people who use drugs in particular, a public sense of the crisis has never quite taken hold, despite years of growing overdose deaths and harm across communities. </p>
<p>The pandemic has <a href="https://www.cbc.ca/news/canada/manitoba/margaret-swan-covid-matt-murray-raske-chief-john-lane-1.5756872">exacerbated risk and harm for people who use drugs</a>. However, it would be inaccurate and short-sighted to suggest that the spike in drug-related deaths over the past year is solely, or even primarily, the result of the pandemic.</p>
<p>Rather, current realities should be understood as the result of decades-long, pre-pandemic political decisions and the consequent, entrenched policy failures. From the <a href="https://www.vice.com/en/article/xdmgpj/how-canadas-rehab-centres-are-failing-opioid-users">lack of welfare and treatment services</a> to the <a href="https://drugpolicy.org/issues/discrimination-against-drug-users">criminalization of drug use and resulting stigmatization</a>, it is long-standing political inaction and failed policy measures that have resulted in the thousands of lives lost to overdoses and now, drug toxicity. </p>
<p>The pandemic has simultaneously intensified the problem and laid bare the urgent and immediate need for radical change to Canada’s drug policies. </p>
<h2>Drug-related deaths during the COVID-19 pandemic</h2>
<p>Earlier this month, <a href="https://thetyee.ca/News/2021/04/14/BC-Marks-Fifth-Anniversary-Overdose-Emergency-Decriminalization/">B.C. entered its fifth year of a public health emergency</a> related to drug overdoses. And this past year has been the worst so far: across the country, overdose deaths reached a record high with <a href="https://calgaryherald.com/news/postpandemic/canadas-hidden-crisis-how-covid-19-overshadowed-the-worst-year-on-record-for-overdose-deaths">4,000 lives lost in 2020</a>. The vast majority of these deaths are <a href="https://www.publichealthontario.ca/-/media/documents/o/2020/opioid-mortality-covid-surveillance-report.pdf?la=en">accidental</a>. </p>
<p>However, these numbers do not include overdoses that are not fatal but still produce harm, pain and health consequences for users, loved ones and communities. <a href="https://doi.org/10.1016/j.drugpo.2020.102958">Research has only begun to examine</a> the ways drug use and associated harms have changed in the face of increased drug toxicity and increased social vulnerability. </p>
<p>There are a number of pandemic-related reasons for the reported spike in drug-related deaths. For one, drug supply chains have been disrupted by the closure of the Canada-United States border which has resulted in <a href="https://www.cbc.ca/news/canada/ottawa/drugs-border-closed-fentanyl-1.5622414">increased drug toxicity</a>. Users and advocates are now signalling a shift from a drug “overdose” to a drug “toxicity” crisis. Last year, <a href="https://thetyee.ca/News/2021/04/15/For-One-Day-BC-Activists-Handed-Out-Clean-Heroin-Cocaine/">over one-third</a> of all deaths of people under the age of 44 were caused by poisoned drugs in B.C. Many other provinces are seeing a similar trend.</p>
<figure>
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<figcaption><span class="caption">B.C. marks five years since declaring public health emergency due to toxic drug deaths.</span></figcaption>
</figure>
<p>What is more, public health measures aimed at curbing the spread of COVID-19 have had a number of <a href="https://bcmj.org/blog/crossroads-intersecting-public-health-emergencies-covid-19-and-overdose-crisis-bc">unintended consequences</a> that have gravely impacted the well-being and survival of people who use drugs. </p>
<p><a href="https://www.policyalternatives.ca/publications/reports/state-inner-city-report-2020">Community-based organizations</a> have noted the extent to which access to life-saving supports (like overdose prevention services, food and housing) have been restricted by physical distancing and other public health guidelines. </p>
<p>But as these organizations have struggled to pivot their services in response to ever-changing COVID-19 conditions, their ability to provide direct support and interact with people who use drugs has become more challenging. </p>
<p>This has meant that <a href="https://doi.org/10.1016/j.drugpo.2020.102896">people are more likely to use drugs alone</a>, which increases risk and limits access to care and support that contribute to safety and survival if an emergency should arise. </p>
<p>This particular gap in COVID-19 policy has starkly highlighted the pressing need for access to safe consumption supplies (<a href="https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/understanding-naloxone/">including Naloxone</a>) during the pandemic and beyond.</p>
<h2>Crisis as an opportunity for radical policy change</h2>
<p>It is important that we study and understand how the pandemic and the overdose crisis are connected. But it is even more important that we remember the decades of drug policy failures that have provided the perfect breeding ground for the devastation that has been unfolding this past year. </p>
<p>Crises, like COVID-19, can be pivotal moments in recognizing problems in need of a solution and clarifying our views about how society should work by allowing us to push for real systemic change. As researchers studying the nature of and criminal legal and public health responses to a so-called <a href="https://www.ctvnews.ca/canada/winnipeg-s-meth-crisis-requires-immediate-action-advocates-1.4488571?cache=fntnfcwxeqoveki%3FclipId%3D68596">“meth crisis” in Manitoba</a>, we believe it is essential to identify the <a href="https://c0c42d9a-a170-4571-949c-ea8bd55b102f.filesusr.com/ugd/3ac972_5e8f476e080541b790a8dd4d6187a9d3.pdf">relationship between current cascading and overlapping crisis points</a> and understand them within wider political and social context. </p>
<p>We need to consider radical remedies to drug overdoses and deaths. First and foremost, <a href="https://drugpolicy.ca/about/publication/harm-reduction-in-canada-what-governments-need-to-do-now/">decriminalizing the possession of illicit drugs for personal use </a>. <a href="https://www.theguardian.com/us-news/commentisfree/2016/jul/05/why-de-criminalize-all-drugs-stigma">Decriminalization</a> promises the opportunity to prevent accidental deaths and harm due to a toxic drug supply. It also contributes to <a href="https://drugpolicy.org/resource/stigma-and-people-who-use-drugs">reducing stigma</a> and associated barriers to accessing supports. </p>
<p>Earlier this month, B.C. <a href="https://thetyee.ca/News/2021/04/14/BC-Marks-Fifth-Anniversary-Overdose-Emergency-Decriminalization/">announced</a> that the province will “seek an exemption from drug possession laws under Section 56 of the Controlled Drugs and Substances Act.” Users and advocates alike are wary of the announcement, however, stifling their excitement until words turn to action. </p>
<p>In the meantime, <a href="https://www.dulf.ca/">people who use drugs and activists</a> will continue to advocate for decriminalization and access to safe, regulated supply. For the <a href="https://thetyee.ca/News/2020/06/23/Safe-Supply-Drug-Demo/">second year</a> in a row, people have <a href="https://thetyee.ca/News/2021/04/15/For-One-Day-BC-Activists-Handed-Out-Clean-Heroin-Cocaine/">distributed</a> clean heroin, cocaine and methamphetamine to people over 18 who already use illicit drugs in Vancouver’s Downtown Eastside. </p>
<p>If COVID-19 has not provided the push for our governments to take radical action, and if now is not the time to undo the harms of past drug policies, when will it be?</p><img src="https://counter.theconversation.com/content/158514/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katharina Maier and her research team receive funding from the Social Sciences and Humanities Research Council of Canada for her research on drugs and crisis. </span></em></p><p class="fine-print"><em><span>Rebecca Hume does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Across the country, overdose deaths have spiked during the COVID-19 pandemic.Katharina Maier, Assistant Professor, Criminal Justice, University of WinnipegRebecca Hume, Senior Research Assistant, Criminal Justice, University of WinnipegLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1437312020-09-03T12:23:57Z2020-09-03T12:23:57ZAddiction treatment shrinks during the pandemic, leaving people with nowhere to turn<figure><img src="https://images.theconversation.com/files/355364/original/file-20200828-23-t3tf4v.jpg?ixlib=rb-1.1.0&rect=21%2C0%2C4820%2C3199&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Josh Ledesma displays safe injection supplies with outreach specialist Rachel Bolton outside the Access Drug User Health Program drop-in center in Cambridge, Massachusetts on March 31, 2020. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/site-coordinator-josh-ledesma-displays-safe-injection-news-photo/1209081159?adppopup=true">Craig F. Walker/The Boston Globe via Getty Images</a></span></figcaption></figure><p>COVID-19 has overshadowed the U.S. opioid crisis, but that doesn’t mean opioid addiction has gone away. During the COVID-19 pandemic, the opioid crisis has gotten worse. Drug overdose death rates rose <a href="https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html">13% in the first half of 2020</a>. COVID-19 threatens to dismantle an already frayed addiction treatment system, creating a <a href="https://doi.org/10.1038/s41591-020-0898-0">crisis on top of a crisis.</a> </p>
<p>The opioid crisis, or, more aptly, the <a href="https://www.changingthenarrative.news/polysubstances">overdose crisis</a>, has plagued the U.S. for two decades. Drug overdose is the leading cause of accidental death, <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">claiming 70,000 American lives each year</a>. Opioids contribute to 130 deaths daily, enough people to fill a commercial airliner. </p>
<p>As a <a href="https://www.researchgate.net/scientific-contributions/80833856-Elizabeth-Chiarello">medical sociologist</a> who has researched the opioid crisis for the last decade, I have seen the havoc it has wrought. Here is how I see COVID-19 making it worse. </p>
<h2>A glimmer of hope, dashed</h2>
<figure class="align-center ">
<img alt="A road sign advertises help for addiction in West Virginia, one of the states hit hardest by the opioid crisis." src="https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=389&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=389&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=389&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=489&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=489&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354190/original/file-20200821-22-590eav.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=489&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In the city of Logan, West Virginia, a road sign advertises help for addiction.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/road-sign-advertises-help-for-addiction-on-march-26-2019-in-news-photo/1139164952?adppopup=true">Andrew Lichtenstein/Corbis via Getty Images</a></span>
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<p>Overdose deaths increased steadily each year since 1999 until they <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">declined 4.1% in 2018</a>, largely due to fewer deaths involving prescription opioids. <a href="https://www.nytimes.com/interactive/2019/07/17/upshot/drug-overdose-deaths-fall.html">Experts suggest</a> that lower opioid prescribing rates, <a href="https://pubmed.ncbi.nlm.nih.gov/30138057/">expanded treatment access</a> and increased naloxone access help explain the decline.</p>
<p>That brief downturn gave way to <a href="https://www.nytimes.com/interactive/2020/07/15/upshot/drug-overdose-deaths.html">steeply rising overdose death rates in 2019 and 2020</a> as deaths involving other drugs like cocaine and methamphetamine rose. </p>
<p>Not only are numbers going up, but the drugs that contribute to overdose have changed. </p>
<p>Many overdose deaths <a href="https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf">involve multiple drugs</a>. Prescription drugs now play a less prominent role than heroin, cocaine and methamphetamine. Synthetic fentanyl – <a href="https://theconversation.com/fentanyl-widely-used-deadly-when-abused-60511">a potent illegal opioid manufactured in labs</a> – poses the biggest threat. It contributes to <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">twice as many overdose deaths</a> as prescription opioids.</p>
<h2>Inadequate addiction treatment</h2>
<p>The overdose death rate – <a href="https://www.kff.org/other/state-indicator/opioid-overdose-death-rates/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">20.7 deaths per 100,000 people</a> – comes as no surprise to people familiar with U.S. addiction treatment.</p>
<p>Only <a href="https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf">17% of people with addiction get treatment</a>. </p>
<p>And addiction treatment is notoriously fragmented and underfunded. <a href="https://www.ncbi.nlm.nih.gov/books/NBK19830/">Cordoned off from mainstream health care</a>, the addiction treatment industry receives <a href="https://thehill.com/opinion/healthcare/407755-effective-regulation-of-the-addiction-treatment-industry-will-take">scant regulation</a>. Quality varies. <a href="https://www.samhsa.gov/data/sites/default/files/2016_NSSATS.pdf">Only one-third of facilities</a> provide medications for addiction treatment, evidence-based care <a href="https://doi.org/10.1001/jamanetworkopen.2019.20622">that reduces overdose risk</a>. </p>
<p>In the face of inadequate addiction treatment, harm reduction strategies are effective. <a href="https://www.drugpolicy.org/issues/harm-reduction">Harm reductionists</a> encourage people who use drugs to use strategies that protect them from overdose, infectious disease and abscesses from sharing or reusing syringes.</p>
<p>Programs that reduce harm include <a href="https://newrepublic.com/article/158645/coronavirus-blowing-best-response-opioid-crisis">naloxone programs</a> that distribute naloxone throughout communities and <a href="https://www.cdc.gov/ssp/syringe-services-programs-summary.html">syringe services programs</a> that distribute clean syringes to people who inject drugs. These programs, while effective, receive tepid support, largely due to stigma. Naloxone distribution programs and syringe services programs operate on <a href="https://doi.org/10.1016/j.drugpo.2019.04.006">shoestring budgets with limited hours</a> that have only become more restricted during the pandemic. </p>
<figure class="align-center ">
<img alt="COVID-19's emergence has further complicated the opioid crisis." src="https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=512&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=512&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=512&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=643&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=643&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354191/original/file-20200821-18-1r3i2on.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=643&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A medical assistant in Charlestown, Massachusetts takes a swab sample from from a patient.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/medical-assistant-suleika-nunez-takes-a-swab-sample-from-news-photo/1265742379?adppopup=true">Matt Stone/MediaNews Group/Boston Herald via Getty Images</a></span>
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<h2>Clash of the crises</h2>
<p>When the COVID-19 pandemic began, the federal government <a href="https://doi.org/:%2010.1377/hblog20200331.557887">took measures</a> to lessen the pandemic’s impact on the opioid crisis. </p>
<p>The government lowered barriers to medications for addiction treatment by allowing methadone clinics to give patients medication to take home and by allowing physicians to provide buprenorphine, another drug used in recovery, through telemedicine. These measures reduced in-person contact. </p>
<p>But people dealing with the disorder still face challenges. For one, they cannot attend in-person support groups. <a href="https://www.health.harvard.edu/blog/a-tale-of-two-epidemics-when-covid-19-and-opioid-addiction-collide-2020042019569">Social isolation</a> increases the likelihood of drug use and overdose. While figures are not yet available, much anecdotal evidence suggests that coping with the pandemic increases stress and anxiety while <a href="https://qz.com/1889798/covid-19-is-making-the-opioid-crisis-much-worse/">disrupting routines</a> that are important for recovery.</p>
<p>And, COVID-19 has made the illegal drug supply <a href="https://www.washingtonpost.com/health/2020/07/01/coronavirus-drug-overdose/">more dangerous</a>. In the illicit market, drugs contain various substances. A person who purchases heroin might end up with a mix of heroin, fentanyl and oxycodone, drugs of varying strengths. People who use drugs typically get them from a known supplier, so they know what they are getting and how much to take. </p>
<p><a href="http://www.unodc.org/documents/data-and-analysis/covid/Covid-19-and-drug-supply-chain-Mai2020.pdf">COVID-19 interrupted the illicit drug trade</a>, so there were fewer drugs coming into the country. When supply runs low, people do not stop using drugs; <a href="https://www.aamc.org/news-insights/covid-19-and-opioid-crisis-when-pandemic-and-epidemic-collide">they get drugs of unknown composition from new suppliers</a>. If someone buys heroin but unknowingly receives much stronger fentanyl, the overdose risk skyrockets. People die because they do not know what drug they are taking.</p>
<h2>Crisis compounded</h2>
<p>In addition, COVID-19 exacerbates the trauma that leads to overdose. Addiction is a <a href="https://press.princeton.edu/books/hardcover/9780691190785/deaths-of-despair-and-the-future-of-capitalism">“disease of despair,”</a> meaning it is more common among people with poor social and economic prospects. Mental health conditions, job loss and housing instability all contribute to drug use. </p>
<p>COVID-19 makes treatment less available. Treatment centers struggling to stay open are <a href="https://www.npr.org/sections/health-shots/2020/06/15/865006675/a-new-addiction-crisis-treatment-centers-face-financial-collapse">reducing hours and furloughing staff</a>. <a href="https://doi.org/10.1007/s10461-020-02886-2">Syringe service program site closures</a> and <a href="https://www.businessinsider.com/indiana-and-texas-police-officers-no-longer-equipped-with-naloxone-2020-4">stalled naloxone programs</a> undermine harm reduction efforts.</p>
<p>Strategies to expand treatment have been of some help. However, only physicians who already have an <a href="https://www.samhsa.gov/medication-assisted-treatment/become-buprenorphine-waivered-practitioner">X Waiver</a> – a special dispensation to prescribe opioids for addiction – can provide telemedicine for buprenorphine. The federal government’s actions have moved care online, but only minimally increased treatment capacity. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1298989660060790786"}"></div></p>
<h2>A systemic solution</h2>
<p>Things are dire, but leaders can deploy effective strategies now. In the short term, leaders can double down on harm reduction. They can blanket communities with naloxone, putting it in every library, gas station, pharmacy and vending machine, making it as commonplace as a fire extinguisher. They can invest in syringe services programs and encourage people to use <a href="https://doi.org/10.1186/s12954-018-0276-0">drug test strips to test for fentanyl</a>. </p>
<p>They can expand medications for addiction treatment by <a href="https://doi.org/10.1001/jamapsychiatry.2018.3685">eliminating the X waiver</a>, letting all licensed physicians provide them, and by allowing pharmacists to provide buprenorphine, an approach <a href="https://www.bostonglobe.com/metro/2019/03/12/getting-addiction-care-pharmacy/m1mcceVlLRXX1W9X3WdeOP/story.html">showing favorable results in Rhode Island</a>. They can expand Medicaid, which requires insurers to cover treatment for addiction. These measures could save lives.</p>
<p>Leaders also need a long-term strategy that tackles the root causes of addiction. As COVID-19 makes clear, disrupting the drug supply does not make addiction disappear – it puts people with addiction at greater risk. The rise in cocaine overdose deaths is especially worrying, because while medications for addiction treatment work for opioid use disorders, <a href="https://doi.org/%2010.1097/YCO.0000000000000518">they do not work for cocaine use disorders</a>. </p>
<p>In the last 20 years, the U.S. has cycled through <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">overdose spikes</a> due to prescription opioids, then heroin, then fentanyl. Now cocaine and methamphetamine pose looming threats. </p>
<p>Investing in healthy communities is the best line of defense against overdose. A stronger social safety net would improve problems that lie at the root of addiction such as unemployment, homelessness and mental health conditions. Building infrastructure to prevent and treat addiction will equip our communities to weather storms like COVID-19. </p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p><img src="https://counter.theconversation.com/content/143731/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Elizabeth Chiarello receives funding from the National Science Foundation.</span></em></p>COVID-19 plagues an overtaxed opioid addiction treatment system.Elizabeth Chiarello, Associate Professor of Sociology, Saint Louis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1377122020-05-13T20:05:27Z2020-05-13T20:05:27Z2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year<figure><img src="https://images.theconversation.com/files/334556/original/file-20200513-82403-l35x3e.jpg?ixlib=rb-1.1.0&rect=26%2C0%2C5964%2C3988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In a single year, extra-medical opioid use caused more than 2,200 deaths, 32,000 hospital admissions and resulted in the loss of over 70,000 years of life in Australia. </p>
<p>“Extra-medical” opioid use includes both the illegal use of opioids such as heroin, and the misuse of pharmaceutical opioids – that is, when they’re not used as prescribed or intended.</p>
<p>In a <a href="http://ndri.curtin.edu.au/NDRI/media/documents/publications/T277.pdf">report released today</a>, we’ve quantified the social costs of pharmaceutical opioid misuse and illicit opioid use in Australia over the financial year 2015-16.</p>
<p>We found extra-medical opioid use came at a cost of an estimated A$15.7 billion.</p>
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<h2>The scope of the problem</h2>
<p>An <a href="https://www.aihw.gov.au/getmedia/15db8c15-7062-4cde-bfa4-3c2079f30af3/21028a.pdf.aspx?inline=true">Australian survey</a> showed more than 645,000 people used extra-medical opioids in the previous year.</p>
<p>But because of the stigma around opioid use, estimates from <a href="https://www.aihw.gov.au/getmedia/15db8c15-7062-4cde-bfa4-3c2079f30af3/aihw-phe-214.pdf.aspx?inline=true">national surveys</a> of how many people use extra-medical opioids or how many people would be classified as “dependent” may be underestimates.</p>
<p>We used results from the <a href="https://vizhub.healthdata.org/gbd-compare/">Global Burden of Disease study</a> to estimate more than 104,000 people in Australia were opioid-dependent in 2015-16, putting them at high risk of harms associated with their drug use.</p>
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Read more:
<a href="https://theconversation.com/opioid-dependence-treatment-saves-lives-so-why-dont-more-people-use-it-122537">Opioid dependence treatment saves lives. So why don't more people use it?</a>
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<p>While Australia has so far avoided the pharmaceutical opioid crisis seen elsewhere, especially in the United States, the number of Australian deaths due to pharmaceutical opioids outstrip those from <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Drug%20Induced%20Deaths%20July%202019%20Drug%20Trends%20Bulletin_Final_0.pdf">heroin</a>. </p>
<p>In 2017, only 28% of opioid deaths involved illicit opioids alone. Some 63% involved pharmaceutical opioids and the remainder involved both.</p>
<h2>Let’s break down the costs</h2>
<p>Premature deaths accounted for about 80% of the costs of opioids to society, both in tangible and intangible costs. </p>
<p>As the average age of death from opioids is quite young (<a href="http://ndri.curtin.edu.au/NDRI/media/documents/publications/T277.pdf">43 years</a>), each death results in many potential years of life being lost. We calculated 70,000 years of life were lost as a result of premature deaths from opioids in 2015-16. </p>
<p>The intangible cost is the value society is willing to pay to prevent pain and suffering or premature death, which we come to through a variety of modelling techniques. </p>
<p>The tangible costs are the economic contributions the deceased person would have made through employment and unpaid household work, as well as the costs to employers in replacing an employee.</p>
<p>Making up the tangible costs, we also found crime accounted for $940 million, workplace costs such as from absenteeism and injury were $460 million, hospital inpatient care $250 million, and costs to other health services were $830 million. </p>
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<p>Typically, economic modelling doesn’t include any “harms” to the consumer, as those harms are part of a rational decision to consume. But for someone who has a drug dependence, that decision may be affected by the dependence and related consequences such as withdrawal. </p>
<p>As including those costs is controversial, we calculated them, but did not add them to our total. Based on data from the <a href="https://www.sciencedirect.com/science/article/pii/S0140673613615305">Global Burden of Disease study</a> we estimated the value of the lost quality of life for the 104,000 people dependent on opioids at $14.9 billion. </p>
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Read more:
<a href="https://theconversation.com/fixing-pain-management-could-help-us-solve-the-opioid-crisis-90919">Fixing pain management could help us solve the opioid crisis</a>
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<p>We also looked at lost quality of life for partners and children living with a person dependent on opioids. We calculated there were more than 41,000 adults and 70,000 children living in these households in 2015-16. </p>
<p>Based on <a href="https://www.ncbi.nlm.nih.gov/pubmed/16244100">research</a> on the impact of living with an alcohol dependent person, we estimated the value of their lost quality of life at $12 billion. </p>
<p>These tentative estimates were also omitted from the overall total.</p>
<h2>Tackling the problem</h2>
<p>Since a low point of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0376871617304040">529 deaths</a> in 2006, we’ve seen an increasing trend in deaths from extra-medical opioid use in Australia. But recent initiatives could serve to reduce deaths and other costs. </p>
<p>In Australia, “<a href="https://link.springer.com/content/pdf/10.1007/s40265-019-01154-5.pdf">take home naloxone</a>”, a drug that can reverse the effects of an opioid overdose, is increasingly available with support from the federal and state and territory governments.</p>
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Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
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<p>While most deaths documented in our report were due to drug toxicity (overdose), liver disease and liver cancer due to hepatitis C virus (HCV) accounted for 39% of extra-medical opioid deaths. </p>
<p>In March 2016, the Pharmaceutical Benefits Scheme subsidised <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/ANSPS_National-Data-Report-2013-2017.pdf">a new treatment</a> for HCV.</p>
<p>This development has the potential to markedly reduce HCV related-disease and death for people dependent on opioids. A study in New South Wales has already noted a <a href="https://www.sciencedirect.com/science/article/abs/pii/S0168827819302752">significant decline</a> in HCV-related deaths and ill health in a broader population.</p>
<p>Needle and syringe programs remain important in preventing <a href="https://www.acon.org.au/wp-content/uploads/2015/04/Evaluating-the-cost-effectiveness-of-NSP-in-Australia-2009.pdf">blood borne viruses</a> for people who inject opioids. Along with access to opioid treatment (both pharmacological and psycho-social) these programs are central to our efforts to prevent and reduce opioid-related disease and deaths.</p>
<p>We’ve also seen regulatory changes. Between 2000 and 2013, 1,437 deaths involved <a href="https://www.mja.com.au/system/files/issues/203_07/10.5694mja15.00183.pdf">codeine</a>. So in 2018 increased restrictions were placed on over-the-counter medications containing codeine. </p>
<p>Initial findings are <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.14798">promising</a> but we look forward to evidence about the longer-term effects of this approach.</p>
<h2>There’s more we could be doing</h2>
<p>It’s important to recognise costs are typically estimated, for example the amount of time a general practitioner spends treating opioid-related conditions. </p>
<p>There are also other costs we know occurred, but where we can’t attribute a specific amount to opioids, such as efforts at our borders to address drug importation. So overall expenditure is the best approximation rather than a definitive figure.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-new-hepatitis-c-drugs-could-tackle-liver-cancer-too-73455">How new hepatitis C drugs could tackle liver cancer, too</a>
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</em>
</p>
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<p>Social cost studies like this one provide a focus on the overall harms associated with a condition that can drive debate, policy reform and the allocation of health resources. </p>
<p>It’s critical we continue to enhance access to a range of treatments for opioid dependence and continue with other strategies already in place to tackle this tragic loss of life. </p>
<p>In addition, we need to focus on examining the impact of online supply of “counterfeit” and other pharmaceuticals outside of medical regulation, and develop targeted responses where indicated.</p><img src="https://counter.theconversation.com/content/137712/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Tait works for the National Drug Research Institute, Curtin University which has received Australian Government funding to undertake alcohol and other drug research and related activities and in particular funding to support the work reported in this article. Robert Tait has received funding from Australian and state government agencies to undertake alcohol and other drug work and NHMRC research funding. He has also received funding from 'not-for-profit' organisations for work in the alcohol and other drug field. He is affiliated with the Australasian Professional Society Alcohol and Other Drug Research (member, state representative, director). </span></em></p><p class="fine-print"><em><span>Aqif Mukhtar works for NDRI which has received Australian Government funding to undertake alcohol and other drug research and related activities and in particular funding to support the work reported in this article. He is also works with WA Department of Health. </span></em></p><p class="fine-print"><em><span>Steve Allsop works for the National Drug Research Institute Curtin University which has received Australian Government funding to undertake alcohol and other drug research and related activities and in particular funding to support the work reported in this article.
