tag:theconversation.com,2011:/ca/topics/opioids-1046/articlesOpioids – The Conversation2024-03-08T17:12:03Ztag:theconversation.com,2011:article/2250242024-03-08T17:12:03Z2024-03-08T17:12:03ZAnxiety drug pregabalin linked to rising number of deaths – here’s what you should know<figure><img src="https://images.theconversation.com/files/580673/original/file-20240308-30-m9sql2.jpg?ixlib=rb-1.1.0&rect=16%2C0%2C5557%2C3673&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Pregabalin on its own is typically not dangerous – but can cause harm if taken alongside certain drugs.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pouring-capsules-pill-bottle-into-hand-141666325">Brian A Jackson/ Shutterstock</a></span></figcaption></figure><p>There has been a significant rise in deaths linked to the commonly prescribed anxiety drug, pregabalin. While in 2018 there were 187 deaths linked to pregabalin in England and Wales, this number was <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/adhocs/1765deathregistrationsrelatedtogabapentinorpregabalinenglandandwales2018and2022">more than double</a> in 2022 – with 441 deaths linked to the drug.</p>
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<p>Recent press reports have framed these deaths as signalling a “<a href="https://www.thetimes.co.uk/article/7ad460de-b356-4965-81d2-e7dfa2051bfa">US-style opioid epidemic</a>” caused by a medicine that “<a href="https://www.dailymail.co.uk/news/article-13154113/pregabalin-anti-depressant-anxiety-drug-effects.html">destroys lives</a>”. This is not an equitable comparison, given <a href="https://www.cdc.gov/drugoverdose/deaths/index.html">hundreds of thousands</a> of Americans have died due to opioids. These reports may only serve to cause undue panic about the drug, especially among those who have been prescribed it.</p>
<p><a href="https://www.nhs.uk/medicines/pregabalin/">Pregabalin</a> (also known by the brand names Lyrica and Alzain) is used to treat a variety of health conditions, including epilepsy, nerve pain and anxiety. The drug was <a href="https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(22)00275-7/fulltext">first approved for use</a> in Europe and the US in 2004. </p>
<p>Pregabalin has <a href="https://link.springer.com/article/10.1007/s40264-020-00985-6">rewarding properties</a>, and can produce feelings of <a href="https://www.talktofrank.com/drug/pregabalin#how-it-feels">euphoria, calmness and relaxation</a>. These effects may explain why even people who don’t have a prescription seek out pregabalin. </p>
<p>Pregabalin on its own is typically not dangerous, although as with all medication there are <a href="https://www.mayoclinic.org/drugs-supplements/pregabalin-oral-route/side-effects/drg-20067411?p=1">potential side effects</a> – including confusion and headaches. It can also carry the <a href="https://cks.nice.org.uk/topics/neuropathic-pain-drug-treatment/prescribing-information/pregabalin/">risk of dependence</a>, especially if taken long term. </p>
<p>But where pregabalin can become dangerous, whether <a href="https://link.springer.com/article/10.1007/s40264-020-00985-6">used as prescribed or not</a>, is if it’s taken alongside <a href="https://www.mayoclinic.org/drugs-supplements/pregabalin-oral-route/precautions/drg-20067411">other drugs</a> that it interacts negatively with. Pregabalin should ideally be avoided alongside other opioids, certain sleep aids, benzodiazepines (another class of anxiety drug), muscle relaxants and even certain diabetes and epilepsy drugs. Most fatalities attributed to pregabalin are due to interactions with other drugs, leading to a suppression of breathing.</p>
<p>An analysis of <a href="https://bpspubs.onlinelibrary.wiley.com/doi/full/10.1111/bcp.15352">pregabalin deaths in England</a> between 2004-2020 has shown that in over 90% of deaths, the presence of other opioids (including methadone or morphine) was detected. However, in only a quarter of cases were these opioids actually prescribed to the person. This suggests that people were probably sourcing these drugs through illicit means and not through their doctor. Likewise, it’s not clear from the data whether pregabalin had been prescribed, or if the person sourced it without a prescription. </p>
<p>Although this data only goes up to 2020, it’s likely that the picture is similar for the recent deaths linked to pregablin.</p>
<h2>Fatalities</h2>
