tag:theconversation.com,2011:/ca/topics/fentanyl-28070/articlesFentanyl – The Conversation2024-02-15T13:33:58Ztag:theconversation.com,2011:article/2222442024-02-15T13:33:58Z2024-02-15T13:33:58ZNitazenes are a powerful class of street drugs emerging across the US<figure><img src="https://images.theconversation.com/files/574223/original/file-20240207-20-k3tcfe.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C7790%2C5217&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Nitazenes, like this powder sample, are a class of synthetic opioids more potent than morphine and fentanyl.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/alex-krotulski-associate-director-and-forensic-toxicologist-news-photo/1836064649">Joe Lamberti/The Washington Post via Getty Images</a></span></figcaption></figure><p><em><a href="https://bouldercounty.gov/news/emerging-drug-information-nitazenes/">Two deaths in Boulder County, Colorado, in 2023</a> are the latest in the U.S. to be blamed on the powerful class of synthetic opioids called nitazenes. Most health systems cannot detect nitazenes, so the exact number of overdoses is unknown, but they’re implicated in <a href="https://doi.org/10.7759/cureus.40736">more than 200 deaths</a> in Europe and North America since 2019, including <a href="https://cdn.theconversation.com/static_files/files/3058/Colorado_nitazenes.pdf?1707842742">11 in Colorado since 2021</a>. One of the two Boulder County deaths is linked to a new formulation called N-Desethyl etonitazene, which was <a href="https://www.cfsre.org/nps-discovery/monographs/n-desethyl-etonitazene">identified by a national laboratory</a>, and is thought to be the first related death.</em></p>
<p><em>The Conversation interviewed <a href="https://scholar.google.com/citations?hl=en&user=Ne94jgIAAAAJ">Dr. Christopher Holstege</a>, professor of emergency medicine and pediatrics at the University of Virginia School of Medicine and director of the Blue Ridge Poison Center, where opioid overdoses are increasing. He explains why nitazenes are so potent and deadly.</em></p>
<h2>What are nitazenes?</h2>
<p>Nitazenes are a class of synthetic opioids that contains more than 20 unique compounds, <a href="https://www.dea.gov/stories/2022/2022-06/2022-06-01/new-dangerous-synthetic-opioid-dc-emerging-tri-state-area">including isotonitazene</a>, which was first identified in 2019 and is known on the streets as ISO. It also includes protonitazene, metonitazene and etonitazene.</p>
<p>Nitazenes are psychoactive substances, or <a href="https://doi.org/10.1177%2F2045125320967197">“designer drugs,”</a> that aren’t controlled by any laws or conventions but <a href="https://www.unodc.org/LSS/Page/NPS">pose significant health risk</a> to the public. These substances have recently surfaced as illegal street drugs. </p>
<p>Researchers have relatively little information on how the human body reacts to nitazenes because the drugs have never gone through clinical trials. But lab tests show certain nitazenes could be <a href="https://doi.org/10.7759/cureus.40736">hundreds to thousands of times more potent</a> than morphine and 10 to 40 times stronger than fentanyl.</p>
<p>The U.S. Drug Enforcement Agency has classified many formulations of nitazenes as <a href="https://www.federalregister.gov/documents/2021/12/07/2021-26263/schedules-of-controlled-substances-temporary-placement-of-butonitazene-etodesnitazene-flunitazene">Schedule 1 drugs under the Controlled Substances Act</a>, meaning they have no medical use and have a high risk of abuse.</p>
<h2>When were nitazenes first developed?</h2>
<p>Nitazenes were initially <a href="https://www.deadiversion.usdoj.gov/drug_chem_info/benzimidazole-opioids.pdf">developed in the 1950s</a> by the pharmaceutical research laboratories of the Swiss chemical company CIBA Aktiengesellschaft. It synthesized numerous substances in the drug class to be used as painkillers. </p>
<p>However, nitazenes were never approved by the U.S. Food and Drug Administration <a href="https://doi.org/10.7759/cureus.40736">for medical use in humans</a>. They were nearly forgotten outside of specialized research circles until they reemerged as street drugs in 2019. As law enforcement has cracked down on other drugs such as fentanyl, illegal labs have used <a href="https://doi.org/10.7759/cureus.40736">historical pharmacology research</a> to formulate analogs of nitazenes as street drugs. </p>
<p>Since 2019, <a href="https://doi.org/10.1093%2Fjat%2Fbkab117">at least six formulas</a> have come from the original patent, but others, like the one detected in Boulder, are brand new. <a href="https://doi.org/10.1093%2Fjat%2Fbkab117">Specialized lab testing</a> is required to identify nitazenes in toxicology samples, and <a href="https://www.ccsa.ca/sites/default/files/2022-03/CCSA-CCENDU-Drug-Alert-Nitazenes-2022-en_0.pdf">fentanyl test strips can’t detect nitazene analogs</a>.</p>
<p>But since <a href="https://doi.org/10.1016/j.forsciint.2021.110686">first being detected</a>, nitazenes have been blamed for <a href="https://doi.org/10.7759/cureus.40736">200 drug-related overdose deaths</a> in Europe and the United States. Although nitazenes are now identified as illegal street drugs in numerous countries, many medical providers aren’t <a href="https://doi.org/10.7759/cureus.40736">even aware they exist</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/574225/original/file-20240207-21-5ih0d9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Blue pills on a black background" src="https://images.theconversation.com/files/574225/original/file-20240207-21-5ih0d9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/574225/original/file-20240207-21-5ih0d9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/574225/original/file-20240207-21-5ih0d9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/574225/original/file-20240207-21-5ih0d9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/574225/original/file-20240207-21-5ih0d9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/574225/original/file-20240207-21-5ih0d9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/574225/original/file-20240207-21-5ih0d9.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">Isotonitazene has shown up in pill form mixed with other drugs such as oxycodone.</span>
<span class="attribution"><a class="source" href="https://www.dea.gov/onepill/images">DEA</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>What types of nitazenes are showing up on the streets?</h2>
<p>Nitazene first appeared in 2019 in the Midwest as a <a href="https://www.federalregister.gov/documents/2023/08/18/2023-17778/schedules-of-controlled-substances-placement-of-metonitazene-in-schedule-i">white powdery substance</a> similar to cocaine. <a href="https://www.dea.gov/stories/2022/2022-06/2022-06-01/new-dangerous-synthetic-opioid-dc-emerging-tri-state-area">It later appeared</a> on the streets of Washington, D.C., as yellow, brown and white powders. Since 2022, the DEA has found other types of nitazenes in both <a href="https://www.federalregister.gov/documents/2023/10/25/2023-23379/schedules-of-controlled-substances-temporary-placement-of-n-desethyl-isotonitazene-and-n-piperidinyl">powder and blue tablet forms</a>.</p>
<p>Nitazenes are also <a href="https://www.federalregister.gov/documents/2023/10/25/2023-23379/schedules-of-controlled-substances-temporary-placement-of-n-desethyl-isotonitazene-and-n-piperidinyl">mixed with other street drugs</a> such as heroin and fentanyl and with fake oxycodone pills, without users knowing it. </p>
<p>The Justice Department has indicted several <a href="https://www.justice.gov/opa/pr/justice-department-announces-eight-indictments-against-china-based-chemical-manufacturing">companies in China</a>, alleging that they ship the raw chemicals to make nitazenes to Mexico and the U.S., where they get mixed by cartels and traffickers, then distributed on the streets.</p>
<h2>What are signs of a nitazene overdose?</h2>
<p>The toxic effects of nitazene resemble those associated with other classic opioids such as morphine and fentanyl and include small pupils and slowing of the respiratory and central nervous systems, which can lead to death.</p>
<p>Because of the potency of the nitazenes, symptoms can develop rapidly after someone is exposed, killing them before they can get medical care.</p>
<h2>Does naloxone counteract the effects of overdose?</h2>
<p>Naloxone, commonly <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">known as Narcan</a>, is <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7137a5.htm">reportedly effective</a> in reversing overdoses due to nitazene, but larger and <a href="https://www.cdc.gov/mmwr/volumes/71/wr/mm7137a5.htm">multiple doses might be required</a>.</p><img src="https://counter.theconversation.com/content/222244/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher P. Holstege 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>An overdose death in Boulder County, Colorado, was linked to a powerful new formulation of a designer drug never approved for use in humans.Christopher P. Holstege, Professor of Emergency Medicine and Pediatrics, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2206082024-01-15T13:37:47Z2024-01-15T13:37:47ZKush: what is this dangerous new west African drug that supposedly contains human bones?<figure><img src="https://images.theconversation.com/files/568481/original/file-20240109-30-g2zjue.jpg?ixlib=rb-1.1.0&rect=31%2C31%2C2971%2C1963&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-african-man-smoking-joint-588753893">DeanP/Shutterstock</a></span></figcaption></figure><p>A new drug called kush is <a href="https://www.channel4.com/news/kush-a-drug-sometimes-mixed-with-human-bones-is-ravaging-sierra-leone#:%7E:text=Kush%20is%20a%20mysterious%20new,the%20drug's%20cocktail%20of%20ingredients">wreaking havoc in west Africa</a>, particularly in Sierra Leone where it is estimated to kill around a dozen people each week and <a href="https://www.telegraph.co.uk/global-health/terror-and-security/kush-synthetic-drug-addiction-epidemic-west-africa/#:%7E:text=But%20it's%20not%20just%20Sierra,the%20region%20are%20now%20addicted.">hospitalise thousands</a>. </p>
<p>The drug, taken mostly by <a href="https://www.telegraph.co.uk/global-health/terror-and-security/kush-synthetic-drug-addiction-epidemic-west-africa/#:%7E:text=But%20it's%20not%20just%20Sierra,the%20region%20are%20now%20addicted.">men aged 18 to 25</a>, causes people to fall asleep while walking, to fall over, to bang their heads against hard surfaces and to walk into moving traffic.</p>
<p>Kush should not be confused with the drug of the same name found in the US, which is a mixture of <a href="https://www.houstoniamag.com/news-and-city-life/2016/08/so-what-exactly-is-kush-city-council-is-asking-ice-house-september-2016">“an ever-changing host of chemicals”</a> sprayed on plant matter and smoked. Kush in Sierra Leone is quite different; it is a <a href="https://www.telegraph.co.uk/global-health/terror-and-security/kush-synthetic-drug-addiction-epidemic-west-africa/#:%7E:text=Kush%20first%20emerged%20in%20Sierra,under%20%C2%A3400%20a%20year">mixture</a> of cannabis, fentanyl, tramadol, formaldehyde and – according to some – ground down <a href="https://www.youtube.com/watch?v=fKc3SDBoFtA">humans bones</a>.</p>
<p>It is mixed by local criminal gangs, but the constituent drugs have international sources, facilitated no doubt by the internet and digital communications. </p>
<p>While cannabis is widely grown in Sierra Leone, the fentanyl is thought to originate in clandestine laboratories in China where the drug is manufactured illegally and shipped to west Africa. Tramadol has a similar source, namely illegal laboratories across Asia. Formaldehyde, which <a href="https://www.justice.gov/archive/ndic/pubs11/12208/index.htm#:%7E:text=Embalming%20fluid%20is%20a%20compound,resulting%20in%20a%20prolonged%20high.">can cause hallucinations</a>, is also reported in this mixture. </p>
<p>As for ground human bones, there is no definitive answer about whether or not they occur in the drug, where such bones would come from, or why they might be incorporated into the drug. Some people say that <a href="https://www.channel4.com/news/kush-a-drug-sometimes-mixed-with-human-bones-is-ravaging-sierra-leone#:%7E:text=Kush%20is%20a%20mysterious%20new,the%20drug's%20cocktail%20of%20ingredients">grave robbers</a> provide the bones, but there is no direct evidence of this. </p>
<p>But why would bones be incorporated into the drug? Some suggest that the sulphur content of the bones causes a high. Another reason might be the drug content of the bones themselves, if the deceased was a fentanyl or tramadol user. </p>
<p>However, both are unlikely. Sulphur levels in bones are not high. Smoking sulphur would result in highly toxic sulphur dioxide being produced and inhaled. Any drug content in bones is orders of magnitude less than that required to cause a physiological effect.</p>
<h2>Where is the drug found?</h2>
<p>The drug is reported in both <a href="https://www.telegraph.co.uk/global-health/terror-and-security/kush-synthetic-drug-addiction-epidemic-west-africa/#:%7E:text=Kush%20first%20emerged%20in%20Sierra,under%20%C2%A3400%20a%20year">Guinea and Liberia</a>, which share porous land borders with Sierra Leone, making drug trafficking easy. </p>
<p>Kush costs around five leones (20 UK pence) per joint, which may be used by two or three people, with up to 40 joints being consumed in a day. This represents a massive spend on drugs and illustrates the addictive nature of the mixture, in a country where the annual income per capita is <a href="https://tradingeconomics.com/sierra-leone/gdp-per-capita#:%7E:text=The%20Gross%20Domestic%20Product%20per,percent%20of%20the%20world%27s%20average.">around £500</a>.</p>
<p>The effects of the drug vary and depend on the user and the drug content. Cannabis causes a wide variety of effects, which include euphoria, relaxation and an altered state of consciousness. </p>
<p>Fentanyl, an extremely potent opioid, produces euphoria and confusion and causes sleepiness among a wide range of other side-effects. Similarly, tramadol, which is also an opioid but less potent than fentanyl (100mg tramadol has the same effect as 10mg morphine) results in users becoming sleepy and “spaced out” – disconnected from things happening around them. </p>
<figure class="align-center ">
<img alt="Blisterpacks of tramadol pills" src="https://images.theconversation.com/files/568482/original/file-20240109-27-4m2gnf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/568482/original/file-20240109-27-4m2gnf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=345&fit=crop&dpr=1 600w, https://images.theconversation.com/files/568482/original/file-20240109-27-4m2gnf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=345&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/568482/original/file-20240109-27-4m2gnf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=345&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/568482/original/file-20240109-27-4m2gnf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=434&fit=crop&dpr=1 754w, https://images.theconversation.com/files/568482/original/file-20240109-27-4m2gnf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=434&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/568482/original/file-20240109-27-4m2gnf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=434&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Kush can contain tramadol, an opioid.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pain-killer-capsules-called-tramadol-hcl-789515359">Saowanee K/Shutterstock</a></span>
</figcaption>
</figure>
<p>The danger of the drug is twofold: the risk of self-injury to the drug taker and the highly addictive nature of the drug itself. A further problem is the need to finance the next dose, often achieved through prostitution or criminal activity.</p>
<h2>Joining the ranks of existing polydrugs</h2>
<p>Kush is another example of polydrug mixtures of which forensic scientists are becoming increasingly aware. Another tobacco and cannabis-based drug, <a href="https://www.sciencedirect.com/science/article/pii/S037907381830481X">nyaope</a>, otherwise known as whoonga, is found in South Africa. This time the tobacco and cannabis are mixed with heroin and antiretroviral drugs used to treat Aids, some of which are <a href="https://www.scielo.org.za/scielo.php?pid=S0038-23532021000600018&script=sci_arttext">hallucinogenic</a>. </p>
<p>A further polydrug, <a href="https://mg.co.za/article/2002-07-05-high-on-the-white-pipe/">“white pipe”</a>, a mixture of methaqualone (Mandrax), cannabis and tobacco, is smoked in southern Africa. These drugs are inexpensive and provide an escape from unemployment, the drudgery of poverty, sexual and physical abuse, and the effect, in some cases, especially in west Africa, from having been a child soldier. So what can be done about these drugs? </p>
<p>The effectiveness of legislation alone is questionable, and many of those who attend the very limited rehabilitation centres return to drug use. Perhaps what is required is an integrated forensic healthcare system where legislative control is backed up by properly resourced rehabilitation centres coupled with a public health and employment programme. What changes are made in response to this epidemic remains to be seen.</p><img src="https://counter.theconversation.com/content/220608/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Cole receives funding and "in kind" support from the European Union and a number police forces and forensic science organisations around the world to carry out research. </span></em></p>A new polydrug is destroying lives in west Africa.Michael Cole, Professor of Forensic Science, Anglia Ruskin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2148952023-11-30T17:23:43Z2023-11-30T17:23:43ZBuvidal: is it really a ‘game changer’ in the treatment of problematic opioid use?<p>To overcome problematic opioid use, traditional forms of opioid substitution therapy, such as <a href="https://www.nhs.uk/medicines/methadone/">methadone</a> and <a href="https://www.nhs.uk/medicines/buprenorphine-for-pain/">oral buprenorphine</a>, have become valuable tools. <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002209.pub2/full?highlightAbstract=opioid">Research</a> shows that patients receiving substitution therapy are more likely to stay in treatment and stop using heroin than patients receiving treatments that do not involve substitutes – such as counselling or group therapy.</p>
<p>But not all those on substitute medication are able to stop using illicit opioids. Some continue to use them in addition to the substitute. One <a href="https://www.sciencedirect.com/science/article/abs/pii/S0376871621001460">barrier</a> to success is the need to attend a clinic or pharmacy every day, or every few days, to obtain the substitute. </p>
<p>In early 2019, a new form of substitute treatment, long-acting injectable buprenorphine, was approved for use in the UK. Unlike methadone and oral buprenorphine, <a href="https://www.nice.org.uk/advice/es19/evidence/evidence-review-pdf-6666819661#:%7E:text=Buprenorphine%20prolonged%2Drelease%20injection%20is,buprenorphine%20prolonged%2Drelease%20injection%20subcutaneously.">long-acting injectable buprenorphine</a> is administered via an injection either weekly or monthly. The treatment – also known by its brand names Buvidal or Sublocade – has been heralded as a “<a href="https://nation.cymru/news/welsh-university-carries-out-game-changer-drug-treatment-research/">game changer</a>” by both doctors and patients. </p>
<h2>Opioids</h2>
<p>In 2021, nearly 5,000 drug-related deaths were <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2021registrations">registered</a> in England and Wales. About half of those involved an opioid. </p>
<p>Opioids are a class of drugs that include substances derived from the opium poppy. They include <a href="https://www.nhs.uk/medicines/morphine/">morphine</a> and <a href="https://www.emcdda.europa.eu/publications/drug-profiles/heroin_en">heroin</a>, as well as synthetic alternatives that mimic the effects of naturally occurring opioids such as <a href="https://www.nhs.uk/medicines/tramadol/">tramadol</a> and <a href="https://bnf.nice.org.uk/drugs/fentanyl/">fentanyl</a>.</p>
<p>Opioids work in the brain to produce a variety of effects, including pain relief. They also produce feelings of euphoria, joy and pleasure. Opioids have a depressant effect on the body, so if someone overdoses, they can stop breathing and may die. Overdose is a particular risk for those who use illegally obtained opioids of unknown strength, such as heroin.</p>
<p>Often people are unable to stop using opioids despite the risk of death and the serious negative health and social consequences. Such drugs are hard to give up, partly because stopping causes painful physical and psychological withdrawal symptoms.</p>
<h2>Opioid substitution therapy</h2>
<p>An effective form of treatment for problematic opioid use is opioid substitution therapy, where illegally obtained opioids are substituted for prescribed alternatives. </p>
<p>Providing a legal substitute of known purity is useful in many ways. Most notably, it removes the need to buy and use illicit opioids. This reduces the risk of <a href="https://www.bmj.com/content/357/bmj.j1550">overdose</a> and the need to commit crimes like <a href="https://academic.oup.com/bjc/article-abstract/49/4/513/2747197">theft and shoplifting</a> to get money to pay for drugs.</p>
<p>But while daily attendance and supervised consumption may help to minimise the risk of misuse, it also has its drawbacks. For example, it can bring patients into regular contact with their former drug-using networks and can require time-consuming journeys that interfere with employment, education and other responsibilities.</p>