Steve Allsop has received funding from Australian and state government agencies to undertake alcohol and other drug work and NHMRC research funding.
Steve Allsop is Chair of the WA Network of ALcohol and other Drug Agencies and Deputy Chair of the Australian National Advisory Council on Alcohol and other Drugs. </span></em></p><p class="fine-print"><em><span>Steve Whetton receives funding from the Australian Government to undertake alcohol and other drug research, through a research collaboration with Curtin University. He has also received funding from state and territory governments to undertake research into the impacts of alcohol and other drugs, including being called by the NSW Crown Solicitor's office as an expert witness in NCAT hearings on appeals against liquor licensing decisions.</span></em></p>A new report counts the social costs of pharmaceutical opioid misuse and illegal opioid use in Australia for 2015/2016. The numbers are fairly grim.Robert Tait, Senior Research Fellow, National Drug Research Institute, Curtin UniversityAqif Mukhtar, Research Associate, Curtin UniversitySteve Allsop, Professor, National Drug Research Institute, Curtin UniversitySteve Whetton, Deputy Director, SA Centre for Economic Studies, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1239622020-04-21T12:47:47Z2020-04-21T12:47:47ZPharmacists could be front-line fighters in battle against opioid epidemic<figure><img src="https://images.theconversation.com/files/315053/original/file-20200212-61929-1m6slzs.jpg?ixlib=rb-1.1.0&rect=48%2C24%2C5400%2C3564&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">On average, more than 130 Americans die from an opioid overdose every day.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/19331187675272/">AP Photo/Keith Srakocic</a></span></figcaption></figure><p>When you stop at your local pharmacy to pick up a toothbrush or an antacid, soon you may also be able to buy an over-the-counter drug to reverse an opioid overdose. The lifesaving drug, naloxone, currently requires a prescription, but it may become available as an over-the-counter purchase in 2020. </p>
<p>Despite the <a href="https://www.cdc.gov/vitalsigns/opioids/index.html">national decrease in opioid prescriptions</a> since 2012, the <a href="https://www.cdc.gov/drugoverdose/data/prescribing.html">opioid crisis</a> continues. Access to prescription opioids have decreased due to <a href="https://doi.org/10.1111/add.14394">stricter legislation</a>, insurance regulations and the Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain. At the same time, the use of heroin and illegally manufactured synthetic opioids, such as fentanyl and counterfeit prescription opioids, has <a href="https://www.cdc.gov/nchs/data/databriefs/db356-h.pdf">escalated</a>. </p>
<p>In addition, <a href="https://doi.org/10.1001/jama.2018.2844">nearly 80% of opioid overdoses</a> involve multiple substances, compounding the risk of a fatal overdose. This reinforces the need for widespread, convenient naloxone access accompanied by <a href="https://doi.org/10.1097/ADM.0000000000000223">training on how to administer</a> this reversal drug. </p>
<p>As a <a href="https://cphs.wayne.edu/profile/ai6726">professor of pharmacy</a> and pharmacist, I believe that many more pharmacists can be engaged in providing naloxone for their patients.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Communities demand attention for the damage caused by the opioid crisis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/new-york-nyusa-0831-overdose-awareness-1168887157">Shutterstock.com/SCOOTERCASTER</a></span>
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<h2>Essential medication to save a life</h2>
<p>An opioid overdose can depress a person’s respiratory center to the point where breathing stops, resulting in death. Naloxone can reverse this effect within minutes. With minimal training, anyone can safely administer naloxone in various forms – nasal spray, auto-injector or intramuscular injection – to effectively buy more time and get medical help for someone who has overdosed. </p>
<p>Naloxone has been used in hospitals for more than 40 years to reverse excess sleepiness and respiratory depression from opioid anesthesia and pain medication or to treat overdoses in the emergency room. During the 1990s, naloxone use expanded <a href="https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio">into communities</a> to first responders, laypersons and, most importantly, to people who use drugs to reverse opioid overdoses. </p>
<p>The U.S. surgeon general issued an <a href="https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html">advisory</a> in April 2018 encouraging family, friends and individuals at risk for an opioid overdose to carry naloxone and be trained to administer it. <a href="http://doi.org/10.1001/jamainternmed.2019.0272">Research shows</a> that wider access to naloxone is associated with fewer deaths. Naloxone could <a href="https://doi.org/10.1186/s12954-019-0352-0">successfully reverse</a> every witnessed opioid overdose, but only if naloxone is in the hands of a trained bystander. The challenge has been how to get naloxone to the people who need it.</p>
<p>In 48 states and the District of Columbia, pharmacists are now able to dispense naloxone under a standing order that does not require a physician’s prescription, or they can <a href="https://ldi.upenn.edu/brief/expanding-access-naloxone-review-distribution-strategies">directly prescribe naloxone</a>. But people may still be hesitant to ask for naloxone.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Pharmacies may one day dispense naloxone as an over-the-counter drug.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/naloxone-medicine-used-block-effects-opioids-1591052014">PureRadiancePhoto/Shutterstock.com</a></span>
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</figure>
<h2>Why community pharmacists are key</h2>
<p><a href="https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder">Opioid use disorder</a> is a chronic, relapsing, lifelong condition. Managing opioid use disorder requires sustained treatment and support, similar to other chronic conditions, such as diabetes and heart disease. But opioid use disorder often carries a social stigma, which can make people hesitant about seeking help through traditional health care channels. </p>
<p>People may be afraid to request a prescription for naloxone because they may be accused of misusing drugs. Others may not know how or where to obtain naloxone, particularly if they don’t have a regular health care provider. People who use drugs report <a href="https://doi.org/10.1007/s11606-015-3394-3">feeling stigmatized</a>, while <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082708/">providers including pharmacists may be uncomfortable</a> starting a conversation with patients about the importance of carrying naloxone. </p>
<p>Yet the greater the access to naloxone, the more likely this lifesaving drug will be administered to reverse an overdose. I believe that pharmacists in the community are ideally positioned as a local resource to obtain naloxone. Community pharmacies have evolved into <a href="https://www.michiganpharmacists.org/Portals/0/patients/communitypharmacy.pdf">neighborhood health centers</a> where individuals can access a variety of services outside a traditional clinical setting including immunizations, health screenings and lab monitoring. </p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Vial of naloxone.</span>
<span class="attribution"><a class="source" href="http://www.Shutterstock.com/418417357">PureRadiancePhoto/Shutterstock.com</a></span>
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<p><a href="https://doi.org/10.1097/ADM.0000000000000223">Pharmacists</a> can recommend and provide naloxone, opioid education and overdose prevention information to high-risk individuals and their support network. Pharmacists can make their pharmacy a safe and nonjudgmental resource, where people obtain and learn to administer naloxone, seek self-care advice and reduce harm from drug use, including clean needles and syringes. And pharmacists are well positioned to provide connections to local programs for recovery and support. They can make referrals to supportive health care providers and provide “whole person” care for vulnerable individuals. </p>
<h2>Federal support to halt deadly overdoses</h2>
<p>The U.S. Department of Health and Human Services recognizes the importance of addressing opioid use disorder and the opioid crisis with a <a href="https://www.hhs.gov/opioids/about-the-epidemic/hhs-response/index.html">5-point strategy</a>. This includes better access to opioid use disorder treatment, research funding, improved pain management and expanded naloxone availability in health care and community settings. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Emergency overdose kit.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Drug-Abuse-Treatment/3c546feaea4d4b1a827a397a9aece342/115/0">AP Photo/Jim Cole</a></span>
</figcaption>
</figure>
<p>While naloxone is not yet available for purchase over the counter, the U.S. Food and Drug Administration supports this simple access and has developed a “drug facts naloxone label” with pictures making it easy for anyone to effectively administer the correct dose. Manufacturers can apply for over-the-counter status, and naloxone is expected to become available as an over-the-counter drug <a href="https://doi.org/10.1111/1475-6773.13125">this year</a>. The availability to purchase naloxone without a prescription and over the counter can remove the perceived stigma of having to request it from a health care provider or pharmacist. </p>
<p>Naloxone alone will not mitigate the opioid crisis. Yet the ability to reverse a fatal overdose – having someone nearby who carries and can administer naloxone – allows the survivor another chance to enter <a href="https://doi.org/10.2105/AJPH.2017.304187">treatment that addresses</a> the social, structural, genetic, behavioral and individual factors of opioid use disorder. Pharmacists have an important role in helping to remove the stigma associated with requesting and carrying naloxone by openly discussing its benefits and making naloxone available to all patients. </p>
<p>[<em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>.]</p><img src="https://counter.theconversation.com/content/123962/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Victoria Tutag Lehr has received funding from MDHHS, BCBSMF, Amerisource-Bergen.
</span></em></p>Pharmacists are well positioned to provide communities with a lifesaving drug.Victoria Tutag Lehr, Professor of Pharmacy, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225372019-11-03T18:55:46Z2019-11-03T18:55:46ZOpioid dependence treatment saves lives. So why don’t more people use it?<figure><img src="https://images.theconversation.com/files/299607/original/file-20191031-187898-1v815y4.jpg?ixlib=rb-1.1.0&rect=0%2C16%2C5597%2C3709&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">To reduce opioid-related harms, we must ensure treatments for opioid dependence are accessible to those who need them. </span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>In Australia last year, <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2018%7EMain%20Features%7EOpioid-induced%20deaths%20in%20Australia%7E10000">1,123 people</a> died from opioids – illicit drugs such as heroin, and pain relievers such as codeine, oxycodone and morphine. If used regularly, physical and psychological dependence can develop.</p>
<p>In recent years most deaths have been due to <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/contents/table-of-contents">pharmaceutical opioids</a> – that is, overdoses of strong pain medicines. Though heroin-related deaths are <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/data">increasing rapidly</a>, so we need evidence-based responses for both.</p>
<p>One key approach to reducing these deaths is treatment for opioid dependence. Although the evidence shows treatments such as methadone and buprenorphine <a href="https://www.ncbi.nlm.nih.gov/pubmed/24500948">are effective</a>, people who are dependent on opioids continue to face barriers to accessing them.</p>
<p>These include cost, stigma, restrictiveness of the treatment regime, and a lack of places to go to receive treatment. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">Weekly Dose: Naloxone, how to save a life from opioid overdose</a>
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</p>
<hr>
<h2>Opioid dependence treatment</h2>
<p>The dependence treatment backed by the strongest evidence is called “opioid agonist treatment”. An opioid “agonist” means a drug that produces opioid effects in the body.</p>
<p>Opioid agonist treatment is when a known and legal opioid medicine (the opioid “agonist”) is provided in a therapeutic setting, like a clinic or pharmacy, in a regular dose. This removes the need for using additional opioids by reducing craving and withdrawal.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=785&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=785&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=785&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=986&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=986&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=986&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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</figure>
<p>Staying in treatment <a href="https://www.ncbi.nlm.nih.gov/pubmed/7259424">longer</a> is associated with better outcomes, with best results seen when treatment is continued <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/FAQ%20Pharmacetuical%20Opioid%20Dependence%20Treatment_0.pdf">for 12 months or more</a>. So this is a longer-term treatment providing an opportunity to make sustainable changes, as opposed to a short-term detox.</p>
<p>The two most common medicines used in Australia are methadone and buprenorphine. Both are available through general practitioners and community pharmacies, as well as specialist clinics. Newer forms such as <a href="https://www1.racgp.org.au/newsgp/clinical/advocates-hail-game-changing-pbs-listing-of-long-a">long-acting buprenorphine</a> have also recently entered the market. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
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<p>Methadone is what we call a “full opioid agonist”. It mimics the effects of other opioids, such as codeine or morphine, and it can remove the need to take other opioids by preventing opioid withdrawal and craving. Taken in daily oral doses methadone does not produce euphoria, or a “high”. At higher doses, methadone also blocks the effects of other opioids, helping to prevent return to other opioid use.</p>
<p>Buprenorphine (often provided in combination with naloxone, a medicine used to reverse the effects of an opioid overdose) is referred to as a “partial opioid agonist”. It’s less sedating and, unlike methadone and other opioids, is less likely to cause <a href="https://academic.oup.com/bja/article/100/6/747/303263">breathing difficulties</a> and overdose. </p>
<h2>Treatment is effective</h2>
<p>High-quality <a href="https://www.ncbi.nlm.nih.gov/pubmed/24500948">evidence</a> shows these treatments work. They help reduce opioid use, improve health, prevent the spread of blood borne viruses by reducing the likelihood people continue to inject, are cost effective, and reduce crime. </p>
<p>The most profound effects of these treatments is their ability to save lives. Risk of death while in treatment is <a href="https://www.bmj.com/content/357/bmj.j1550">substantially reduced</a>, by around half compared to when a person is dependent on opioids and not receiving treatment.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Opioids include pain relievers like codeine, oxycodone and morphine, and illicit drugs like heroin.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
</figcaption>
</figure>
<p>These treatments have been shown to <a href="https://ndarc.med.unsw.edu.au/resource/frequently-asked-questions-opioid-agonist-treatment-pharmaceutical-opioid-dependence">work just as well</a> for people who develop dependence to prescribed opioids and people who use heroin. </p>
<p>In 2005 the World Health Organisation put methadone and buprenorphine on their list of <a href="https://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/">essential medicines</a>, recognising their importance in treating opioid dependence.</p>
<p>So it might be surprising to learn many people in Australia who could benefit from these treatments choose not to use them, or are not able to access them.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-methadone-the-most-effective-treatment-for-heroin-dependence-59814">Weekly Dose: methadone, the most effective treatment for heroin dependence</a>
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<hr>
<h2>4 barriers to treatment</h2>
<p><strong>Cost</strong></p>
<p>Opioid agonist treatments attract some subsidies, but their dispensing fees are not covered by Australia’s <a href="http://www.pbs.gov.au/info/about-the-pbs">Pharmaceutical Benefits Scheme</a>, which subsidises prescription drugs. Where treatment usually adds up to A$35-A$70 a week, cost can be a <a href="https://creidu.edu.au/policy_briefs_and_submissions/10-opioid-pharmacotherapy-fees-a-long-standing-barrier-to-treatment-entry-and-retention">key barrier</a> to access.</p>
<p><strong>Stigma</strong></p>
<p>Some people choose not to access these treatments because they see them <a href="https://www.ncbi.nlm.nih.gov/pubmed/29762767">as being for people who use heroin</a>, or don’t want to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.12859">attend services seen as being for people who use illicit drugs</a>. </p>
<p>Other people believe these treatments are just replacing one opioid with another, and are not aware of their strong scientific support. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fixing-pain-management-could-help-us-solve-the-opioid-crisis-90919">Fixing pain management could help us solve the opioid crisis</a>
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<p><strong>Restrictiveness of the treatment regime</strong></p>
<p>The need to attend a pharmacy daily for dosing at the start of treatment can affect work, study or family commitments. </p>
<p><strong>Nowhere to go</strong></p>
<p>Finally, treatment access is limited in some regions because there are not enough GPs who prescribe these treatments. This is despite a change from many state governments in recent years to reduce barriers to prescribing. </p>
<p>In <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/pharmacotherapy/buprenorphine-and-naloxone-prescribing-guidelines">Victoria</a> and New South Wales, for example, all GPs can prescribe buprenorphine treatment without additional training. Nonetheless, prescriber numbers have been slow to increase, with some GPs remaining hesitant to offer these treatments.</p>
<h2>People turning to short-term treatments instead</h2>
<p>As a result of these barriers, many people who are dependent on opioids choose not to seek help, or are not able to access the treatment they need. </p>
<p>Some choose to access shorter-term treatments such as a “detox”, where over the course of seven to ten days they cease opioids while their withdrawal symptoms are treated with medications.</p>
<p>This is concerning because the rates of relapse from short-term treatment are high, and research shows the risk of non-fatal or fatal opioid overdose increases <a href="https://www.ncbi.nlm.nih.gov/pubmed/17280803">following short-term treatment</a>. This means these short-term treatments contribute to opioid-related deaths rather than preventing them. </p>
<p>To stem the loss of life from opioid use in Australia, it’s critical we break down the barriers to the opioid dependence treatments we know are most effective. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-what-happened-when-codeine-was-made-prescription-only-no-the-sky-didnt-fall-in-124169">Here's what happened when codeine was made prescription only. No, the sky didn't fall in</a>
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</em>
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<img src="https://counter.theconversation.com/content/122537/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Nielsen has received funding from Indivior and Seqirus, and is the current recipient of an NHMRC Research Fellowship (#1163961) </span></em></p>Treatments for opioid dependence, such as methadone and buprenorphine, are effective. But some people who stand to benefit are missing out.Suzanne Nielsen, Associate Professor and Deputy Director, Monash Addiction Research Centre, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1219282019-10-18T11:20:42Z2019-10-18T11:20:42ZThis overdose-reversal medicine could reduce opioid deaths – so why don’t more people carry it?<figure><img src="https://images.theconversation.com/files/297547/original/file-20191017-98661-f386zs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naloxone, available as a nasal spray called Narcan or in injectable form, resuscitates 100% of people who overdose if administered quickly. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Overdose-Drug/25e6e79fdb614993a29ae319310ae4b4/31/0">AP Photo/Patrick Semansky</a></span></figcaption></figure><p>Forty-seven thousand Americans <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334822/">died of opioid-related overdoses</a> in 2017 – similar to the number of deaths from <a href="https://www.cdc.gov/nchs/fastats/accidental-injury.htm">car accidents</a> and <a href="https://www.cdc.gov/nchs/fastats/injury.htm">gun violence</a>. </p>
<p>That number <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/add.13265">could have been much lower</a> had more people received naloxone, a medication that reverses opioid-related overdose.</p>
<p>Naloxone is <a href="https://injepijournal.biomedcentral.com/articles/10.1186/s40621-015-0041-8">safe, non-addictive and highly effective</a>. And it does more than save lives: When used <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005759/">shortly after overdose</a>, naloxone reduces the likelihood of long-term brain damage from diminished blood flow. </p>
<p>Available as an injection or nasal spray, naloxone can <a href="https://www.ncbi.nlm.nih.gov/pubmed/18422830">be administered</a> by <a href="https://www.tandfonline.com/doi/abs/10.1080/10903127.2017.1371262">anyone trained to do so</a> - assuming, that is, that someone has it on hand at the scene of the overdose.</p>
<h2>Restricted access</h2>
<p><a href="https://www.washingtonpost.com/local/dc-politics/dc-police-officers-to-carry-opioid-overdose-antidote-naloxone/2019/01/18/b76de64a-1b44-11e9-8813-cb9dec761e73_story.html">Police</a>, firefighters and medical first responders are increasingly <a href="http://www.nchrc.org/law-enforcement/us-law-enforcement-who-carry-naloxone/">equipped with naloxone</a>. </p>
<p>However, the true first responders to an overdose often aren’t professionals but the friends, family and peers of people who <a href="https://www.mdmag.com/medical-news/public-drug-users-are-most-likely-to-reverse-peer-overdoses">use heroin and other opioids</a>. Relatively few of these “laypeople” have access to naloxone, which is available via <a href="https://www.golead.co/naloxone/">community distribution</a>, a doctor’s prescription or, <a href="https://www.japha.org/article/S1544-3191(16)30890-1/fulltext">in states that allow naloxone to be sold without a prescription</a>, from a pharmacy.</p>
<p>While <a href="https://journals.lww.com/journaladdictionmedicine/Fulltext/2019/08000/Naloxone_Availability_and_Pharmacy_Staff_Knowledge.5.aspx">at least 41 states</a> allow pharmacists to dispense the medicine without a prescription, many pharmacies <a href="https://jamanetwork.com/journals/jama/fullarticle/2714519">fail to actually stock it</a>. In California, <a href="https://jamanetwork.com/journals/jama/fullarticle/2714519">only a quarter of all pharmacies</a> carried naloxone last year.</p>
<p>As opioid-related deaths have soared, there’s <a href="https://www.scopus.com/record/display.uri?eid=2-s2.0-84931827775&origin=inward">been an increase</a> in programs working to get naloxone into the community. Health centers like <a href="https://www.pppgh.org">Prevention Point Pittsburgh</a>, for example, train people likely to witness overdose on how to recognize the signs and give them free naloxone.</p>
<p>However, the <a href="https://www.sciencedirect.com/science/article/pii/S0955395917303468">most recent available data suggest</a> that relatively few communities with high rates of opioid-related deaths actually have such programs. </p>
<p>Even emergency medical personnel, or EMS, may not have naloxone when they need it. </p>
<p>Most U.S. states <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/acem.12485">only authorize</a> intermediate- and advanced-level EMS to carry and administer the drug. But in many parts of the country – particularly <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2014.302520">rural and tribal areas</a> – EMS with basic training <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2014.302520">are often the only medical first responders</a> immediately available in emergencies.</p>
<h2>‘Moral hazard’</h2>
<p>One impediment to increased naloxone access is the argument that reviving overdose victims will encourage opioid use.</p>
<p>Naloxone critic Dr. Harold Jonas, founder of the website Sober.com, has <a href="https://www.elitecme.com/resource-center/health-systems-management/narcan-saving-lives-or-enabling-addicts">warned health care providers</a> that naloxone creates a safety net, making people think “they don’t need treatment for substance abuse and … continue using at will.”</p>
<p>The fear that life-saving interventions encourage reckless behavior – a concern historically used to oppose everything from <a href="https://www.bmj.com/content/332/7541/605.short">condoms</a> to <a href="https://journals.sagepub.com/doi/abs/10.1177/001872088202400105">seat belts</a> – is called “<a href="http://static.stevereads.com/papers_to_read/the_economics_of_moral_hazard.pdf">moral hazard</a>.” </p>
<p>There is <a href="https://www.ncbi.nlm.nih.gov/pubmed/29610001">no peer-reviewed, empirical evidence</a> that naloxone use encourages opioid use. But this argument remains <a href="https://www.nytimes.com/2016/07/28/us/naloxone-eases-pain-of-heroin-epidemic-but-not-without-consequences.html">pervasive</a>. </p>
<p>Often, politicians combine moral hazard with budgetary arguments to oppose broader naloxone distribution. </p>
<p>The prices of some naloxone products have been <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1609578">rising</a>. Between 2009 and 2016, naloxone manufactured by Amphastar <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1609578">almost doubled</a> in price, from US$20.34 to $39.60 per dose. </p>
<p>In 2017, the city of Middletown, Ohio, <a href="https://www.journal-news.com/news/the-overdose-epidemic-comes-massive-cost-middletown-millions/6GRKXqaDortkhgLwqdxHHP/">spent</a> almost $35,000 on naloxone administered by EMS in 966 opioid overdose calls – <a href="https://www.journal-news.com/news/middletown-opioid-crisis-staggering-numbers-for-2017/BXcNXOEd88a8mAN7qBGc9I/">up from</a> $11,000 and 532 calls in 2016.</p>