<p>The recent rise in pregablin deaths partly coincides with an increase in the number of people prescribed the drug. In the UK alone, there were <a href="https://academic.oup.com/jat/article/47/1/e20/6839276">8.4 million prescriptions</a> for pregabalin in 2022. This is up from 5.5 million in 2016. </p>
<p>This might suggest that more support needs to be provided to reduce patient risk – particularly in relation to co-use of other drugs. Prescribers and patients both <a href="https://www.gov.uk/government/publications/misuse-of-illicit-drugs-and-medicines-applying-all-our-health/misuse-of-illicit-drugs-and-medicines-applying-all-our-health">need to be educated</a> about the potential risks of using pregabalin – including the <a href="https://www.gov.uk/government/publications/prescribed-medicines-review-report">potential of dependency</a>. Patients and prescribers also need to be aware of the drugs that pregabalin interacts with and the effects such combinations might have. </p>
<p>Prescribers should also <a href="https://www.nice.org.uk/guidance/ng215">regularly review</a> pregabalin prescriptions to ensure that patients are still <a href="https://bmjopen.bmj.com/content/9/3/e021535">benefiting from it</a>. If not, recommending other treatments – such as <a href="https://www.tandfonline.com/doi/full/10.3109/09540261.2011.606803">psychological therapies</a>, if a person is taking the drug for anxiety – might be more suitable.</p>
<p>But in light of the profile of drugs involved in deaths previously linked to pregabalin, it’s clear that drug education alone won’t be enough.</p>
<figure class="align-center ">
<img alt="Three vials of methadone." src="https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/580676/original/file-20240308-29-y399de.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Methadone is one drug that should never be taken alongside pregabalin.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/vial-methadone-injection-syringe-on-black-1758754181">Bernard Chantal/ Shutterstock</a></span>
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<p>Certain groups may be at greater risk of harm from pregabalin. For example, people with a history of substance use disorder have a high level of <a href="https://link.springer.com/article/10.1007/s40265-020-01432-7">co-occurring</a> mental health problems, and may be prescribed pregabalin as a short-term treatment for anxiety. But because mental health and drug treatment support are typically provided by <a href="https://meam.org.uk/wp-content/uploads/2022/06/Co-occurring-conditions-briefing-FINAL-June-2022.pdf">different services</a>, a lack of communication between these services can sometimes mean that one service is not always fully aware of what drugs the other is prescribing – potentially leading to <a href="https://www.emerald.com/insight/content/doi/10.1108/ADD-04-2013-0010/full/html">harmful drug interactions</a>. </p>
<p>Evidence also suggests that illicit pregabalin use is a <a href="https://link.springer.com/article/10.1007/s40265-020-01432-7">growing problem</a> in both Europe and North America. Its <a href="https://www.gov.uk/government/publications/circular-0192018-control-of-pregabalin-and-gabapentin-under-the-misuse-of-drugs-act-1971/control-of-pregabalin-and-gabapentin-under-the-misuse-of-drugs-act-1971">availability as a street drug</a> may mean users aren’t aware of the risks of taking pregabalin alongside other drugs – such as the synthetic opiate, methadone.</p>
<p>There’s the added complication of fear of negative consequences. Someone prescribed pregabalin who uses illicit drugs may not declare this to their doctor. People who use illicit opioids less frequently (such as for recreational purposes or to self-treat pain or mental health problems) are also at <a href="https://www.tandfonline.com/doi/abs/10.1080/14740338.2023.2193397">elevated risk</a>.</p>
<p>Evidence also shows that more people living in the <a href="https://bmjopen.bmj.com/content/10/3/e029624.abstract">north of England</a> are prescribed pregabalin compared to those living in the south. Other research has also shown a link between <a href="https://academic.oup.com/pmj/article/98/1157/193/6958957">social deprivation and drug prescribing</a> – with people living in more deprived areas of England being prescribed drugs such as pregabalin at higher rates. Those living in deprived areas may not get the support they need – including support to know the risks of taking or combining certain drugs, putting them at greater risk of harm.</p>