<p>Long-acting injectable buprenorphine does not have these drawbacks. It is not unlike <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369037/">long-acting</a> forms of contraception, in that the medicine releases slowly over time, thereby avoiding the peaks and troughs associated with oral formulations.</p>
<p>When the pandemic broke and the UK went into lockdown, <a href="https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs_en">concerns</a> were raised by experts that daily attendance at clinics or pharmacies for opioid substitution medication might increase the risk of COVID transmission. </p>
<p>Keen to stop the spread of the virus while also providing safe and continuous treatment to patients, the Welsh government <a href="https://committees.parliament.uk/writtenevidence/107535/pdf/">agreed</a> to fund the roll-out of long-acting injectable buprenorphine to drug services across Wales. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/WlWJxfHVY9I?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Two doctors discuss Buvidal from the perspective of lived experience.</span></figcaption>
</figure>
<p>That decision was supported by <a href="https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-023-01348-5">emerging evidence</a> of the effectiveness of the medication from a drug service in south Wales that had been piloting the medicine before the pandemic. </p>
<h2>Results</h2>
<p>While the primary aim at that time was to stop the spread of COVID, it quickly became clear that the medication was benefiting patients in many other ways. </p>
<p>Patients taking part in a <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">survey</a> about the new medication reported reductions in cravings, lower levels of anxiety, reductions in offending and abstinence from illicit opioids. They described rebuilding their lives, getting jobs, reconnecting with family members and heralded long-acting injectable buprenorphine as a “game changer”, “life changing” and even a “miracle”. </p>
<p>Positive results have also been reported in <a href="https://www.jsatjournal.com/article/S0740-5472(22)00058-7/fulltext">systematic reviews</a> that summarise the findings of the currently small, and not very robust, body of evidence on the effectiveness of the medication.</p>
<p>However, alongside the reports of success, less positive <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">stories</a> have emerged suggesting that the treatment may not be a silver bullet. Some patients have found the transition onto the medication challenging because it required them to be in full withdrawal before their first dose. </p>
<p>Others have been overwhelmed with emotions because the medication made them feel so clear-headed that their past traumas – suppressed by years of illicit opioid use – had begun to resurface. There have also been <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">reports</a> of an increase in crack cocaine use among some patients and concerns about the reduced amount of contact (from daily to monthly) with drug services.</p>
<p>Even though there is a “<a href="https://pubmed.ncbi.nlm.nih.gov/16764215/">ceiling effect</a>” that reduces the risk of overdose, this medication still carries a risk of respiratory depression. This risk is <a href="https://pubmed.ncbi.nlm.nih.gov/15957155/">greater</a> among those using alcohol, benzodiazepines or other opioids such as heroin.</p>
<p>Long-acting injectable buprenophine is still in its infancy worldwide, so the evidence for its effectiveness is slim. To determine if it really is a “game changer”, experts will need to look at its impact across a wider range of outcomes, over longer periods and with larger samples than have been considered to date.</p><img src="https://counter.theconversation.com/content/214895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katy Holloway receives funding from Welsh Government and is a member of Welsh Government's National Implementation Board for Drug Poisoning Prevention. </span></em></p><p class="fine-print"><em><span>Fabrizio Schifano receives funding from Welsh Government. Currently a World Health Organization (WHO) member of the Expert Committee on Drug Dependence (ECDD; 2023). Previously, Schifano was a member of the ACMD UK and an expert advisor of the European Medicines Agency (EMA) for Psychiatry. </span></em></p>Long-acting injectable buprenorphine is also known by the brand names Buvidal or Sublocade.Katy Holloway, Professor of Criminology, University of South WalesFabrizio Schifano, Chair in Clinical Pharmacology and Therapeutics, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2173732023-11-16T02:22:26Z2023-11-16T02:22:26ZBiden-Xi meeting at APEC a reminder of the importance of global summits in dangerous times<p>For three decades, the leaders of the Asia Pacific Economic Cooperation (APEC) forum have met to advance their shared interests in improving trade and investment across the region. </p>
<p>This year’s meeting in San Francisco has a particular prominence. US President Joe Biden and his Chinese counterpart Xi Jinping have met for the first time since last year’s G20 summit in Bali, amid efforts by the two great powers to improve their fraught relationship. APEC is normally held alongside the annual ASEAN and East Asia summits, but those jamborees were held a little earlier this year, giving the trans-Pacific grouping some much-needed clear air.</p>
<p>Established in 1989, APEC was intended to drive trade liberalisation in the Asia-Pacific at a time when global efforts had stalled. US President Bill Clinton was the inaugural host of the leaders’ meeting in 1993. In the 1990s, the grouping launched ambitious goals about free trade and took on what now seems like a curious mix of members. </p>
<p>APEC is one of the few international bodies in which Taiwan participates, alongside Hong Kong and the People’s Republic of China. The grouping manages this by having member economies, rather than states. It also includes Canada, Mexico, Peru and Chile, but not India. While many countries use the “Indo-Pacific” label to describe the region, APEC is a reminder that not so long ago the region’s future was imagined in rather different terms.</p>
<p>By the early 2000s, political interest in advancing free trade had ebbed and APEC’s influence began to wane. This was exacerbated by ASEAN’s offshoots, such as the East Asia Summit and the ASEAN Regional Forum, appearing better placed to advance a cooperative agenda. </p>
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<p>But the grouping remained valuable to its members less for the specific policy benefits it could provide, and more for the annual opportunity to gather and occasionally manage crises. </p>
<p>In 2001, the APEC summit in Shanghai allowed then US President George Bush and Chinese leader Jiang Zemin to meet and reset their relations following <a href="https://www.theguardian.com/gall/0,8542,468363,00.html">an incident in April that year</a> in which a US EP3 reconnaissance aircraft was forced to crash land on Hainan Island. China held 24 crew members and the craft for ten days. </p>
<p>US-China relations were badly damaged, and APEC created the space for a high-level reset. Then, as now, the forum provides a useful pretext for the leaders to meet without either side feeling they were signalling weakness by travelling to the other’s territory.</p>
<p>Two decades later, and US-China relations have been in their most difficult phase since the normalisation of relations in the 1970s. The much-anticipated meeting between Xi and Biden appears to have been a success. </p>
<p>In the lead-up, both sides sought to manage expectations, making clear that neither anticipated any major breakthrough in relations. However, the four-hour discussion seems to have produced several important achievements. Perhaps the most important, at least in terms of managing risk, is the reopening of communication channels between the countries’ militaries, which had been shut down by Beijing in response to the then US House Speaker Nancy Pelosi’s visit to Taiwan in August last year. </p>
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<p>China has also <a href="https://www.theguardian.com/world/2023/nov/14/biden-china-fentanyl-deal">agreed to crack down</a> on exporters who manufacture chemicals used in fentanyl production, and have agreed to establish a forum to maintain separation between AI and nuclear weapons systems. </p>
<p>Reportedly, the two leaders also discussed the <a href="https://apnews.com/live/apec-summit-live-updates">question of Taiwan</a>. The island has long been a regional flashpoint, but in recent years it has become a lighting rod for hawks on both sides of the Pacific. Both would benefit from a less heated environment. </p>
<p>More broadly, Biden and Xi appear to have succeeded in putting a floor under the relationship, and while they’re still some way from an agreed set of “rules of the road” in managing their regional competition, Asia can take some comfort that communication between the two is now better and the trajectory of the relationship is more positive than it has been.</p>
<p>Beijing and Washington have incentives for improving their relations. China’s economy is its worst shape since the reform era began. Biden faces wars in Ukraine and Gaza, and has surprisingly poor domestic political stocks less than a year out from the presidential election. </p>
<p>While the summit has improved things, the expectation bar was set low. The contest between the world’s two biggest economies remains heated, largely without guardrails and of immense risk.</p>
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<p>APEC is more than just the US and China bilateral meeting. The group is about economic cooperation, and in the coming days the US will also try to deliver more on the so-far meagre offerings of its “<a href="https://www.dfat.gov.au/trade/organisations/wto-g20-oecd-apec/indo-pacific-economic-framework">Indo-Pacific Economic Framework</a>”. </p>
<p>While its efforts to advance things like infrastructure standards and supply chain resilience will be appreciated, the real prize – improved access to the US market – remains politically off the table. This will limit what Washington can achieve.</p>
<p>The members of the Comprehensive and Progressive Agreement on <a href="https://www.dfat.gov.au/trade/agreements/in-force/cptpp/comprehensive-and-progressive-agreement-for-trans-pacific-partnership">Trans-Pacific Partnership</a> (CPTPP), a trade agreement established after the US withdrew from its predecessor the TPP, will also gather to consider new applicants. Taiwan and China are prominent among these, but it is unlikely either will be allowed to join in the short term.</p>
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<a href="https://theconversation.com/the-drums-of-war-are-receding-but-anthony-albanese-still-faces-many-uncertainties-on-his-trip-to-china-216727">The 'drums of war' are receding, but Anthony Albanese still faces many uncertainties on his trip to China</a>
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<p>APEC 2023 is a reminder of how important multilateral gatherings are in times of geopolitical crisis. Without the excuse that the summit provided, there can be no doubt Xi and Biden would have found it much harder to meet and achieve what are, in the context of their parlous relations, some important positive steps to stabilise regional geopolitics. </p>
<p>Yet it is also a salutary reminder of the real limits of multilateralism in the region. The summit normally concludes with an agreed joint statement, but differences in views about Russia’s invasion of Ukraine, the Gaza conflict and myriad other issues mean that even the veneer of concord is unlikely. The old expansive institutions seem not to be well suited to the current period of heightened geopolitical tension.</p><img src="https://counter.theconversation.com/content/217373/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nick Bisley has received funding from the Commonwealth government for research on regional multilateralism.</span></em></p>Despite a positive meeting, the contest between the world’s two biggest economies remains heated, largely without guardrails and of immense risk.Nick Bisley, Dean of Humanities and Social Sciences and Professor of International Relations at La Trobe University., La Trobe UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2137162023-10-16T21:49:31Z2023-10-16T21:49:31ZThe roots of the North American opioid crisis, and 3 key strategies for stopping it<figure><img src="https://images.theconversation.com/files/554088/original/file-20231016-21-1blzbh.jpg?ixlib=rb-1.1.0&rect=31%2C7%2C4866%2C3210&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approaching the opioid crisis from a public health perspective includes massively increasing access to care and treatment for patients experiencing substance use disorder.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-roots-of-the-north-american-opioid-crisis-and-3-key-strategies-for-stopping-it" width="100%" height="400"></iframe>
<p>The Netflix series <em><a href="https://www.netflix.com/ca/title/81095069">Painkiller</a></em> recently depicted how the over-prescribing of the medicine OxyContin wreaked havoc on American society. </p>
<p>Today the grim reality is that opioid-related deaths in North America reached a record level in 2022, with more than <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">109,000 fatalities in the United States</a>. The same year in Canada, <a href="https://www.statista.com/statistics/812260/number-of-deaths-from-opioid-overdose-canada-province/">deaths exceeded 7,400</a>, a number equivalent to 20 opioid-related deaths every day, and this is <a href="https://www.thelancet.com/infographics-do/opioid-crisis-north-america">likely to continue to increase over the coming years</a>.</p>
<p>The opioid overdose crisis has been ongoing for over two decades in Canada and the U.S. The current mortality rate is greater than the <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5021a2.htm">worst years</a> of the <a href="https://www.jstor.org/stable/41994093">HIV/AIDs epidemic</a> in these <a href="https://doi.org/10.14745%2Fccdr.v43i12a01">countries</a>. </p>
<p><a href="https://www.canada.ca/en/health-canada/services/opioids.html">Opioids</a> are drugs primarily used to treat severe pain, such as after surgery. When prescribed responsibly they are an effective medication, but if over-prescribed or used recreationally they can lead to an addiction (known as <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">opioid use disorder</a>) that can result in overdose death and wider community problems.</p>
<h2>The roots of the crisis</h2>
<p>After introduction of the opioid painkiller OxyContin in 1996, <a href="https://doi.org/10.2105%2FAJPH.2007.131714">Purdue Pharma marketed the drug aggressively</a>, underplaying its potential for addiction. Prescriptions increased and many patients became addicted. Purdue Pharma eventually <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">pleaded guilty to criminal charges in 2020</a>.</p>
<p>To address addiction, <a href="https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4997.pdf">prescription monitoring programs</a> aimed to limit supply but many patients then sought illicit opioids, leading to large heroin markets in the 2010s. </p>
<p>From 2015 onwards, illegally made <a href="https://www.canada.ca/en/health-canada/services/substance-use/controlled-illegal-drugs/fentanyl.html">fentanyl</a> — a very strong opioid that is easy to manufacture — became widely available, and rapidly replaced the heroin market. Fentanyl is extremely toxic — up to 100 times stronger than heroin — and is largely responsible for the increase in overdose deaths. </p>
<p>Now North Americans face an urgency on how to end the suffering. There is no single solution given the complexity of the problem, but we explain three potential strategies for treating patients and managing this epidemic.</p>
<h2>1. Treat substance use disorders as a public health problem</h2>
<p>The traditional “<a href="https://www.lse.ac.uk/ideas/publications/reports/ending-drugs">war on drugs</a>” approach that focuses only on criminalization has been unsuccessful. In reality the data shows that illegal drug prices have fallen whilst purity and deaths have increased. <a href="https://www.themarshallproject.org/2021/07/15/inside-the-nation-s-overdose-crisis-in-prisons-and-jails">Overdose deaths have also increased in prisons</a> showing that places with even the highest level of security are vulnerable to drug smuggling.</p>
<p>Focusing on the opioid crisis through a public-health approach includes massively increasing access to care and treatment for patients experiencing substance use disorder. It requires more evidence-based services such as addiction clinics, psychotherapy harm reduction strategies and education for both patients and families about treatments that are available to them. </p>
<p>Beyond initial treatment there should be continued professional social support and a wider national effort to address the <a href="https://doi.org/10.2105%2FAJPH.2017.304187">socioeconomic causes</a> in disadvantaged communities. </p>
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<p>Just as there is <a href="https://www.youtube.com/watch?v=HHiN7JftdcY">stigma associated with addiction</a> that stops people from seeking help, there also appears to be stigma at the political and community level, as there is reluctance to fully acknowledge community drug problems. This <a href="https://doi.org/10.1371/journal.pmed.1002969">stigma needs to be reduced</a> so patients can get help.</p>
<h2>2. Find better treatments through research</h2>
<p>There are currently three main medicines approved for <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">treating patients with opioid use disorder</a> in Canada and the U.S.: methadone, buprenorphine/naloxone and extended-release naltrexone.</p>
<p>Although these are effective when used, there are barriers to access and long-term engagement with these treatments. <a href="https://thetyee.ca/News/2023/10/06/Catastrophe-No-Sense-Crisis/">Less than 10 per cent of overdose survivors have access to meaningful care.</a> The limited number of medications available does not work for everyone. We need more innovation to rapidly increase access to care and to find better therapies that suit the needs of different patients.</p>
<p>For example, our <a href="https://www.bccsu.ca/about/">research centre in Vancouver</a>, is evaluating a slow-release formulation of morphine compared to methadone, which has been the dominant treatment for the past 40 years. This study will generate real-world evidence on the effectiveness of novel treatments in contexts of increasing fentanyl use.</p>
<p>Other research is exploring <a href="https://classic.clinicaltrials.gov/ct2/show/NCT05985850">cannabis-based therapy</a> and the <a href="https://www.bccsu.ca/road-to-recovery-study/">best pathways patients can access for recovery</a>. These research initiatives aim to increase the number of evidence-based treatments that can be used to enhance patient recovery and quality of life.</p>
<h2>3. Stop the international spread of the epidemic</h2>
<p>Currently the epidemic is contained within North America but there is the real <a href="https://doi.org/10.1007/s40429-018-0231-x">concern of the crisis spreading</a> to other countries. There is a steady <a href="https://theconversation.com/over-the-counter-opioids-does-britain-have-a-codeine-problem-205331">increase in prescription</a> and illicit opioid use in the United Kingdom and other European countries, which should be an early warning sign that they do not follow the same trajectory. Clinicians must remain actively vigilant on how they prescribe these drugs. </p>
<p>There should be <a href="https://doi.org/10.1016/S0140-6736(21)02252-2">greater international regulation</a> in the marketing and operational strategies of pharmaceuticals, and oversight of the “<a href="https://www.science.org/content/article/fda-s-revolving-door-companies-often-hire-agency-staffers-who-managed-their-successful">revolving door</a>” between industry and regulator employment. There is a potential conflict of interest when pharma companies hire the government employees who oversee their applications. As shown in <em>Painkiller</em>, the FDA regulator who initially had issues with the drug’s approval, and then later approved it, subsequently went on to work for Purdue.</p>
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<a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids</a>
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<p>Another concern is that the current increase in overdose deaths is coinciding with increased deaths where other illicit recreational drugs, such as cocaine and benzodiazepines, are <a href="https://www.bccsu.ca/blog/news/fentanyl-laced-cocaine-appears-in-b-c-amid-calls-for-safe-supply/">contaminated with fentanyl</a> unknown to the users. More effort should be made towards the public awareness of the dangers of an increasingly toxic drug market.</p>
<p>Speaking at a health-care summit in June, Rahul Gupta, the <a href="https://www.politico.com/news/2023/06/07/gupta-opioid-crisis-deaths-00100756">director of the U.S. Office of National Drug Control Policy</a>, said, “There is almost no other area today (that) affects our public health, national security and economic prosperity.”</p>
<p>Valuable knowledge has been gained in confronting this crisis. Governments and communities should support evidence-based recommendations to help patients. There are still many challenges, but they are not beyond solving.</p><img src="https://counter.theconversation.com/content/213716/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael Smith Foundation for Health Research/ St. Paul’s Foundation Scholar Award.
Peer-review grants from the Canadian Institutes of Health Research and Vancouver Foundation.
Partial funding from Indivior for an investigator initiated study.