<p>Citing cost, <a href="https://www.washingtonpost.com/news/to-your-health/wp/2017/06/28/a-council-members-solution-to-his-ohio-towns-overdose-problem-let-addicts-die/">Middletown Councilmember Dan Picard</a> has said the city should refuse to resuscitate people who overdose repeatedly. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=488&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=488&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=488&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=613&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=613&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=613&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tess Nishida, a pain pharmacist at the University of Washington, holding a vial of naloxone, Oct. 7, 2016.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Washington-Opioids/73792f4373aa4ef29f43f1745c60ae28/50/0">AP Photo/Ted S. Warren</a></span>
</figcaption>
</figure>
<h2>Naloxone is cost-effective</h2>
<p>Since the opioid crisis <a href="https://www.brookings.edu/research/pinpointing-opioid-in-most-impacted-communities/">disproportionately hurts low-income communities</a> like Middletown, our team of <a href="https://sph.umich.edu/hmp/phdstudents/townsend-tarlie.html">health policy</a> and <a href="https://sph.umich.edu/epid/phdstudents/blostein-freida.html">epidemiology</a> researchers at the University of Michigan conducted a study to determine whether naloxone is a good use of the scarce resources available to reduce opioid-related deaths. </p>
<p>Our study, published in <a href="https://www.sciencedirect.com/science/article/pii/S0955395919302099">International Journal of Drug Policy</a>, found that naloxone is extremely cost-effective. </p>
<p>We analyzed the cost-effectiveness of giving naloxone to three different groups: laypeople, police and firefighters and EMS. </p>
<p>When all three groups have naloxone, it costs about $16,000 per year of “high-quality” year of life saved. We accounted for quality of life as well as quantity, since problematic substance use increases the risk of <a href="https://www.sciencedirect.com/science/article/pii/S1473309916303255">hepatitis, HIV and other illnesses</a>.</p>
<p>As life-saving interventions go, $16,000 per high-quality year of life is <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/215852">an excellent deal</a>. The public defibrillators used to revive people in cardiac arrest <a href="https://www.sciencedirect.com/science/article/pii/">come out to around $53,797</a>. And a breakthrough class of new cancer drugs <a href="https://www.tandfonline.com/doi/full/10.1080/14737167.2018.1467270">run $100,000 to $150,000</a> per high-quality year of life saved. </p>
<p>Naloxone actually saves society money when we take the lost economic productivity from fatal overdoses into account, we found. Hard-hit communities may see naloxone as an expense – but they’re actually saving the city money by keeping more of its workforce alive. </p>
<p>This finding holds even when we add in a city’s criminal justice costs associated with opioid use.</p>
<p>Naloxone would remain cost-effective even if the “moral hazard” concerns were true. We found that overdose rates would have to rise 20% for lay distribution of naloxone to cease being cost-effective – a large margin of error for an <a href="https://www.sciencedirect.com/science/article/pii/S0306460318301382">unsubstantiated</a> worry.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Surgeon General Jerome Adams, right, directs a session on naloxone administration, Jackson, Mississippi, May 17, 2018.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Surgeon-General-Opioids/e1b532220f88482ca57f39d695ab367e/12/0">AP Photo/Rogelio V. Solis</a></span>
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<h2>Moral imperative</h2>
<p>Our research determined that the most cost-effective strategy is to distribute naloxone to all three groups: laypeople, police and firefighters, and EMS. </p>
<p>If low-income communities can’t afford that much naloxone, however, the next-best scenario is to give the medicine to laypeople plus at least one first responder group – either police and fire or EMS.</p>
<p>Getting naloxone into lay hands is so critical because many overdose witnesses hesitate to call 911 due to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825210/">fear of arrest</a>, stigma or loss of government benefits like subsidized housing. No matter how many first responders have naloxone, the victims in those cases cannot benefit from it. They need someone close by, like another person using opioids, to revive them. </p>
<p>But emergency responders should have naloxone as well since overdose witnesses may not always have naloxone or be <a href="https://www.ncbi.nlm.nih.gov/pubmed/19268564">able and willing to use it</a>. </p>
<p>Sometimes, a single naloxone dose can save two lives.</p>
<p>In 2018, clinicians in North Carolina <a href="https://www.publichealthpost.org/viewpoints/is-there-a-risk-to-naloxone/">treated a pregnant patient</a> who had recently overdosed. Friends had used naloxone to reverse the overdose, allowing her to enter treatment for substance use.</p>
<p>A few months later, she gave birth to a healthy baby. </p>
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<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Opioid overdoses killed 47,000 Americans in 2017 — more than gun violence. Many fewer would have died if they’d been treated with the life-saving drug naloxone, also called Narcan.Tarlise Townsend, Joint PhD Student, Health Policy and Sociology, University of MichiganFreida Blostein, Epidemiological Science PhD Candidate, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1123632019-03-04T11:39:13Z2019-03-04T11:39:13ZPurdue Pharma taps a Gilded Age history of pharmaceutical fraud<figure><img src="https://images.theconversation.com/files/260820/original/file-20190225-26181-1vgkr3o.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Classified advertisement for Leslie Keeley's Gold Cure.</span> <span class="attribution"><span class="source">ProQuest Historical Newspapers: Chicago Tribune, July 21, 1884</span></span></figcaption></figure><p>Newly unsealed <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">documents</a> from a <a href="https://www.propublica.org/article/oxycontin-purdue-pharma-massachusetts-lawsuit-anti-addiction-market">lawsuit</a> by the state of Massachusetts allege that Purdue Pharma, maker of OxyContin and other addictive opioids, actively sniffed out new, sinister ways to cash in on the opioid crisis. </p>
<p>Despite years of <a href="https://www.cnn.com/2019/01/31/health/purdue-pharma-unredacted-lawsuit/index.html">negative press coverage</a>, unwanted attention from regulators, multi-million dollar <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html">fines</a> and several major <a href="https://www.theguardian.com/us-news/2018/nov/19/sackler-family-members-face-mass-litigation-criminal-investigations-over-opioids-crisis">lawsuits</a>, Purdue staff and owners sought to expand the company’s sights beyond its usual array of opioid painkillers. Purdue planned to become an “end-to-end pain provider,” by branching into the market for opioid addiction and overdose medicines, looking to peddle these medicines even while the company continued to aggressively market its addictive opioids. Internal research materials coldly explained the rationale behind this plan: “Pain treatment and addiction <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">are naturally linked</a>.” </p>
<p>As thousands of Americans continue to <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state">overdose on opioids</a> annually, Purdue’s secret <a href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">marketing research</a> predicted that sales of <a href="https://harmreduction.org/issues/overdose-prevention/overview/overdose-basics/understanding-naloxone/">naloxone</a>, the overdose reversal drug, and <a href="https://www.samhsa.gov/medication-assisted-treatment/treatment/buprenorphine">buprenorphine</a>, a medicine used to treat opioid addiction, would increase exponentially. Addiction to Purdue’s opioids would thus drive the sale of the company’s opioid addiction and overdose medicines. Purdue even planned to target as customers patients already taking the company’s opioids and doctors who prescribed opioids excessively, according to the Massachusetts lawsuit filing. To keep the plan quiet, Purdue staff dubbed the scheme “Project Tango.” </p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=756&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=756&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=756&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=950&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=950&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260756/original/file-20190225-26165-5fvf99.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=950&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">According to the Massachusetts lawsuit, Purdue used this graphic in its internal strategy materials to illustrate Project Tango.</span>
<span class="attribution"><a class="source" href="https://www.mass.gov/files/documents/2019/01/31/Massachusetts%20AGO%20Amended%20Complaint%202019-01-31.pdf">State of Massachusetts</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>The audacity of Project Tango enraged many observers. But considered in historical context, the news that Purdue sought to peddle opioid addiction medicines while continuing to sell opioids seems less surprising. In fact, there is clear historical precedent for Purdue’s business plan. Over a century ago, “patent medicine” sellers pioneered this strategy during the U.S.’s Gilded Age opiate addiction epidemic.</p>
<h2>Opiate addiction in the Gilded Age</h2>
<p><a href="https://theconversation.com/opiate-addiction-and-the-history-of-pain-and-race-in-the-us-97430">Opiates</a> were some of the most commonly prescribed medicines in American history until the 20th century. Pills containing opium, hypodermic morphine injections and laudanum, a drinkable liquid concoction of opium and alcohol, constituted half or more of all medicines prescribed in American hospitals during most of the 19th century, <a href="https://books.google.com/books?id=qlIABAAAQBAJ&printsec=frontcover#v=onepage&q&f=false">according to research</a> by the historian <a href="https://hshm.yale.edu/people/john-harley-warner">John Harley Warner</a>. Opiates were also present in countless “<a href="https://dp.la/exhibitions/patent-medicine/1860-1920/opiates-alcohol-herbs">patent medicines</a>,” over-the-counter panaceas made of secret ingredients, often sold under catchy brand names like <a href="https://www.nytimes.com/1860/12/01/archives/mrs-winslows-soothing-syrup-for-children-teething-letter-from-a.html">Mrs. Winslow’s Soothing Syrup</a>. Americans could choose from <a href="https://books.google.com/books?id=27_cBAAAQBAJ&printsec=frontcover&dq=medical+monopoly&hl=en&sa=X&ved=0ahUKEwiTtb_m9t_gAhWCm4MKHXWVBnsQ6AEIKDAA#v=onepage&q=by%20the%20middle%20of%20the%201880s%20there%20were%20at%20least&f=false">5,000</a> brands of patent medicines marketed for all manner of ailments by the 1880s. In 1904, just before federal oversight began, patent medicines had matured into an astonishingly profitable industry, with <a href="http://sk.sagepub.com/reference/the-sage-encyclopedia-of-alcohol-social-cultural-and-historical-perspectives/n361.xml?fromsearch=true">estimated</a> sales at US$74 million dollars annually – equivalent to about $2.1 billion dollars <a href="http://www.in2013dollars.com/us/inflation/1904?amount=74000000">today</a>.</p>
<p>Opiate-laced prescriptions and patent medicines often caused addiction. The historian <a href="https://davidcourtwright.domains.unf.edu">David T. Courtwright</a> estimates that opiate addiction rates in the U.S. skyrocketed to 4.59 per thousand Americans by the 1890s – a high rate, although lower than the rate of fatal opioid overdoses in recent <a href="https://www.drugabuse.gov/drugs-abuse/opioids/opioid-summaries-by-state">years</a>. Most individuals developed addictions through medicines, rather than the infamous smoking variety of opium. Victims of “the habit” cut across <a href="https://books.google.com/books/about/Dark_Paradise.html?id=VxUuPa3cnLMC&printsec=frontcover&source=kp_read_button#v=onepage&q&f=false">demographic</a> lines, encompassing middle-class housewives suffering from menstrual pain, Civil War veterans reeling from amputations and many others in between.</p>
<p>Yet even for those who became addicted to prescription opiates, the condition was socially <a href="https://collections.nlm.nih.gov/bookviewer?PID=nlm:nlmuid-66640200R-bk#page/18/mode/2up">stigmatized</a> and physically dangerous. Like today, addiction to opiates often led to fatal overdose, condemnation and sometimes even involuntary commitment to mental asylums. As one doctor <a href="https://babel.hathitrust.org/cgi/pt?id=hvd.li2wt1;view=1up;seq=557">reported</a> to the Iowa Board of Health in 1885, addicted people lived “truly in a veritable hell.”</p>
<p>To avoid these frightful outcomes, desperate, opiate-addicted Americans frequently sought out medical treatment for their condition.</p>
<p>Gilded Age Americans could choose from a range of <a href="https://books.google.com/books?id=_MGJmdV-J4oC&pg=PA64&source=gbs_toc_r&cad=2#v=onepage&q&f=false">therapies</a> for opiate addiction. Wealthy patients frequented plush private clinics, where they could receive inpatient treatment for opiate addiction. The most popular were the <a href="https://daily.jstor.org/inside-a-nineteenth-century-quest-to-end-addiction/">Keeley Institutes</a>, which offered patients injections of the “Bichloride of Gold” remedy, invented by the doctor Leslie Keeley.</p>
<p>Scores of Keeley Institutes sprang up around the <a href="https://archive.org/details/bannerofgold2119reed/page/n35">country</a> in the late 19th century, a testament to the popularity of Keeley’s “Gold Cure,” which he marketed for alcoholism and drug addiction. No up-and-coming Gilded Age city was complete without a Keeley Institute. At the <a href="http://sk.sagepub.com/reference/the-sage-encyclopedia-of-alcohol-social-cultural-and-historical-perspectives/n286.xml?fromsearch=true">height</a> of the Gold Cure craze, there were 118 institutes serving 500,000 Americans between 1880 and 1920. Even the federal government had a <a href="https://books.google.com/books/about/Sing_Not_War.html?id=AgmVvmoeQ_gC&printsec=frontcover&source=kp_read_button#v=onepage&q=keeley&f=false">contract</a> with Keeley to provide the Gold Cure to addicted veterans. Although injections of the Gold Cure had little intrinsic medical value, historians believe that socializing with other like-minded patients in the Keeley Institutes may have helped some patients recover from addiction.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=894&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=894&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=894&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1123&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1123&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260758/original/file-20190225-26149-8hrtsm.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1123&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advertisement for the main Keeley Center, in Dwight, Illinois, 1908.</span>
</figcaption>
</figure>
<p>Keeley faced stiff competition, however. Other popular therapies for opiate addiction included patent medicine “cures” and “antidotes,” which were cheaper than inpatient care. These could be ordered by mail without a prescription, and consumed in the privacy of one’s home, away from prying eyes. </p>
<p>Fueled by high demand, during its heyday at the turn of the 20th century, addiction cures bloomed into a multimillion-dollar sector of the patent medicine industry. Dozens of pharmaceutical companies peddled their “cures” to willing, opiate-addicted customers, which they marketed through pamphlets, postcards, and newspaper and magazine classifieds.</p>
<p>Ironically, these “cures” for opiate addiction almost universally contained opiates, unbeknownst to hopeful customers, who received little therapeutic benefit by today’s standards. But in an era before federal regulation of medicines and narcotics, there were no effective safeguards to protect addiction patients from medical fraud. </p>
<h2>Pharmaceutical fraud</h2>
<p>Much like Purdue Pharma, which <a href="https://www.statnews.com/2016/09/22/abbott-oxycontin-crusade/">famously</a> marketed Oxycontin as non-addictive precipitating the opioid crisis, Gilded Age patent medicine companies also fraudulently marketed their addiction treatments as non-addictive, targeting and intentionally deceiving addicted customers. For their part, Gilded Age doctors were deeply skeptical of such products, and they often accused proprietors of fraud in medical journals and newspapers.</p>
<p>Samuel B. Collins of La Porte, Indiana, inventor of the “Painless Opium Antidote,” one of the era’s most popular brands, insisted that his <a href="http://lcweb2.loc.gov/service/gdc/scd0001/2006/20060714002th/20060714002th.pdf">product</a> was not addictive. Collins was proven a fraud, however, by a skeptical Maine doctor, who in 1876 sent off a sample of Collins’ product to several chemists for analysis. Their tests <a href="https://www.nejm.org/doi/full/10.1056/NEJM187610260951705">indicated</a> that the Painless Opium Antidote contained enough morphine to perpetuate opiate addiction, actually fueling demand for Collins’s product, rather than curing the underlying addiction.</p>
<p>Despite the overwhelming evidence, however, without any effective medical regulation or oversight, Collins maintained his fraud for decades. His business strategy presaged Purdue’s Project Tango by targeting vulnerable opiate-addicted individuals.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=1061&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=1061&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=1061&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1334&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1334&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260765/original/file-20190225-26156-1pvzqs4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1334&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advertisement for Theriaki, a painless cure for the opium habit. Exterior view of Dr. Collins’ Opium Antidote Laboratory, LaPorte, Indiana.</span>
<span class="attribution"><span class="source">National Library of Medicine</span></span>
</figcaption>
</figure>
<p>After decades of exposés by doctors and journalists, however, the opiate addiction cure trade collapsed during the Progressive Era under mounting public pressure and new federal legislation. One famous “muckraking” exposé, <a href="https://archive.org/details/greatamericanfr02adamgoog/page/n122">The Great American Fraud</a> by the journalist <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2901284/">Samuel Hopkins Adams</a>, pulled back the curtain on the industry of opiate addiction cures for millions of appalled readers. </p>
<figure class="align-left ">
<img alt="" src="https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=890&fit=crop&dpr=1 600w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=890&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=890&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1118&fit=crop&dpr=1 754w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1118&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/260766/original/file-20190225-26184-1wfa44j.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1118&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Collier’s ad, Dec., 1905, after the publication of articles on patent medicine fraud.</span>
<span class="attribution"><span class="source">Wikimedia Commons</span></span>
</figcaption>
</figure>
<p>Hopkins painted such a scathing portrait of opiate addiction cures, whose proprietors the writer dismissed as “scavengers,” that the American Medical Association <a href="https://www.jstor.org/stable/2710829?seq=1#page_scan_tab_contents">paid</a> to disseminate Adams’s reporting as part of a lobbying campaign for the regulation of patent medicines. This strategy paid off. Although far from perfect solutions, the <a href="https://history.house.gov/Historical-Highlights/1901-1950/Pure-Food-and-Drug-Act/">Pure Food and Drug Act</a> of 1906 and the <a href="http://www.drugpolicy.org/blog/today-100th-anniversary-harrison-narcotics-tax-act">Harrison Narcotics Tax Act</a> of 1914 regulated the ingredients and sale of patent medicines and narcotics, including opiate addiction medicines. These measures ultimately ensured that Collins, Keeley and other patent medicine sellers could no longer prey upon opiate-addicted customers.</p>
<p>Like its Gilded Age predecessors, today’s Big Pharma actively schemes to profit off of vulnerable, addicted customers, even while taking steps to ensure that opioid addiction persists. I believe that only sustained, vigilant oversight can prevent the reemergence of a medical Gilded Age, one in which companies like Purdue Pharma can manufacture an addiction crisis and charge customers for “curing” it.</p><img src="https://counter.theconversation.com/content/112363/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan S. Jones does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Considered in historical context, Purdue’s plan to peddle opioid addiction medicines to vulnerable people is not so surprising. Gilded-Age pharmaceutical companies used similar strategies.Jonathan S. Jones, PhD Candidate in History, Binghamton University, State University of New YorkLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1043832018-10-15T10:28:59Z2018-10-15T10:28:59ZDispatches from the morgue: Toxicology tests don’t tell the whole story of the opioid epidemic<figure><img src="https://images.theconversation.com/files/240281/original/file-20181011-154542-16imlcg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Mortality data show only the final result of opioid overdose, not why it happens.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/scene-hospital-morgue-where-corpses-taken-761983000?src=UWs3b11-wDD_bFApQ5lCKg-1-0">Skyward Kick Productions/Shutterstock.com</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-sa/4.0/">CC BY-NC-SA</a></span></figcaption></figure><p>“Drug overdoses killed more Tennesseans than ever last year, fentanyl deaths up 70 percent,” a recent headline from my hometown newspaper, <a href="https://www.tennessean.com/story/news/2018/08/20/tennessee-overdose-deaths-2017-opioid-fentanyl/1044057002/">The Tennessean</a>, proclaimed. </p>
<p>Variations of this headline have become routine across the U.S. In June 2017, a reporter at <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">The New York Times</a> revealed that opioid overdose deaths in 2016 in the U.S. surpassed the peak number of car deaths, a record that had stood since 1972. <a href="https://www.vox.com/policy-and-politics/2017/7/7/15925488/opioid-epidemic-deaths-2016">Vox</a>, an internet media outlet, announced that “in one year, drug overdoses killed more Americans than the entire Vietnam War did,” while <a href="https://www.cbsnews.com/news/drug-overdose-deaths-heroin-opioid-prescription-painkillers-more-than-guns/">CBS News</a> claimed that “drug overdoses now kill more Americans than guns.”</p>
<p>These and similar dispatches from America’s morgues sound like an alarm bell. But, what do all these dead opiate users actually tell us about the opioid crisis? Having studied the history of drug screens, I’d say not much as much as we’d hoped, it turns out. </p>
<h2>The world the screens make</h2>
<p>Drug screens serve a number of clinical purposes. For clinicians in methadone programs, drug screens are an <a href="https://www.ncbi.nlm.nih.gov/pubmed/10473015">incomparable, albeit contentious, resource</a> to monitor patient compliance. For pathologists and medical examiners, screens identify chemicals present in a corpse. However, clinical care is only one fraction of why these screens matter. </p>
<p>Epidemiologists, scientists who study populations of people to learn about disease and injury patterns, aggregate machine-assisted, post-mortem diagnoses into the data of public health. Policymakers weigh these stats in forming governmental interventions. Screens, then, form a foundation on which decisions about medical care and governmental responsibility rest.</p>
<p>But, where did drug screens come from, how do they work and how reliable are they in helping us address the opioid crisis?</p>
<h2>Measuring drug addiction</h2>
<p>The first narcotics screens emerged in the <a href="http://jpet.aspetjournals.org/content/109/1/8">mid-1950s</a>. My own unpublished research has turned up two tests that composed most drug screening: the Nalorphine Test and chromatography. </p>
<p>The Nalorphine Test, also called the Nalline Test, comprised two steps. First, subjects received an injection of an opiate antagonist, N-<a href="https://ascpt.onlinelibrary.wiley.com/doi/pdf/10.1002/cpt196126713">allylnormorphine</a>. </p>
<p><a href="https://reference.medscape.com/drugs/opioid-antagonists">Opiate antagonists</a> are chemicals that sit on opioid receptors without activating them, essentially working the opposite of opiates. In the human body, antagonists induce withdrawal symptoms, including pupil dilation. After administering the antagonist, a clinician measured the pupil size against standardized circles – a ruler called the pupillometer.</p>
<p>Jailers and physicians were especially keen on this method. One <a href="https://www-heinonline-org.proxy.library.vanderbilt.edu/HOL/Page?handle=hein.journals/fedpro27&div=28&start_page=32&collection=journals&set_as_cursor=0&men_tab=srchresults">physician</a> remarked that “the test was designed to be and has been used as a club over the head of the addict whom no one should believe.” </p>
<p><a href="https://www.tandfonline.com/doi/abs/10.3109/10826087309048772">Critics</a> reaffirmed that the test was a club, describing the procedure’s painful induced withdrawals and its supposedly inexact methods. Accuracy was not paramount to the Nalorphine test. Its utility was forcing patients and prisoners alike to fear discovery. </p>
<h2>A gold standard emerges</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=451&fit=crop&dpr=1 754w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=451&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/240279/original/file-20181011-154583-1ryw65t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=451&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Chromotography has been considered the best way to test for drugs.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/illustration-chemistry-chromatography-technique-separating-components-1173724111?src=Fh-PjdNvU9UarRHL9735qQ-1-7">Nasky/Shutterstock.com</a></span>
</figcaption>
</figure>
<p><a href="https://www.britannica.com/science/chromatography">Chromatography</a> involves separating a specimen – urine, blood, hair, even organs! – into its constituent chemicals. </p>
<p>Two types of chromatography exist and serve distinct goals. Thin-layer chromatography identifies the component chemicals in a specimen, while gas-liquid chromatography combined with a mass spectrometer (GLC-MS) identifies and weighs the mass of each substance. </p>
<p>Chromatography, unlike the Nalorphine test, found an early audience among toxicologists and chemists. The benefit of chromatography is its ability to quantify, and, supposedly, to render objective diagnoses.</p>
<p>Eventually, chromatography won out. GLC-MS remains the gold standard in drug testing. Insofar as GLC-MS measures the quantities of a given chemical, these screens work great. However, I remain skeptical of marshaling its results to understand the opioid crisis.</p>