<p>Understanding exactly why these deaths are happening is important for developing strategies to reduce harm and deaths from the drug. Simply stopping pregabalin prescriptions does not seem practical or safe, as it’s considered a <a href="https://bnf.nice.org.uk/drugs/pregabalin/">useful and effective medicine</a> that many people benefit from. Placing tougher restrictions on illicit pregabalin would also not be practical, and could even lead to greater harm – which is exactly what happened after it was made a <a href="https://blogs.bmj.com/bmj/2019/03/29/ian-hamilton-reclassifying-pregabalin-gabapentin-only-moves-problem-other-drugs/">Class C drug</a> in 2019.</p>
<p>Understanding why people are combining pregabalin with other drugs, prescribed or not, is crucial for anything meaningful to be done.</p><img src="https://counter.theconversation.com/content/225024/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives funding from public grant awarding bodies for alcohol and other drugs research, and fees from (international) not-for-profit organisations and government departments for consultation work. He is an unpaid member of the Scientific Advisory Board of the Mind Foundation, an unpaid advisor to the UK Drug Education Forum, and an unpaid co-opted member of UK Government Advisory Council on the Misuse of Drugs (ACMD) Working Groups.</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>Pregabalin is prescribed for a number of conditions – including epilepsy, anxiety and nerve pain.Ian Hamilton, Honorary Fellow, Department of Health Sciences, University of YorkHarry Sumnall, Professor in Substance Use, Liverpool John Moores UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2230612024-02-20T13:17:55Z2024-02-20T13:17:55ZNearly 2 million Americans are using kratom yearly, but it is banned in multiple states: A pharmacologist explains the controversy<figure><img src="https://images.theconversation.com/files/574217/original/file-20240207-16-58upgw.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C1989%2C855&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Kratom products are sold online and at smoke shops and gas stations, like this one in Lone Tree, Colo.</span> <span class="attribution"><span class="source">Amanda Mascarelli</span></span></figcaption></figure><p><em><a href="https://nida.nih.gov/research-topics/kratom">The herbal substance kratom</a>, derived from the leaves of a <a href="https://doi.org/10.1093/ajhp/zxz221">Southeast Asian tree</a>, is used by <a href="https://doi.org/10.1016%2Fj.amepre.2021.02.004">nearly 2 million people</a> in the United States annually. It can be easily purchased at gas stations and convenience stores, smoke shops and online, and is marketed as an “herbal supplement.”</em></p>
<p><em>Proponents claim that kratom has many of the pain-relieving benefits of traditional opioids and that it can potentially be used as a treatment for opioid dependence.</em></p>
<p><em>The primary concern about kratom is that it can mimic how synthetic opioids work in the body, potentially causing overdoses, severe withdrawal symptoms and other serious health issues. As a result, the <a href="https://www.fda.gov/news-events/public-health-focus/fda-and-kratom#">Food and Drug Administration recommends against its use</a>.</em></p>
<p><em>The Conversation asked C. Michael White, a pharmacist at the University of Connecticut who has been <a href="https://doi.org/10.1080/17512433.2024.2305798">studying the science behind kratom</a> <a href="https://theconversation.com/the-dangers-and-potential-of-natural-opioid-kratom-87581">for many years</a>, to explain its potential benefits and why consumers should use caution with this product.</em></p>
<h2>How does kratom work in the body?</h2>
<p>Kratom doesn’t contain just one active ingredient; rather, it is made up of many substances that induce effects in the body. This is very common for <a href="https://theconversation.com/nature-is-the-worlds-original-pharmacy-returning-to-medicines-roots-could-help-fill-drug-discovery-gaps-176963">natural products</a>, since the cells of the plant make a variety of chemicals for different purposes.</p>
<p>When the body is experiencing pain, it releases hormones called endorphins that <a href="https://doi.org/10.1590/s0100-879x2010007500086">stimulate opioid receptors</a> to mildly reduce the transmission of local pain sensations to the brain. This same process also causes the release of the neurotransmitter dopamine, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3104618/">inducing a feeling of pleasure</a> to neutralize the pain. </p>