</span></em></p><p class="fine-print"><em><span>Rohan Anand 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>There were more than 100,000 opioid-related deaths in North America in 2022. How the crisis grew to such proportions, and three potential paths to ending it.Rohan Anand, Post Doctoral Fellow, British Columbia Centre on Substance Use, University of British ColumbiaM. Eugenia Socias, Assistant Professor, Dept of Medicine, University of British Columbia and Research Scientist with the BC Centre on Substance Use, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2125892023-09-25T16:24:23Z2023-09-25T16:24:23ZNitazenes: synthetic opioids more deadly than fentanyl are starting to turn up in overdose cases<p>The synthetic opioid fentanyl is well known for the many lives it has claimed – mainly <a href="https://www.cdc.gov/stopoverdose/fentanyl/index.html">in the US</a>, but <a href="https://www.statista.com/statistics/470910/death-by-fentanyl-drug-poisoning-in-england-and-wales/">elsewhere too</a>. Now, a less well-known class of synthetic opioids called nitazenes is starting to crop up in overdose cases, on both sides of the Atlantic. </p>
<p>Nitazenes have recently been the subject of a <a href="https://www.cas.mhra.gov.uk/ViewandAcknowledgment/ViewAlert.aspx?AlertID=103236">national patient safety alert</a> in the UK as a result of a spike in opioid-related deaths over the last two months, with several cases involving nitazenes. </p>
<p>Some drugs in the nitazene class are 100 times more potent than morphine – so about as potent as fentanyl. However, nitazenes may be more deadly.</p>
<p>A <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2808868?resultClick=3">recent study</a>, published in Jama Network Open, reported that people who overdosed on nitazenes typically needed two or more doses of the overdose-reversal drug naloxone, whereas those who overdosed on fentanyl typically only needed one dose.</p>
<p>Nitazenes were first developed by a Swiss company called Ciba Pharmaceuticals in the 1950s as a new type of potent painkiller (analgesic). But the drugs never made it to market. </p>
<p>It appears that chemists in clandestine labs have <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10361140/">pored over old research papers</a> looking for new synthetic opioids to make and stumbled across this class of deadly drugs. </p>
<p>These new synthetic opioids are illegal in the UK as they are covered under the <a href="https://www.legislation.gov.uk/ukpga/2016/2/contents/enacted">Psychoactive Substances Act 2016</a>, which bans all chemical compounds capable of producing a psychoactive effect in people. </p>
<h2>How do they work?</h2>
<p>Opioids act at sites in the brain, and elsewhere in the body, called mu-opioid receptors. These brain receptors, when activated, can relieve pain, and at high doses evoke feelings of euphoria followed by drowsiness.</p>
<p>Morphine, heroin and fentanyl all activate these mu-opioid receptors. However, fentanyl can do so at much lower doses than morphine or heroin – and some nitazenes can relieve pain at even lower doses than fentanyl. </p>
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<p>For example, a <a href="https://doi.org/10.1016/j.drugalcdep.2023.109939">study</a> in rats found that a nitazene called N-desethyl isotonitazene provided pain relief at a dose nearly ten times smaller than that needed for fentanyl, and around 1,400 times less than that for morphine, to see the same effect.</p>
<p>Not only do these drugs relieve pain and cause euphoria, they also suppress the respiratory system. That is, they reduce breathing, and this is the cause of death in opioid overdose. </p>
<p>N-desethyl isotonitazene causes <a href="https://doi.org/10.1016/j.isci.2023.107121">apnea</a> (where breathing stops) at about a third of the dose of fentanyl. It also takes much longer to recover normal breathing after N-desethyl isotonitazene (208 minutes) compared with fentanyl (67 minutes). One must assume, therefore, that some nitazenes may have the potential to be more deadly than fentanyl and heroin.</p>
<p>There are also issues with nitazenes being used as adulterants in other illicit drugs, such as <a href="https://www.nbcnews.com/health/health-news/fentanyl-stimulants-drives-fourth-wave-overdose-epidemic-us-rcna104953">cocaine</a>, benzodiazepines and <a href="https://www.talktofrank.com/drug/synthetic-cannabinoids">synthetic cannabinoids</a> (“spice”). Illicit drug users may be unwittingly taking opioids and need to be aware of the risk of respiratory depression.</p>
<p>Several nitazenes have been found in overdose cases recently, and the number of new drugs in this class (called analogs) emerging on the streets appears to be growing. However, the true extent of this drug’s penetration into the illicit market is <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10361140/#REF8">not known</a> as many testing facilities are not set up to test for nitazenes. </p>
<p>And it isn’t just nitazenes that we need to be concerned about. There are also new non-nitazene synthetic opioids, such as the <a href="https://doi.org/10.1016/j.forsciint.2023.111775">brorphine-like compounds</a>. As with nitazenes, these drugs have been found to be slightly more potent than fentanyl, and much more potent than heroin or morphine, in lab tests.</p>
<p>Mercifully, opioid overdose can be reversed with naloxone – which blocks the mu-opioid receptors and is very effective if given in time. </p>
<p>Public health agencies in the UK have highlighted the need to educate heroin users, and those who come into contact with them, about nitazenes and how to treat overdose with naloxone.</p><img src="https://counter.theconversation.com/content/212589/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colin Davidson acts as an expert witness on psychoactive substances for the Defense Science Technology Labs</span></em></p>Nitazenes were developed as a powerful class of painkiller in the 1950s, but they were abandoned – until now.Colin Davidson, Professor of Neuropharmacology and Head of School of Pharmacy & Biomedical Sciences, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2103162023-07-31T15:26:30Z2023-07-31T15:26:30ZOpioids and cocaine are a deadly combination – and ‘polydrug’ deaths are rising<figure><img src="https://images.theconversation.com/files/540138/original/file-20230731-251277-bhfjl1.jpg?ixlib=rb-1.1.0&rect=8%2C0%2C2987%2C1994&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/mans-hand-holding-on-palm-plastic-1056695408">DedMityay/Shutterstock</a></span></figcaption></figure><p>Drug deaths in the US involving both opioids and cocaine have increased dramatically in the past decade, according to a <a href="https://stacks.cdc.gov/view/cdc/129733">new report</a> from the Centers for Disease Control and Prevention (CDC).</p>
<p>Drug-related deaths associated with stimulants, such as cocaine, methamphetamine, amphetamine and methylphenidate, doubled between 2011 and 2021. And deaths associated with using both stimulants and opioids, such as heroin, morphine, fentanyl and methadone, increased by about sevenfold over the same period. The biggest increases have been seen since about 2019. </p>
<p>Cocaine and methamphetamine are stimulant drugs, whereas opioids, such as heroin and methadone, are depressants. This means that cocaine and methamphetamine will, among other things, make you euphoric and more alert with more energy, while heroin has the opposite effect. After an initial rush of euphoria, heroin users report a long period of drowsiness. </p>
<p>It is unclear why people take both types of drugs together. It is not thought that the euphoric effects are changed significantly by taking these drugs together, but cocaine may help with acute withdrawal from heroin. Another explanation is that, by taking both types of drug together, the user balances the stimulant and depressant effects of the drugs. Some medicated opioid abusers take stimulants for an alternative high or to counteract the sedative effects of their medication. </p>
<h2>Different mechanism</h2>
<p>These drugs work via different mechanisms. The stimulants work mostly by activating the brain’s dopamine system. Dopamine is a neurotransmitter, or chemical messenger, important in the brain reward system, so it is critical to both feeling joy and euphoria.</p>
<p>Heroin and similar drugs such as methadone or fentanyl work via the body’s opioid system. The brain and body have various proteins attached to cell surfaces involved in transmitting the opioid signals. The most relevant proteins here are the mu opioid receptors. These receptors are activated by opioid painkillers.</p>
<p>Unfortunately, it is easy to overdose on opioids such as heroin. Overdose can lead to respiratory depression and then respiratory failure. This is when there are long pauses between breaths, which become more like sighs and then a loss of consciousness followed by cessation of breathing. </p>
<figure class="align-center ">
<img alt="Heroin addicts nodding off" src="https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/540151/original/file-20230731-256057-j6pxbd.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">Opioids can cause respiratory depression.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/no-drugs-concept-man-woman-aids-533628886">Lipik Stock Media/Shutterstock</a></span>
</figcaption>
</figure>
<p>The exact mechanism whereby opioids cause respiratory depression is unknown but probably involves opioid receptors found in the brainstem.</p>
<p>Cocaine and methamphetamine are less likely to kill you but are still dangerous drugs causing heart palpitations, increased blood pressure and increased risk of stroke. Methamphetamine is especially associated with dangerous <a href="https://www.tandfonline.com/doi/epdf/10.4161/23328940.2014.982049?needAccess=true&role=button">hyperthermia</a> leading to multi-organ toxicity. </p>
<p>Taking stimulants together with an opioid clearly increases your risk of drug-related death.</p>
<p>One reason that we may be seeing more drug-related deaths is due to the increased use of fentanyl. Fentanyl is a synthetic opioid that is <a href="https://www.drugs.com/medical-answers/fentanyl-compare-heroin-opiates-3569710/">50 times</a> more potent than heroin and 100 times more potent than morphine, with a faster onset of action. It is therefore more likely to lead to respiratory depression than other opioids, such as heroin or methadone. </p>
<p>Fentanyl is increasingly being used as an <a href="https://www.clinicaterapeutica.it/2022/173/1/11_DI_TRANA.pdf">adulterant</a> in street drugs, such as heroin. This is because it is cheap and very powerful, so only a small amount is needed to have a large effect.</p>
<h2>Europe’s problem too</h2>
<p>It is not just the US that is seeing a rise in so-called polydrug-related deaths. Data from the <a href="https://www.emcdda.europa.eu/publications/european-drug-report/2023/drug-induced-deaths_en">European Monitoring Centre for Drugs and Drug Abuse</a>) show that deaths from polydrug use, especially those involving opioids, are also increasing in Europe. The European data shows that it is mostly men who are dying and that older age groups are increasingly dying from drug taking. </p>
<p>Taken together, it can be seen that there may be a worldwide increase in polydrug-related deaths and in particular those involving both stimulants and opioids.</p><img src="https://counter.theconversation.com/content/210316/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Colin Davidson 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>The US has seen a huge rise in drug deaths in the past decade involving a stimulant and a depressant.Colin Davidson, Professor of Neuropharmacology and Head of School of Pharmacy & Biomedical Sciences, University of Central LancashireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2086452023-07-07T12:27:15Z2023-07-07T12:27:15ZChina’s ties to Cuba and growing presence in Latin America raise security concerns in Washington, even as leaders try to ease tensions<figure><img src="https://images.theconversation.com/files/536158/original/file-20230706-17-yl4bur.jpg?ixlib=rb-1.1.0&rect=58%2C0%2C6470%2C4164&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">U.S. Treasury Secretary Janet Yellen arrives at Beijing Capital International Airport in Beijing, China, on July 6, 2023.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/treasury-secretary-janet-yellen-arrives-at-beijing-capital-news-photo/1507503422?adppopup=true">Pedro Pardo/POOL/AFP via Getty Images</a></span></figcaption></figure><p>There is a push by leaders in Washington and Beijing to get U.S.-China relations back on track. U.S. Secretary of State <a href="https://theconversation.com/china-and-the-us-are-locked-in-struggle-and-the-visit-by-secretary-of-state-blinken-is-only-a-start-to-improving-relations-207981">Antony Blinken met with President Xi Jinping</a> in China in June 2023 to reopen the lines of communication between the countries. And Treasury Secretary Janet Yellen is spending four days in China, beginning July 6, 2023, to try to stabilize U.S.-China economic ties.</p>
<p>But work to steady security issues between the two countries, a longtime point of contention, may have a longer horizon.</p>
<p>In fact, the U.S. military’s decision to <a href="https://www.cnn.com/2023/02/03/politics/china-us-balloon-intl/index.html">shoot down a suspected Chinese spy balloon</a> that had been flying over the country in February 2023 derailed the scheduled diplomatic trip Blinken planned for China earlier in the year.</p>
<p>Now there are <a href="https://www.wsj.com/articles/cuba-to-host-secret-chinese-spy-base-focusing-on-u-s-b2fed0e0?mod=article_inline">news reports that China made deals</a> with Cuba to <a href="https://www.reuters.com/world/china-post-spy-facility-cuba-off-southeastern-us-wsj-2023-06-08/">set up an electronic eavesdropping station</a> on the island nation, just 90 miles from Florida – something <a href="https://www.wsj.com/articles/cuba-to-host-secret-chinese-spy-base-focusing-on-u-s-b2fed0e0?mod=article_inline">Cuban government officials have denied</a> – and to build a <a href="https://www.wsj.com/articles/beijing-plans-a-new-training-facility-in-cuba-raising-prospect-of-chinese-troops-on-americas-doorstep-e17fd5d1">military training facility</a> there. Such moves reflect <a href="https://time.com/5936037/us-china-latin-america-influence/">efforts by China to grow its influence</a> in Latin America and the Caribbean. </p>
<p>A Biden administration official in June said China’s spying from Cuba is an ongoing issue that predates the president’s time in office and that U.S. intelligence knew China had upgraded existing <a href="https://www.reuters.com/world/china-has-been-spying-cuba-some-time-us-official-says-2023-06-10/">espionage facilities</a> in Cuba in 2019.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/536166/original/file-20230706-17-oy0vu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="An illuminated spy balloon flies in the night sky near lit buildings and above a sanded section of a beach near the ocean." src="https://images.theconversation.com/files/536166/original/file-20230706-17-oy0vu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536166/original/file-20230706-17-oy0vu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=423&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536166/original/file-20230706-17-oy0vu1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=423&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536166/original/file-20230706-17-oy0vu1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=423&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536166/original/file-20230706-17-oy0vu1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=531&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536166/original/file-20230706-17-oy0vu1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=531&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536166/original/file-20230706-17-oy0vu1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=531&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A suspected Chinese spy balloon flies over Myrtle Beach, S.C., on Feb. 4, 2023, before the U.S. military shot it down.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/chinese-spy-balloon-flies-over-the-myrtle-beach-sc-united-news-photo/1246809673?adppopup=true">Peter Zay/Anadolu Agency via Getty Images</a></span>
</figcaption>
</figure>
<p>As <a href="https://sipa.fiu.edu/people/staff/profiles/jack-gordon-institute/leland-lazarus.html">a researcher of China-Latin America relations</a> and a former U.S. government official, I have seen firsthand China’s growing influence in Latin America and the Caribbean and am concerned about its <a href="https://www.forbes.com/sites/miltonezrati/2022/11/07/chinas-latin-america-move/?sh=2261482a1d52">far-reaching implications for U.S. national security</a>.</p>
<h2>Too close for comfort</h2>
<p>China’s planned spy base and military training facility in Cuba would be located near the <a href="https://www.cnn.com/2013/09/09/world/guantanamo-bay-naval-station-fast-facts/index.html">U.S. naval station in Guantanamo Bay</a>, home to several <a href="https://www.bloomberg.com/opinion/articles/2023-06-13/cuban-base-would-let-china-spy-on-us-military-targets-in-florida#xj4y7vzkg">U.S. military facilities</a> like <a href="https://www.southcom.mil/">U.S. Southern Command</a> in Miami and <a href="https://www.centcom.mil/">U.S. Central Command</a> and <a href="https://www.socom.mil/">U.S. Special Operations Command</a> both in Tampa, along with their various component commands.</p>
<p>The facility would allow Chinese intelligence officers to better intercept sensitive military information transmitted between U.S. military commands, track senior U.S. diplomatic and military leaders as they travel across the region, monitor U.S. naval and commercial ship movement and gain details about U.S. military exercises, conferences and training <a href="https://www.southcom.mil/About/Area-of-Responsibility/">with various Latin American and Caribbean countries</a>.</p>
<p>The facility could also bolster China’s use of telecommunications networks to spy on U.S. citizens. </p>
<p>U.S. officials have long suspected Chinese telecommunications companies <a href="https://www.wsj.com/articles/u-s-tracked-huawei-zte-workers-at-suspected-chinese-spy-sites-in-cuba-355caddc">Huawei and ZTE</a> of setting up servers and network equipment around the world, including in Cuba, to help the Chinese government collect sensitive information about local government leaders and private citizens. </p>
<p>Chinese companies such as <a href="https://www.reuters.com/article/china-panama-idUSL8N1MU072">China Harbor Engineering Company</a> have constructed dozens of deep-water port projects in Latin American and Caribbean countries, where Chinese intelligence agencies could track U.S. commercial or naval ship movements around important sea lanes like the Panama Canal, <a href="https://www.southcom.mil/Portals/7/Documents/Posture%20Statements/2023%20SOUTHCOM%20Posture%20Statement%20FINAL.pdf?ver=rxp7ePMgfX1aZVKA6dl3ww%3d%3d">which could help China understand where to restrict U.S. maritime routes</a> during a potential military conflict.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/536170/original/file-20230706-18-46b0t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man wearing a light blue, open-collared shirt, reads into a microphone from a sheet of paper." src="https://images.theconversation.com/files/536170/original/file-20230706-18-46b0t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536170/original/file-20230706-18-46b0t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=437&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536170/original/file-20230706-18-46b0t1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=437&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536170/original/file-20230706-18-46b0t1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=437&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536170/original/file-20230706-18-46b0t1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=549&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536170/original/file-20230706-18-46b0t1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=549&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536170/original/file-20230706-18-46b0t1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=549&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Cuban Foreign Vice Minister Carlos Fernandez de Cossio rejected U.S. press reports about a planned Chinese espionage base there during a press conference on June 8, 2023.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/cuban-foreign-vice-minister-carlos-fernandez-de-cossio-news-photo/1258544010?adppopup=true">Yamil Lage/AFP via Getty Images</a></span>
</figcaption>
</figure>
<p>Chinese companies have also either built or operate <a href="https://features.csis.org/hiddenreach/china-ground-stations-space/">12 space research facilities</a> in South America that can be used for legitimate space research. But U.S. and other officials have voiced concern that these same sites could be used <a href="https://www.reuters.com/article/us-space-argentina-china-insight-idUSKCN1PP0I2">to spy on U.S. satellites</a> and intercept sensitive information. </p>
<h2>Illegal Chinese police</h2>
<p>Chinese police forces are a growing presence as well. In April 2023, the FBI arrested two Chinese citizens for allegedly operating an <a href="https://www.nytimes.com/2023/04/17/nyregion/fbi-chinese-police-outpost-nyc.html">illegal police station</a> in New York City’s Chinatown. According to The New York Times, the men <a href="https://www.nytimes.com/2023/04/17/nyregion/fbi-chinese-police-outpost-nyc.html">allegedly harassed Chinese dissidents</a> living in the U.S. </p>
<p>China <a href="https://www.cnn.com/2022/12/04/world/china-overseas-police-stations-intl-cmd/index.html">allegedly operates 100 of these police outposts</a> around the world. Fourteen of them are in eight Latin American and Caribbean countries. </p>
<p>China has also been stepping up its law enforcement engagement in Latin American and the Caribbean, <a href="https://www.defensa.com/centro-america/china-dona-miles-equipos-tacticos-proteccion-panama">donating anti-bullet vests</a>, <a href="https://www.tn8.tv/nacionales/china-dona-trajes-de-proteccion-a-la-policia-nacional-de-nicaragua/">helmets</a> and <a href="https://newssourcegy.com/news/china-donates-military-equipment-and-vehicles-to-guyana-defence-force/">vehicles to local security forces</a>, and Latin American and Caribbean law enforcement officers have gone to China to receive training.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/536167/original/file-20230706-24-inmlu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A sign that reads, " src="https://images.theconversation.com/files/536167/original/file-20230706-24-inmlu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536167/original/file-20230706-24-inmlu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536167/original/file-20230706-24-inmlu5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536167/original/file-20230706-24-inmlu5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536167/original/file-20230706-24-inmlu5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536167/original/file-20230706-24-inmlu5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536167/original/file-20230706-24-inmlu5.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">The FBI suspects the Chinese government used this building in Chinatown in New York City as a secret police station to intimidate dissidents living in the U.S.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/building-that-is-suspected-of-being-used-as-a-secret-police-news-photo/1483121085?adppopup=true">Spencer Platt/Getty Images</a></span>