<h2>The pitfalls of a toxicological imagination</h2>
<p>Drug screens aren’t just a means of diagnosing overdoses. They constitute a distinct mode of making and interpreting biological data using specialized laboratory measuring devices, a perspective I call the “toxicological imagination.” That perspective imports pitfalls into individual, and, by extension, aggregate cases alike.</p>
<p>First, GLC can never prove conclusively that this or that drug is responsible for an individual death. GLC belches out results in milligrams/milliliter, but the significance of these numbers is relative. And there is no universal lethal dosage. GLC-MS can’t account for individual tolerance levels, which affect the dose at which a drug becomes lethal. </p>
<p>Screens have to be juxtaposed against other data: patient history, anatomical and histological observation, and social setting of the death. Synthesis of all this data reinjects the human, and all of its subjectivity, into diagnosis.</p>
<p>Second, screens overemphasize misleading concerns, especially drug potency levels. Remember when we thought crack was going to kill us all because it was supposedly so much stronger than cocaine? Fentanyl currently sits on crack’s vacated throne in this regard.</p>
<p>When we evaluate the opioid crisis by confirmed overdose deaths, we advance the kinds of interpretations that colored reactions to, for example, crack.</p>
<h2>An alternative to the toxicological imagination?</h2>
<p>Instead, I think we need to discern the medical landscapes that turn an overdose into a mortality. What is the availability of <a href="https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio">Narcan</a>, an opiate antagonist that reverses an overdose? Where is the nearest ER? How easily can drug users access in-patient rehab? </p>
<p>I choose these questions specifically to raise the point that when we see individual and aggregate deaths, or observe the potency of x, y or z drug, we miss out on distal causes that produce an overdosing death. Using overdose deaths or drug potency as a basis to address the opioid crisis is akin to responding to Hurricane Katrina knowing only its wind speed or inches of rain.</p>
<p>Let me be plain: I’m trying to say that drug screens, regardless of their sensitivity, can never reconstruct the social relations that underwrite individual mortalities.</p><img src="https://counter.theconversation.com/content/104383/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Justin Wade Hubbard does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The toll of the opioid epidemic is often derived from toxicology reports. These rely on drug tests. A medical historian explains these tests and how they fall short of capturing why people are dying.Justin Wade Hubbard, Doctoral Candidate, Medical History, Vanderbilt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1029552018-09-11T15:21:30Z2018-09-11T15:21:30ZFear of police stop and search can deter opioid users from carrying anti-overdose kits<figure><img src="https://images.theconversation.com/files/235836/original/file-20180911-144473-1r4v3bj.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naloxone counteracts the effects of an overdose. </span> <span class="attribution"><span class="source">Ethypharm</span></span></figcaption></figure><p>The levels of fatal overdose in the UK are catastrophic. More than 4,500 people <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2017registrations">died of</a> a drug-related death in 2017 alone. In Scotland, the figure <a href="https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-related-deaths-in-scotland/2017">totalled</a> 934, the highest ever annually recorded. Drug mortality rates in Scotland per head of population are roughly two and half times higher than the UK average, and <a href="http://www.emcdda.europa.eu/system/files/publications/4667/Assessment%20of%20drug-induced%20death%20data.pdf">among the</a> highest in Europe. The vast majority of these deaths continue to involve opioids such as heroin, morphine and methadone. </p>
<p>One of the Scottish government’s flagship responses to this drug death crisis <a href="https://www.tandfonline.com/doi/full/10.3109/09687637.2012.682232">has been</a> a national <a href="https://en.wikipedia.org/wiki/Naloxone">naloxone</a> programme. Naloxone is an antidote that has been used in emergency medicine since the 1970s to treat the effects of opioid overdoses. Scotland began freely supplying naloxone kits to people who use drugs for peer administration in 2011, becoming the first country in the world to do so nationally. It also made them available to drug users’ friends and family and to practitioners working in the field. </p>
<p><a href="https://gov.wales/topics/people-and-communities/communities/safety/substancemisuse/harm/naloxone/?lang=en">Wales</a> and <a href="https://www.theguardian.com/world/2014/feb/16/norway-trial-nasal-spray-antidote-heroin-overdose">Norway</a> have since launched comparable national programmes. Drug users in England <a href="https://www.gov.uk/government/publications/widening-the-availability-of-naloxone/widening-the-availability-of-naloxone">have been</a> receiving kits since 2015, but this is at the <a href="https://www.release.org.uk/blog/take-home-naloxone-england">discretion</a> of local authorities, so availability varies around the country. Other countries, including <a href="https://www.ncbi.nlm.nih.gov/pubmed/29744980">Australia</a>, <a href="https://towardtheheart.com/naloxone">Canada</a> and the <a href="https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html">US</a>, are a similar mixed bag of availability – though in many cases, people have to pay. </p>
<p>In Scotland, around 40,000 naloxone kits <a href="https://www.isdscotland.org/Health-Topics/Drugs-and-Alcohol-Misuse/Publications/2017-11-07/2017-11-07-Naloxone-Report.pdf?28605288268">have been</a> supplied to date. Mortality rates among those at greatest risk – people recently released from prison – <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30656-6/fulltext?code=lancet-site">have plummeted</a>, from roughly 10% to 4% in a decade. Yet this is completely overshadowed by the surging figure for drug deaths as a whole, 87% of which were from opioids. One of the only other regions where stats about the impact of naloxone kits are available is British Columbia, which <a href="https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30044-6/fulltext?code=lancet-site">showed that</a> almost 300 people had been saved by their programme since it was rapidly expanded in 2016. </p>
<p>In 2015, we <a href="https://www.sciencedirect.com/science/article/pii/S037687161600106X">reported Scottish data</a> which highlighted an unusual paradox: naloxone kits were reaching growing numbers of people who inject drugs, but fewer than one in ten kits were being carried around as intended. Our latest data, illustrated in the graph below, suggests this was not a blip; carriage rates of naloxone remain stubbornly low.</p>
<p><strong>Naloxone kits among people who inject drugs in Scotland, 2011-2018</strong></p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/235670/original/file-20180910-123107-1dzwupj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/235670/original/file-20180910-123107-1dzwupj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/235670/original/file-20180910-123107-1dzwupj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=284&fit=crop&dpr=1 600w, https://images.theconversation.com/files/235670/original/file-20180910-123107-1dzwupj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=284&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/235670/original/file-20180910-123107-1dzwupj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=284&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/235670/original/file-20180910-123107-1dzwupj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=357&fit=crop&dpr=1 754w, https://images.theconversation.com/files/235670/original/file-20180910-123107-1dzwupj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=357&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/235670/original/file-20180910-123107-1dzwupj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=357&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><span class="source">Needle Exchange Surveillance Initiative, Health Protection Scotland</span></span>
</figcaption>
</figure>
<p>This issue wouldn’t be very important if we could be sure that the majority of drug use was taking place in people’s homes, where kits are likely to be accessible. But we know from <a href="https://bmcpublichealth.biomedcentral.com/track/pdf/10.1186/s12889-018-5718-9">recent research</a> conducted in Glasgow that many people inject drugs in public places. So why are people who inject drugs not carrying their naloxone kits around with them? </p>
<h2>Stop and search</h2>
<p>To find out, we recently carried out <a href="https://www.sciencedirect.com/science/article/pii/S0955395918301427">in-depth interviews</a> with a group of people who injected drugs. One key issue that emerged was a perception that police carrying out routine stop and searches would view the kits as drug paraphernalia because a needle is included. Although none of our interviewees were basing this on a real-life account, they feared they would end up getting taken to a police station for a fuller search. </p>
<p>Stop and search <a href="https://fullfact.org/crime/stop-and-search-england-and-wales/">has been</a> an issue with policing in England <a href="http://news.bbc.co.uk/1/hi/uk/2246331.stm">for decades</a>, but only came to the fore in Scotland in 2014. This was thanks to <a href="http://www.sccjr.ac.uk/wp-content/uploads/2014/01/Stop_and_Search_in_Scotland1.pdf">findings</a> that rates were almost four times higher than in England and Wales; and that in most cases, suspects were being asked to “voluntarily” give consent rather than because police believed they may be carrying drugs or a weapon or whatever. </p>
<p>Yet on the back of a huge amount of negative publicity, Police Scotland has gradually clamped down on stop and search in the past five years. It introduced a new <a href="https://beta.gov.scot/binaries/content/documents/govscot/publications/guidance/2017/05/guide-stop-search-scotland/documents/00517807-pdf/00517807-pdf/govscot:document/?inline=true">code of practice</a> in May 2017, along with <a href="http://www.maklu-online.eu/en/tijdschrift/ejps/volume-5/special-issue-changes-policing-improve-service-del/changing-stop-and-search-scotland/">significant changes</a> to search policy. Even before these changes, the levels of stop and search <a href="http://www.scotland.police.uk/about-us/police-scotland/stop-and-search/stop-and-search-data-publication/">had dropped</a> by more than half. Overall, they have reduced dramatically. </p>
<p>It may be that people who inject drugs are not aware of Police Scotland’s new approach – or they may still feel at risk of being stopped anyway. The reduction in stop and search rates is certainly likely to have been more marked for people in general than for opioid users. This points to an urgent need for the police to reassure people that no action will be taken if they are found carrying the kits – and more generally to raise awareness around the code of practice. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/235846/original/file-20180911-144485-wbvuxb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/235846/original/file-20180911-144485-wbvuxb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/235846/original/file-20180911-144485-wbvuxb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/235846/original/file-20180911-144485-wbvuxb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/235846/original/file-20180911-144485-wbvuxb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/235846/original/file-20180911-144485-wbvuxb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/235846/original/file-20180911-144485-wbvuxb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/235846/original/file-20180911-144485-wbvuxb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drug users fear police attitudes to naloxone.</span>
<span class="attribution"><span class="source">Police Scotland</span></span>
</figcaption>
</figure>
<p>In many states in the US, among other countries, naloxone is carried by the police as part of their routine kit. Police are often the first responders at drug overdose incidents and equipping them in this way can save lives. One such state is Indiana, where <a href="https://www.sciencedirect.com/science/article/pii/S0376871614018900">research found</a> attitudes toward naloxone among officers to be overwhelmingly positive. There have been <a href="https://www.telegraph.co.uk/news/2018/08/31/police-should-carry-overdose-kits-treat-addicts-crime-commissioner/">recent calls</a> for the police in the UK to adopt the same practice. It could send a strong message that the police support naloxone carriage. </p>
<p>In Scotland, police and partners <a href="https://twitter.com/PSsafercomms/status/1035589765683441664">have at least begun</a> raising awareness about naloxone among officers. Given that <a href="http://www.legislation.gov.uk/asp/2012/8/contents/enacted">the purpose</a> of Scottish policing is to improve public well-being and safety, this certainly makes sense. Ensuring that police practices reduce, rather than exacerbate, harms to drug users is an important part of that. Policing is part of the picture; now more than ever, collective action can help reduce drug-related deaths.</p><img src="https://counter.theconversation.com/content/102955/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew McAuley has received funding in the past from the Scottish government. </span></em></p><p class="fine-print"><em><span>Liz Aston previously received funding from the Scottish Institute for Policing Research and Police Scotland to conduct research on stop and search with Dr Megan O’Neill (University of Dundee).</span></em></p>Naloxone programmes have sprung up in the UK and elsewhere, but drug death rates keep climbing.Andrew McAuley, Senior Research Fellow, School of Health and Life Sciences, Glasgow Caledonian UniversityLiz Aston, Associate Professor of Criminology, Edinburgh Napier UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/997102018-08-06T11:59:43Z2018-08-06T11:59:43ZRecord level of drug deaths in England and Wales – latest official figures<figure><img src="https://images.theconversation.com/files/230743/original/file-20180806-191035-1x5gwsk.jpg?ixlib=rb-1.1.0&rect=0%2C41%2C997%2C516&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/572107339?src=xkrNWz93-ROm5-8EfxQDqw-1-0&size=medium_jpg">C_KAWI/Shutterstock.com</a></span></figcaption></figure><p>For the fifth year in a row, the number of drug-related deaths reported in England and Wales has risen to record levels, according to the latest figures from the Office for National Statistics. In 2017, 2,503 deaths were <a href="https://www.ons.gov.uk/releases/deathsrelatedtodrugpoisoninginenglandandwales2017registrations">recorded</a> as “drug misuse”. This comes on top of July’s announcement of an 8% increase in drug-related deaths in <a href="https://www.nrscotland.gov.uk/statistics-and-data/statistics/statistics-by-theme/vital-events/deaths/drug-related-deaths-in-scotland/2017">Scotland</a>. </p>
<p>In Great Britain, as a whole, deaths from drugs overtook <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/668504/reported-road-casualties-great-britain-2016-complete-report.pdf">traffic</a> fatalities as a leading cause of death in 2008, and they have risen particularly sharply since 2012.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230737/original/file-20180806-191028-9n9qx4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drug deaths versus road deaths.</span>
<span class="attribution"><span class="source">ONS</span></span>
</figcaption>
</figure>
<p>Jump in a car and everything around you is designed with safety in mind, from the roads to the construction of the vehicle. But with drugs, you are on your own. Policy <a href="https://www.theguardian.com/commentisfree/2017/jul/15/home-office-drugs-strategy-users-policy-public-services">effort</a> is centred on preventing drug use rather than protecting people when they use substances. </p>
<h2>Blaming the dead</h2>
<p>The government’s response to these latest figures will undoubtedly be to deflect attention from the failure of policy and blame those who died instead, arguing that they were part of <a href="https://www.theguardian.com/politics/2018/apr/04/seaside-towns-are-hotspots-for-heroin-deaths-says-ons">an ageing cohort</a> of drug users whose lifestyles and poor choices contributed to their early deaths.</p>
<p>The people most likely to die are working class, over 40 and living in de-industrialised areas. Drug death rates are nine times higher in the most <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/halfofheroinmorphinemisusedeathhotspotsinenglandandwalesareseasidelocations/2018-04-04">deprived</a> neighbourhoods than in the richest areas. </p>
<p>Unfortunately, investment in treatment does not match local need, so those areas with the greatest need get the least <a href="https://www.theguardian.com/society/2017/oct/14/drug-overdoses-rise-most-treatment-cuts-are-deepest">resources</a>. </p>
<h2>Deaths could be reduced</h2>
<p>There is a lot of research on how to reduce these deaths. In 2016, the government’s scientific advisers, the Advisory Council on the Misuse of Drugs (ACMD), summarised this evidence for ministers in a <a href="https://www.gov.uk/government/publications/reducing-opioid-related-deaths-in-the-uk">report</a>. The ACMD’s recommendations include wider provision of naloxone, a medicine that reverses opioid overdose. </p>
<p>The ACMD also called for central funding of heroin-assisted treatment. It advised that areas with high concentrations of injecting drug use should consider setting up medically supervised drug consumption rooms. These have been <a href="https://www.bbc.co.uk/news/uk-england-40674453">shown</a> to reduce drug-related health problems. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/230742/original/file-20180806-191022-2qdab7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Naloxone can reverse the effects of opioids.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/confirm/1062517577?src=QGLUS5Jpmb64KqjXIA3yrQ-1-9&size=medium_jpg">Tomas Nevesely/Shutterstock</a></span>
</figcaption>
</figure>
<p>The most important recommendation was to invest in opioid substitution therapy. This treatment prescribes substitutes for heroin – such as methadone or buprenorphine – to people who are dependent. It is effective in retaining patients, reducing crime and avoiding the spread of infectious disease, such as HIV and viral hepatitis. It is <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/add.12971">estimated</a> that the expansion of this treatment in the 2000s was saving about 880 lives per year by the end of that decade. </p>
<p>Since then, there have been substantial cuts to the funding of drug treatment services. Spending on adult drug treatment services is <a href="https://www.health.org.uk/blog/health-investment-needs-long-term-thinking">projected</a> to have fallen by 26% in the four years from 2014. This led the ACMD <a href="https://www.gov.uk/government/publications/commissioning-impact-on-drug-treatment">to describe</a> funding cuts as “the biggest single threat” to the outcomes of drug treatment. </p>
<h2>Empty promises</h2>
<p>In its response to the ACMD’s recommendations, ministers claimed to accept them all, except drug consumption rooms. But their actions have not lived up to this claim. There has been no new funding for opioid substitution therapy, which continues to be cut.</p>
<p>A <a href="https://www.release.org.uk/blog/take-home-naloxone-england">survey</a> of local authorities in 2017, conducted by the charity <a href="https://www.release.org.uk/">Release</a>, found that the provision of naloxone in England is still patchy and inadequate. Some areas with high levels of drug-related deaths, like <a href="https://fingertips.phe.org.uk/profile/public-health-outcomes-framework/data#page/3/gid/1000042/pat/6/par/E12000001/ati/102/are/E06000001/iid/92432/age/1/sex/4">Hartlepool</a>, had no plans to introduce this life-saving medication.</p>
<p>The government also failed to follow ACMD’s recommendation to improve reporting and research on drug-related deaths. Taken together, there has been a comprehensive failure to take steps to reduce deaths. And, predictably, deaths have risen.</p>
<h2>Death by indifference</h2>
<p>Fatal road traffic accidents have successfully been reduced, not by banning cars but by employing evidence of what is effective in protecting people while they drive. We won’t reduce drug-related deaths by continuing to focus on banning drugs. </p>
<p>It’s not lack of know how that’s killing people – we already know how to reduce <a href="https://scottishrecoveryconsortium.org/assets/files/Resources/drugs-related-deaths-rapid-evidence-review.pdf">deaths</a> – but, as with road traffic deaths, investment and political will are needed to stop people dying as a result of using drugs. Government policy has the veneer of caring about people who die and the family and friends they leave behind, but another 2,503 needless deaths suggest otherwise.</p><img src="https://counter.theconversation.com/content/99710/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton is affiliated with Alcohol Research UK. </span></em></p><p class="fine-print"><em><span>Alex Stevens is a member of the Advisory Council on the Misuse of Drugs. He was the lead author of its 2016 report on Reducing Opioid-Related Deaths in the UK. He does not speak for the ACMD, but writes here in his capacity as an academic.</span></em></p>There are proven ways to reduce drug deaths. Unfortunately, the UK government is not implementing them.Ian Hamilton, Lecturer in Mental Health and Addiction, University of YorkAlex Stevens, Professor in Criminal Justice and Faculty Director of Public Engagement, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/991192018-07-20T10:37:10Z2018-07-20T10:37:10ZNaloxone remains controversial to some, but here’s why it shouldn’t be<figure><img src="https://images.theconversation.com/files/228088/original/file-20180717-44076-1o1bibp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">U.S. Surgeon General Dr. Jerome Adams demonstrates the proper procedure for administering a nasal injection of naloxone on reporter Jennifer Lott, left, during a visit to the University of Mississippi Medical Center in Jackson, Miss., May 17, 2018. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/search?st=mr&reference=9a6a09cf2c1d4c88b42cfb39555491b3">AP Photo/Rogelio V. Solis</a></span></figcaption></figure><p>The overdose-reversing drug naloxone <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm">saves thousands of lives</a> each year and is <a href="https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf">more widely available</a> today than ever. So why do overdose deaths across the U.S. <a href="https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html">continue to rise</a>?</p>
<p>According to one 2018 <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3170278">study</a>, naloxone itself is partly to blame. Naloxone, the authors of the study wrote, increases opioid use and does not reduce opioid-related mortality overall because it provides users with a “safety net” and thus encourages riskier drug use. The paper set off a Twitterstorm and <a href="https://www.theatlantic.com/health/archive/2018/03/moral-hazard-opioid/555389/">controversy</a> even among those who don’t air their disagreements digitally. </p>
<p>From the perspective of a <a href="https://profiles.ucsf.edu/cyrus.ahalt">public health researcher</a>, I can say the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4584734/">weight of evidence</a> suggests that naloxone, which is often sold as the brand name Narcan, is a vital tool in fighting the overdose epidemic and, in fact, is too often not available where it is needed most. </p>
<h2>Scant evidence of moral hazard</h2>
<p>The “<a href="https://economictimes.indiatimes.com/definition/moral-hazard">moral hazard</a>” discussed in this study is an economic term, not an ethical one. It describes increasingly risky behavior in response to policies or innovations that lessen associated consequences. An example? Driving more recklessly with auto insurance than without.</p>
<p>The authors infer increased risk-taking based on trends such as ER use, crime and death, that they otherwise cannot explain. They marshal a few journalistic accounts of parties where users intentionally overdose and revive each other with naloxone. They also cite a health risk behavior literature describing increased sexual risk taking in response to anti-retroviral treatment.</p>
<p>But harm reduction experts <a href="https://www.thefix.com/narcan-party-hysteria-puts-value-drug-users-lives">have said</a> that journalistic accounts of “Narcan parties” are inaccurate and public officials who have warned of their danger acknowledge, on follow-up, that the <a href="https://theoutline.com/post/1964/narcan-parties-heroin-overdoses?zd=3&zi=inblzavm">parties are urban legend</a>. </p>
<p><a href="https://jamanetwork.com/journals/jama/fullarticle/199091">Other studies</a> of increased sexual risk behavior in response to anti-retroviral treatment conclude that this is a patient-education problem. In fact, though the relevant research on naloxone is limited, <a href="https://www.ncbi.nlm.nih.gov/pubmed/16956873">the</a> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2570543/">few</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/19268564">studies</a> that have been conducted echo the anti-retroviral literature in emphasizing education as critical to <a href="https://www.bmj.com/content/346/bmj.f174">achieving harm reduction</a>. Providing education and training alongside naloxone <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3163671/">improves users’ ability</a> to accurately identify and <a href="https://www.tandfonline.com/doi/full/10.1080/08897077.2015.1110550?src=recsys">confidently respond</a> to overdoses. But <a href="https://www.tandfonline.com/doi/full/10.1080/08897077.2015.1010032?src=recsys">more research is needed</a> to ensure that the overdose education and naloxone distribution model achieves harm reduction beyond reversing overdoses.</p>
<h2>Problems with naloxone availability</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228089/original/file-20180717-44100-ogga61.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In this Jan. 23, 2018, photo, Leah Hill, a behavioral health fellow with the Baltimore City Health Department, wears a shirt advertising the health department’s opioid overdose awareness efforts.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Overdose-Drug/c36205905ce94b3cbc1c5638cab3f320/4/0">AP Photo/Patrick Semansky</a></span>
</figcaption>
</figure>
<p>The moral hazard study also assumes that naloxone is widely available in states that have passed naloxone laws allowing broader distribution. Yet there is evidence that access often remains critically limited despite these laws. New Hampshire’s <a href="https://anyoneanytimenh.org/">Anyone Anytime</a> program, for example, provides a wealth of resources but <a href="https://ndews.umd.edu/sites/ndews.umd.edu/files/marsch-ndews-webinar-slides-nh-hotspot-09-11-17.pdf">the drug is still often not on hand</a> because “consumers report significant barriers to access … high cost, fear of police, fear of stigmatization, lack of knowledge, fear of withdrawal. Responders report mixed feelings about making it available to the public.”</p>