<p>Traditional opioids, like morphine and fentanyl, stimulate these same receptors to such a degree that they more potently numb pain, induce a <a href="https://doi.org/10.3389%2Ffpsyt.2022.835816">euphoric feeling</a> that can lead to addiction, and suppress the <a href="https://theconversation.com/pain-and-anxiety-are-linked-to-breathing-in-mouse-brains-suggesting-a-potential-target-to-prevent-opioid-overdose-deaths-174187">drive to breathe</a>, which can result in death.</p>
<p>One of the key constituents of kratom is an <a href="https://doi.org/10.1021/acscentsci.9b00141">organic compound called mitragynine</a>. It interacts with the same opioid receptors as morphine and fentanyl, but does not recruit the beta-arrestin-2 (the reason for breathing suppression). As a result, kratom can provide pain relief with a lower risk <a href="https://doi.org/10.1021/acs.jmedchem.1c00726">of slowed or stopped breathing</a> compared to traditional opioids. </p>
<p>Kratom also contains a small amount of <a href="https://doi.org/10.1021%2Facscentsci.9b00462">7-hydroxymitragynine</a>, which is thought to more potently stimulate opioid receptors, leading to a greater risk of opioidlike adverse events. </p>
<p>One of the risks associated with kratom use is that products can <a href="https://www.tampabay.com/investigations/2023/12/09/tampa-bay-times-tested-20-kratom-products-heres-what-we-found/">differ dramatically in the doses</a> of 7-hydroxymitragynine. In other words, one kratom product could be more dangerous than another. When kratom is used in high doses, it <a href="https://doi.org/10.1093/ajhp/zxz221">can lead to seizures</a> and other issues. Since kratom products are not FDA-regulated, there is no uniformity to the products.</p>
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<figcaption><span class="caption">The FDA says kratom is addictive and warns against its use.</span></figcaption>
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<h2>What is kratom’s legal status in the US?</h2>
<p>Kratom’s current legal status is complicated. Kratom is not a prescription or over-the-counter drug, and while it is derived from a plant, it does not meet the FDA’s definition of a <a href="https://www.fda.gov/news-events/public-health-focus/fda-and-kratom">dietary supplement, food or food additive</a>. </p>
<p>Natural products marketed in the U.S. <a href="https://www.fda.gov/food/information-consumers-using-dietary-supplements/questions-and-answers-dietary-supplements#">before Oct. 15, 1994</a>, were grandfathered in under the FDA’s list of dietary supplements. But since kratom came on the market later, the FDA would have to find, based on a history of use or other evidence, that when used under the conditions recommended or suggested in the labeling, the natural product can <a href="https://ods.od.nih.gov/About/DSHEA_Wording.aspx#sec8">reasonably be expected to be safe</a> – like the FDA does for all new dietary supplement ingredients. </p>
<p>In 2016, in response to increasing calls to <a href="https://www.tandfonline.com/doi/full/10.1080/15563650.2019.1569236">poison control centers,</a> the Drug Enforcement Administration sought to ban kratom by <a href="https://doi.org/10.2146/ajhp161035">making it a Schedule I drug</a>. This means the agency felt it had no currently accepted medical use and a high potential for abuse. But backlash from the public and <a href="https://www.usnews.com/news/articles/2016-09-23/45-congressmen-ask-dea-not-to-ban-kratom-next-week">support from congressional members</a> made the agency postpone a final decision. So kratom is currently listed as <a href="https://www.dea.gov/factsheets/kratom">a “drug of concern</a>.”</p>
<p>Seven states and some counties have <a href="https://www.redstormscientific.com/kratom-legality-in-the-u-s-by-state/">banned the sale of kratom</a>. But in 2023, the <a href="https://www.govtrack.us/congress/bills/118/hr5905/text">U.S. House</a> and <a href="https://www.congress.gov/bill/118th-congress/senate-bill/3039">Senate proposed legislation</a> to prevent the FDA from regulating kratom more stringently than they do a dietary supplement or a food additive, in order to keep the product accessible to consumers. </p>
<h2>Is kratom an effective pain reliever?</h2>
<p>A 2024 literature review concluded that <a href="https://effectivehealthcare.ahrq.gov/products/plant-based-chronic-pain-treatment/living-review">there are no clinical trials</a> evaluating the effects of kratom on chronic pain management. </p>