</figcaption>
</figure>
<p>Chinese technology companies <a href="https://techcrunch.com/2022/11/28/fcc-huawei-zte-hikvision-hytera-dahua-ban/">Huawei, ZTE, Dahua and Hikvision</a> have donated surveillance cameras and facial recognition technology to city governments in Argentina, Brazil, <a href="https://dialogo-americas.com/articles/china-exports-citizen-control-model-to-bolivia/">Bolivia,</a> <a href="https://www.nytimes.com/2019/04/24/technology/ecuador-surveillance-cameras-police-government.html">Ecuador</a>, <a href="https://www.stabroeknews.com/2019/07/27/news/guyana/advanced-city-surveillance-system-unveiled/">Guyana</a> and <a href="https://www.caribbeannationalweekly.com/news/caribbean-news/china-to-upgrade-cctv-security-system-in-suriname/">Suriname</a>. </p>
<p>While these Chinese companies deploy these technologies to help Latin American and Caribbean governments reduce crime, they could also use them to spy on U.S. government personnel living in these countries. In fact, the U.S. has <a href="https://www.cnn.com/2022/11/26/us/us-washington-huawei-zte-ban-security-risk-intl-hnk/index.html">banned some of these companies</a> out of concern they spy for the Chinese government.</p>
<p>China’s participation in law enforcement activities in these countries erodes the U.S. position as the region’s preferred security partner.</p>
<h2>Decades of growing influence</h2>
<p>Meanwhile, a major source of conflict between the U.S. and China is the supply of the drug fentanyl. In April 2023, the Biden administration declared fentanyl 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</a> to U.S. national security. The fentanyl global supply chain often ends on U.S. streets, but it begins in various pharmaceutical company labs in China. The U.S. <a href="https://home.treasury.gov/news/press-releases/jy1413">Treasury</a> and <a href="https://www.justice.gov/opa/pr/justice-department-announces-charges-against-china-based-chemical-manufacturing-companies">Justice</a> departments have sanctioned or charged several Chinese companies and individuals for knowingly selling fentanyl precursors to Mexican cartel operatives, who then produce the deadly fentanyl and sell it to Americans.</p>
<p>The China-Cuba connection is just one example of how the Chinese government and Chinese companies have been expanding their influence on America’s doorstep for decades. Not just through trade and investment, but also through espionage, military, law enforcement and drug activities. Such activities will greatly affect U.S. national security for years to come.</p><img src="https://counter.theconversation.com/content/208645/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Leland Lazarus is a Term Member of the Council on Foreign Relations, a nonresident Fellow of the Atlantic Council Global China Hub, and a Board Member of the Fulbright Association.</span></em></p>The US and China are talking again, but security issues between the two countries linger.Leland Lazarus, Associate Director of National Security, Florida International UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2047832023-07-04T21:51:22Z2023-07-04T21:51:22ZScaling up community drug-checking services in B.C. could help respond to the overdose crisis<figure><img src="https://images.theconversation.com/files/535609/original/file-20230704-27-lyamti.jpg?ixlib=rb-1.1.0&rect=30%2C105%2C4986%2C3083&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drug checking is a harm reduction practice that provides chemical analysis of substances. Fentanyl test strips help drug users ensure that substances are free of dangerous fentanyl. </span> <span class="attribution"><span class="source">(AP Photo/Carlos Giusti)</span></span></figcaption></figure><p>British Columbia is in the midst of an enduring drug overdose crisis that continues to claim hundreds of people every year with no end in sight. With a <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf">significant rise in deaths over the last seven years</a>, innovative responses are urgently needed.</p>
<p>Among these responses is community drug checking, which continues to gain traction in both public health practice and research. Drug checking is a harm reduction practice that provides chemical analysis of substances. This is not only to inform harm reduction for people who use, buy and sell drugs (<a href="https://doi.org/10.1186/s12954-021-00545-w">and those who support them</a>), but also to monitor the supply for emerging trends that inform both the community and policymakers about the state of the unregulated supply, <a href="https://doi.org/10.1016/j.drugalcdep.2022.109427">which remains volatile, unpredictable and dangerous</a>. </p>
<p>As researchers providing drug checking on Vancouver Island, we see value in exploring new ways to deliver this service to reach more people who use drugs, at a scale required to address the current crisis.</p>
<h2>Drug checking in global perspective</h2>
<p><a href="https://doi.org/10.1111/add.15734">While drug checking has been around since the 1990s</a>, it remains an underused intervention that is often limited in both scope and scale. However, innovations in <a href="https://doi.org/10.3390/ijerph191911960">how and where the service is provided</a>, as well as <a href="https://doi.org/10.1016/j.drugpo.2022.103611">technological advancements within analytical chemistry and instrumentation</a>, are helping to overcome these limitations.</p>
<p>Internationally, groups like the <a href="https://www.drugs-test.nl/en/about-dims/">Drug Information Monitoring System</a> in the Netherlands have been pioneering drug checking and continuing to inform drug-checking research and practice internationally. </p>
<p>While services in some countries remain beholden by archaic <a href="https://doi.org/10.1016/j.drugalcdep.2022.109425">prohibitory legislative environments that challenge the legality of drug checking</a>, others are finding success in embedding drug checking within novel legal frameworks, <a href="https://doi.org/10.1108/DHS-03-2022-0016">like the legalization of drug checking in New Zealand</a>.</p>
<h2>Drug checking in Canada</h2>
<figure class="align-right ">
<img alt="A person's hand seen using a fentanyl test strip to test a dose of heroin in a small container" src="https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=624&fit=crop&dpr=1 600w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=624&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=624&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=784&fit=crop&dpr=1 754w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=784&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/535606/original/file-20230704-29-rsezno.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=784&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A drug user places a fentanyl test strip into a mixing container to check for contamination, using a fentanyl test strip.</span>
<span class="attribution"><span class="source">(AP Photo/Bebeto Matthews)</span></span>
</figcaption>
</figure>
<p>In Canada, drug checking has its origins in the festival and rave scene as a grassroots bottom-up response to the harms of an unregulated market. <a href="http://michelow.ca/doc/drug-checking-guide-online-v1.pdf">The oldest drug-checking project has provided critical services at Shambhala Music Festival in Salmo, B.C.</a> for the last two decades. </p>
<p>The success of drug checking in festival settings for <a href="https://doi.org/10.17269/s41997-018-0126-6">lowering potential harms and highlighting broader trends</a> is now <a href="https://doi.org/10.1186/s12889-021-11243-4">increasingly being evaluated as a response to the overdose crisis</a> in B.C. and <a href="https://drugchecking.cdpe.org/">other parts of the country</a>. </p>
<p>Drug checking alone is not enough to curb the dramatic increase in drug toxicity deaths in the province and nationally. However, some of its strengths include <a href="https://doi.org/10.1108/DHS-01-2022-0005">generating evidence of trends</a> within the drug supply, as well as evidence for its effectiveness as a harm-reduction measure. It can also be <a href="https://doi.org/10.1080/09687637.2022.2087487">incorporated into other harm reduction programs and methods</a>, including safe supply.</p>
<h2>Substance: The Vancouver Island drug-checking project</h2>
<p>Our <a href="https://substance.uvic.ca/">research-based service in Victoria, B.C.</a> has spent the last five years developing and evaluating drug-checking service models while conducting robust multi-disciplinary research in the fields of social work, chemistry, computer science and public health. This research provides evidence to support services that <a href="https://doi.org/10.1186/s12954-020-00373-4">respond to the unique needs of people accessing drug-checking services</a>.</p>
<p>On the chemistry side, our research <a href="https://doi.org/10.1002/jrs.6133">evaluates and improves analytical technologies and methods, and boosts their effectiveness in detecting fentanyl and other adulterants</a>. Public health research highlights <a href="https://doi.org/10.1186/s12889-021-11243-4">how drug checking goes beyond individualistic responses to act within community, market and policy arenas</a>. This research supports services that <a href="https://doi.org/10.1186/s12954-020-00373-4">respond to the unique needs of people accessing drug-checking services</a>.</p>
<h2>Vancouver Island’s unique model of drug checking</h2>
<p>In responding to the challenges of scaling up drug-checking services, <a href="https://doi.org/10.1108/DHS-01-2022-0005">we developed a unique distributed drug-checking model</a> to increase the reach of these services. </p>
<p>This model aims to fill in gaps in service delivery for diverse communities that are vulnerable to the unregulated drug supply. It also highlights the importance of multidisciplinary research and service design that draws critical insight from multidisciplinary fields to better inform drug-checking services. </p>
<figure class="align-center ">
<img alt="A window with a logo in a circle reading Substance, est. 2018, surrounded by paper hearts with handwritten messages." src="https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=360&fit=crop&dpr=1 600w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=360&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=360&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/535630/original/file-20230704-21-fkqtxb.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">
<figcaption>
<span class="caption">Substance’s distributed model provides a hybrid, easy-to-use drug-checking program that blends immediate portable drug-checking technologies for timely harm reduction with more comprehensive lab-based technologies that provide greater accuracy of drug composition.</span>
<span class="attribution"><span class="source">(Substance)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Drawing on a network that enables the collection of samples in various locations and communities, our distributed model provides a hybrid, easy-to-use drug-checking program. The program blends immediate portable drug-checking technologies for timely harm reduction with more comprehensive lab-based technologies that provide greater accuracy of drug composition. </p>
<p>Through the use of <a href="https://doi.org/10.1186/s12954-023-00764-3">specialized spectrometers and test</a> strips distributed at various sites and connected to a central server and database, drug analysis can be done remotely within our central hub. These results get looped back to service users distributed across Vancouver Island who also have the opportunity to receive further analysis at a later time using a lab-based method called <a href="https://doi.org/10.1111/dar.13370">paper spray mass spectrometry</a>.</p>
<p>This model responds to the unique challenges of providing critical harm reduction across geographical locations and within different communities. Through the distributed model, we continue to evaluate what works best for whom in <a href="https://theconversation.com/why-the-drug-poisoning-crisis-in-b-c-wont-be-addressed-by-the-new-decriminalization-policy-199239">the context of an ever-changing drug supply and policy landscape</a>. </p>
<p>Most consumables in Canada have quality controls that help inform purchasing and consumption decisions. People who use drugs and those who support them deserve the same. It is long past time that we respond to the enduring crisis to the magnitude it deserves. </p>
<p><a href="https://doi.org/10.1186/s12954-022-00727-0">Drug checking everywhere for everyone</a>: is it possible? It is certainly a worthwhile goal with life-saving potential, and we will continue working to achieve it.</p><img src="https://counter.theconversation.com/content/204783/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Bruce Wallace received funding from Health Canada, the Canadian Institutes of Health Research, the Social Sciences and Humanities Research Council, Vancouver Foundation, and the Island Health Authority. </span></em></p><p class="fine-print"><em><span>Dennis Hore received funding from Health Canada, the Natural Sciences and Engineering Research Council of Canada, and the Canadian Institutes of Health Research.</span></em></p><p class="fine-print"><em><span>Piotr Burek 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>Most consumables in Canada have quality controls that inform purchasing and consumption decisions. People who use illicit drugs deserve the same. Drug checking provides that harm-reduction service.Piotr Burek, Master of Arts student, Social Dimensions of Health Program, University of VictoriaBruce Wallace, Professor, School of Social Work, University of VictoriaDennis Hore, Professor, Chemistry, University of VictoriaLicensed 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>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/HzAvzNoUERE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<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/1981312023-03-21T12:42:53Z2023-03-21T12:42:53ZIncreases in opioid overdoses in Pennsylvania varied by county during the COVID-19 pandemic<figure><img src="https://images.theconversation.com/files/516095/original/file-20230317-26-u4bttz.jpg?ixlib=rb-1.1.0&rect=32%2C14%2C1964%2C1416&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pills are one of the more common ways of ingesting opioids.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/OpioidGuidelines/b14b1e15c96b42f782bebfdf60a359c9/photo">AP Photo/Keith Srakocic</a></span></figcaption></figure><p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take about interesting academic work.</em></p>
<h2>The big idea</h2>
<p>The COVID-19 pandemic intensified the opioid epidemic, according to our new research, which finds that <a href="https://doi.org/10.1016/j.healthplace.2022.102938">opioid overdoses increased in Pennsylvania</a> in 2020 compared with 2018 and 2019. </p>
<p>Yet general trends obscure critical local variations. Specifically, 19 Pennsylvania counties saw statistically significant increases in opioid overdose rates. The people who live in those 19 counties are both socially and economically diverse, signaling that overdoses did not just worsen for one group of people.</p>
<p>In our study, we analyzed age-adjusted rates of opioid-related overdose incidents, reported by emergency services personnel, at the county level in Pennsylvania from 2018 to 2020. This measure is based on the number of overdose incidents to which EMS responded during the study period. We also interviewed public health providers to identify the key factors influencing opioid misuse.</p>
<p>Opioid overdoses are the leading cause of <a href="https://www.ddap.pa.gov/overdose/Pages/Overdose_Overview.aspx">accidental death in Pennsylvania</a>, according to the Centers for Disease Control and Prevention. From 2010 to 2019, rates of opioid-related deaths in Pennsylvania almost quintupled, rising from <a href="http://wonder.cdc.gov/mcd-icd10.html">5 per 100,000 people</a> to 23.7 per 100,000 people. In 2020, it rose to <a href="https://www.cdc.gov/drugoverdose/deaths/2020.html">42.4 per 100,000 people</a>.</p>
<p>In earlier work, we showed that the <a href="https://theconversation.com/opioid-overdoses-spiked-during-the-covid-19-pandemic-data-from-pennsylvania-show-161635">initial four months of the COVID-19 pandemic</a> saw an increase in opioid overdoses in Pennsylvania. Our latest study extended this analysis through 2020.</p>
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<h2>Why it matters</h2>
<p>Since the early 1990s, the opioid epidemic has gone through several waves. First, high death rates were <a href="https://doi.org/10.1111/ajt.13776">caused by prescription opioids</a>, particularly among white rural populations. The epidemic then shifted to heroin use, and expanded to include <a href="https://doi.org/10.1177/0033354920968806">urban and non-Hispanic Black populations</a>. More recently, synthetic opioids like fentanyl have been the <a href="https://doi.org/10.15585%2Fmmwr.mm675152e1">main cause of overdoses</a>.</p>
<p>Overdose rates increased in Pennsylvania at the start of the COVID-19 pandemic. This initial increase occurred at the same time as a mandatory stay-at-home order that was designed to reduce the spread of the virus. While this order was a necessary response, it resulted in a range of social effects, including job losses, mental illness, isolation and reduced access to inpatient addiction treatment services.</p>
<p>In our newest study, we examined the longer-term trends and spatial patterns for the opioid epidemic. Our research shows statistically significant county-level changes in the age-adjusted rates of opioid-related overdose incidents before and after the onset of the COVID-19 pandemic. Some Pennsylvania counties saw a significant increase in opioid overdose rates, including some with small populations, while others saw a significant decrease. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/iFnX_Q_B-ko?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Heroin injections can lead to heart infections that can kill.</span></figcaption>
</figure>
<p>Health care providers agree that while opioid misuse has increased across the state, local conditions matter and directly affect the epidemic. As one health provider told us in an interview, “There’s a lot of variation between counties. You can drive 20 minutes across the line, and it almost seems like a different state. I think the rates of use are similar, but you see different sorts of associated factors with substance use in these counties.”</p>
<p>In order to understand social factors, we examined differences in opioid overdose rates between men and women and between Black and white people. Our research shows overdose rates among men and women were declining from 2018 to 2019 but jumped in 2020. These trends were also declining among Black and white individuals from 2018 to 2019, but those groups also experienced a large increase from 2019 to 2020. A benefit of our research is that it shows that broader segments of the population are now being affected by the opioid epidemic.</p>
<h2>What’s next</h2>
<p>Our work is finding that the stress associated with the COVID-19 pandemic was overwhelming for many people, resulting in an increase in substance misuse or relapses. We believe research and policy attention to these factors is urgently needed, especially in states like Pennsylvania that were experiencing high rates of substance use prior to the pandemic. </p>
<p>Future work could evaluate whether funds are effectively distributed to address the effects of social isolation and the social inequities surrounding opioid misuse.</p><img src="https://counter.theconversation.com/content/198131/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brian King receives funding from the Department of Geography and College of Earth and Mineral Science at the Pennsylvania State University.</span></em></p><p class="fine-print"><em><span>Andrea Rishworth, Louisa M. Holmes, and Ruchi Patel 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>Pennsylvania has long had one of the highest death rates from drug overdose in the US. But new studies suggest counties throughout the state have different rates of opioid deaths.Brian King, Professor of Geography, Penn StateAndrea Rishworth, Postdoctoral Fellow in Geography, University of TorontoLouisa M. Holmes, Researcher of Geography, Penn StateRuchi Patel, Doctoral Student in Geography, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1992392023-02-06T20:53:55Z2023-02-06T20:53:55ZWhy the drug poisoning crisis in B.C. won’t be addressed by the new decriminalization policy<p>On the same day that British Columbia began a new era in drug policy with the <a href="https://www2.gov.bc.ca/gov/content/overdose/decriminalization">decriminalization of simple possession of some drugs</a>, the province’s chief coroner provided a <a href="https://www2.gov.bc.ca/gov/content/life-events/death/coroners-service/statistical-reports">devastating update</a> about the number of lives lost to illicit drugs during the previous year. </p>
<p>On Jan. 31, 2023, B.C. began a <a href="https://www2.gov.bc.ca/assets/gov/overdose-awareness/decriminalization_factsheet.pdf">three-year pilot project</a> under which simple possession of some drugs (opioids, methamphetamine, cocaine and MDMA) can no longer lead to criminal prosecution or even seizure of the drugs by police. The policy applies to possession of up to 2.5 grams of substance for personal use.</p>
<p>While a major step in the right direction, decriminalization does nothing to tackle what is fuelling the drug-poisoning crisis: the makeup of a toxic and unregulated drug supply. </p>
<p>In fact, imposed carry restrictions of 2.5 grams could theoretically lead to unintended consequences as drugs become more potent to fit within legal limits. </p>
<p>The stated goal of the decriminalization policy change is to <a href="https://theconversation.com/decriminalizing-drug-use-is-a-necessary-step-but-it-wont-end-the-opioid-overdose-crisis-162497">remove the stigma associated with drug use</a> to encourage people to seek help when they need it. </p>
<p>While the effects that decriminalization may have on the stigma of drug use remain to be seen, what it won’t affect is the toxicity of the drug supply that is killing thousands of Canadians each year.</p>
<h2>Inconsistent and unreliable drug supply</h2>
<p>Chemical analysis of drugs (such as from <a href="https://drugcheckingbc.ca/video/">drug checking</a> or police investigations) can tell us what is circulating in the supply, but <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">toxicology results</a> from those who have died from overdoses tell us what is actually causing death. </p>
<p>These data sources describe how increases in adulteration of drugs with fentanyl analogues, <a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">benzodiazepines</a> and animal tranquilizers like <a href="https://substance.uvic.ca/blog/xylazine/">xylazine</a> are driving the drug poisoning crisis. </p>