<p>After Ohio <a href="http://pharmacy.ohio.gov/Pubs/NaloxoneResources.aspx">passed its naloxone law</a> in 2014, overdose deaths <a href="https://www.cincinnati.com/story/news/2017/08/30/ohio-drug-overdose-deaths-more-than-double-thanks-fentanyl/618778001/">surged</a>. But the Cuyahoga County Sheriff’s and Cleveland Police departments did not start carrying naloxone until <a href="https://www.cleveland.com/metro/index.ssf/2017/08/cuyahoga_county_sheriffs_offic_2.html">mid-2017</a>, and as the Cleveland Plain Dealer <a href="https://www.cleveland.com/healthfit/index.ssf/2018/04/life-saving_overdose_antidote.html">reported</a> as recently as April 2018, “Narcan should be available across northeast Ohio, but it’s not.” A <a href="https://www.tandfonline.com/doi/full/10.1080/08897077.2015.1132294?src=recsys">recent study</a> in Ohio found persistent barriers to naloxone distribution similar to those experienced in New Hampshire, including cost, stigma and legal fears. </p>
<p>The law enforcement community concurs. Though many states had passed naloxone laws, a 2017 Police Executive Research Forum <a href="http://www.policeforum.org/assets/opioids2017.pdf">report</a> underscored the persistent need for greater distribution. The first of its “10 Actions Police Chiefs and Sheriffs Can Take” read: “Equip officers with naloxone.” That report went further, arguing that naloxone should be distributed as broadly as possible, including to the general public: “Police chiefs and sheriffs also can use their positions of leadership in the community to call for widespread distribution of naloxone … at drug treatment facilities, homeless shelters, and other locations.”</p>
<h2>The real hazard: Fentanyl</h2>
<p>There is a better explanation for the continued rise in overdose deaths, and I believe it suggests that naloxone should be far more widely distributed.</p>
<p>From 2013 to 2016 – when most <a href="https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf">states passed naloxone laws</a> – fentanyl seizures at the border <a href="https://www.hsgac.senate.gov/imo/media/doc/Owen%20Testimony.pdf">rose astronomically</a>. In 2017, nearly 1,800 pounds were seized. To put that in perspective, consider that a <a href="https://www.statnews.com/2016/09/29/why-fentanyl-is-deadlier-than-heroin/">lethal dose</a> weighs 2 milligrams. By then, fentanyl was already the drug <a href="https://jamanetwork.com/journals/jama/article-abstract/2679931?redirect=true">most commonly involved</a> in overdose deaths. </p>
<p>The study’s authors assert that “broadening naloxone access increased the use of fentanyl.” But <a href="https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/research-use-misuse-fentanyl-other-synthetic-opioids">evidence</a> suggests that fentanyl deaths commonly occur among unknowing users because heroin and other drugs are easily and often <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a2.htm">adulterated</a> with cheaper, more potent fentanyl. The <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a2.htm">Centers for Disease Control and Prevention</a> notes that fentanyl follows the supply of white powder heroin in the U.S. precisely because it can be easily concealed and passed off as pure heroin. As a result, fentanyl is far less common in states, such as California, where black tar or brown powder heroin are predominant. </p>
<p>Indeed, the federally funded Fentanyl HotSpot <a href="https://ndews.umd.edu/sites/ndews.umd.edu/files/marsch-ndews-webinar-slides-nh-hotspot-09-11-17.pdf">study describes</a> the drug’s rise as a supply issue: “Consumers report buying any opioid that is available from their dealer, and widely acknowledge that fentanyl-laced heroin is most available.” </p>
<p>These perspectives from people on the ground – users, first responders and others – are particularly critical to understanding the complex relationships between fentanyl, naloxone and drug use behavior because secondary data on fentanyl are <a href="https://jamanetwork.com/journals/jama/article-abstract/2679931?redirect=true">unusually</a> <a href="https://www.theatlantic.com/health/archive/2018/05/americas-opioid-crisis-is-now-a-fentanyl-crisis/559445/">unreliable</a>. That is why the authors of the “moral hazard” study cannot control for it. Instead, their claim that moral hazard is driving fentanyl use is an inference, one that dangerously belies the fact that naloxone has not been widely distributed in many places - like New Hampshire and Cuyahoga County, Ohio - where overdose deaths continue to rise.</p>
<h2>Missed opportunity</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/228091/original/file-20180717-44091-1npu5f9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A Narcan package. Many states report a shortage or difficulty obtaining the drug.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/may-26-2017ogden-utah-usa-naloxone-648230575?src=Hf4hNNIhEJEhuObQuW7feg-1-0">PureRadiancePhotos/Shutterstock.com</a></span>
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</figure>
<p>A few public officials, like Maine’s Governor <a href="https://www.pressherald.com/2018/01/28/maine-falls-behind-other-states-in-efforts-to-prevent-overdose-deaths/">Paul LePage</a>, believe that naloxone does not, on balance, benefit society. But naloxone skepticism is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3008773/">rare among experts</a>. No professional organization has taken the position that distribution should be limited in order to prevent riskier drug use. The <a href="https://www.apha.org/policies-and-advocacy/public-health-policy-statements/policy-database/2014/07/16/13/08/reducing-opioid-overdose-through-education-and-naloxone-distribution">American Public Health Association</a> and the <a href="https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html">U.S. surgeon general</a> have issued unambiguous statements in support of naloxone’s broadest possible use.</p>
<p>Naloxone is not itself the answer to the country’s drug crisis. Nor can making it so widely available be achieved without <a href="https://www.washingtonpost.com/news/to-your-health/wp/2017/06/28/a-council-members-solution-to-his-ohio-towns-overdose-problem-let-addicts-die/?utm_term=.db0f527bc023">costs</a> – from the financial cost of Narcan kits to an increased burden on emergency services to the psychological toll that reviving the same person time and again can exact on responders. </p>
<p>Undoubtedly, another cost is that some users will use naloxone as a “safety net.” But it remains a powerful public health tool. It saves hundreds of lives every day and, if distributed with appropriate education and training, has the potential to save many thousands more. The research needed now would identify strategies to mitigate those costs and to distribute naloxone as widely as possible.</p><img src="https://counter.theconversation.com/content/99119/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cyrus Ahalt does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>One study argues that naloxone increases opioid use because it protects against death from overdose. But a closer analysis shows Narcan is the number one public health tool to fight the overdose epidemic.Cyrus Ahalt, University of California, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/941542018-04-26T10:39:10Z2018-04-26T10:39:10ZAn addiction researcher shares 6 strategies to address the opioid epidemic<figure><img src="https://images.theconversation.com/files/215651/original/file-20180419-163975-1q6oydu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Chris Burkett deposits old needles at a needle exchange program in Aberdeen, Wash., June 14, 2017. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Despair-and-Donald-Trump/043b3d09c47c4b11b3477c1ceaff6c21/7/0">AP Photo/David Goldman</a></span></figcaption></figure><p>The devastating <a href="https://www.hhs.gov/opioids/about-the-epidemic">opioid epidemic</a> is one of the largest public health problems facing the U.S. Over <a href="https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf%202016">2.5 million</a> people in the U.S. suffer from opioid use disorder. </p>
<p>Four in five new heroin users <a href="https://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease">started out misusing prescription painkillers</a>. A 2015 analysis by the Centers for Disease Control and Prevention found people who are addicted to painkillers are <a href="https://www.cdc.gov/vitalsigns/heroin/index.html">40 times more likely to be addicted to heroin</a>.</p>
<p>The <a href="https://www.cdc.gov/drugoverdose/epidemic/inde">epidemic</a> actually began more than three decades ago. In 1980, crack and cocaine addiction contributed to the thousands of overdose deaths, whereas now people die from pain relievers and synthetic opioids such as fentanyl. </p>
<p>In 1990, I began studying its relationship to HIV and the experiences of people with multiple addictions. My research team and I have recruited research participants from emergency rooms, methadone programs, jails, prisons, alternative to incarceration projects, and HIV and primary care clinics. We have examined barriers to accessing care for drug addiction and HIV, and some of the lessons we have learned apply to the broader population.</p>
<h2>Two faces of the opioid addiction</h2>
<p>Years ago, I interviewed Jennifer, a former nurse, who was prescribed antidepressants to cope with childhood sexual abuse trauma. When this didn’t help, she stole narcotics from her clinic and was fired. With no access to pain pills, Jennifer began using heroin and cocaine. She reported facing stigma from health care providers due to her addiction, and she lacked access to counseling for depression. Jennifer’s case is not unique; many women face a lack of access to services addressing trauma and gender-based violence. </p>
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<img alt="" src="https://images.theconversation.com/files/215662/original/file-20180419-163982-we01rv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/215662/original/file-20180419-163982-we01rv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=432&fit=crop&dpr=1 600w, https://images.theconversation.com/files/215662/original/file-20180419-163982-we01rv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=432&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/215662/original/file-20180419-163982-we01rv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=432&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/215662/original/file-20180419-163982-we01rv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=543&fit=crop&dpr=1 754w, https://images.theconversation.com/files/215662/original/file-20180419-163982-we01rv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=543&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/215662/original/file-20180419-163982-we01rv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=543&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Tarryn Vick takes a dose of methadone at a clinic in Hoquiam, Wash., where she is being treated for drug addiction, June 15, 2017.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Despair-and-Donald-Trump/31b268b3452d461e8de9978178bb5f17/3/0">AP Photo/David Goldman</a></span>
</figcaption>
</figure>
<p>More recently, our research team interviewed John, who started using narcotics prescribed for back pain. His need for increasingly higher dosages exceeded the number of pills his physician would prescribe, so he turned to friends and then began heroin and injection drug use. </p>
<p>Although incarcerated numerous times for accidents while driving impaired, he said he was never asked about addiction or referred to drug treatment by his primary care office. Since John detoxed “cold turkey” in prison, he often overdosed after his release, reuniting with his “running buddies.” Recently, one of John’s buddies saved his life by using a free <a href="https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio">naloxone</a> kit from a health department stall at a street fair. John was lucky: Thousands of opioid users cannot access naloxone.</p>
<h2>Not addressing the core causes</h2>
<p>Though overprescribing opioids may have contributed to the current epidemic, many addiction experts believe that the root causes remain <a href="https://www.drugabuse.gov/about-nida/noras-blog/2017/10/addressing-opioid-crisis-means-confronting-socioeconomic-disparitie">poverty, incarceration, drug and health policies</a>, stigma toward people who use drugs, and a lack of access to drug treatment. </p>
<p>Yet much of what has been done to end the opioid epidemic has focused mainly on [reducing the amount of prescription painkillers] and <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1874575">improving drug monitoring programs</a> to identify newly filled prescriptions, which are not the real solutions to the growing opioid epidemic. In my view, there has been no clear policy action or plan to address the major root causes of the problem and improve access to drug treatment. President Donald Trump‘s plan to address the opioid epidemic <a href="https://www.vox.com/policy-and-politics/2018/3/21/17147580/trump-sessions-death-penalty-opioid-epidemich">emphasizes punishment</a>, reduction of supply, and law enforcement strategies with no potential to produce important change in the crisis.</p>
<p>Here are my six recommendations to address the opioid epidemic.</p>
<ul>
<li>Increase Medicaid coverage for drug treatment in all states</li>
</ul>
<p>The number of states providing benefits for addiction treatment grew with the creation of Affordable Care Act in 2010 and the expansion of Medicaid benefits – but only for states that opted to expand. Now, 32 states and the District of Columbia have adopted Medicaid expansion, which provides medical coverage including addiction treatment for most low-income adults. </p>
<p>However, <a href="https://www.kff.org/medicaid/issue-brief/the-coverage-gap-uninsured-poor-adults-in-states-that-do-not-expand-medicaid/">an estimated 2.5 million Americans fall into a coverage gap, where they are not eligible for Medicaid</a> because <a href="https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">their state did not expand</a> and they make too little to qualify for marketplace subsidies. </p>
<ul>
<li>Integrate drug treatment into primary care </li>
</ul>
<p>Medication assisted treatment – the practice of treating addiction with medicines – must be made available in primary care settings and integrated with health care services. The majority of the 2.5 million individuals with an opioid use disorder <a href="https://www.integration.samhsa.gov/about-us/esolutions-newsletter/integrating-substance-abuse-and-primary-care-services">do not receive evidence-based MAT</a>. <a href="https://www.integration.samhsa.gov/about-us/esolutions-newsletter/integrating-substance-abuse-and-primary-care-services">Few states have integrated this treatment</a>. </p>
<p>The Affordable Care Act is designed to promote improved <a href="https://www.integration.samhsa.gov/about-us/esolutions-newsletter/integrating-substance-abuse-and-primary-care-services">integration of substance use in health care services</a> in a more efficient and cost-effective way. <a href="https://addiction.surgeongeneral.gov/">There is extensive scientific evidence</a> supporting <a href="http://www.nejm.org/doi/full/10.1056/NEJMp1402780">integration into primary care</a>.</p>
<p>Some of the major barriers include <a href="https://www.samhsa.gov/about-us/who-we-are/laws-regulations">state and federal regulations</a> on credentialing and provision of medication-assisted treatment, such as strict rules on how and who can prescribe buprenorphine in primary care settings; shortage of physicians with training to treat substance use disorders; and clinic costs to meet the demands of staff training. </p>
<ul>
<li> Reduce stigma of health care providers toward drug users</li>
</ul>
<p>While health care providers understand addiction is a disease, research shows they commonly view addiction as a moral failure. In fact, <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2011.03601.x#b16">studies show</a> that <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/j.1360-0443.2011.03601.x#b20">negative attitudes</a> by health professionals toward patients with substance use disorders are common. They are a major reason individuals do not seek, receive or complete addiction treatment or access harm reduction services such as syringe access programs. </p>
<ul>
<li>Increase and customize programs that reduce harm</li>
</ul>
<p>I believe harm reduction – access to services aiming to reduce harm from the addiction rather than just treating it – is critical. Syringe exchange programs allow people with addiction trade in used syringes for new ones, reducing exposure to HIV, hepatitis C or other diseases that occur frequently in those with addiction. <a href="https://doi.org/10.1016/j.drugalcdep.2014.10.012">Supervised injection facilities</a> would provide a safe place for drug users to inject illicit substances with medical staff nearby.</p>
<ul>
<li>Address neglected populations within the criminal justice system</li>
</ul>
<p>Those addicted to opioids in prison and jails are often left untreated. Medication assisted treatment, such as the use of methadone, buprenorphine and naltrexone <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(14)62338-2/fulltext">should be provided to all inmates</a>. Upon release, individuals should receive naloxone to use on themselves or others. To avoid relapse, access to addiction treatment and other care <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3190599/">is imperative</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/215664/original/file-20180419-163962-pe0ogl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/215664/original/file-20180419-163962-pe0ogl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/215664/original/file-20180419-163962-pe0ogl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/215664/original/file-20180419-163962-pe0ogl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/215664/original/file-20180419-163962-pe0ogl.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/215664/original/file-20180419-163962-pe0ogl.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/215664/original/file-20180419-163962-pe0ogl.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The anti-overdose drug naloxone saves hundreds of lives a year.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/layton-utah-march-11-2016-vial-418417357?src=yxhk5RlsCJWIWmP3P4Hahg-1-1">PureRadiancePhoto/Shutterstock.com</a></span>
</figcaption>
</figure>
<ul>
<li> Make naloxone available to all<br></li>
</ul>
<p>I have seen countless research participant lives saved by relatives, friends and partners who received naloxone. <a href="https://www.cato.org/publications/research-briefs-economic-policy/little-help-friends-effects-naloxone-access-good">Recent evidence</a> shows states that actively promoted naloxone experienced 9 to 11 percent reductions in opioid-related deaths. States need strategies to make naloxone available and affordable to everyone, not just first responders. Medicaid should also reimburse naloxone prescriptions for home settings. </p>
<p>Even after 30 years, drug use remains stigmatized and individuals are left untreated. Understanding stories like Jennifer’s and John’s help destigmatize drug use and convey the need to address addiction in primary health care settings and link individuals to treatment in their communities.</p><img src="https://counter.theconversation.com/content/94154/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nabila El-Bassel receives funding from the National Institutes of Health. </span></em></p>Opioids kill 100 people each day in the US, more than vehicular accidents. Those addicted are often left without treatment. An addiction researcher offers six steps to address the epidemic.Nabila El-Bassel, Professor of Social Work, Director of Social Intervention Group, Columbia UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/895562018-01-12T00:00:43Z2018-01-12T00:00:43ZHow to stop overdoses? Prevent them to begin with<p>The Public Health Agency of Canada recently released projections that <a href="https://www.canada.ca/en/public-health/news/2017/12/statement_from_theco-chairsofspecialadvisorycommitteeontheepidem.html">2017 will have seen a total of more than 4,000 opioid-related deaths</a>. </p>
<p>This is a catastrophic increase from the <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/apparent-opioid-related-deaths-report-2016-2017-december.html">2,861 deaths across Canada in 2016</a>. And it confirms, tragically, that the <a href="https://theconversation.com/why-canada-should-declare-a-national-opioid-emergency-too-87325">public health emergency of fatal and non-fatal overdose and drug poisoning</a> continues to take an unprecedented human toll across Canada.</p>
<p>Drug deaths are dramatically outpacing anything we have seen before. For example, British Columbia, the province hardest hit by the crisis, recorded <a href="https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf">1,208 lives lost</a> from January to the end of October 2017. This is an increase of 77 per cent over the same period in 2016, and 200 per cent over 2015. </p>
<p>And British Columbia is not alone in these dramatic increases: Data from Ontario report <a href="https://news.ontario.ca/mohltc/en/2017/12/ontario-expanding-opioid-response-as-crisis-grows.html">336 opioid-related deaths</a> from May to July this year, a 68 per cent increase over the same period in 2016.</p>
<p>Laudable responses have rightly focused on immediate health outcomes such as reversing overdoses amid a drug supply contaminated with fentanyl or fentanyl analogues such as carfentanil. </p>
<p>To build a truly effective response to the crisis, however, Canada must also address the socio-economic factors linked to overdose risk — including <a href="https://doi.org/10.1503/cmaj.1031416">homelessness and housing insecurity</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/15108744">insufficient support following release from prison</a>, <a href="http://dx.doi.org/10.1371/journal.pone.0125568">severe poverty</a> and <a href="http://dx.doi.org/10.1007/s13524-017-0565-3">low educational attainment</a>.</p>
<h2>Life-saving measures</h2>
<p>Nationally, the percentage of all overdose deaths involving fentanyl has risen to <a href="https://www.canada.ca/en/public-health/services/publications/healthy-living/apparent-opioid-related-deaths-report-2016-2017-december.html">74 per cent in 2017 from 53 per cent in 2016</a>. </p>
<p>These increases seem likely to continue unless we legalize and regulate the drugs at the centre of the crisis. This would allow people to access information about drug potency and purity, but <a href="https://www.thestar.com/news/canada/2017/09/07/pm-says-no-to-decriminalizing-drugs-bc-addictions-minister-open-to-idea.html">the federal government explicitly does not support decriminalization</a>.</p>
<p>In this context, other life-saving responses — including supervised consumption and overdose prevention facilities, drug testing, the distribution of overdose-reversing Naloxone and access to injection and non-injection opioid-assisted treatment — are all expanding. All are crucial in reducing death from overdose. </p>
<p>It is difficult to fathom the size of the death toll if these measures were not in place. </p>
<p>The good news is that <a href="http://www.pivotlegal.org/the_overwhelming_case_for_overdose_prevention_sites">not a single one of the 108,804 visits to the first Overdose Prevention Site on Vancouver’s Downtown Eastside has resulted in a fatality</a>, despite 255 overdoses at the facility between Dec. 25, 2016 and Oct. 9, 2017. </p>
<p>Unquestionably, these efforts are saving lives.</p>
<h2>Limited access to interventions</h2>
<p>Access to overdose-related interventions is restricted geographically and available almost exclusively in urban centres. And the expansion of supervised injection facilities across the country has focused on urban, not rural, areas. Nevertheless, responses to the overdose crisis are gaining momentum.</p>
<p>The <a href="https://www.theglobeandmail.com/news/national/health-canada-proposes-to-allow-doctor-requests-to-prescribe-heroin/article30020597/">federal government is, for example, taking needed steps</a> to support the <a href="http://www.gazette.gc.ca/rp-pr/p1/2017/2017-04-22/html/reg3-eng.html">expanded availability of heroin-assisted treatment</a>. This enables individuals with severe substance use disorder to access medical opioids whose potency and purity is controlled. But it can be challenging to connect people living in rural areas to health services, which may limit their access to treatment. </p>
<p>Even with an overdose-response infrastructure with adequate coverage in place, most of these efforts do not stop overdoses — they merely prevent them from becoming fatal. </p>
<p>To achieve meaningful reductions in overdose death we need to prevent overdoses from occurring in the first place. </p>
<h2>Income assistance an overdose risk</h2>
<p>The most recent <a href="https://www2.gov.bc.ca/assets/gov/public-safety-and-emergency-services/death-investigation/statistical/illicit-drug.pdf">BC Coroners Service report</a> on illicit drug overdose deaths included this startling figure: During the days following income assistance payments, the rate of fatal overdose was significantly higher than at other times of the month. </p>
<p>In the first 10 months of 2017, this amounted to an average of nearly six fatal overdoses per day on the Wednesday to Sunday following income assistance payments, compared to 3.6 deaths per day at other times.</p>
<p>While this report is specific to B.C., most jurisdictions in Canada distribute income assistance in the same way: Once a month to all recipients on the same day.</p>
<p>This data is consistent with <a href="http://dx.doi.org/10.1016/j.socscimed.2016.11.006">existing research linking income assistance to increased drug use</a>. People have known for many years that income assistance payments — a critical component of the social safety net that reduces some of the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913691/">health harms of poverty</a> — are associated with increases in drug use and <a href="http://dx.doi.org/10.1016/j.drugpo.2016.05.010">overdose risk</a>. </p>
<p>People receiving these payments rely on monthly incomes that keep them significantly below the poverty line. The lack of financial security has negative implications for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1913691/">drug use</a>, <a href="http://dx.doi.org/10.1136/jech-2014-205079">drug-related harm</a> and <a href="https://doi.org/10.1371/journal.pone.0125568">overdose risk</a>. </p>
<p>Trends like this signal opportunities for action. Considering how social and socio-economic conditions increase overdose risk will be essential to overdose response efforts that adopt a preventive approach.</p>
<h2>Homelessness, unemployment, chronic pain</h2>
<p>Socio-economic marginalization — which includes <a href="https://doi.org/10.3109/00952999709040943">inadequate income</a>, <a href="http://dx.doi.org/10.1111/1467-9566.12344">exclusion from the labour market</a>, participation in illegal or <a href="http://dx.doi.org/10.1136/jech-2014-205079">prohibited income generation</a> like drug-dealing or theft, and <a href="http://dx.doi.org/10.1016/j.drugalcdep.2011.07.008">housing or food insecurity</a> — is a <a href="http://dx.doi.org/10.1136/jech-2014-205079">key driver of illicit drug use and drug-related harm</a>. </p>
<p>This kind of marginalization shapes whether and how people use drugs, how they experience the impacts and their access to a broad range of health and social services. It is relevant to the overdose crisis in many different ways.</p>
<p>For example, when someone loses their housing they may also lose the space, routines and social interactions that allow them to use opioids more safely. </p>
<p>Someone experiencing chronic pain may not have the resources to consistently access care and, as a result, may begin self-medicating with street drugs of unknown potency and purity. </p>
<p>This kind of socio-economic marginalization could also look like someone who goes through a family dissolution, who has to move quickly and often painfully to establish a new domestic situation with less financial and social stability, and who ends up using drugs in high-risk ways. </p>
<p>Or it could take the form of someone being released from prison, not having the resources to transition smoothly or access treatment, and relapsing in the context of a toxic drug supply.</p>
<h2>Broadening overdose prevention</h2>
<p>Current efforts to prevent overdose fatalities are extremely important. They are expanding nationally, as evidenced by the leap from two to 28 <a href="https://www.canada.ca/en/health-canada/services/substance-abuse/supervised-consumption-sites/status-application.html">Health Canada-approved supervised drug consumption facilities</a> in 2017, alongside new overdose prevention sites operating in select locations across the country. </p>
<p>Also critical are interventions to deal with the toxic drug supply. Ideally these would also involve the legalization and regulation of the drugs fuelling the current crisis. </p>
<p>Currently they include expanded <a href="http://www.bccsu.ca/news-release/province-expands-fentanyl-testing-and-launches-drug-checking-pilot-in-vancouver/">drug-testing</a> services and the recent announcement of a <a href="https://www.theglobeandmail.com/news/british-columbia/bc-pilot-project-to-distribute-clean-opioids-to-people-at-high-risk-of-overdose/article37392053/">British Columbia pilot to distribute “clean opioids” (hydromorphone)</a> to people at high risk of overdose.</p>
<p>But, as this public health emergency continues to deepen, we must also incorporate broader understandings of overdose risk into our response and prevention efforts.</p>
<p>Reducing the socio-economic marginalization associated with overdose risk for people who use illicit drugs will be essential. Meaningfully addressing the overdose crisis means addressing the socio-economic factors that increase overdose risk to begin with.</p>
<hr>
<p><em><strong>Read more: <a href="https://theconversation.com/ca/topics/canadas-opioid-crisis-46272">Solutions to Canada’s opioid crisis</a></strong></em></p>
<hr><img src="https://counter.theconversation.com/content/89556/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lindsey Richardson receives funding from the Michael Smith Foundation for Health Research and the Canadian Institutes of Health Research. </span></em></p><p class="fine-print"><em><span>Jenna Van Draanen receives funding from the Michael Smith Foundation for Health Research. </span></em></p>Catastrophic increases in opioid overdose deaths across Canada require a broad response – tackling housing, food and income insecurity as well as the contaminated drug supply.Lindsey Richardson, Research Scientist, BC Centre on Substance Use and Assistant Professor, Department of Sociology, University of British ColumbiaJenna Van Draanen, Postdoctoral Fellow, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/873252017-11-15T23:18:46Z2017-11-15T23:18:46ZWhy Canada should declare a national opioid emergency too<p>In the United States, President Donald Trump has <a href="http://www.cnn.com/2017/10/26/politics/donald-trump-opioid-epidemic/index.html">formally declared the opioid overdose crisis to be a national public health emergency</a>. The numbers he cited speak for themselves: More than 64,000 Americans died from opioid overdose last year, which translates to more than 175 per day, or almost seven every hour.</p>
<p>The situation in Canada is just as devastating, with opioid overdoses estimated to cause at least <a href="http://www.cbc.ca/news/politics/opioid-hospitalization-cihi-1.4285968">16 hospitalizations</a> and <a href="https://beta.theglobeandmail.com/news/national/opioid-related-overdose-figures-show-grim-reality-of-canadian-epidemic/article36257932/?ref=http://www.theglobeandmail.com&">eight</a> deaths each day. </p>
<p>This did not happen overnight. The number of opioid overdose deaths has risen at an alarming rate since the early 2000s. Now, more than a decade later, communities, health professionals and some politicians <a href="https://www.theglobeandmail.com/news/politics/jagmeet-singh-addresses-opioid-crisis-in-speech-to-bc-ndp-at-party-convention/article36837626/">such as NDP Leader Jagmeet Singh</a>, are still pushing for a national health emergency to be declared here in Canada as well.</p>
<p>By declaring a national <a href="http://laws-lois.justice.gc.ca/eng/acts/E-4.5/page-1.html">public welfare emergency</a>, the federal government could both acknowledge the scale of the opioid overdose crisis and unlock funds critical to a successful response. </p>
<p>Such a move would not be without precedent.</p>
<h2>From SARS and H1N1 to opioid deaths</h2>
<p>We should have learned by now, from past health crises that have affected our entire nation. </p>
<p>When 44 deaths were caused by SARS in Canada in 2003, the National Advisory Committee on SARS and Public Health <a href="https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/publicat/sars-sras/pdf/sars-e.pdf">urged the Government of Canada</a> to “consider incorporating in legislation a mechanism for dealing with health emergencies” — one that “would be activated in lockstep with provincial emergency acts in the event of a pan-Canadian health emergency.”</p>
<hr>
<p><em><strong>Read more: <a href="https://theconversation.com/ca/topics/canadas-opioid-crisis-46272">Solutions to Canada’s opioid crisis</a></strong></em></p>
<hr>
<p>In 2009, when <a href="http://www.statcan.gc.ca/pub/82-003-x/2010004/article/11348-eng.htm">428 deaths were caused by the H1N1 flu virus</a> in Canada, an Emergency Operations Centre was mobilized 24 hours a day, seven days a week for several weeks. This provided <a href="https://www.canada.ca/content/dam/phac-aspc/migration/phac-aspc/about_apropos/evaluation/reports-rapports/2010-2011/h1n1/pdf/h1n1-eng.pdf">more than 6,000 person-days of manpower</a> to help coordinate emergency responses across the country.</p>
<p>In comparison, <a href="https://www.canada.ca/en/health-canada/services/substance-abuse/prescription-drug-abuse/opioids/federal-actions.html">only 113 person-days of assistance for the opioid crisis</a> have been reported by the Public Health Agency of Canada — to help write reports in two jurisdictions last year — <a href="https://beta.theglobeandmail.com/news/national/opioid-related-overdose-figures-show-grim-reality-of-canadian-epidemic/article36257932/?ref=http://www.theglobeandmail.com&">despite more than 2,800 deaths from opioid overdoses in 2016 alone</a>. </p>
<p><br></p>
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<img alt="" src="https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=324&fit=crop&dpr=1 600w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=324&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=324&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=407&fit=crop&dpr=1 754w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=407&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/194845/original/file-20171115-19768-1p2zqpn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=407&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Public Health Agency of Canada’s response to the opioid crisis versus the H1N1 flu.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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</figure>
<p><br></p>
<p>The federal government has already implemented important measures, such as <a href="https://www.canada.ca/en/health-canada/services/substance-abuse/prescription-drug-abuse/opioids/federal-actions.html">improving access to life-saving treatments</a> and <a href="https://beta.theglobeandmail.com/news/national/federal-government-approves-three-supervised-injection-sites-in-toronto/article35189403/">approving supervised injection sites</a> across the country. </p>
<p>However, there is still much more that can be done. </p>
<h2>Funding pain management research</h2>
<p>For instance, Statistics Canada is mandated to produce statistics on the health of Canadians. Unfortunately, the latest available data on painkiller misuse was released in 2012 (via the <a href="http://www23.statcan.gc.ca/imdb/p2SV.pl?Function=getSurvey&SDDS=5015&lang=en&db=imdb&adm=8&dis=2">Canadian Community Health Survey – Mental Health</a>) and no updated version has been collected since. Scientists across the country are eager to help, but may not have the resources to do so. </p>
<p>Providing national public data repositories would allow researchers across the country to help determine overdose trends, high-risk sub-populations and other important information that could inform national policy decisions and target health responses where they are most urgently needed.</p>
<p>The federal government also has the power to determine which areas of research should be given priority in funding. New initiatives such as the <a href="http://www.cihr-irsc.gc.ca/e/44597.html">Canadian Research Initiative in Substance Misuse</a> are an important step forward for guiding evidence-based treatments for substance-use disorders. </p>
<p>Priority funding pools could also be set aside to encourage research, education and clinical care targeted toward finding <a href="https://theconversation.com/how-to-fix-canadas-opioid-crisis-it-starts-with-pain-and-the-prescription-pad-78512">safer pain management approaches</a> — a serious problem that exists for much of the opioid-using population. Currently, there is a concerning lack of evidence-based alternative treatments for chronic pain patients whose opioid prescriptions are being cut off.</p>
<h2>All hands on deck</h2>
<p>Finally, empowering the health-care workforce to help address the opioid epidemic is essential. </p>
<p>In the United States, nurse practitioners (NPs) and physician assistants (PAs) play an important role. The Comprehensive Addiction and Recovery Act signed by President Obama on July 22, 2016, <a href="https://elearning.asam.org/buprenorphine-waiver-course">authorizes qualified NPs and PAs to prescribe medications for patients with Opioid Use Disorder</a>. This provides <a href="https://www.ahrq.gov/research/findings/factsheets/primary/pcwork2/index.html">more than 86,000 extra people</a> who could be eligible to help prescribe life-saving addiction treatments, in addition to physicians. </p>
<p>In Canada, there is not enough recognition of the <a href="https://theconversation.com/better-medical-education-one-solution-to-the-opioid-crisis-81019">potential role for nurses and other allied health professionals to help</a>. Allocating funding for more training and staffing for these skilled professionals would promote an “all hands on deck” approach to assessing and treating pain and addiction, administering overdose-reversing interventions, assisting with urgent clinical research and educating and supporting affected communities. </p>
<p>If Canada were to declare a public welfare emergency, more health centres with skilled staff performing these essential roles could be immediately mobilized to help curb the opioid epidemic.</p>
<p>It’s time to recognize the opioid overdose crisis as the national public health emergency that it is.</p><img src="https://counter.theconversation.com/content/87325/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pauline Voon is a Research Associate with the BC Centre on Substance Use. She receives funding from the Canadian Institutes of Health Research through a Vanier Canada Graduate Scholarship and a doctoral scholarship from the Pierre Elliott Trudeau Foundation - an independent, non-partisan charity foundation.</span></em></p>Opioids kill an average of eight people every day in Canada. The federal government must officially declare this a ‘public welfare emergency’ and invest the funds critical to a humane response.Pauline Voon, Research Associate at the BC Centre on Substance Use and Doctoral Candidate in Population and Public Health, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/817342017-08-08T00:56:18Z2017-08-08T00:56:18ZHow Big Pharma is hindering treatment of the opioid addiction epidemic<figure><img src="https://images.theconversation.com/files/181290/original/file-20170807-25539-iz6tj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Paul Wright, in treatment for opioid addiction in June 2017 at the Neil Kennedy Recovery Clinic in Youngstown Ohio, shows a photo of himself from 2015, when he almost died from an overdose. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Medicaid-Cuts-Opioid-Epidemic/2e3bf787f50d4b0aa7161ad9618e4239/24/0">AP Photo/David Dermer</a></span></figcaption></figure><p>“A crippling problem.” “A total epidemic.” “A problem like nobody understands.” These are the words President Trump used to describe the opioid epidemic ravaging the country during a <a href="https://www.whitehouse.gov/the-press-office/2017/03/29/remarks-president-trump-listening-session-opioids-and-drug-abuse">White House listening session</a> in March. </p>
<p>The percentage of people in the U.S. dying of drug overdoses has effectively <a href="https://www.cdc.gov/drugoverdose/data/index.html">quadrupled</a> since 1999, and drug overdoses now rank as the <a href="https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdose-deaths-are-rising-faster-than-ever.html">leading cause of death</a> for Americans under 50. </p>
<p>Drugs do exist to reverse opioid overdoses or treat long-term opioid addiction. But while opioids have become easier and easier to obtain through illicit markets and <a href="https://www.nytimes.com/2017/06/10/business/dealbook/opioid-dark-web-drug-overdose.html">sellers on the dark web</a>, a drug that could save countless lives has become increasingly out of reach. </p>
<p>Consider the addiction treatment drug, <a href="https://www.drugs.com/suboxone.html">Suboxone</a>. Patents and other <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2815667">exclusivities</a> on the basic version of Suboxone expired some time ago, yet the price remains sky-high, and <a href="https://judiciary.house.gov/wp-content/uploads/2016/09/Ketcham-Testimony-.pdf">access problems</a> persist. Oral film strips now <a href="https://judiciary.house.gov/wp-content/uploads/2016/09/Ketcham-Testimony-.pdf">cost</a> over US$500 for a 30-day supply; even simple tablets <a href="https://judiciary.house.gov/wp-content/uploads/2016/09/Ketcham-Testimony-.pdf">cost</a> a whopping $600 for a 30-day supply. The cost alone puts the medication out of reach for many.</p>
<p>I study the pharmaceutical industry, and I see how drug companies are able to play games that keep competition out and prices high. Lack of access to addiction treatment drugs like <a href="https://www.drugs.com/suboxone.html">Suboxone</a> can be traced, in part, to the soaring prices, access problems and anti-competitive conduct that has become business as usual in the pharmaceutical industry across the board. </p>
<h2>Patent incentives</h2>
<p>Pharmaceutical companies have brought tremendous advances in medicine. I believe they should be adequately compensated for the enormous amount of time and resources needed to develop a new drug. Our intellectual property system is designed to do just that, rewarding companies that bring new drugs to market with a competition-free period – 20 years from the patent application date – during which they can recoup their profits. </p>
<p>After this defined period, generic versions of the drug are supposed to appear on pharmacy shelves, bringing down prices to levels that can be borne more easily by consumers and the health care market generally.</p>
<p>Brand-name companies, however, engage in myriad games to make sure theirs is the only version of the drug on pharmacy shelves, long after generics should have joined the ranks. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=479&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=479&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=479&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=602&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=602&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180929/original/file-20170803-5621-1gj5ank.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=602&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Martin Shkreli en route to a federal court house Aug. 3, 2017 in the fourth day of jury deliberations in the trial of the former drug company CEO. He was found guilty on three counts of fraud.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Martin-Shkreli-Trial/e537fe493fba424292a1b9bd08e94493/7/0">AP Photo/Seth Wenig</a></span>
</figcaption>
</figure>
<p>Martin Shkreli, the infamous pharmaceutical industry CEO responsible for hiking the cost of his company’s lifesaving drug from <a href="https://www.theatlantic.com/news/archive/2017/08/shkreli-fraud-history-balleisen/536115/">$13.50 to $750 overnight</a>, once <a href="http://www.telegraph.co.uk/news/worldnews/northamerica/usa/11882281/American-hedge-funder-Martin-Shkreli-increases-price-of-Aids-related-drug-by-5000pc.html">tweeted</a> that “Every time a drug goes generic, I grieve.” </p>
<p>And it is not just a case of a few bad apples. Complex schemes to hold off generic competition are widespread throughout the pharmaceutical industry, as I have <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2833151">found in my research</a>.</p>
<h2>The games pharma plays, sort of like Monopoly®</h2>
<p><a href="https://www.washingtonpost.com/news/wonk/wp/2017/01/11/trump-on-drug-prices-pharma-companies-are-getting-away-with-murder/">Legislators</a> on <a href="http://jamanetwork.com/journals/jama/fullarticle/2533698">both</a> sides of the aisle have decried sky-high drug prices, but it can be hard to pin down the specific behavior to address. Pharmaceutical game-playing has grown over the decades into a multi-headed monster, with a new tactic popping up as soon as the old one is cut off. My colleague and I set out to clearly identify and expose these various games in our book, “<a href="https://www.cambridge.org/core/books/drug-wars/15B23E6F67F7A4659B573016DC05F883">Drug Wars: How Big Pharma Raises Prices and Keeps Generics Off the Market.</a>” </p>
<p>One game we analyzed involved the <a href="https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfcfr/CFRSearch.cfm?FR=10.30">filing of petitions</a> at the Food and Drug Administration (FDA) that raise unfounded or frivolous concerns in an effort to delay generic competitors.</p>
<p>Some of the petitions were just stunning to us. For example, some petitions soberly ask the FDA to require, well, what it already <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2833151">requires</a>, such as ensuring that the generic drug product is stable and has an appropriate shelf life. Other petitions tie the application up in knots for reasons that are hard, even for the FDA, to discuss with a straight face. </p>
<p>For example, the company that manufactures the blood pressure medicine <a href="http://www.webmd.com/drugs/2/drug-7243/plendil-oral/details">Plendil</a> filed a <a href="https://www.regulations.gov/document?D=FDA-2007-P-0123-0002">petition</a> asking the FDA to delay approval of generics by citing concerns over how different types of oranges in orange juice might affect absorption of the medication and demanding additional information on the juice used in the clinical trials. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/180930/original/file-20170803-5640-k3s8o6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">A drug company argued that the types of oranges used in orange juice played a role in whether generic versions of the drug should be permitted.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/glass-squeezed-orange-juice-fresh-juicy-596489408?src=4DnbgYOEqQxHp5Iawf7FNA-1-4">Facanv/Shutterstock.com</a></span>
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</figure>
<p>Although <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2832319">80 percent</a> of these petitions are eventually denied, it takes time and resources for the FDA to review each petition. </p>
<p>Citing concerns over citizen petition games, Congress recently required the FDA to respond to such petitions within five months, but a five-month delay for a blockbuster drug can be worth hundreds of millions of dollars. (The Federal Trade Commission recently filed an <a href="https://www.ftc.gov/news-events/press-releases/2017/02/ftc-charges-shire-viropharma-inc-abused-government-processes">antitrust suit</a> against Shire ViroPharma for attempts to hold off competition related to its gastrointestinal drug Vancocin, a campaign that included 24 filings related to a single petition.) Congress also gave the FDA the ability to summarily deny petitions when appropriate, a power that the FDA has failed to use even once. </p>
<p>By parsing through 12 years of FDA data, we found that out of all citizen petitions filed, the percentage of petitions with the possibility of delaying generic entry <a href="https://www.cambridge.org/core/books/drug-wars/15B23E6F67F7A4659B573016DC05F883">doubled</a> since 2003, rising from 10 percent to 20 percent. Thus, in some years, one in five petitions filed at the FDA on any topic, including tobacco, food and dietary supplements, had the potential to delay generic competition. </p>
<p>Moreover, we found that <a href="https://www.cambridge.org/core/books/drug-wars/15B23E6F67F7A4659B573016DC05F883">40 percent</a> of such petitions were filed a year or less before the FDA approved the generic, indicating that companies are using these petitions as a last-ditch effort to hold off competition.</p>
<p>There are plenty of other games to play, as well. For example, generic applicants need samples of the brand-name drug to show the FDA that their version is equivalent; some brand-name companies flatly <a href="http://www.hpm.com/pdf/blog/THALOMID%20-%20Celgene%20MTD%20re%20BE%20Sample.pdf">refused</a> to sell samples to generic companies. </p>
<p>Another common tactic involves making tiny modifications to the dosage or formulation of a drug just as the original patents are about to expire. This strategy, known as “<a href="https://poseidon01.ssrn.com/delivery.php?ID=207103102008005127081027011085084077015002001000090086121025069112086094029103094091030096049125038001052023094108031096120003046002046043009065001117079098101061037082102103070094110088115110108098099114122115103124069097093018086122115118112110&EXT=pdf">product hopping</a>,” allows the drug company to obtain a brand-new set of patents on their “new and improved” version of the drug. </p>
<p>Even if the patents are overturned – and studies show that generics convince courts to overturn the <a href="https://www.ftc.gov/sites/default/files/documents/reports/generic-drug-entry-prior-patent-expiration-ftc-study/genericdrugstudy_0.pdf">majority</a> of patents they challenge – the process again takes time. </p>
<p>Much of the attention is focused on patents, but the <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2815667">13 regulatory exclusivities</a> that the FDA doles out also help create competition-free zones. These offer months or even years of additional protection, by taking steps such as carrying out pediatric studies or developing drugs for rare diseases termed “orphan drugs.” Drug companies have stretched these systems to the point at which the costs to society far outweigh the benefits.</p>
<h2>The crippling cost of medicine</h2>
<p>One can understand the motivation – delaying entry of a generic competitor for even a few months can translate into <a href="https://papers.ssrn.com/sol3/papers.cfm?abstract_id=2815667">billions</a> of dollars in extra revenue for the brand-name company. Thus, drug companies string out games that obstruct and delay competition, one after another. As I noted when <a href="https://judiciary.house.gov/wp-content/uploads/2016/09/114-97_22123.pdf">testifying</a> before Congress about such strategies, “A billion here, a billion there; that adds up to real money.”</p>
<p>In 2015, <a href="https://www.wsj.com/articles/for-prescription-drug-makers-price-increases-drive-revenue-1444096750">80 percent</a> of the profit growth of the 20 largest drug companies resulted from price hikes. And drugs are vastly more expensive in the U.S. than abroad. (The liver failure drug Syprine, for example, sells for less than $400 a year in many countries; in the U.S., the average list price is <a href="http://www.vanityfair.com/news/2016/06/the-valeant-meltdown-and-wall-streets-major-drug-problem">US$300,000</a>. Gilead’s hepatitis C drug, Sovaldi, <a href="http://www.fiercepharma.com/sales-and-marketing/hep-c-drug-tourism-has-begun-as-patients-seek-harvoni-sovaldi-overseas">reportedly</a> sells for the equivalent of $1,000 abroad – in the U.S., it sells for $84,000.) </p>
<p>The industry can do this, in part, because unlike the demand for other goods, the demand for pharmaceuticals is highly inelastic. Consumers will continue to pay for the drugs that can save their lives, even if it breaks the bank. </p>
<h2>The impact on addiction treatment</h2>
<p>Nowhere is the pain of these games more troubling than in the market for opioid addiction medicine. </p>
<p>In September, <a href="https://judiciary.house.gov/hearing/treating-opioid-epidemic-state-competition-markets-addiction-medicine/">I testified</a> before a House Judiciary Subcommittee at a hearing about the state of competition in the markets for addiction medicine, noting that, while “Open and vigorous competition is the backbone of U.S. markets…we are not seeing that in the market for addiction medicine.” </p>
<p>Pharmaceutical companies often argue that high profits are needed to fund development of new drugs, some of which don’t make it to market.</p>
<p><a href="https://judiciary.house.gov/hearing/treating-opioid-epidemic-state-competition-markets-addiction-medicine/">“The competitive market is structured to take maximum advantage of savings from brand competition,”</a> testified Anne McDonald Pritchett, vice president, policy and research for the Pharmaceutical Research and Manufacturers of America. </p>
<p>However, open and vigorous competition is certainly not what the manufacturer behind the addiction treatment drug Suboxone <a href="https://www.cambridge.org/core/books/drug-wars/15B23E6F67F7A4659B573016DC05F883">had in mind</a> when it combined several games to fight off generics appearing on the horizon. These games included <a href="https://www.ftc.gov/news-events/press-releases/2012/11/ftc-files-amicus-brief-explaining-pharmaceutical-product-hopping">product hopping</a> (shifting the market to a new form of the drug just as the exclusivity expires so pharmacists cannot fill the prescription with a generic), refusing to cooperate with generic companies on safety plans, and petitioning the FDA to impose safety measures on generic versions that were never required for the brand-name version.</p>