<p>Fentanyl has been the main opioid sold on the unregulated market for several years. It is typically sold mixed into other powders like caffeine or sugars to make a final product. </p>
<p>Drug supply monitoring has shown that fentanyl concentration in these powders sold on the street can range from zero to nearly 100 per cent, with a standard sample in B.C. being <a href="https://drugcheckingbc.ca/wp-content/uploads/sites/2/2023/01/Drug_Checking_BC_Nov_20224.pdf">around 10–15 per cent</a>. </p>
<p><a href="https://doi.org/10.1093/aje/kwab129">Research conducted in Vancouver</a> has described how fentanyl concentration in these samples was somewhat consistent between 2018 and early 2020, with variability between samples even decreasing over that period. What that may speak to is producers of fentanyl reaching a sort of “sweet spot” that satisfies their customers. People who sell drugs have described how they <a href="https://doi.org/10.1016/j.drugpo.2020.102845">listen to feedback</a> from their regulars and adjust the product to meet their customers’ needs. </p>
<p>However, following the start of the COVID-19 pandemic, <a href="https://epiresearch.org/wp-content/uploads/2022/06/2022-Abstract-Book.pdf#page=77">variation in potency between fentanyl samples rose dramatically</a>, leading to further unpredictability. These changes to the fentanyl supply around the spring of 2020 coincided with rates of drug poisonings previously not seen in the province. </p>
<p>Under B.C.’s decriminalization framework, possession for personal use caps at 2.5 grams of substance. While 2.5 grams may be more than enough MDMA for a night out, it may not be enough heroin to last a single day for someone who has a high opioid tolerance. People who use drugs say that to abide by these limits, they will be forced to make <a href="https://vancouver.citynews.ca/2022/05/31/bc-decriminalization-drugs/">more frequent, smaller purchases.</a> With the drug supply as volatile and unpredictable as it is, every new purchase puts someone at risk. </p>
<h2>Legal limit may affect potency</h2>
<p>Since we know that the drug supply is dynamic, it raises a question: Will the imposed legal carry limit of 2.5 grams result in increased potency of fentanyl to fit within the new 2.5-gram threshold? </p>
<p>Increases in average potency of fentanyl has been <a href="https://www.inhsu.org/resource/fentanyl-concentration-in-drug-checking-samples-and-risk-of-drug-related-mortality-during-an-illicit-drug-toxicity-crisis-in-vancouver-canada-a-time-series-analysis/">shown to be linked to increased drug poisonings</a> in the same geographic area. If the unregulated fentanyl market adjusts to fit more active ingredient into a smaller package, there will be downstream effects on people lives. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Cropped image of a person holding a hand-lettered sign reading 'Every death is a drug policy failure'" src="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/508487/original/file-20230206-31-5cy44g.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">An advocate holds a sign at a demonstration in Victoria in April 2022. Decriminalization alone may have little effect on drug deaths without changes to the addiction treatment system.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Chad Hipolito</span></span>
</figcaption>
</figure>
<p>The provincial and federal governments have <a href="https://www.theglobeandmail.com/canada/british-columbia/article-federal-minister-promises-data-on-impact-of-decriminalization/">committed to a data-driven approach</a> to decriminalization. Ongoing drug supply monitoring will help public health professionals characterize what changes occur to the unregulated drug supply as a result of the policy change. Yet the act of decriminalizing drugs for personal use does not have any direct effect on the cause of the ongoing poisoning crisis. </p>
<p>The <a href="https://news.gov.bc.ca/releases/2023PSSG0008-000109">consensus among experts</a> has consistently pointed to unpredictable drugs from an unregulated supply and the absence of a functioning addiction treatment system. For those who want to seek treatment, the lack of available space leaves people waiting, once again left to rely on the toxic drug supply. </p>
<p>If B.C. is serious about confronting the leading cause of unnatural death in the province, it is going to take far more than decriminalizing simple drug possession. People who use drugs require an alternative to the toxic unregulated supply to not be risking their lives every time they use drugs. </p>
<p>Increasing access to a safer supply of drugs through a <a href="https://theconversation.com/safer-supply-of-opioids-saves-lives-providing-alternatives-to-toxic-street-drugs-177925">variety of formats</a> and providing meaningful funding for accessible treatment options are some examples of ways the province can take immediate steps to make an impact. </p>
<p>In the meantime, <a href="https://bc.ctvnews.ca/illicit-drug-death-toll-surpasses-2-000-in-b-c-for-a-2nd-consecutive-year-1.6253605">six more people will die today</a> from a drug poisoning in B.C. And another six will die tomorrow. How many more days can this go on?</p><img src="https://counter.theconversation.com/content/199239/count.gif" alt="The Conversation" width="1" height="1" />
<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>As British Columbia begins a new era in drug policy, the drug poisoning crisis continues without an end in sight.Samuel Tobias, PhD Student, School of Population and Public Health, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1918182022-10-12T15:23:25Z2022-10-12T15:23:25ZRainbow fentanyl – the newest Halloween scare<figure><img src="https://images.theconversation.com/files/488560/original/file-20221006-22-2zni7j.jpg?ixlib=rb-1.1.0&rect=227%2C168%2C4662%2C3254&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Trends in recreational or illicit drug use often make the jump to Halloween warnings.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/hand-dropping-pills-on-blue-background-royalty-free-image/1042683302?phrase=pills different colors&adppopup=true">Malte Mueller/fstop via Getty Images</a></span></figcaption></figure><p>Every year around the middle of October, reporters start contacting me wanting to talk about rumors of contaminated Halloween treats. </p>
<p>That’s because I track media coverage of reported incidents of trick-or-treaters receiving razor blades in apples or pins and poison in candy bars. <a href="https://udspace.udel.edu/bitstream/handle/19716/726/DSpace.revised%20thru%2021.pdf?sequence=3&isAllowed=y">My data goes back to 1958</a>, and my principal finding is simple: I can’t find any evidence that any child has ever been killed or seriously injured by a contaminated treat picked up in the course of trick-or-treating. </p>
<p>This often surprises people who assume that Halloween sadism is both very real and very common.</p>
<p>Stories about contaminated treats <a href="https://theconversation.com/when-halloween-became-americas-most-dangerous-holiday-123132">are best understood as contemporary legends</a>. They’re tales we’ve all heard, that we’ve been assured are true. They warn that we live in a dangerous world filled with villainous strangers who could harm us if we aren’t careful.</p>
<p>This year, reporters began reaching out earlier than usual, in late September, and they wanted to talk about a new alleged threat: “<a href="https://www.nbcnews.com/news/us-news/young-people-are-targeted-brightly-colored-rainbow-fentanyl-government-rcna49503">rainbow fentanyl</a>.”</p>
<h2>Kids are next</h2>
<p><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">Fentanyl</a> is a very powerful synthetic opioid that has caused thousands of overdoses and deaths over the past two decades. In August 2022, <a href="https://www.dea.gov/press-releases/2022/08/30/dea-warns-brightly-colored-fentanyl-used-target-young-americans">drug enforcement authorities</a> noted that pills containing fentanyl were being manufactured in various colors. DEA Administrator Anne Milgram <a href="https://www.dea.gov/press-releases/2022/08/30/dea-warns-brightly-colored-fentanyl-used-target-young-americans">said</a>, “Rainbow fentanyl – fentanyl pills and powder that come in a variety of bright colors, shapes and sizes – is a deliberate effort by drug traffickers to drive addiction amongst kids and young adults.”</p>
<p>Many news outlets covered <a href="https://www.nbcnews.com/news/us-news/young-people-are-targeted-brightly-colored-rainbow-fentanyl-government-rcna49503">this story</a>, including the notion that the colors might be some sort of marketing ploy to attract younger drug users. But then some people started connecting rainbow fentanyl to Halloween.</p>
<p><a href="https://www.snopes.com/news/2022/09/28/rainbow-fentanyl-scare-halloween/">Interviewed on Fox News</a> on Sept. 20, 2022, Republican National Committee Chairwoman Ronna McDaniel declared, “Every mom in the country is worried, what if this gets into my kid’s Halloween basket?” <a href="https://www.thedailybeast.com/fox-news-goes-into-full-panic-on-rainbow-fentanyl-advises-against-trick-or-treating-this-halloween">Other Fox commentators</a> suggested that parents might want to protect their children by not letting them go trick-or-treating this year. And, to prove the bipartisan appeal of protecting children, Senate Majority Leader Chuck Schumer, a Democrat, <a href="https://www.cbsnews.com/newyork/news/sen-chuck-schumer-warns-drug-dealers-pushing-rainbow-fentanyl-to-children/">repeated the warnings</a>.</p>
<h2>September crime lays the groundwork</h2>
<p>It’s worth considering what’s familiar and what’s new about these warnings. </p>
<p>One fairly standard element is commentators’ readiness to link September crime news to the possibility that it might presage what could happen on Halloween. </p>
<p>In 1982 there was a spate of <a href="https://history.com/news/extra-strength-tylenol-poisonings-1982">Tylenol poisonings</a> – seven people died after purchasing and consuming tampered packages of pills. Many commentators then warned that parents needed to be extra vigilant when examining Halloween treats. Those deaths also led to a dramatic increase in protective packaging for all sorts of products to discourage tampering. </p>
<figure class="align-center ">
<img alt="Man wearing glasses and suit speaks into microphone while holding a white bottle of pills." src="https://images.theconversation.com/files/489020/original/file-20221010-23-jwtda4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/489020/original/file-20221010-23-jwtda4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/489020/original/file-20221010-23-jwtda4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/489020/original/file-20221010-23-jwtda4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/489020/original/file-20221010-23-jwtda4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/489020/original/file-20221010-23-jwtda4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/489020/original/file-20221010-23-jwtda4.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">David Clare, president of Johnson & Johnson, testifies before a Senate subcommittee after a spate of Tylenol poisonings.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/david-clare-president-of-johnson-and-johnson-the-makers-of-news-photo/515207528?phrase=tylenol%20poisoning&adppopup=true">Bettmann/Getty Images</a></span>
</figcaption>
</figure>
<p>Similarly, the 9/11 terrorist attacks led to rumors about Halloween 2001 threats – that there were plans to <a href="https://www.snopes.com/fact-check/mall-o-ween/">attack a mall</a> where some parents let their children go trick-or-treating, or that terrorists had purchased <a href="https://www.snopes.com/fact-check/candy-man/">massive amounts of candy</a>, presumably so they could poison the treats before distributing them.</p>
<p>Trends in recreational or illicit drug use often make the jump to Halloween warnings. In 2014, the year that Colorado first allowed state-licensed retail sales of recreational marijuana, <a href="https://www.youtube.com/watch?v=9wQdLzyN8AU">the Denver Police posted online warnings</a> that parents ought to keep an eye out for THC-laced edible candies in Halloween treats. Yet after Halloween had passed, <a href="https://www.vox.com/policy-and-politics/2017/10/27/16512108/marijuana-legalization-halloween-candy-edibles">a department spokesperson admitted</a>, “We are not aware of any cases of children ingesting marijuana candy during Halloween season.” </p>
<p>Similarly, in 2019, <a href="https://www.cnn.com/2019/10/28/health/cdc-vaping-death-data-mmwr">September reports</a> of deaths caused by vaping black-market THC-infused cartridges were coupled with news that Pennsylvania authorities had confiscated commercial THC candies – supposedly smuggled from a state where they could be purchased legally – to generate another round of Halloween warnings.</p>
<h2>The irrationality of it all</h2>
<p>One obvious hole in these concerns is that drugs tend to cost more than candy – <a href="https://blog.heyemjay.com/how-much-are-edibles/">marijuana edibles</a>, for example, run somewhere in the neighborhood of a dollar or two per dose or more. </p>
<p>Fentanyl is considerably more <a href="https://bedrockrecoverycenter.com/street-price-of-drugs/prescription/fentanyl/">expensive</a>. It is not unreasonable to wonder just what a fentanyl dealer’s overarching goal might be if in passing the drug off as candy. The suggestion that a school-age kid would go from accidental user of fentanyl to a paying addict is far-fetched.</p>
<p>Of course, the villains in contemporary legends aren’t expected to behave rationally. Ask why gang members would attempt to kill motorists who <a href="https://www.snopes.com/fact-check/lights-out/">blink their headlights at them</a> – an urban legend from the 1980s – and the response is likely to be, “That’s just the sort of thing those sadistic people do.” It might not make any sense for someone to give a brightly colored opioid pill or THC-infused candy to a small child, but it isn’t impossible, is it? Such reasoning is thought to justify ringing the alarm bells.</p>
<p>Often there is a kernel of truth to these fears. Certainly fentanyl is a dangerous drug. But American history <a href="https://www.routledge.com/American-Fear-The-Causes-and-Consequences-of-High-Anxiety/Stearns/p/book/9780415955423">can be read as a long line of fears</a> about witches, immigrants, drugs, conspirators and so on. These fears emerge as reflections of current social changes. Yes, things are always changing, and this can always frighten some people. But it is also true that, in retrospect, these fears are usually exaggerated.</p>
<p>What seems new about describing rainbow fentanyl as a Halloween danger is the willingness of important political figures and news media outlets to spread the warnings. Most past claims about Halloween sadism lack such prominent spokespeople. </p>
<p>But in a time when many news outlets seem intent on maintaining their audiences by <a href="https://doi.org/10.1177/23780231211024776">frightening them</a>, and increased <a href="https://www.annualreviews.org/doi/10.1146/annurev-polisci-072012-113747">political polarization</a> seems to stall efforts to devise workable social policies, calls for protecting our children from the threats of boogeyman drug dealers return us to the spirit of Halloween: offering up fresh ways to keep people scared.</p><img src="https://counter.theconversation.com/content/191818/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joel Best 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>Like clockwork, September crime news is often cast as an ominous sign of what could happen on Halloween.Joel Best, Professor of Sociology and Criminal Justice, University of DelawareLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1911752022-09-28T10:46:37Z2022-09-28T10:46:37Z‘Gutter water’, ‘monkey tail’ and smoked faeces: new dangers on Nigeria’s drug scene<figure><img src="https://images.theconversation.com/files/486064/original/file-20220922-15282-eqedpv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some people take the new drugs to prolong sex.</span> <span class="attribution"><span class="source">PIUS UTOMI EKPEI/AFP via Getty Images</span></span></figcaption></figure><p>New, unconventional drugs are <a href="https://www.emerald.com/insight/content/doi/10.1108/DAT-02-2020-0003/full/html">becoming popular</a> in Nigeria, designed by dealers and users to replicate the effects of illegal substances like cannabis, cocaine, and ecstasy. They affect how the brain works and cause changes in mood, feelings and behaviour. Policymakers have labelled them as “new psychoactive substances” because they’re not recognised under international conventions. </p>
<p>These psychoactive substances are found all over the world, and they’re growing in popularity. But little empirical research has been conducted on the uptake of these new drugs in many non-western contexts, especially in Africa. More information is needed because using substances like these is harmful to health. Policymakers need proper evidence regarding their availability, use, and effects to provide evidence-based interventions.</p>
<p>It appears that people in Nigeria are creating new drugs either because they can’t afford more traditional narcotics, or because they’re not controlled (and therefore difficult to detect), or because they’re strong.</p>
<p>As my colleagues and I documented in <a href="https://www.sciencedirect.com/science/article/pii/S2667118221000064">a mini review of recent insights on the topic</a> in Nigeria, most new psychoactive substances are extremely potent. Some drug users prefer them to conventional narcotics because they want to experience a more intense and longer high. </p>
<p>We also found that some people will take these substances – such as tramadol – to give them more energy for hard labour. Others use them because they want to last longer during sex. </p>
<p>These new psychoactive substances pose a public health threat, but because they’re new and not easy to detect, they are not controlled – for instance, by the <a href="https://www.unodc.org/unodc/en/treaties/single-convention.html?ref=menuside">1961 Single Convention on Narcotic Drugs</a> or the <a href="https://www.unodc.org/unodc/en/treaties/psychotropics.html?ref=menuside">1971 Convention on Psychotropic Substances</a>. </p>
<p>Traditional drugs – like cannabis, cocaine, and ecstasy – are controlled under these conventions, making them easier to detect, categorise and regulate internationally. </p>
<p>Studies that reveal more about the substances being used in Nigeria and their effects on users will help inform public health interventions.</p>
<h2>Types of drugs</h2>
<p>New psychoactive substances exist all over the world, and they’re growing in popularity. The United Nations Office on Drugs and Crime identified <a href="https://www.unodc.org/LSS/Announcement/Details/eff8dc38-7ab0-42b0-8cd9-753b89953fcc">almost 900</a> new substances between 2009 and 2018. These were found across 119 countries and territories, in all regions of the world.</p>
<p>In western countries, people use synthetic opioids, like tramadol and fentanyl, and synthetic cannabinoids. </p>
<p><a href="https://www.sciencedirect.com/science/article/pii/S2667118221000064">Our mini-review</a> of empirical studies conducted in different parts of Nigeria mapped the types, availability, and motivations for taking these new psychoactive substances.</p>
<p>In Nigeria, aside from a few imported new psychoactive substances like tramadol, most of them are locally sourced and can be obtained free of charge or at a low cost. </p>
<p>There’s a cocktail called “gutter water”, which is made from a mix of tramadol, cannabis, codeine and vodka. Other popular cocktails include “monkey tail” – a combination of homemade spirit, cannabis and psychoactive plant roots, seeds and stems – or a mixture of sodium hypochlorite solution (bleach) and carbonated soft drinks. </p>
<p>There are also pure plant-based substances. Some people will chew or smoke dried cassava and pawpaw leaves or seeds, zakami (<em>Datura metel</em>) seeds, and moringa (zogale) leaves.</p>
<p>Other popular ways to get psychoactive effects involve sniffing burnt tyres, hydrogen sulphide gas (sewer gas), or nail polish. </p>
<p>There are other new substances that people who are desperate or very poor try to use, but it is unknown whether these produce psychoactive effects that can get them high. These include smoking the whitish elements of lizard dung or human faeces. Others will drink 10-day-old human urine for the same reason. </p>
<h2>Addressing the issue</h2>
<p>Although research on the harms caused by using new psychoactive substances is at an early stage in Nigeria, <a href="https://www.tandfonline.com/doi/abs/10.1080/10911359.2020.1790462">one study</a> found that some tramadol users experienced seizures or convulsions after taking the substance, and a few users died from a drug overdose.</p>
<p>Because drug availability <a href="https://www.tandfonline.com/doi/abs/10.1080/10911359.2020.1790462">often correlates</a> with high drug use, it’s logical to say that without strategies to address the new drugs, their use may continue to rise. </p>
<p>Therefore, there is a need to initiate a strategy to address the issue. This must be underpinned by sound research. There must be comprehensive data that maps the availability, types, patterns, and motives for taking these new drugs among Nigerians.</p>
<p>A nationwide campaign will be essential. It must give young people the information they need on the dangers of substance use. </p>
<p>Credible government sources like the National Orientation Agency of Nigeria and the Ministry of Health should champion this effort. Campaigns should aim at deterring people from ever trying new psychoactive substances. Efforts must also be made to reorient those who already use the substances without stigmatising them. </p>
<p>For the campaign to be successful, the Nigerian police and other law enforcement agencies that often use intimidation and <em>war on drug</em> approaches to enforce laws should be distanced. This is primarily because brutalising drug users <a href="https://www.tandfonline.com/doi/abs/10.1080/09687637.2021.2004998">has not</a> reduced drug availability and use in Nigeria. </p>
<p>Finally, official corruption – blamed <a href="https://www.unodc.org/documents/data-and-analysis/bulletin/2019/19-11671_ebook.pdf#page=39">for fuelling</a> the availability of tramadol – must be tackled immediately.</p><img src="https://counter.theconversation.com/content/191175/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emeka Dumbili received funding from the Tertiary Education Trust Fund (TETFUND) in 2012. </span></em></p>People in Nigeria are creating new drugs either because they can’t afford more traditional narcotics, because they’re not controlled or because they’re strong.Emeka Dumbili, Lecturer, Nnamdi Azikiwe UniversityLicensed 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/1779252022-03-11T16:31:22Z2022-03-11T16:31:22ZSafer supply of opioids saves lives: Providing alternatives to toxic street drugs<figure><img src="https://images.theconversation.com/files/450317/original/file-20220307-109224-rux7pe.jpg?ixlib=rb-1.1.0&rect=710%2C486%2C5059%2C3288&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Methamphetamine, heroin and cocaine distributed by the Drug User Liberation Front, a grassroots organization proving a safe supply of illicit drugs, in Vancouver, in April 2021.