<p>The opioid addiction epidemic is a complex problem, and there are no simple answers. One thing, however, is certain. The U.S. system should not reward companies for blocking generic competition. When we do that, the American public pays the price.</p><img src="https://counter.theconversation.com/content/81734/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robin Feldman receives funding through the Institute for Innovation Law, which she directs at UC Hastings College of the Law. Full funding information for the Institute can be found at <a href="http://innovation.uchastings.edu/about/funding/">http://innovation.uchastings.edu/about/funding/</a></span></em></p>The number of people dying from opioid overdose continues to rise, in part because of cheap street drugs. Yet the price of a drug used to treat addiction is out of reach for many.Robin Feldman, Professor of Intellectual Property, University of California College of the Law, San FranciscoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/732702017-03-09T02:56:24Z2017-03-09T02:56:24ZWeekly Dose: while the media panic about ice, we should worry about carfentanil<figure><img src="https://images.theconversation.com/files/158652/original/image-20170228-29942-5zatbp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Most people who take carfentanil think they're taking something else, usually heroin. </span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>While the <a href="https://theconversation.com/ice-wars-message-is-overblown-and-unhelpful-72719">media seem embroiled</a> in a <a href="http://www.huffingtonpost.com/christopher-j-ferguson/how-journalists-contribut_b_6213190.html">moral panic</a> about methamphetamine or “ice”, those of us who actually work with overdose patients are nervously watching out for a far more dangerous drug: carfentanil.</p>
<p>You may have heard of <a href="https://theconversation.com/weekly-dose-fentanyl-the-anaesthetic-that-may-have-been-used-as-a-chemical-weapon-on-chechen-rebels-62966">fentanyl</a>, a synthetic opioid similar to morphine, the drug derived from the opium poppy. Fentanyl is 50 to 100 times more potent than morphine, but there wouldn’t be a day that goes by where we don’t use it in the emergency department, mostly for pain relief. </p>
<p>Carfentanil is an ultra-potent synthetic version of this. Its only legitimate use is in veterinary practice for large animals such as elephants. Its distribution is restricted to veterinarians engaged in zoo and exotic animal practice, wildlife management programs, and researchers.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=599&fit=crop&dpr=1 600w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=599&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=599&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=753&fit=crop&dpr=1 754w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=753&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/160096/original/image-20170309-24211-2mgswg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=753&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<h2>How does it work?</h2>
<p>The human body manufactures neuropeptides called endorphins. Opioids work by binding to endorphin receptors in the body, namely opioid receptors. </p>
<p>There are several types of receptors, all which, when activated, create slightly different effects - some make you feel good, or sleepy, or less anxious. </p>
<p>One, called the μ-receptor, is very good at mediating respiratory depression. And carfentanil can activate this receptor better than almost any other opiate.</p>
<h2>How was it developed?</h2>
<p>Developed in the mid-1970s as a large animal sedative (Wildnil), carfentanil is 10,000 times more potent than morphine. A lethal dose in humans is only 20 micrograms. That is the weight of ten snowflakes, or a single grain of pollen.</p>
<p>It is so potent that lab technicians require special protective equipment to analyse it, and have to have the antidote at the lab bench. It <a href="http://www.elephantcare.org/Drugs/carfenta.htm">takes only 10mg</a> to knock down a wild African elephant. An <a href="http://www.ajemjournal.com/article/S0735-6757(10)00117-8/abstract">unfortunate veterinarian</a> who merely splashed some on his eye while trying to sedate an elk required resuscitation.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-fentanyl-the-anaesthetic-that-may-have-been-used-as-a-chemical-weapon-on-chechen-rebels-62966">Weekly Dose: fentanyl, the anaesthetic that may have been used as a chemical weapon on Chechen rebels</a>
</strong>
</em>
</p>
<hr>
<h2>What are its uses?</h2>
<p>Carfentanil has no therapeutic human application. And for most consumers who have ingested it, they have done so involuntarily, thinking it was another drug, usually heroin.</p>
<p>So why is it available? In the world of heroin, “quality” is frequently conflated with potency. A product that may be significantly “cut” can be dosed with minute quantities of fentanyl-like products to give the impression of enhanced value. By increasing the perceived “purity” of a shipment, you can increase its apparent value. </p>
<p>It’s particularly useful that the manufacture of carfentanil is entirely synthetic, and not reliant on the vagaries of crops in Afghanistan’s Helmand province, or border patrols in Herat Province. It’s far easier to smuggle a suitcase of an ultra-potent product globally than a shipping container of something more “dilute” and organic.</p>
<h2>Why should we be so concerned about it?</h2>
<p>The first epidemic of fentanyls and fentanyl-related compounds <a href="https://en.wikipedia.org/wiki/%CE%91-Methylfentanyl">dates back to the 1970s</a>. Between 2005 and 2007, another product, this time from Mexico, <a href="https://www.justice.gov/archive/ndic/pubs11/20469/index.htm">killed hundreds of Americans</a>. </p>
<p>Globally, we are now seeing a third wave of fentanyl-related deaths, dating from perhaps late 2013, far more serious than any that preceded it. There were over <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a2.htm">5,000 deaths in the US alone in 2014</a>. Ohio state had <a href="https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a3.htm">over 1,100 deaths in 2015 alone</a>. The figures for 2016 could be far greater still.</p>
<p>Those of us in the business of tracking down new illicit drugs in Australia have felt the malign presence of the fentanyls for a while now. We have been forewarned by our overseas colleagues - equally aghast at their escape into the open market. <a href="https://www.eventbrite.com.au/e/new-and-novel-psychoactive-substances-challenges-for-healthcare-workers-tickets-22756633704#">We predicted</a> the synthetic fentanyls would be a major issue for Australia in April 2016. </p>
<p>For about a year, we’ve been hearing reports of “heroin” overdoses that are no longer responding to standard doses of our normal opiate antidote, <a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">naloxone</a>. That is usually about 2mg, but in cases we suspect involved carfentanil and its close cousins, it can take ten times more to make someone breathe again.</p>
<p>In December, a carfentanil seizure was <a href="http://www.couriermail.com.au/news/carfentanil-deadly-tranquilliser-found-for-the-first-time-in-australia/news-story/21cf74b4e9d2fe46ec8263e60aee343a">reported in Sydney</a> - last month <a href="http://www.dailymail.co.uk/news/article-4233436/Queensland-Police-issue-warning-carfentanil-drug.html">another in Brisbane</a>. Like a lethal strain of flu, now it’s here, and all we can do is work furiously to prevent it becoming established. This involves engagement with the consumer community, an approach which doesn’t appear to be viewed favourably by Australian policy makers.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">Weekly Dose: Naloxone, how to save a life from opioid overdose</a>
</strong>
</em>
</p>
<hr>
<p>In many ways, the fentanyl-related compounds connect many of the problems and solutions of modern drugs policy in Australia. Many are novel products, manufactured to pharmaceutical purity, as the global drug market mutates into something darker and less tangible. Their emergence has been catalysed by a Big Pharma peddled epidemic of opiates, <a href="https://www.theguardian.com/science/2016/may/25/opioid-epidemic-prescription-painkillers-heroin-addiction">coupled with a subsequent crackdown in availability</a>.</p>
<p>We have no meaningful toxicological early warning system that widely shares data in Australia - we rely on whispers. Consumers who overdose are unlikely to survive outside of a medically-supervised injecting centre, providing yet more pressure for the <a href="https://theconversation.com/why-australia-needs-drug-consumption-rooms-53215">expansion of those services in Australia</a> - and yet still, they are opposed.</p>
<p>The tabloid press would have us believe the drug “ice” is currently the biggest threat to Australian society. But doctors and drug professionals alike will tell you that potentially, the unfettered spread of carfentanil and the illicit synthetic fentanyls is much worthier of your fear.</p><img src="https://counter.theconversation.com/content/73270/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Caldicott is a recipient of an NH&NMRC Partnership Grant. He is affiliated with ATODA, and provides bipartisan medical advice on illicit drugs to state and federal agencies. He is the Clinical Lead of the Australian Drug Observatory (ANU)</span></em></p>Carfentanil is an ultra-potent synthetic opioid. Its only legitimate use is in veterinary practice for large animals such as elephants, but it sneaks into heroin shipments to increase its potency.David Caldicott, Emergency Medicine Consultant, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/649722016-09-09T10:26:46Z2016-09-09T10:26:46ZDrugs fatalities overtake car fatalities for the first time<figure><img src="https://images.theconversation.com/files/137080/original/image-20160908-25249-1ct7wc5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-276472910/stock-photo-man-injecting-himself-with-a-small-hypodermic-needle-possibly-administering-medication-for-a-disease-such-as-diabetes.html?src=NLK3gv9RXwwEBCFGAW-lgA-1-0">NAS CREATIVES/Shutterstock.com</a></span></figcaption></figure><p>Seven years ago, <a href="http://articles.latimes.com/2011/sep/17/local/la-me-drugs-epidemic-20110918">fatalities from opiates</a> overtook fatalities due to road accidents in the US. Sadly, the same phenomenon is now playing out in England. The latest figures from the Office for National Statistics (ONS), show that last year, 1,732 people died in <a href="https://www.gov.uk/government/statistics/reported-road-casualties-in-great-britain-main-results-2015">traffic accidents in the UK</a> compared with <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations">1,989</a> who died due to opiates in England alone.</p>
<p>New psychoactive substances, referred to as “legal highs”, have <a href="https://theconversation.com/stories-about-legal-high-deaths-are-bound-up-in-media-hysteria-24360">received significant media attention</a>, and deaths due to these drugs have risen by 40%, but opiate deaths now outnumber legal-high deaths by 19 to 1, despite a <a href="https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2015-to-2016-csew">steady decline</a> in opiate use in England and Wales over the last decade.</p>
<p>Of course, opiates are not the only problem – deaths due to cocaine have reached the highest on record at 320, increasing by nearly 30% since last year – but opiates are what we should really be focusing on. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=377&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=377&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=377&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=474&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=474&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137200/original/image-20160909-13363-1uib24s.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=474&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Drug deaths.</span>
<span class="attribution"><span class="source">Office for National Statistics</span></span>
</figcaption>
</figure>
<h2>Premature and preventable</h2>
<p>Drug-related deaths of males outnumber those of females by three to one and 60% of deaths occur in 30- to 49-year-olds – compared with an <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/lifeexpectancies/bulletins/lifeexpectancyatbirthandatage65bylocalareasinenglandandwales/2015-11-04">average life expectancy</a> for the rest of the population of 80. </p>
<p>Health complications resulting from drug use do not entirely explain this inequality in life span. A range of factors are likely to be involved. Purity and quality of heroin are not as critical, borne out by <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13516/full">decades of research</a>. Rather it is the risk of accidental overdose by more experienced and tolerant heroin users. Equally, combining heroin with alcohol and or a benzodiazapine such as diazepam <a href="http://www.sciencedirect.com/science/article/pii/S0376871612002785">increases the risk of death</a>. In 1993, one in four deaths were attributed to combining alcohol with opiates; this has now reached one in two. </p>
<p>In 2010, the newly elected Conservative government introduced a <a href="https://www.gov.uk/government/publications/drug-strategy-2010">new treatment strategy</a>. The policy emphasised the importance of achieving abstinence from drugs rather than merely reducing the harm they can cause. This recovery agenda may have inadvertently contributed to the rise in drug deaths. Unfortunately, even if abstinence is achieved, the <a href="http://bit.ly/2cbURiS">odds of relapsing</a> are high. Abstinence <a href="http://www.bjmp.org/files/2013-6-1/bjmp-2013-6-1-a601.pdf">reduces the ability</a> to tolerate previously manageable doses of heroin, resulting in an overdose for some. </p>
<h2>Treatment risk</h2>
<p>Treatment does reduce mortality. A <a href="http://www.nta.nhs.uk/uploads/trendsdrugmisusedeaths1999to2014.pdf">recent report</a> showed that most opiate deaths were of people not in treatment. Treatment usually involves providing a substitute drug with the aim of weaning the individual off heroin. Methadone and buprenorphine are commonly used to do this. But there are two critical factors, retaining people in treatment and what happens when treatment finishes. The month following treatment is particularly important as a person’s tolerance to opiates will have reduced, increasing the risk of overdose <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13087/full">if the person relapses</a>. Following up people at this critical stage could help reduce the risk of fatality. </p>
<p>But the challenge is how to engage those who are not in treatment. Attracting this group requires a more radical approach. <a href="https://theconversation.com/why-australia-needs-drug-consumption-rooms-53215">Drug consumption rooms</a> provide a safe place for people to use their drugs, providing clean syringes for those who inject heroin. These facilities have an impressive record of reducing fatalities due to drug use. And, just as important, they are the first step towards engaging a marginalised group into health and social care. We don’t need any more evidence as to their value – we need what politicians crave: <a href="http://www.tandfonline.com/doi/abs/10.3109/14659891.2016.1143049">public support</a>.</p>
<p>Naloxone can also temporarily reverse the effects of an opiate overdose. Making this drug available to opiate users and their families offers the potential to reduce fatalities. Scotland has pioneered this by implementing a <a href="http://onlinelibrary.wiley.com/doi/10.1111/add.13265/pdf">national naloxone policy</a> and new regulations in England have <a href="https://www.gov.uk/government/publications/widening-the-availability-of-naloxone/widening-the-availability-of-naloxone">allowed this approach to be mirrored</a>. This development gives workers and heroin users access and permission to administer naloxone when an overdose occurs.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137083/original/image-20160908-25260-hhapzw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Naloxone can reverse the effects of an opiate overdose.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/pic-418417357/stock-photo-layton-utah-march-11-2016-vial-of-naloxone-drug-which-is-used-for-opiate-drug-overdose-it-is-now-available-to-patients-without-a-prescription-or-over-the-counter.html?src=HeShWLVmobUTJtghilzrNw-1-0">PureRadiancePhoto/Shutterstock.com</a></span>
</figcaption>
</figure>
<h2>A glimpse into the future?</h2>
<p>The US has witnessed a 200% rise in prescription-opiate deaths since the millennium, driven by <a href="http://onlinelibrary.wiley.com/doi/10.1111/ajt.13776/full">increasing availability and lower costs</a>. The regulatory and marketing environments differ in the US and the UK. In the UK, open marketing of opiates is prohibited and there are stricter controls and monitoring of prescribing. But current drug control measures are outdated and <a href="http://www.tandfonline.com/doi/abs/10.3109/14659891.2014.980861">easily circumvented by the internet</a>.</p>
<p>So we need to carefully monitor the use and misuse of a range of prescription drugs such as tramadol. Tramadol is an analgesic used for moderate to severe pain. Prescriptions for tramadol rose dramatically over the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2015registrations">last decade</a>, as did deaths thought to be the result of misusing the drug. This prompted new regulations which came into force last year with the aim of curbing tramadol-related deaths. This year’s ONS data shows that one year after the introduction of these regulations deaths have reduced, but we will need to see if this trend continues.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=366&fit=crop&dpr=1 600w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=366&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=366&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=460&fit=crop&dpr=1 754w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=460&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/137202/original/image-20160909-13345-2cdpp9.PNG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=460&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tramadol deaths.</span>
<span class="attribution"><span class="source">Office for National Statistics</span></span>
</figcaption>
</figure>
<p>A clear measure of the UK government’s ambition to reduce inequality is <a href="http://www.huffingtonpost.co.uk/clare-bambra/theresa-may-health-inequalities_b_11716312.html">halting the rise in drug overdoses</a>. Avoidable fatalities due to drugs serve as a barometer of how equal our society is and how we respond to individual vulnerability. We all lose out when an individual dies this way.</p>
<p>Public Health England has responded to the trend in drug fatalities, publishing <a href="http://www.nta.nhs.uk/uploads/phe-understanding-preventing-drds.pdf">several recommendations</a>. There are some welcome aims but they could be bolder. The time has come to introduce drug consumption rooms – it’s a life or death decision.</p><img src="https://counter.theconversation.com/content/64972/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ian Hamilton is affiliated with Alcohol Research UK.. </span></em></p><p class="fine-print"><em><span>Mark Monaghan does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Opiates have emerged as a significant threat to public health in the UK.Ian Hamilton, Lecturer in Mental Health, University of YorkMark Monaghan, Lecturer in Crimimology and Social Policy, Loughborough UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/634592016-08-31T02:46:16Z2016-08-31T02:46:16ZWeekly Dose: Naloxone, how to save a life from opioid overdose<figure><img src="https://images.theconversation.com/files/133908/original/image-20160812-16327-x0jnkt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naloxone has been made available over the counter from a pharmacist so loved-ones of drug users can have it on hand in the event of an overdose.</span> <span class="attribution"><span class="source">from www.shutterstock.com.au</span></span></figcaption></figure><p>Naloxone is an opioid antagonist, used as an “antidote” for opioid overdose which includes heroin, and opioid pain medicines such as morphine, fentanyl and codeine. It has been used since the 1970s by ambulance services and hospital emergency departments, and in these settings has been shown to be safe, reliable and effective.</p>
<p>Naloxone does not produce intoxication and has no effect on people who do not have opioids in their system. Over recent years, programs have been established in a number of countries to supply naloxone to people who use opioids, and their carers, family or friends to enable naloxone to be administered by a trained layperson in an emergency to prevent fatal opioid overdose. These programs <a href="http://www.ncbi.nlm.nih.gov/pubmed/27028542">have been found to</a> reduce overdose deaths, with few adverse events reported.</p>
<p>In Australia in February 2016, naloxone changed from being available only with a prescription to also being on sale over-the-counter in pharmacies. This aimed to make it easier for people who may witness an opioid overdose to access naloxone and keep it on hand.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/135888/original/image-20160830-28244-1sa2pfh.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/135888/original/image-20160830-28244-1sa2pfh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/135888/original/image-20160830-28244-1sa2pfh.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=869&fit=crop&dpr=1 600w, https://images.theconversation.com/files/135888/original/image-20160830-28244-1sa2pfh.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=869&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/135888/original/image-20160830-28244-1sa2pfh.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=869&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/135888/original/image-20160830-28244-1sa2pfh.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1092&fit=crop&dpr=1 754w, https://images.theconversation.com/files/135888/original/image-20160830-28244-1sa2pfh.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1092&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/135888/original/image-20160830-28244-1sa2pfh.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1092&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
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</figure>
<h2>How does it work?</h2>
<p>Naloxone is a competitive opioid antagonist, with high affinity for opioid receptors (the parts of the brain where opioids work) in the central nervous system. This means naloxone will compete with other opioids, such as heroin or morphine, to bind to the opioid receptors, knocking other opioids off the receptor. </p>
<p>Naloxone has no opioid effect at the receptor, and importantly in the case of an overdose, reverses the effects of opioids already in the body. As opioids depress respiration, when naloxone reverses this effect, it helps to restore respiration.</p>
<h2>How was it developed?</h2>
<p>Naloxone was developed by chemist <a href="http://www.nytimes.com/2013/12/15/business/jack-fishman-who-helped-develop-a-drug-to-treat-overdoses-dies-at-83.html?_r=1">Jack Fishman</a> more than 50 years ago in an attempt to treat constipation from opioids. </p>
<p>Since then it has been widely used to reverse the effects of opioids by paramedics and in hospitals. In the past 20 years, there has been a large expansion of programs where naloxone is supplied for people to take home for layperson administration (for a bystander who witnesses an overdose). </p>
<p>These programs have been recommended by the <a href="http://www.who.int/substance_abuse/publications/management_opioid_overdose/en/">World Health Organization</a> in response to rising opioid-related deaths.</p>
<h2>Australian experience</h2>
<p>In Australia, take-home naloxone programs have been operating in various states and territories, largely as small demonstration programs, <a href="https://theconversation.com/explainer-what-is-naloxone-and-how-can-it-help-save-drug-users-who-overdose-48812">since 2012</a>. </p>
<p>Many pilot programs involved peer advocacy groups and were operated through services for people who inject drugs. More recently, naloxone has become more embedded in routine health care in a small number of <a href="http://www.ncbi.nlm.nih.gov/pubmed/27071354">health services in NSW</a>.</p>
<h2>How is it used?</h2>
<p>Potential overdose bystanders (friends or family of people who use opioids) are trained to identify an overdose, call an ambulance, administer naloxone and start basic life support while they wait for the ambulance to come. </p>
<p>In Australia, it is usually given as an intramuscular injection (an injection into the muscle), and starts working within a few minutes. Usually a first dose of 400 micrograms is administered in the shoulder or thigh, followed by a second dose of 400mcg if there is no change after two to five minutes. </p>
<p>Naloxone has a short half-life so effects can wear off in 30 minutes to an hour. The person can then return to an overdose state, so it is important an ambulance is called and the person is monitored by others even if the initial dose has worked.</p>
<h2>Is naloxone just for heroin overdoses?</h2>
<p>Naloxone will reverse the effects of any opioid – heroin or pharmaceutical opioids. A common misconception is that naloxone is not effective for potent opioids such as <a href="https://ndarc.med.unsw.edu.au/blog/powerful-opioid-fentanyl-poses-serious-risk-fatal-overdose">fentanyl</a> or buprenorphine, but with <a href="http://www.ncbi.nlm.nih.gov/pubmed/16764215">higher doses</a>, naloxone does work. However, supporting breathing and calling an ambulance becomes even more important with stronger opioids. </p>
<p>In Australia, most (70%) fatal overdoses <a href="https://ndarc.med.unsw.edu.au/resource/changing-nature-opioid-overdose-deaths-australia">now involve pharmaceutical opioids</a>, with heroin involved in only three out of ten opioid overdoses.</p>
<h2>Side-effects</h2>
<p>The main concern is that after reversing the effects on opioids in an individual, they will experience opioid withdrawal. This is less common with the doses used in Australia though it was more common when larger doses were routinely used. </p>
<p>One concern with inducing opioid withdrawal symptoms is that a person may feel quite unwell, and then use more opioids to feel better, which may lead to a subsequent overdose.</p>
<h2>Current challenges</h2>
<p>The main challenges with naloxone are around the way it is delivered. Not all people feel comfortable giving an injection. The pre-filled syringe is relatively easy to use but there is currently very limited stock in Australia.</p>
<p>Ampoules are a little harder to draw up and administer the naloxone, but have been successfully used in Australia and internationally. Intranasal formulations (nasal sprays) have been developed in the United States but there are <a href="http://www.ncbi.nlm.nih.gov/pubmed/26840916">concerns</a> about how much of the naloxone is effective, and what dose needs to be given when administered in this way.</p><img src="https://counter.theconversation.com/content/63459/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>SN is supported by a NHMRC Research Fellowship (#1013803). The National Drug and Alcohol Research Centre at the University of New South Wales is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvements Grant Fund.