</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><p>Over 25,000 Canadians have died from opioid overdose since 2016 — with <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/">6,306 people dying in 2020</a> alone. </p>
<p>The overdose crisis is driven by an unregulated drug supply made up mostly of fentanyl, increasingly potent fentanyl analogues such as carfentanil, and more recently, <a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">unregulated benzodiazepines</a>. Early in the COVID-19 pandemic, fentanyl directly contributed to <a href="https://odprn.ca/research/publications/opioid-related-deaths-and-healthcare-use/">89 per cent of all overdose deaths</a> in Ontario. </p>
<p>The volatility and toxicity in the unregulated drug supply continues to lead to more deaths. The British Columbia coroner’s report shows that <a href="https://news.gov.bc.ca/releases/2022PSSG0010-000188">more people died in 2021</a> from suspected illicit toxic drugs than ever before. In 2021, there was a 26 per cent increase in overdose deaths compared to 2020. </p>
<p>The Public Health Agency of Canada recently estimated that without new interventions, <a href="https://www.canada.ca/en/health-canada/services/opioids/data-surveillance-research/modelling-opioid-overdose-deaths-covid-19.html">another 8,000 overdose deaths will occur in 2022</a>. Addressing this devastating crisis requires bold action that includes expanding current evidence-based harm reduction and treatment services, alongside new interventions to prevent overdose deaths.</p>
<h2>Safer supply</h2>
<p><a href="https://www.canada.ca/en/health-canada/services/opioids/responding-canada-opioid-crisis/safer-supply.html">Safer supply</a>, the practice of providing a medical prescription for pharmaceutical drugs of known quality, is one of those new interventions. In Ontario, safer supply programs are run mostly by community health centres that specialize in providing care to our most marginalized community members. These small pilot programs are a low-barrier first step alternative to the toxic drug supply.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Orange signs with black block lettering instructions on how to pick up safe supply of illicit drugs." src="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.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">Safe supply programs are run mostly by community health centres.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>There are several <a href="https://www.canada.ca/en/health-canada/services/substance-use/canadian-drugs-substances-strategy/funding/substance-use-addictions-program.html">research studies funded across Canada</a> to evaluate different parts of these pilot safer supply programs. We are public health researchers involved in some of these studies, and initial results are promising.</p>
<p>At London’s Intercommunity Health Centre, close to 250 clients are prescribed pharmaceutical opioids as a daily-dispensed prescription that they take home and use at their discretion. <a href="https://lihc.on.ca/wp-content/uploads/2022/01/2021-SOS-Evaluation-Full.pdf">A recent evaluation of this program</a> reported decreased use of fentanyl and other street-acquired drugs, reduced hospitalizations and a dramatic decrease in overdoses among clients.</p>
<p>Importantly, clients reported that the program was saving their life and helped them to take steps to improve their health. </p>
<h2>Addiction treatment models</h2>
<p>Unfortunately, there has been <a href="https://www.theglobeandmail.com/opinion/article-as-a-doctor-i-was-taught-first-do-no-harm-thats-why-i-have-a-problem/">opposition to safer supply programs</a> from some in the addiction treatment community. Such opposition has the potential to undermine public support for people who use drugs and the expansion of lifesaving interventions that are urgently needed. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A hand holding a small box labelled 'Ingredients: Cocaine. Please see insert. NOT FOR SALE. Keep away from children and pets.'" src="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.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">A client of the Drug User Liberation Front in Vancouver holds safe supply cocaine.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Current interventions to respond to opioid use don’t work for everyone. Opioid agonist treatments (OAT) like methadone and buprenorphine, are intended to reduce cravings for opioids and manage withdrawal symptoms, but they do not produce euphoria or the high associated with other opioids. </p>
<p>There are issues with both access and retention in OAT. Fewer than <a href="https://doi.org/10.1111/add.14947">70 per cent</a> of people who are diagnosed with an opioid use disorder ever start OAT. And although retention rates vary, an Ontario study found that after one year, <a href="https://doi.org/10.1097/adm.0000000000000156">less than half</a> of people who do start are still using OAT. Although there isn’t a set rule for how long someone should stay on OAT, generally <a href="https://www.camh.ca/-/media/files/professionals/canadian-opioid-use-disorder-guideline2021-pdf.pdf">longer treatment is associated with better outcomes</a>.</p>
<p>Despite low retention rates, addiction medicine has been reluctant to address the barriers to care that people who use drugs have been <a href="https://doi.org/10.1016/j.drugpo.2021.103364">attempting to call attention to for years</a>. </p>
<p>People who use drugs have highlighted for a long time how restrictions around take-home doses reduce people’s ability to stay in methadone programs. And they are right — when restrictions on taking home doses of methadone were loosened during the COVID-19 pandemic to facilitate physical distancing, <a href="https://doi.org/10.1001/jama.2022.1271">retention to methadone improved</a> without increased negative outcomes like overdose. </p>
<h2>Listening to drug users</h2>
<p>To address the toxic drug poisonings that are killing Canadians at such an alarming rate, we need to start listening to people who use drugs when they tell us what’s not working with the current system. </p>
<p>The war on drugs has so demonized people who use drugs that they are mostly dismissed by addiction medicine experts when they have tried to say <a href="https://sway.office.com/UjvQx4ZNnXAYxhe7?ref=Link&loc=play">what will help their communities</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People holding signs in support of safer drug supply marching in a street" src="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.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">People march in the Downtown Eastside to call on the government to provide a safe supply of illicit drugs in April 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Groundbreaking grassroots work being done by organizations such as the <a href="https://www.dulf.ca/">Drug User Liberation Front</a> (DULF) in Vancouver has highlighted the demand for <a href="https://filtermag.org/compassion-clubs-vancouver/">a non-medicalized model for a safer supply</a> of drugs. </p>
<p>DULF has organized in its community to distribute tested drugs to keep people alive during a crisis; contrast this to prominent members of the addiction medicine community attempting to use their social power to <a href="https://filtermag.org/people-who-use-drugs-safer-supply/">deliberately undermine</a> their efforts. </p>
<p>Opposition to safer supply often misrepresents both the aim and benefits of safer supply. Safer supply is intended to keep people alive — and it works. </p>
<h2>Building new models</h2>
<p>We need new options. Both for people for whom current addiction treatment models have not worked and for those who simply don’t need or want treatment. </p>
<p>People are dying from using a toxic drug supply. Building models of care that listen to the voices of people who use drugs and centre their needs is critical and should not be dismissed based on the fears of doctors who act as gatekeepers of the status quo. The status quo did not prevent, and it will not address, the overdose crisis. </p>
<p>Urgent actions — like decriminalization and access to a regulated drug supply — are part of the policy changes needed to address the toxic drug crisis in Canada. But for the people at risk of drug poisoning today, and for their friends, families and loved ones, safer supply represents a real chance at preventing more tragedy.</p><img src="https://counter.theconversation.com/content/177925/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose A Schmidt is employed as a research coordinator at the University of Toronto on a project that receives funding from The Ontario HIV Treatment Network about Safer Supply programs in Ontario.</span></em></p><p class="fine-print"><em><span>Gillian Kolla receives funding from a Canadian Institutes of Health Research Banting Postdoctoral Researcher Award and a Canadian Network on Hepatitis C (CanHepC) Postdoctoral Fellowship. She has consulted for Parkdale Queen West Community Health Centre, London Intercommunity Health Centre, The Neighbourhood Group, Street Health, and The Working Centre. </span></em></p><p class="fine-print"><em><span>Nat Kaminski is part of the University of Toronto research project on Safe Supply in Ontario, and is president of The Peel Drug Users Network & Ontario Network of People who use drugs and secretary of the Canadian Association of People who use drugs. They reviewed the guidelines for safe supply in Ontario and advocate for the expansion of services medically prescribed safe supply.</span></em></p>People are dying from using a toxic drug supply. Safer supply and other approaches that listen to the needs of people who use drugs are critical to saving lives and addressing the opioid crisis.Rose A Schmidt, PhD candidate, Dalla Lana School of Public Health, University of TorontoGillian Kolla, Postdoctoral research fellow, Canadian Institute for Substance Use Research, University of VictoriaNat Kaminski, Research assistant, School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1722122021-11-22T13:31:04Z2021-11-22T13:31:04ZHow the pandemic helped spread fentanyl across the US and drive opioid overdose deaths to a grim new high<figure><img src="https://images.theconversation.com/files/432742/original/file-20211118-23-14aslbz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3997%2C2656&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Emblems of America's epidemics.</span> <span class="attribution"><span class="source">David Gannon/AFP via Getty Images</span></span></figcaption></figure><p>For the past 20 years, I have been engaged in efforts to end the opioid epidemic, as a <a href="https://heller.brandeis.edu/facguide/person.html?emplid=fed1af017db070b94ce59c13714f1e7970a787ad">public health official, researcher and clinician</a>. And for every one of those years I have looked on as the number of deaths from drug overdoses has set a new record high. </p>
<p>Yet even knowing that trend I was surprised by the <a href="https://www.cnn.com/2021/11/17/health/drug-overdose-deaths-record-high/index.html">latest tally from the CDC</a> showing that for the first time ever, the number of Americans who fatally overdosed over the course of a year surpassed 100,000. In a 12-month period ending at the end of April 2021, <a href="https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm">some 100,306 died in the U.S.</a>, up 28.5% over the same period a year earlier. </p>
<p>The soaring death toll has been fueled by a much more dangerous black market opioid supply. Illicitly synthesized fentanyl – a potent and inexpensive opioid that has driven the rise in overdoses since it emerged in 2014 – is increasingly replacing heroin. Fentanyl and fentanyl analogs were <a href="https://www.cnn.com/2021/11/17/health/drug-overdose-deaths-record-high/index.html">responsible for almost two-thirds</a> of the overdose deaths recorded in the 12 months period ending in April 2021.</p>
<p>It is especially tragic that these deaths are mainly occurring in people with a disease – opioid addiction – that is both preventable and treatable. Most heroin users want to avoid fentanyl. But increasingly, the heroin they seek is mixed with fentanyl or what they purchase is just fentanyl without any heroin in the mix.</p>
<p>While the spread of fentanyl is the primary cause of the spike in overdose deaths, the coronavirus pandemic also made the crisis worse.</p>
<p>The <a href="https://www.economist.com/graphic-detail/2021/03/30/opioid-deaths-in-america-reached-new-highs-in-the-pandemic">geographical distribution of opioid deaths</a> makes it clear that there has been a change during the pandemic months.</p>
<p>Before the COVID-19 health crisis, the skyrocketing increase in fentanyl-related overdose deaths in America was <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2725487">mainly affecting the eastern half of the U.S.</a>, and hit especially hard in urban areas like Washington, D.C., Baltimore, Philadelphia and New York City. A possible reason behind this was that in the eastern half of the U.S., heroin has mainly been available in powder form rather than the black tar heroin more common in the West. It is easier to mix fentanyl with powdered heroin.</p>
<p>COVID-19 resulted in less cross-national traffic, which made it harder to <a href="https://www.unodc.org/documents/data-and-analysis/covid/Covid-19-and-drug-supply-chain-Mai2020.pdf">smuggle illegal drugs across borders</a>. Border restrictions make <a href="https://www.latimes.com/world-nation/story/2020-04-20/cartels-are-scrambling-virus-snarls-global-drug-trade">it harder to move bulkier drugs</a>, resulting in smugglers’ increased reliance on fentanyl – which is more potent and easier to transport in small quantities and as pills, making it easier to traffic by mail. This may have helped fentanyl spread to areas that escaped the earlier surge in fentanyl deaths.</p>
<p>Opioid-addicted individuals seeking prescription opioids instead of heroin have also been affected, because counterfeit pills made with fentanyl <a href="https://www.dea.gov/alert/sharp-increase-fake-prescription-pills-containing-fentanyl-and-meth">have become more common</a>. This may explain why public health officials in <a href="https://www.economist.com/graphic-detail/2021/03/30/opioid-deaths-in-america-reached-new-highs-in-the-pandemic">Seattle and elsewhere</a> are reporting many fatalities resulting from use of counterfeit pills.</p>
<p>Another factor that may have contributed to the soaring death toll is that the pandemic made it <a href="https://www.nytimes.com/2021/01/04/nyregion/addiction-treatment-coronavirus-new-york-new-jersey.html">harder for those dependent on opioids to get in-person treatment</a>.</p>
<p>More than anything else, what drives opioid-addicted individuals to continue using is that without opioids they will experience severe symptoms of withdrawal. Treatment, especially with buprenorphine and methadone, has to be easy to access or addicted individuals will continue using heroin, prescription opioids or illict fentanyl to stave off withdrawal. Some treatment centers innovated in the face of lockdowns, for example, by allowing more patients to <a href="https://apnews.com/article/science-health-pandemics-coronavirus-pandemic-c36442b3fe8f2074e2fe3907d11ca579">take methadone unsupervised at home</a>, but this may not have been enough to offset the disruption to treatment services.</p>
<p>And maintaining access to treatment is crucial to avoid relapse, especially during the pandemic. Research has shown that social isolation and stress – which <a href="https://www.healthaffairs.org/do/10.1377/hblog20200609.53823">became more common</a> <a href="https://www.apa.org/news/press/releases/stress/2020/report-october">during the pandemic</a> – increase the chances of a <a href="https://khn.org/news/addiction-is-a-disease-of-isolation-so-pandemic-puts-recovery-at-risk/">relapse in someone in recovery</a>.</p>
<p>In the past, one slip might not be the end of the world for someone in recovery. But given the extraordinarily dangerous black market opioid supply, any slip can result in death.</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-youresmart">You can read us daily by subscribing to our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/172212/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Kolodny receives federal funding for research on opioid addiction treatment and serves as an expert witness on behalf of states and counties in litigation against the opioid industry. He is also a co-founder of Physicians for Responsible Opioid Prescribing.</span></em></p>The number of fatal drug overdoses in the US over a 12-month period has surpassed 100,000 for the first time. Fentanyl is the main driver of the spike in deaths.Andrew Kolodny, Co-Director of Opioid Policy Research, Brandeis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671002021-09-16T12:11:03Z2021-09-16T12:11:03ZOxyContin created the opioid crisis, but stigma and prohibition have fueled it<figure><img src="https://images.theconversation.com/files/421389/original/file-20210915-17-1lvjamv.jpg?ixlib=rb-1.1.0&rect=6%2C12%2C997%2C597&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People around the world mourned loved ones on International Overdose Awareness Day on Aug. 31, 2021.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/edmontonians-pose-wooden-crosses-with-roses-on-news-photo/1234986137?adppopup=true"> NurPhoto/Getty Images</a></span></figcaption></figure><p>The <a href="https://theconversation.com/how-the-purdue-opioid-settlement-could-help-the-public-understand-the-roots-of-the-drug-crisis-166701">highly contentious</a> <a href="https://www.npr.org/2021/09/01/1031053251/sackler-family-immunity-purdue-pharma-oxcyontin-opioid-epidemic">Purdue Pharma settlement</a> announced Sept. 1, 2021, comes at a pivotal time for the U.S. overdose crisis: 2020 was the worst year on record, with over <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">93,000 Americans</a> losing their lives to fatal drug overdose. The drug overdose epidemic, now more than two decades long, has claimed the lives of <a href="https://www.cdc.gov/opioids/data/index.html">more than 840,000</a> people since 1999. Current estimates suggest that some <a href="https://www.rand.org/content/dam/rand/pubs/research_reports/RR3100/RR3140/RAND_RR3140.pdf">2.3 million people</a> in the U.S. use heroin and <a href="https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis">1.7 million people</a> use pharmaceutical opioids without a prescription. </p>
<p>Since 2016, I’ve <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">studied the overdose crisis</a> with an eye to understanding its roots as well as its ramifications. As a <a href="https://www.holycross.edu/academics/programs/sociology-and-anthropology/faculty/emily_b_campbell">sociologist</a>, I came to this area of research in my own quest for meaning, as each year brought more funerals of former classmates and friends. What I found was an increasingly dangerous drug environment for people who use drugs, often exacerbated by policies not founded in research and by attitudes that harm those affected.</p>
<h2>How prohibition fuels dangerous markets</h2>
<p>Research shows that <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">the illicit drug market adapts</a> to both demand and drug enforcement efforts. </p>
<p>The first consequence of increased demand is that drugs become <a href="https://doi.org/10.1016/j.drugpo.2007.11.016">cheaper over time</a>. For example, the price of heroin and cocaine have been falling for decades. Political economists explain that demand, coupled with globalization, increases efficiency and competition. The result is that there are more drugs on the illicit market, which in turn lowers prices. </p>
<p>Second, as a response to drug prohibition, <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">drugs become more potent</a>. A stronger product in a smaller package is easier to transport and harder to detect. The American overdose crisis has become <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">a case study</a> in the devastating interplay of demand and prohibition. </p>
<p>OxyContin was released in 1996 and <a href="https://doi.org/10.2105/AJPH.2007.131714">mass-marketed as a revolutionary intervention</a> in the medical treatment of pain. Purdue Pharma, its maker, <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html?smid=url-share">knowingly downplayed</a> its addictive potential. As an opioid and central nervous depressant, <a href="https://doi.org/10.1300/J069v23n04_01">OxyContin has effects</a> similar to those of morphine or heroin. Not surprisingly, studies show that prescription patterns of opioids from 1999 to 2008 were <a href="https://pubmed.ncbi.nlm.nih.gov/22048730/">directly linked to a surge in overdose deaths</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pill bottle and pills of OxyContin prescription-only pain medication" src="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Oxycontin prescription-only pills were aggressively promoted to primary care physicians as a safe and effective pain control method for patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/oxycontin-pills-oxycodone-hydrochloride-prescription-only-news-photo/563590877?adppopup=true">Lawrence K. Ho/Los Angeles Times via Getty Images</a></span>
</figcaption>
</figure>
<p>As concern over opioid overdose grew, doctors’ prescribing practices <a href="https://doi.org/10.1007/s11013-016-9496-5">came under scrutiny</a>. In 2010, Purdue Pharma replaced the original OxyContin with an <a href="https://doi.org/10.1001/jamapsychiatry.2014.3043">“abuse deterrent” formulation</a> that was more difficult to crush and inhale. As a result, many people who were addicted to OxyContin turned to heroin, which was <a href="https://doi.org/10.1162/rest_a_00755">cheaper and easier to get</a>. This spurred a surge in heroin-related fatal overdoses, which is often termed the <a href="https://doi.org/10.1016/j.drugpo.2019.01.010">second wave of the overdose crisis</a>.</p>
<p>The growing market for heroin paved the way for the <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">introduction of fentanyl</a> into the illicit U.S. drug market. Fentanyl, a drug used in medical settings for severe pain, is <a href="https://www.drugabuse.gov/publications/drugfacts/fentanyl">50 times more potent than heroin</a>. From the standpoint of efficiency for shipping and trafficking, fentanyl is easier to transport and sell than heroin. Fentanyl’s entry into the illicit drug market, in particular in combination with heroin, <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">led to a doubling and tripling </a>of overdose deaths around 2012 to 2013. </p>
<p><a href="https://journals.lww.com/co-psychiatry/fulltext/2021/07000/the_rise_of_illicit_fentanyls,_stimulants_and_the.4.aspx">Since then, fentanyl</a> <a href="https://doi.org/10.1016/j.drugpo.2021.103353">has contaminated</a> the U.S. illicit drug supply: It is often found in not just heroin but cocaine, MDMA – commonly known as Ecstasy – methamphetamine and counterfeit prescription pills. The result is that most people <a href="https://doi.org/10.1016/j.drugpo.2019.07.008">do not know the potency or contents</a> of what they are using. </p>
<p>As the overdose crisis evolves, <a href="https://doi.org/10.1007/s40615-021-01007-6">communities of color</a> in particular have experienced a surge in fatal overdoses – deaths that are often preventable. And most recently, COVID-19 supply chain disruptions led people to use whatever was available, causing <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2021.306256">a surge in overdoses</a> from drug mixing. </p>
<h2>Barriers to treatment</h2>
<p>Too often, people who use drugs are bombarded with messages that are not supported by research and that deepen the harm. </p>
<p>Public health officials and community leaders urge people to seek treatment and highlight that recovery is within reach. Yet, roughly 70% of people who seek treatment are <a href="https://www.rcorp-ta.org/sites/default/files/2020-06/Improving-Access-to-Evidence-Based-Medical-Treatment-for-OUD_FINAL.pdf">unable to access it</a>. <a href="https://doi.org/10.1080/10826084.2017.1363238">Barriers to treatment</a> include health care costs, lack of available treatment options and social stigma. Research also demonstrates that some people are not ready for treatment or <a href="https://doi.org/10.1080/10826084.2017.1310247">do not want to be sober</a>.</p>
<p>Sobriety is touted as the ultimate goal for people who use drugs. Yet research shows that addiction is a <a href="https://doi.org/10.1038/s41386-020-00950-y">recurring brain disease</a>, and relapse is highly likely. Most people who use drugs do so in a <a href="https://www.ucpress.edu/book/9780520293472/hurt">sporadic way</a> that features bouts of controlled and uncontrolled use as well as sobriety. It is also well documented that fear of arrest and shame encourages people to hide their drug use in ways that <a href="https://doi.org/10.1080/10826084.2020.1790008">increase their risk</a> of a fatal overdose. This is because when people use alone, there is no one there to call 911 or perform CPR should an overdose occur. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding up phone with image of brother and son who died after taking fentanyl-laced drugs" src="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Laurie Restivo’s brother, David Restivo, 47 (left on phone image), died from fentanyl-laced heroin, and her son, Jason Fisher Jr., 25 (right), died from fentanyl-laced cocaine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/fentanyl-overdose-restivo-johnson-laurie-restivo-displays-a-news-photo/1315873058?adppopup=true">Reading Eagle/MediaNews Group via Getty Images</a></span>
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</figure>
<p>In terms of effective treatment, <a href="https://doi.org/10.1176/appi.ps.201300256">medically assisted treatments</a> are considered the gold standard for opioid use disorder, yet they are still <a href="https://doi.org/10.1111/jrh.12328">underutilized</a>. <a href="https://doi.org/10.1001/jama.2021.1741">Buprenorphine</a> is an opioid with a “ceiling effect,” meaning it does not intoxicate like morphine or heroin but instead satiates an opioid craving. Buprenorphine assists people in transitioning away from uncontrolled use and mitigates physical cravings. People who are prescribed it are often able to work, attend therapy and regain enjoyment of day-to-day life. </p>
<p>Nonetheless, buprenorphine’s availability <a href="https://doi.org/10.1002/pds.4984">varies widely by state</a>, and people of color are <a href="https://doi.org/10.1377/hlthaff.2020.02261">persistently underprescribed</a> this lifesaving medication. Methadone has been used as a treatment for opioid use disorder since the 1950s, yet it is persistently <a href="https://doi.org/10.1007/s11606-018-4801-3">hard to access</a> long term. Researchers point to the <a href="https://doi.org/10.1080/08897077.2019.1640833">ongoing role of stigma</a> in the underuse of both of these medications. </p>
<h2>Better paths forward</h2>
<p>Public health officials, harm reduction activists and concerned citizens across the U.S. are working to secure <a href="https://doi.org/10.1097/01.NPR.0000534948.52123.fb">safer injection sites</a> where people can use drugs in the presence of medical staff. Such sites facilitate the prevention of fatal overdose by assuring an adequate and timely medical response and open a pathway for further health care and addiction-related treatment. In response to the pandemic’s strains on inpatient care facilities, <a href="https://doi.org/10.1016/j.jsat.2021.108552">take-home methadone</a> availability was expanded in new ways – a change that some treatment experts <a href="https://doi.org/10.1016/j.jsat.2020.108246">hope will be permanent</a>. </p>
<p>For people who use drugs, the <a href="https://doi.org/10.1016/j.jhealeco.2019.01.001">potency and contents of their drugs are often unknown</a>. <a href="https://doi.org/10.1016/j.drugpo.2018.10.001">Drug-checking programs</a> allow people to inspect the <a href="https://doi.org/10.1016/j.drugpo.2018.09.009">contents of their drugs for fentanyl</a> at home with a simple test strip. Such programs have recently gained traction with <a href="https://www.cdc.gov/media/releases/2021/p0407-Fentanyl-Test-Strips.html">federal support</a>. States also continue to expand <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049966/">access to naloxone</a>, an overdose reversal nasal spray that is simple to administer. People who use drugs or have loved ones who use drugs are encouraged to receive training on how to administer naloxone and to carry the nasal spray on them. </p>
<p>Those who argue for a <a href="https://doi.org/10.1503/cmaj.201618">safer supply</a> and <a href="https://doi.org/10.1016/j.socscimed.2021.113986">decriminalization of drugs</a> point to success abroad. <a href="https://www.rand.org/content/dam/rand/pubs/working_papers/WR1200/WR1263/RAND_WR1263.pdf">Heroin-assisted treatment</a> is shown to be effective in keeping people away from an unpredictable drug market, thus lowering the risk of overdose. Germany’s use of <a href="https://doi.org/10.1111/j.1360-0443.2008.02185.x">heroin-assisted treatment</a> improved patients’ physical and mental health while dramatically reducing illicit drug use. In the early 2000s, <a href="https://doi.org/10.1177/2050324516683640">Portugal decriminalized</a> all drugs in response to consistently having the highest fatal overdose rates in Western Europe. With diversion of funds away from prohibition to education and treatment, Portugal saw a drop in overall drug use and now boasts among the lowest fatal overdose rates in Western Europe.</p>
<p>Americans are the world’s <a href="https://doi.org/10.1111/add.14234">largest consumers</a> of drugs and consistently have among the highest rates of opioid and cocaine dependence globally. In <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">my own research</a>, I’ve found that people often describe drug use as a battle between sobriety and death. But the heartbreaking surge in accidental, fatal overdose deaths tells a much more complex story. Ignoring the evidence will surely cost many more lives.</p>
<p><em>If you or someone you care about has a substance use disorder and wants help, you can call SAMHSA’s National Helpline: 1-800-662-HELP (4357). Immediate emotional support is available from the National Suicide Prevention Hotline 800-273-8255.</em> </p>
<p>[<em>Get our best science, health and technology stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-best">Sign up for The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/167100/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily B. Campbell 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>False narratives about drug addiction and policies that are not supported by research are deepening the overdose epidemic in the US.Emily B. Campbell, Visiting Assistant Professor of Sociology, College of the Holy CrossLicensed 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/1635572021-07-16T12:28:11Z2021-07-16T12:28:11ZDesigning less addictive opioids, through chemistry<figure><img src="https://images.theconversation.com/files/411097/original/file-20210713-19-nm0d98.jpg?ixlib=rb-1.1.0&rect=0%2C21%2C4898%2C3666&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">One potential way to make opioids less addictive is to make them target injured tissue rather than the healthy brain.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/falling-pills-royalty-free-image/1217370301">PM Images/Photodisk via Getty Images</a></span></figcaption></figure><p>What if there was a way for pain patients to get all the pain-relieving power of opioids with none of the addicting side effects? </p>
<p>Opioids are one of the <a href="https://medlineplus.gov/painrelievers.html">most powerful pain medications</a> available, but <a href="https://doi.org/10.7326/M17-0865">millions of Americans</a> have struggled with prescription opioid misuse after getting hooked on the <a href="https://medlineplus.gov/genetics/condition/opioid-addiction/">feelings of calm and euphoria they also induce</a>. But new research suggests there may be a way to chemically tailor opioids to reduce their addictive potential.</p>
<p>The first wave of the opioid epidemic in the United States began in the <a href="https://www.cdc.gov/opioids/basics/epidemic.html">1990s</a>. By 2015, approximately <a href="https://doi.org/10.7326/M17-0865">11.5 million Americans</a> were struggling with prescription opioid misuse. The Centers for Disease Control and Prevention estimates that <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">nearly 500,000 people died</a> from opioid overdose from 1999 to 2019. Recent reports have shown that this ongoing health crisis has only intensified during the <a href="https://doi.org/10.26099/3d62-cv07">COVID-19 pandemic</a>. The U.S. reached a record <a href="https://www.statnews.com/2021/07/14/us-overdose-deaths-record-2020-pandemic/">93,000 overdose deaths in 2020</a>, a 29% increase from the previous year.</p>
<p>Many people with opioid dependencies report using these drugs to relieve <a href="https://dx.doi.org/10.1111%2Fj.1521-0391.2012.00327.x">physical pain</a>: <a href="https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis">Chronic pain treatment</a> is a leading cause of opioid abuse. But there currently are no equivalent medications capable of the providing the same level of pain relief without the potential risk of addiction.</p>
<p>A less addictive opioid, however, could be an important tool to deal with the opioid epidemic. I’m a <a href="https://scholar.google.com/citations?user=df8z7MQAAAAJ&hl=en">physical chemist</a> interested in this problem, and my research group used computational chemistry to investigate how opioids like morphine can be redesigned to <a href="https://doi.org/10.1016/j.cplett.2021.138723">target specific pain regions without affecting the brain</a>. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/8xoOF2x0XzM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">In the process of trying to develop a less addictive painkiller, researchers produced more forms of addictive opioids.</span></figcaption>
</figure>
<h2>The biochemistry of opioids</h2>
<p>There are many different classes of opioids that vary in chemical structure. However, all opioids contain the same type of chemical group that dictates their biochemical activity. Morphine, oxycodone and hydrocodone belong to the same major class of <a href="https://doi.org/10.1111/j.1365-2125.2012.04317.x">epoxymorphinan opioids</a> and share nearly identical <a href="https://doi.org/10.3389/fphar.2018.01210">chemical structures</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Structures of epoxymorphinan structures" src="https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=224&fit=crop&dpr=1 600w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=224&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=224&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=282&fit=crop&dpr=1 754w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=282&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/411297/original/file-20210714-13-bhm9c7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=282&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Morphine, oxycodone, and hydrocodone belong to the same class of opioids and have similar structures.</span>
<span class="attribution"><span class="source">Aaron Harrison</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Fentanyl, on the other hand, belongs to the <a href="https://bpspubs.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1365-2125.2012.04317.x">phenylpiperidine</a> class of opioids and looks quite different.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chemical structures of morphine and fentanyl" src="https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=280&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=280&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=280&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=351&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=351&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409773/original/file-20210705-126536-184hk2x.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=351&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Morphine and fentanyl have different chemical structures but share a nitrogen group that undergo a similar chemical reaction in the bloodstream.</span>
<span class="attribution"><span class="source">Aaron Harrison</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>The chemical structures of these molecules will be a bit of mystery if you haven’t taken an organic chemistry class before. However, we can simplify the picture by focusing on what’s common between them. Both molecules contain a nitrogen that’s part of what’s called an <a href="https://2012books.lardbucket.org/books/introduction-to-chemistry-general-organic-and-biological/s18-13-amines-as-bases.html">amine group</a>. This group can become positively charged via a chemical reaction that happens in water-based environments such as the bloodstream.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Morphine reaction with water to generate active opioid." src="https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=194&fit=crop&dpr=1 600w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=194&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=194&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=244&fit=crop&dpr=1 754w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=244&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/410702/original/file-20210711-25-lz9121.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=244&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Neutrally-charged morphine undergoes a chemical reaction in water to become a positively-charged, biochemically active compound.</span>
<span class="attribution"><span class="source">Aaron Harrison</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>This positively charged structure is the biochemically active form of the opioid – it won’t have any effect on your body until it gains this positive charge. The positive charge on the nitrogen helps these drugs bind to the target site where the pain is originating and provide relief.</p>
<p>The <a href="https://www.news-medical.net/health/pH-in-the-Human-Body.aspx">typical acidity level</a> of the average person’s body provides ideal conditions for morphine and fentanyl to become positively charged. This means that nearly all of the drug that’s consumed will be biochemically active throughout the body. Whether it’s in the brain or at the site of injury, cells all over the body will feel the effects of the drug.</p>
<h2>Making opioids less addictive</h2>
<p>Many of the addictive qualities of opioids are due to the <a href="https://doi.org/10.1177%2F0963689718811060">feelings of calm and euphoria</a> they induce in the brain. For conditions like arthritis and wound and postoperative pain, however, these drugs need to target only the diseased or injured areas of the body to provide pain relief. The question researchers face is whether it’s possible to limit the effect of opioids to specific areas of the body without affecting the brain.</p>
<p>One <a href="https://doi.org/10.1126/science.aai8636">recently proposed solution</a> focuses on the acidity difference between injured and healthy tissue. Injured tissue is more acidic than healthy tissue due to a process known as <a href="https://doi.org/10.1155/2018/1218297">acidosis</a>, where lactic acid and other acidic byproducts <a href="https://dx.doi.org/10.1074%2Fjbc.M112.426254">produced by damaged tissue collect</a>. This means that an opioid could potentially be altered to be positively charged and active only in injured tissue, while staying neutral and inactive in normal tissue. The drug would be biochemically active only at a higher acidity level than found in healthy tissue.</p>
<p>This theory was first explored using <a href="https://doi.org/10.1038/s41598-018-27313-4">fentanyl</a>. Researchers found that introducing a fluorine (F) atom near the nitrogen in the amine group can lower the acidity range in which fentanyl is active, making it less likely to be active at the normal acidity levels of the body.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chemical structure of fluorinated fentanyl" src="https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=349&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=349&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=349&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=439&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=439&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409779/original/file-20210705-105669-1ijeflu.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=439&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Adding a fluorine atom to fentanyl can make it less likely to be biochemically active in healthy body tissues.</span>
<span class="attribution"><span class="source">Aaron Harrison</span></span>
</figcaption>
</figure>
<p>Adding fluorine to fentanyl showed increased opioid activity in the more acidic conditions of injured tissue compared to healthy tissue. This meant that the drug “turned on” only in parts of the body that needed pain relief. In addition, it showed a <a href="https://doi.org/10.1038/s41598-019-55886-1">decrease in the severe side effects</a> associated with opioids, like addictive potential and abnormally decreased breathing rates, while still providing pain relief.</p>
<p>My colleagues and I have recently extended this framework to <a href="https://doi.org/10.1016/j.cplett.2021.138723">morphine</a>. We showed that similar fluorine substitutions can also adjust morphine’s active acidity range to specifically target injured tissue. Given that molecules in the same class of opioids as morphine share similar structures, we believe this approach would also work in other opioids like hydrocodone and oxycodone.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Chemical structure of fluorinated morphine" src="https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=350&fit=crop&dpr=1 600w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=350&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=350&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=439&fit=crop&dpr=1 754w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=439&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/409780/original/file-20210705-35826-d12epj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=439&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Adding a fluorine atom to morphine can make it less likely to be biochemically active in healthy body tissues.</span>
<span class="attribution"><span class="source">Aaron Harrison</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<p>Effectively treating pain without putting patients at risk for addiction remains a significant problem in health care. This approach has been tested only in lab settings and might not be in pharmacies for some time, if ever. But chemically altering existing opioids is a promising avenue towards developing drugs that alleviate pain without causing addiction.</p>
<p>[<em>Understand new developments in science, health and technology, each week.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-understand">Subscribe to The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/163557/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Aaron W. Harrison 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>While the COVID-19 pandemic raged on, the opioid epidemic got worse as drug overdose deaths soared. New research proposes a way to chemically modify opioids to reduce the risk of addiction.Aaron W. Harrison, Assistant Professor of Chemistry, Austin CollegeLicensed 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>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/M8oDFT_RUtI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<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/1466372020-10-02T10:27:02Z2020-10-02T10:27:02ZMisinformation about illicit drugs is spreading on social media – and the consequences could be dangerous<figure><img src="https://images.theconversation.com/files/361345/original/file-20201002-14-1733wvb.jpg?ixlib=rb-1.1.0&rect=33%2C11%2C7315%2C4891&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">For man, social media is the only place they get their news.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/closely-image-woman-making-online-purchase-427841167">GaudiLab/ Shutterstock</a></span></figcaption></figure><p>We’re all familiar with the term “<a href="https://theconversation.com/fake-news-why-people-believe-it-and-what-can-be-done-to-counter-it-70013">fake news</a>” and have probably witnessed the speed at which these stories can circulate on social media. Fake news stories can be about almost any topic, but increasingly misinformation about illicit drugs is becoming common. But the consequences of such false information can be dangerous – even deadly. </p>
<p>There tends to be a high level of interest about drug use myths on social media, driven in part by curiosity, but also fear of the unknown as some <a href="https://www.independent.co.uk/news/long_reads/drug-panics-overdose-spice-monkey-dust-krokodil-mental-health-a8541036.html">new and bizarre threat is reported</a> – but often without any evidence to back up the hysteria. Some of this interest will be amplified by algorithms used by social media platforms, which <a href="https://www.theverge.com/2018/12/4/18124718/google-search-results-personalized-unique-duckduckgo-filter-bubble">tailor content</a> based on user search history. </p>
<p>However, this misinformation is also further spread by mainstream media news outlets that pick up on the popularity and <a href="https://www.independent.co.uk/news/uk/home-news/krokodil-purple-drank-world-s-10-most-deadly-street-drugs-a6719541.html?utm_content=Echobox&utm_medium=Social&utm_source=Twitter#Echobox=1600876508">publish stories</a> repeating the false information. Misinformation on social media is also easy to access, engaging, and may be shared by friends and family, making it appear more trustworthy. And, for many people, <a href="https://www.ofcom.org.uk/about-ofcom/latest/features-and-news/half-of-people-get-news-from-social-media">social media</a> is the only place they get their news. </p>
<p>Dangerous synthetic drugs are common subjects of misleading “fake” news spread on social media. Given their potential dangers, it’s understandable that many people are concerned. This misinformation could be harmful, especially to those who may take the drug. </p>
<p>One such example is the <a href="https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates">deadly drug fentanyl</a>, an opiate that can be anywhere between <a href="https://www.drugabuse.gov/publications/drugfacts/fentanyl">50 to 100 times stronger</a> than morphine. A myth that you can overdose even by <a href="https://www.youtube.com/watch?reload=9&v=61bvi22uOrA">touching a small amount of this drug</a> spread on social media – and was even perpetuated by the United States Drug Enforcement Administration, which claimed that <a href="https://www.dea.gov/press-releases/2016/06/10/dea-warning-police-and-public-fentanyl-exposure-kills">touching or inhaling</a> airborne fentanyl could be deadly. As this warning was issued by a government department, many people took this misinformation seriously. It spread quickly and widely on social media even after the medical community <a href="https://link.springer.com/article/10.1007/s13181-020-00762-y">agreed</a> that overdose due to fentanyl skin contact is impossible.</p>
<p>Researchers tracked the <a href="https://www.sciencedirect.com/science/article/pii/S0955395920302851?dgcid=coauthor">spread of information</a> about fentanyl between 2015 and 2019 by using a media analysis tool which was able to track the number of fake news articles created on and spread by social media, and could also track the number of potential views by looking at article shares. They found that erroneous information had a reach 15 times greater than correct information. Some of this included the myth about how touching the drug could be toxic. Most of this misinformation about fentanyl originated from Facebook posts created in Texas and Pennsylvania, and potentially reached 67 million people. </p>
<figure class="align-center ">
<img alt="Social media icons on smartphone." src="https://images.theconversation.com/files/361348/original/file-20201002-19-1thvlqt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/361348/original/file-20201002-19-1thvlqt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/361348/original/file-20201002-19-1thvlqt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/361348/original/file-20201002-19-1thvlqt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/361348/original/file-20201002-19-1thvlqt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/361348/original/file-20201002-19-1thvlqt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/361348/original/file-20201002-19-1thvlqt.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">Misinformation about fentanyl was spread mainly on Facebook.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/corby-united-kingdom-january-27-2019-1296085084">Erhan Inga/ Shutterstock</a></span>
</figcaption>
</figure>