SN has been an investigator on untied educational grants from Reckitt-Benckiser and Indivior.
</span></em></p><p class="fine-print"><em><span>Simon Lenton is supported by funding from the Australian Government under the Substance Misuse Prevention and Service Improvement Grants Fund through its core funding of The National Drug Research Institute at Curtin University. For more than 10 years he has conducted research based advocacy calling for the wider availability of naloxone.</span></em></p>Naloxone is used as an “antidote” for opioid overdose which includes heroin, and opioid pain medicines such as morphine, fentanyl and codeine.Suzanne Nielsen, Senior Research Fellow, UNSW SydneySimon Lenton, Professor and Deputy Director, National Drug Research Institute, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/629662016-07-27T03:49:44Z2016-07-27T03:49:44ZWeekly Dose: fentanyl, the anaesthetic that may have been used as a chemical weapon on Chechen rebels<p>Fentanyl is a synthetic analgesic (pain relieving) drug in the same class as morphine. It is used to treat acute or chronic pain, including for epidurals given to women during childbirth. </p>
<p>It is thought that in 2002 fentanyl, or a drug based on it, was used by Russian special forces to disable Chechen rebels after a <a href="http://www.bbc.com/news/world-europe-20067384">four-day siege</a> in the Dubrovka theatre in Moscow.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/132101/original/image-20160727-7023-1bzq4pk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/132101/original/image-20160727-7023-1bzq4pk.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=582&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132101/original/image-20160727-7023-1bzq4pk.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=582&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132101/original/image-20160727-7023-1bzq4pk.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=582&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132101/original/image-20160727-7023-1bzq4pk.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=731&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132101/original/image-20160727-7023-1bzq4pk.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=731&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132101/original/image-20160727-7023-1bzq4pk.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=731&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
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<h2>Use</h2>
<p>Fentanyl was developed in the 1950s by the Belgian doctor <a href="http://www.ncbi.nlm.nih.gov/pmc/articles/PMC286262/">Paul Janssen</a> who went on to establish Janssen Pharmaceuticals, which later merged into the global pharmaceutical giant Johnson & Johnson. </p>
<p>The drug is used to treat acute or chronic pain, and acts by binding to opioid receptors throughout the body, thereby inhibiting the transmission of pain signals to the brain. </p>
<p>It is thus an opioid-based drug, in the same class as codeine, methadone, oxycodone, pethidine, and tramadol. It is considered to be up to 100 times more potent than morphine in its ability to relieve pain.</p>
<p>The drug <a href="http://www.druginfo.adf.org.au/drug-facts/naloxone-facts">Naloxone</a> can be used to reverse the effects of fentanyl in overdose cases.</p>
<h2>Formulations</h2>
<p>Women who are given an <a href="http://www.anzca.edu.au/patients/frequently-asked-questions/epidurals-and-childbirth.html">epidural</a> during childbirth will be given an injection that contains a combination of fentanyl and one of two other painkillers, bupivacaine or ropivacaine, both of which are derived from cocaine. The injection is given into the space around the spinal cord, and as such can only be administered by a trained anaesthetist. </p>
<p>For those suffering long-term pain, fentanyl is also supplied in several different formulations. These include lozenges, which are designed to be sucked like lollies, sublingual tablets, which dissolve quickly under the tongue, and patches that are placed on the skin.</p>
<p>For children aged between 1 and 12 years, fentanyl may also be administered as a nasal spray.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/132083/original/image-20160727-7041-27jk3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/132083/original/image-20160727-7041-27jk3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/132083/original/image-20160727-7041-27jk3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/132083/original/image-20160727-7041-27jk3h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/132083/original/image-20160727-7041-27jk3h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/132083/original/image-20160727-7041-27jk3h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/132083/original/image-20160727-7041-27jk3h.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/132083/original/image-20160727-7041-27jk3h.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Fentanyl is a restricted drug as it’s considered a drug of addiction.</span>
<span class="attribution"><a class="source" href="https://www.google.com.au/imgres?imgurl=https%3A%2F%2Fupload.wikimedia.org%2Fwikipedia%2Fcommons%2F4%2F4b%2FFentanyl_patch_packages.jpg&imgrefurl=https%3A%2F%2Fcommons.wikimedia.org%2Fwiki%2FFile%3AFentanyl_patch_packages.jpg&docid=8AJhC2wChRB5GM&tbnid=Up3yCtOoJMZW-M%3A&w=4752&h=3168&bih=1201&biw=2071&ved=0ahUKEwjR7Mbgq5LOAhUDLpQKHWbKA-8QMwgdKAIwAg&iact=mrc&uact=8">Wikimedia Commons</a></span>
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</figure>
<h2>Side effects</h2>
<p>The most common side effects include a rash, redness of the skin, itchiness, and an increased heart rate. While patients may experience the same nausea, vomiting, and constipation that are common of all opioid-based drugs, these side effects are usually less severe for fentanyl.</p>
<p>Fentanyl can also have a depressive effect on coughing and is known to depress the breathing of some patients.</p>
<h2>Possible use on Chechen rebels</h2>
<p>In October 2002 <a href="http://www.bbc.com/news/world-europe-20067384">a group of Chechen rebels</a> took hundreds of people hostage at the Dubrovka theatre in Moscow during a sold-out performance of the musical <a href="https://en.wikipedia.org/wiki/Nord-Ost">Nord Ost</a>. </p>
<p>Having made no progress for nearly four days, Russian special forces pumped a powerful “sleeping gas” into the building, rendering all the rebels and theatre patrons unconscious. </p>
<p>Because the military did not give any prior warning of what they were going to do it was more than an hour before ambulances were available to take people to hospital. In addition, the military refused to provide the name of the gas they had used to medical staff, making treatment decisions very difficult.</p>
<p>It is widely believed the gas used was either fentanyl, or some other fentanyl-based drug, because some patients were found to have the sleeping effects reversed when they were administered naloxone.</p>
<p>Combined, more than 100 of the rebels and theatre patrons died from the gassing.</p>
<h2>Cost</h2>
<p>Fentanyl is only available by prescription because it is classified as a <a href="http://www.nps.org.au/topics/how-to-be-medicinewise/regulation-clinical-trials/medicine-schedules-availability">Schedule 8 medicine - drug of addiction</a>. The cost of the lozenges, tablets, and patches is subsidised by the Australian pharmaceutical benefits scheme and are supplied to patients at a maximum cost of A$38.30 per packet; although the number of doses provided in each packet can vary based on the formulation.</p>
<p>Public hospital patients given fentanyl as an epidural during child birth will not be charged for the cost of the drug. Private patients will have the cost of the drug included as part of their treatment bill which is usually covered by their health insurance.</p><img src="https://counter.theconversation.com/content/62966/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Wheate in the past has received funding from the ACT Cancer Council, Tenovus Scotland, Medical Research Scotland, Scottish Crucible, and the Scottish Universities Life Sciences Alliance. He is affiliated with the Royal Australian Chemical Institute. </span></em></p>It is thought that in 2002 fentanyl, or a drug based on fentanyl, was used by Russian special forces to disable Chechen rebels after a four day stand off in the Dubrovka theatre in Moscow.Nial Wheate, Senior Lecturer in Pharmaceutics, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/611792016-07-20T10:09:01Z2016-07-20T10:09:01ZDespite national efforts to fight addiction, states can tailor – and trim – programs<p>The U.S. Senate <a href="http://www.nytimes.com/2016/07/14/us/politics/senate-opioid-addiction-bill.html?_r=0">approved a bill</a> July 13 with a vote of 92-2 to treat the nation’s opioid addiction crisis. It’s worth noting that one state – Georgia – recently passed a law that could block, rather than expand, access to treatment. Could other states also go in Georgia’s direction? Could it possibly be a good idea? </p>
<p>In 2014, more than 47,000 Americans died from drug overdoses, and two-fifths of these were from opioid-based medicines for pain control, with the most common forms being <a href="http://www.cdc.gov/nchs/data/factsheets/factsheet_drug_poisoning.htm">hydrocodone and oxycodone</a>. </p>
<p>Individuals with prescription drug addiction are also more likely to use cheaper, but more deadly forms of opioid-based illicit drugs, including <a href="http://www.samhsa.gov/data/sites/default/files/NSDUHresultsPDFWHTML2013/Web/NSDUHresults2013.pdf">heroin</a>. Drug addiction is recognized as a chronic health condition, but only <a href="https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf">11 percent</a> of the 23.5 million Americans (ages 11 and older) with substance use disorder actually receive treatment. </p>
<p>These disturbing trends have triggered national responses in addition to the bill passed July 13, which provides treatment and law enforcement professionals with more tools to help those with addiction. The bill would expand access to naloxone, a drug that reverses overdoses. It also would expand treatment programs for those in jails and prisons. </p>
<p>The White House Office of Drug Control Policy, <a href="https://www.drugabuse.gov/about-nida/noras-blog/2015/03/hhs-announces-actions-to-attack-opioid-abuse-crisis">National Institute of Drug Abuse</a>, <a href="http://blog.samhsa.gov/2015/07/27/hhs-launches-multi-pronged-effort-to-combat-opioid-abuse/#.V4fJ_zbSf-Y">Substance Abuse and Mental Health Services Administration</a> (SAMHSA), and U.S. Centers for Disease Control and Prevention, have sounded the alarm to enhance efforts to end the prescription drug abuse epidemic through multiple avenues.</p>
<p>Those efforts include: increasing access to evidence-based <a href="https://www.whitehouse.gov/the-press-office/2016/03/29/fact-sheet-obama-administration-announces-additional-actions-address">medication assisted treatment</a> (MAT), enhancing prescription drug monitoring efforts, and strengthening prescribing guidelines for clinicians. Private foundations, professional organizations, educational institutions, and states are <a href="https://www.cdc.gov/drugoverdose/pdf/guidelines_factsheet-a.pdf">stepping up </a>to meet the national calls for action. </p>
<h2>Too many clinics, says the Peach State</h2>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/130979/original/image-20160718-2127-1w5ylgr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/130979/original/image-20160718-2127-1w5ylgr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=398&fit=crop&dpr=1 600w, https://images.theconversation.com/files/130979/original/image-20160718-2127-1w5ylgr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=398&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/130979/original/image-20160718-2127-1w5ylgr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=398&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/130979/original/image-20160718-2127-1w5ylgr.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/130979/original/image-20160718-2127-1w5ylgr.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/130979/original/image-20160718-2127-1w5ylgr.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=501&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Georgia Capitol at night via Shutterstock.</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/dl2_lim.mhtml?src=UJIBAf-JXoUz8HJTRSmKnQ-1-28&clicksrc=download_btn_inline&id=84305194&size=medium_jpg&submit_jpg=">From www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>And then, there is Georgia. </p>
<p>The Empire State of the South recently placed a <a href="http://www.npr.org/sections/health-shots/2016/06/15/481523994/despite-overdose-epidemic-georgia-caps-the-number-of-opioid-treatment-clinics">moratorium on new treatment clinics</a> that would treat those with addictions. The legislative action appears to truly go against the tide of progress that is being made nationally. </p>
<p>Georgia’s action also highlights the fact that each state has authority to control many aspects of how to fight this battle. While a federal agency, Substance Abuse and Mental Health Services Administration (SAMHSA), offers rules and guidelines for treatment, states have some leeway in licensing treatment clinics. They can also choose how much money they will direct to treat those affected by the epidemic. Thus, to some degree, the likelihood that a person will receive effective treatment depends on which state they live in.</p>
<p>While the death rates have steadily risen from prescription drug overdose in the past few years, the reality is that addiction <a href="https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/evidence-based-approaches-to-drug-addiction-treatment">treatment</a> has been established for nearly two decades. Medication-assisted treatment, or MAT, <a href="http://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat">has proven effective</a> in helping some people who are addicted to opioids, and 12-Step programs and counseling are proving to be useful, additional therapy. In 2001, SAMHSA became the recognized federal entity to oversee the approval process for MAT programs through the enactment of the <a href="http://www.samhsa.gov/medication-assisted-treatment/legislation-regulations-guidelines">Drug Abuse Treatment Act</a> of 2000.</p>
<p>Since the pharmacological agents involved in addiction treatment, such as methadone, buprenorphine and naltrexone,<a href="https://www.drugabuse.gov/news-events/nida-notes/2007/10/impacts-drugs-neurotransmission"> mimic or stimulate brain receptors</a> similarly to the primary prescriptions abused, there is a risk of developing dependence on these medications. <a href="https://theconversation.com/why-its-easier-to-be-prescribed-an-opioid-painkiller-than-the-treatment-for-opioid-addiction-60137">Deliberate safeguards</a> have been established by lawmakers to minimize such risks. </p>
<p>On the clinical side, medication therapies require <a href="http://www.samhsa.gov/prescription-drug-misuse-abuse/samhsas-efforts">direct observation</a> by staff to ensure treatment medicine is not misused. On a wider scale, safeguards exist for eligible clinicians seeking to administer such therapies. In order to become an approved MAT provider, SAMHSA has created a two-stage approval process. </p>
<p>Upon initial approval of being a MAT provider, clinicians are limited to treating 30 patients in the first year. The subsequent approval application increases the cap to 100; although in 2016, SAMHSA <a href="http://www.hhs.gov/about/news/2016/03/29/hhs-takes-steps-increase-access-opioid-use-disorder-treatment-medication-buprenorphine.html">revised this limit</a> to 200 patients. In other words, cautionary principles overseeing MAT providers on both the clinical and patient side run deep.</p>
<h2>State differences</h2>
<p>But despite a coordinated effort by federal agencies to increase or expand access to MATs, states play a role as gatekeeper. States typically require interested <a href="http://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management">MAT clinicians</a> to submit a certificate of need to a public health authority, which relies on the applicant to demonstrate a justifiable demand for MAT services. </p>
<p>The applicant must typically allow financial oversight of MAT services and also provide an address of access issues among intended recipients. Georgia does not <a href="http://www.samhsa.gov/medication-assisted-treatment/buprenorphine-waiver-management">mandate such certificates</a> for MAT approvals. Perhaps, this can explains the discrepancy in the number of MAT clinics in the South.</p>
<p>The <a href="http://news.wabe.org/post/despite-overdose-epidemic-georgia-caps-number-opioid-treatment-clinics">demand for MAT programs </a>in the South far outweighs the supply. Mississippi has one MAT center, Alabama has 24, Tennessee 12, and Florida has 65. Georgia has the most - with 67 - and this has <a href="http://news.wabe.org/post/despite-overdose-epidemic-ga-puts-pause-opioid-programs">perplexed Georgia legislators</a>. Questions surrounding why Georgia has the most clinics in the South, especially in proportion to its population, have been raised by legislators. Who is using these clinics? If the users are from out of state, what does this mean for Georgia residents? What are the financial implications for the state? </p>
<p>A new state law (SB 402: Drug Abuse Treatment and Education Programs) was passed in May in response to these questions. The law effectively creates a <a href="http://www.legis.ga.gov/Legislation/en-US/display/20152016/SB/402">one-year moratorium</a> on approving MAT facilities and providers. It also creates a <a href="http://www.ajc.com/news/news/state-regional-govt-politics/senate-approves-measure-to-halt-new-narcotic-treat/nqZsj/">State Commission on Narcotic Treatment Programs</a> to study licensure requirements. </p>
<h2>Is treatment on their minds?</h2>
<p>Why put the brakes on MAT providers when every federal agency is advocating for more resources, more treatment options, doubling the number of patients in MAT programs serve to 200? </p>
<p>While it is not known if other states are going to follow suit, it does not at present appear so. In the meantime, Georgia leaders are missing an opportunity to serve individuals with the chronic disease of addiction preferring instead to investigate the matter further.</p>
<p>What is most disturbing is that legislators do not have the same concerns on the front end of the epidemic, such as finding out how many prescriptions for controlled substances are being filled in Georgia. Why not question if individuals filling prescriptions are from out of State, or be curious about the financial implications of not having patient limits in terms of prescribing controlled substances versus the federal limits set for MAT patients. </p>
<p>The answers to these questions are difficult to answer in part because Georgia’s Prescription Drug Monitoring Program legally safeguards data collected. That blocks the public from understanding what might be <a href="http://www.jrsa.org/pubs/forum/forum_issues/for33_1.pdf">fueling the prescription drug abuse</a> problem in Georgia. </p>
<p>I believe that Georgia’s moratorium on MATs hurts those who truly need the life-saving treatments the most. There are <a href="https://www.washingtonpost.com/politics/long-waiting-lists-for-drug-treatment-add-to-addicts-desperation/2015/07/26/d8e8e2b2-13ae-11e5-9518-f9e0a8959f32_story.html">wait lists</a> for treatment nationally. Prescription drug overdose death rates in Georgia could increase during the time it takes for legislators to gain a sense of utilization trends of MAT patients. </p>
<p>Who is to blame? This time, it cannot be erroneously attributed to individuals battling the chronic disease of addiction, who are dying while waiting for MAT access. At this time, it appears that no other states are following suit, and there is no good policy reason for them to do so.</p><img src="https://counter.theconversation.com/content/61179/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sheryl Strasser has received external funding from the Substance Abuse and Mental Health Services Administration, The Council of Alcohol and Drugs, as well as the Georgia Department of Behavioral Health and Developmental Disability for evaluation work related to prescription drug abuse prevention programs. Her externally funded projects ended in 2015. </span></em></p>The Senate passed a bill July 13 to address the opioid epidemic. Georgia recently passed a bill that would limit rather than expand the number of treatment centers. Could others follow suit?Sheryl Strasser, Professor of Public Health, Georgia State UniversityLicensed as Creative Commons – attribution, no derivatives.