<p>While fentanyl use might not be common, this sort of misinformation could have dangerous consequences. For example, a person might not help someone who has overdosed if they believe any physical contract with them – even to administer chest compressions – could cause them harm, too. </p>
<p>Other synthetic drugs, including <a href="https://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-12902020000200301&lng=en&nrm=iso&tlng=en">Krokodyl</a> and “spice” (a type of synthetic cannabis) have also triggered widespread misinformation. Krokodyl has been <a href="https://medicalxpress.com/news/2019-06-krokodil-russian-flesh-eating-drug-rare.html">portrayed</a> on social media as a chemical which can eat your flesh, even after only one use. Spice, on the other hand, has <a href="https://www.washingtonpost.com/news/morning-mix/wp/2015/06/16/the-new-drug-that-causes-users-to-rip-off-their-clothes-and-attack-with-super-human-strength/">been described</a> in the media as a drug that causes users to rip off their clothes as if it’s given them “superhuman” strength. </p>
<p>While it’s unlikely someone would take a drug knowing it causes severe damage, the idea of using something to gain extraordinary physical strength might entice potential users. In both instances, this information was wrong, but that didn’t stop them from <a href="https://www.forbes.com/sites/jacobsullum/2014/01/10/krokodil-crock-how-rumors-of-a-flesh-eating-zombie-drug-swept-the-nation/#6d42a7017127">going viral</a> on social media.</p>
<p>It is often the young or naive that are victims of misinformation about some new drug or using a drug to achieve an effect. This is illustrated in a recent case when information about the <a href="https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-about-serious-problems-high-doses-allergy-medicine-diphenhydramine-benadryl">antihistamine Benadryl</a> was circulated on social media. Users reported that consuming this drug caused hallucinations and would challenge each other to take the drug, sadly at least <a href="https://www.salon.com/2020/09/30/benadryl-challenge-claims-the-life-of-one-teen-as-tiktok-claims-to-have-already-banned-the-videos/">one person died</a> as a result.</p>
<p>Beyond these extreme examples, it’s also becoming routine to see misinformation on social media about drugs such as cannabis. In particular, claims being made about <a href="https://news.usc.edu/164317/cannabis-health-social-media-bots-fake-claims/">cannabis-based medicinal products</a>, which suggest that everything from pain to terminal cancer can be cured. These are made despite the lack of research and evidence that support these assertions. Tragically this type of <a href="https://www.pharmout.net/fda-crackdowns-false-claims-cannabis-cbd-medicine-advertisements/">misinformation</a> offers false hope to people who are often at a very vulnerable point in their life. These false claims are harmful in themselves, but could be really damaging if people choose to stop traditional medical intervention and use these products in the belief that their health will improve.</p>
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Read more:
<a href="https://theconversation.com/how-to-spot-fake-news-an-experts-guide-for-young-people-88887">How to spot fake news – an expert's guide for young people</a>
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<p>Misinformation about illicit drugs may also make them sound <a href="https://www.tandfonline.com/doi/full/10.3109/09687637.2016.1149148?casa_token=y5PyrnQ69GAAAAAA%3A26eZqU53akkE6sqehlEObdLmNltBtXOMPVFYKqA_MIrU6shFcsCfs5HhkTdIDvOMP1CLjqGZ3afxczc">more appealing</a> to people who aren’t risk adverse. For them the appeal is in the risk that the drug poses. Widely circulated fake news may even be the reason they try these types of drugs to begin with.</p>
<p>Finding ways of reducing this type of misinformation is important to prevent any dangerous consequences. Social media platforms have an important role to play in regulating information – should they choose to. Educating people in how to spot fake news, and <a href="https://www.pshe-association.org.uk/curriculum-and-resources/resources/drug-and-alcohol-education-%E2%80%94-lesson-plans">better education</a> for young people in schools about drugs may also prevent the further spread of such harmful misinformation. </p>
<p>We need to accept that there will always be interest in drugs and that false information about them will accompany that curiosity. Social media platforms have the ability to mitigate misinformation, but they may not have the will if an action threatens their commercial interests. So young people and their families are left to separate fact from fiction as they try to reduce the potential risks some drugs pose.</p><img src="https://counter.theconversation.com/content/146637/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Patricia Cavazos-Rehg receives funding from National Institutes of Health and the Substance Abuse and Mental Health Services Administration</span></em></p><p class="fine-print"><em><span>Ian Hamilton 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>Social media makes it easy to spread ‘fake news’.Ian Hamilton, Associate Professor of Addiction., University of YorkPatricia Cavazos-Rehg, Professor of Psychiatry, Washington University in St LouisLicensed 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>
</figcaption>
</figure>
<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">
<figcaption>
<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>
</figcaption>
</figure>
<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/1427762020-07-16T12:54:03Z2020-07-16T12:54:03ZHow smugglers are shifting staggering amounts of contraband despite the pandemic<p>On July 1, Italian police made the <a href="https://www.dailysabah.com/world/europe/italy-seizes-daesh-made-drugs-worth-11-billion">largest amphetamine seizure</a> in the world. At the port of Salerno, just south of Naples, they used chainsaws to open large cylinders of paper and industrial machinery that were inside shipping containers from Syria and found 14 tonnes of pills. </p>
<p>In Hong Kong, customs officials seized <a href="https://www.seafoodsource.com/news/environment-sustainability/shark-fin-smugglers-using-coronavirus-as-cover-to-ramp-up-illegal-shipments-into-hong-kong">record numbers</a> of illegal shark fins in April and May, from an estimated 38,500 sharks. Meanwhile, the trade in counterfeit drugs and medical equipment has been in overdrive. US border authorities <a href="https://www.nextgov.com/cio-briefing/2020/06/cbp-has-seized-nearly-900000-counterfeit-and-unsafe-covid-19-supplies/165959/">recently confirmed</a> that they had seized nearly a million units by the beginning of June. </p>
<p>These record seizures are puzzling, since they suggest that such activities are increasing. The trade in illicit and legitimate goods are usually closely connected, with traffickers and smugglers often using <a href="https://www.unodc.org/documents/data-and-analysis/covid/Covid-19-and-drug-supply-chain-Mai2020.pdf">legitimate goods</a> to conceal their commodities – just like in the Italian amphetamine bust. Yet the global trade in legitimate goods has declined sharply during the pandemic and is <a href="https://www.ft.com/content/d870d304-9ee8-4699-ae02-cf4e1c488d2a">forecast to be</a> down 10% year on year in 2020. So what is going on?</p>
<h2>Risk and reward</h2>
<p>To some extent, illicit traffic will be more visible to authorities because legal trade flows have shrunk and there is additional checking at national borders. The seizures are also a sign of criminals taking greater risks because they can make higher returns on scarce goods. In the UK, criminals <a href="https://www.theguardian.com/world/2020/may/09/gangs-take-bigger-risks-to-smuggle-drugs-into-lockdown-britain">have been smuggling</a> drugs in bulk because it’s harder to smuggle lots of smaller shipments. Larger actors can often cope with the increased transaction costs, while petty smugglers sometimes end up getting pushed out of business. </p>
<p>Criminals have had to innovate to keep their supply chains open. A good example is concealing illegal drugs in consignments of <a href="https://www.thetimes.co.uk/article/drug-runners-hiding-stash-in-ppe-consignments-say-police-8qb092rzn">face masks</a> or <a href="https://edition.cnn.com/2020/05/21/world/meth-smuggled-hand-sanitizer-australia-trnd/index.html">other medical supplies</a>. We are also seeing changes in the modes of transport that smugglers are using. Some activities that usually move by air or road – <a href="https://globalinitiative.net/covidcrimewatch-n10/">certain wildlife trafficking</a>, for example – have switched to rail and maritime routes. </p>
<p>Shipping is more attractive because most seaports have continued to operate. In some cases, illicit trade on ships has increased. For example, the port of Antwerp in Belgium <a href="https://www.nbcnews.com/now/video/cocaine-trafficking-rises-amid-global-coronavirus-pandemic-85464133692">reports that</a> cocaine shipments from Latin America have risen. </p>
<p>Yet there have also been drawbacks to maritime smuggling during the pandemic, including cargo congestion at seaports and reduced capacity because of coronavirus restrictions on vessels and crews. Trains, on the other hand, have <a href="https://www.forbes.com/sites/wadeshepard/2020/03/31/china-europe-rail-is-set-to-boom-as-covid-19-chokes-air-sea-and-road-transport/">been running</a> relatively unscathed. They are also less scrutinised by officials and transporting more legal cargo than usual. Hence rail routes from China to Europe have become <a href="https://www.youtube.com/watch?v=-zp6f3jayIE">an attractive alternative</a> for transporting counterfeit consumer goods, for example.</p>
<p>To the extent that smugglers have identified new routes and methods for moving illicit goods, or acquired new knowledge and skills, some of these techniques might well continue after the pandemic. </p>
<h2>Sales and production</h2>
<p>Criminals have had to learn new techniques of concealment and evasion in making and selling their contraband. There have been <a href="https://www.theguardian.com/society/2020/may/07/drug-dealers-posing-joggers-nhs-staff-covid-19-lockdown">reports of</a> drug dealers posing as key workers to move freely in the UK, <a href="https://www.theguardian.com/world/2020/may/09/gangs-take-bigger-risks-to-smuggle-drugs-into-lockdown-britain">using props</a> like NHS badges or high-vis vests. </p>
<p>Before the crisis, there was already a <a href="https://euipo.europa.eu/ohimportal/en/web/observatory/trade-in-fakes-in-small-parcels?TSPD_101_R0=085d22110bab20004ecc5e8edd6c3e5e8dd8d73cd436b771409f26ea5ae8bb652047b0a8057e1d04087524210e14300083c4f069fdd3573de56fd90c3afef8475cd4606b57cc51385689ad83d8687adc549111a7745eb0da6a1045e22d26fe96">growing problem</a> of criminals posting small parcels of illicit goods in the mail. This seems even more popular in some places during the pandemic – mail deliveries of recreational drugs <a href="https://www.shine.cn/news/metro/2006260955/">in Shanghai</a> have risen, for instance. </p>
<p>Online trading has long been the main platform for illicit goods, and this too has grown in 2020. At least 100,000 new websites <a href="http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=GOV/PGC/HLRF/TFCIT(2020)3&docLanguage=En">have emerged</a> since March selling COVID-related substandard or fake medical items. There are <a href="https://corsearch.com/covid-19-and-counterfeiting-how-the-pandemic-is-reshaping-brand-protection-part-2/">also signs of</a> more counterfeit consumer goods selling online, <a href="https://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=GOV/PGC/HLRF/TFCIT(2020)3&docLanguage=En">including</a> fake car parts and accessories. Demand for counterfeits is likely to keep rising as the economy worsens, and because some legitimate goods are more scarce than usual. </p>
<p>Manufacturing of illicit products was temporarily disrupted early in the pandemic. Chinese criminals <a href="https://www.karg-und-petersen.de/anti-piracy-analyst/en/covid-19-disrupts-counterfeiting-and-brand-protection/">couldn’t make</a> counterfeit luxuries, for example, <a href="https://www.insightcrime.org/news/brief/coronavirus-squeezing-mexico-criminal-groups/">or export</a> the usual chemical supplies for making fentanyl, but they were back to business as usual within a few weeks. </p>
<p>Illicit manufacturing did not change as dramatically as other aspects of the trade, partially because it is less flexible. The average producer of counterfeit handbags cannot quickly re-focus on making fake pharmaceuticals. In contrast, a new route for transporting illegal goods can move everything from drugs to wildlife to counterfeit luxuries. </p>
<h2>What next</h2>
<p>Counterfeiting and smuggling have <a href="https://ideas.repec.org/a/eee/respol/v41y2012i2p376-390.html">been made easier</a> by the more dispersed supply chains in our globalised world. Yet these networks are <a href="https://www.supplychaindive.com/news/manufacturing-reshoring-pandemic-thomas/577971/">likely to</a> shrink after the pandemic as multinationals bring some manufacturing nearer home to be less vulnerable to the kind of trade restrictions seen in 2020. Indeed, this “reshoring” <a href="https://www.eft.com/supply-chain/us-reshoring-index-hits-record-high-even-covid-19-pandemic">started before</a> COVID-19, and <a href="https://reshorenow.org/?pageLink=blog-detail&blogLink=the-risks-of-offshoring-intellectual-property-theft">could make</a> smuggling and counterfeiting more difficult.</p>
<p>Shorter and simpler supply chains for legitimate goods will most affect illicit products that are smuggled on the back of them. This would include not only things like drugs concealed in shipping containers but also counterfeit consumer goods “sneaked” into authentic consignments of the same product and sold as the real thing. On the other hand, counterfeits that can be distinguished from the brand-name product usually rely on an independent supply chain. </p>
<p>Deglobalisation is bad news for China-based criminals, <a href="https://daxueconsulting.com/counterfeit-products-in-china/">since they produce</a> most of the world’s counterfeits. They will certainly have to adapt to some companies relocating and diversifying their supply chains and doing <a href="https://info.traceinternational.org/trace-esg-white-paper">more due diligence</a> about their suppliers. </p>
<p>Yet it is difficult to guarantee the ethical standards of your business partners even with greater due diligence, particularly if the economic fallout of the pandemic <a href="http://www.oecd.org/officialdocuments/publicdisplaydocumentpdf/?cote=GOV/PGC/HLRF/TFCIT(2020)3&docLanguage=En">reduces the alternatives</a>. <a href="https://www.project-syndicate.org/commentary/china-unstoppable-economy-domestic-investment-consumption-by-zhang-jun-2020-06">There are</a> also indications that for practical reasons, China’s status as the workshop of the world is unlikely to change dramatically. And even if shorter supply chains make a big difference to the illicit trade, it may just motivate criminals to come up with new ways to meet demand. It may just displace illicit supply chains to places such as Turkey, Thailand and India.</p><img src="https://counter.theconversation.com/content/142776/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alexander Kupatadze 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>Illicit and legitimate trade are closely connected, so how come one seems to be rising while the other has plunged?Alexander Kupatadze, Lecturer in Transnational Crime, King's College LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1347532020-03-26T13:59:19Z2020-03-26T13:59:19ZHow coronavirus is changing the market for illegal drugs<figure><img src="https://images.theconversation.com/files/323280/original/file-20200326-132995-tgg5v0.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Reading between the lines. </span> <span class="attribution"><a class="source" href="https://www.wallpaperflare.com/closeup-photography-of-rolled-banknote-with-cocaine-addiction-wallpaper-zecyl">Wallpaper flare</a></span></figcaption></figure><p>The illicit drug market in the UK <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/868404/Review_of_Drugs_Evidence_Pack_-_FINAL_PUBLICATION_VERSION_1.pdf">turns over</a> more than £10 billion tax-free a year. Unlike the wider economy, we have limited intelligence about how it operates. But like the wider economy, it is certainly not immune to the disruption being caused by the COVID-19 virus. </p>
<p>As borders close, the supply and distribution of most drugs is being restricted – but <a href="https://www.vice.com/en_uk/article/dygebq/drug-dealers-how-coronavirus-affecting-business">particularly</a> those that rely on ingredients <a href="https://www.vice.com/en_uk/article/bvgazz/sinaloa-cartel-drug-traffickers-explain-why-coronavirus-is-bad-for-business">sourced</a> in China. We are already hearing reports of reductios in the supplies of “<a href="http://www.emcdda.europa.eu/publications/drug-profiles/synthetic-cannabinoids">Spice</a>”, for example, the synthetic cannabinoid which is often imported from that part of the world. There are also bound to be problems further down the distribution network. The edict to stay at home will be affecting the ability of city-based dealers to carry out “<a href="https://www.nationalcrimeagency.gov.uk/what-we-do/crime-threats/drug-trafficking/county-lines">county lines dealing</a>”, where they push their product into smaller towns and rural areas. </p>
<p>Previous heroin “droughts” in <a href="https://www.gov.uk/government/publications/reducing-opioid-related-deaths-in-the-uk">the UK</a> and <a href="https://substanceabusepolicy.biomedcentral.com/articles/10.1186/1747-597X-1-11">Australia</a> have been accompanied by temporary falls in deaths, as people reduced their use or substituted with alternatives that were less lethal in an overdose. But more recently, we have seen significant increases in deaths from the <a href="https://www.gov.uk/government/publications/misuse-of-fentanyl-and-fentanyl-analogues">synthetic opioid fentanyl</a> in North America, so we must be alert to the possibility that UK dealers and users will turn to this dangerous substance as heroin supplies dry up. As fentanyl is significantly stronger than heroin it is easier to store and move around due to the smaller quantity required.</p>
<p>Even where a user knows they have bought fentanyl rather than heroin, titrating a safe dose is challenging and this might only become apparent when it’s too late. The UK already has <a href="https://theconversation.com/uk-drug-deaths-continue-to-rise-time-for-action-120449">the highest</a> rate of drug-related deaths in Europe, and the danger now is that the rate may climb even higher. </p>
<p>The government is <a href="https://www.theguardian.com/world/2020/mar/16/government-response-to-coronavirus-led-by-science-grant-shapps">continually stressing</a> that it is led by research evidence in tackling the COVID-19 pandemic, but this doesn’t extend to acting on its advisers’ <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/699825/Letter_from_Victoria_Atkins_MP_to_OBJ.pdf">own recommendation</a> that it should set up drug consumption rooms to reduce the number of deaths from overdoses. It’s difficult to imagine a more important time to heed this advice. </p>
<h2>Another kind of panic buying</h2>
<p>Now that we are all self-isolating, a perfect set of ingredients come together: anxiety, boredom, escapism and loneliness. All of these are candidates for self-medicating with more drugs – as are the abrupt change of routine and being cooped up with family.</p>
<p>Just as we’ve seen <a href="https://theconversation.com/coronavirus-why-people-are-panic-buying-loo-roll-and-how-to-stop-it-133115">people panic buying</a> toilet rolls and paracetamol, consumers of recreational drugs will, if they have the means, stockpile their drug of choice. More than 1.5 million people are <a href="https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2018-to-2019-csew">regular users</a> of drugs in England and Wales alone, and the surge in demand has <a href="https://www.vice.com/en_uk/article/dygebq/drug-dealers-how-coronavirus-affecting-business">already seen reports</a> of the price of drugs escalating.</p>
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<p>Stockpiling might lead people to take more drugs than usual. If they are dependent and subsequently can’t source the drug, they could suddenly end up with a withdrawal problem. This increases the risk that they will try a substitute drug, which again makes it more likely that they will come to harm since they may not be used to the drug or know what a safe dose should be. </p>
<p>The European Monitoring Centre for Drugs and Drug Addiction recently issued some <a href="http://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs">general advice</a> to users on reducing harm during the spread of coronavirus. This was welcome, but it didn’t say anything about the risks from drugs themselves at this time. </p>
<p>We are talking about a market without any quality control or regulation, in which consumers have no idea of the strength of their drug from dose to dose or which chemicals they are exposing themselves to. Mirroring the lack of testing for COVID-19, there’s no routine testing for drugs in the UK and many other countries – other than, say, at <a href="https://theconversation.com/festival-drug-checking-is-here-but-it-now-needs-to-be-expanded-across-the-country-63065">certain music festivals</a>.</p>
<h2>The growing threat</h2>
<p>Public Health England has asked frontline agencies to alert them to examples of drug substitution or contaminated product. Gathering this intelligence makes sense, but is of little benefit unless it is communicated directly to those at risk. This could be viewed by some as a government agency condoning drug use, so it is unlikely to do so directly.</p>
<p>There is already a <a href="https://www.gov.uk/drug-safety-update">similar process</a> for problems with prescribed drugs, as the Medicines and Healthcare Products Regulatory Agency alerts pharmacists, general practitioners and others involved in prescribing or dispensing these drugs to any hazards or emerging risks.</p>
<p>In the case of illegal drugs, the obvious network for feeding back equivalent information is the specialist drug treatment services. Unfortunately, that network <a href="https://transformdrugs.org/we-need-to-support-the-vulnerable-as-covid-19-spreads/">has shrunk</a> significantly over the last decade because the government has <a href="https://theconversation.com/drug-deaths-increase-as-fewer-people-access-treatment-84784">savagely cut</a> the treatment budget. Even then, this network doesn’t reach the majority of people with drug problems, as they are not in treatment. For obvious reasons, such people guard their identity. </p>
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<a href="https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&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">‘Much obliged’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-trafficking-crime-addiction-sale-concept-519449383">Syda Productions</a></span>
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<p>The bottom line is that we need to be smarter and better informed about this large but hidden part of our economy. The pandemic is exposing how little we know, and our inability to protect the significant number of people involved in it. There are persuasive grounds to change our policy approach to drugs, including the potential to <a href="https://journals.sagepub.com/doi/full/10.1177/1477370819887514">reduce the harms done</a> by either no longer criminalising users or even <a href="https://blogs.lse.ac.uk/politicsandpolicy/the-costs-and-benefits-of-a-licensed-taxed-and-regulated-cannabis-market/">legalising sales</a> and reaping the tax revenues. </p>
<p>“Doing what it takes to protect people” has to include everyone – not just those we morally approve of.</p><img src="https://counter.theconversation.com/content/134753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex Stevens is a member of the DrugScience committee, of the board of the International Society for the Study of Drug Policy, and of the Green Party</span></em></p><p class="fine-print"><em><span>Ian Hamilton 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>Prices are surging amid shortages and panic-buying – and we could soon be facing a public health disaster. Ian Hamilton, Associate Professor, Addiction and Mental Health, University of YorkAlex Stevens, Professor in Criminal Justice and Faculty Director of Public Engagement, University of KentLicensed as Creative Commons – attribution, no derivatives.