<p>Research on acute pain tolerance in people is limited to a 2020 study that found <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7309661/">participants who took a dose of kratom could endure immersion</a> of their arms in an ice bath for significantly longer than those who did not take a dose of kratom. However, this study was conducted on chronic kratom users, and their pain tolerance before they took their dose for that study was much lower compared to that of non-kratom users in other studies. This suggests that chronic kratom use is lowering people’s background pain tolerance. </p>
<p>This is similar to another study showing that when people tried to stop taking kratom after chronic use, they experienced significant <a href="https://doi.org/10.1080/02791072.2018.1443234">pain throughout their body</a>. This increased sensitivity and reactivity to pain, called <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/hyperalgesia">hyperalgesia</a>, also occurs with traditional opioids and is one of the reasons why people who use them chronically find it so difficult to get off them. </p>
<p>Taken together, these studies suggest caution before starting kratom as a treatment for chronic pain, especially if safer methods such as acetaminophen, icing and heating, and physical therapy can suffice. </p>
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<figcaption><span class="caption">This South Dakota mother blames kratom for her son’s death.</span></figcaption>
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<h2>Does kratom effectively treat opioid use disorder?</h2>
<p>Some people also claim that kratom could be a natural treatment for withdrawal and other effects of <a href="https://www.cdc.gov/opioids/healthcare-professionals/prescribing/opioid-use-disorder.html#">opioid use disorder</a>, the clinical term for opioid dependence. </p>
<p>A few methodologically weak studies reported that <a href="https://doi.org/10.3389/fphar.2022.801855">participants were able to reduce or stop</a> their use of traditional opioids and that kratom reduced the severity of <a href="https://www.webmd.com/mental-health/addiction/opioid-withdrawal-symptoms/">opioid withdrawal symptoms</a>. These include diarrhea, runny nose and eyes, shaking, fast heartbeat and anxiety. </p>
<p>However, there are no clinical trials comparing kratom to methadone, buprenorphine or naltrexone, the FDA-approved <a href="https://www.fda.gov/drugs/information-drug-class/information-about-medication-assisted-treatment-mat">treatment options for opioid use disorder</a>. So if patients have access to traditional FDA-approved therapies, these are the safest and best place to start. </p>
<p>If traditional options are not effective or patients cannot access them due to financial or logistical barriers, kratom may be a <a href="https://doi.org/10.1002/jcph.1860">potential alternative to illegal opioid products</a>, but it is certainly not risk free. Speaking with a health care professional is critical before making treatment decisions.</p><img src="https://counter.theconversation.com/content/223061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>C. Michael White 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>Long-term use of kratom may actually reduce pain tolerance and cause physical dependence and withdrawal symptoms.C. Michael White, Distinguished Professor of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag: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/2193872024-01-22T13:24:01Z2024-01-22T13:24:01ZUntrained bystanders can administer drone-delivered naloxone, potentially saving lives of opioid overdose victims<figure><img src="https://images.theconversation.com/files/569922/original/file-20240117-23-cg30az.jpg?ixlib=rb-1.1.0&rect=9%2C0%2C3285%2C2198&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Drone deliveries would be particularly effective in places where emergency responders can't respond quickly.</span> <span class="attribution"><a class="source" href="https://engineering.purdue.edu/AAE/Aerogram/2023-2024/articles/28-narcan-delivery-by-drone">Vincent Walter/Purdue University</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span></figcaption></figure><p>An onlooker – even one without prior training – can successfully administer <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html">naloxone</a> to an overdose victim within about a minute of a drone delivering the lifesaving opioid reversal agent. That’s the key finding of <a href="https://doi.org/10.1177/11782218231211830">my team’s newly published study</a>.</p>
<p>Naloxone is also known by the <a href="https://theconversation.com/fda-approval-of-over-the-counter-narcan-is-an-important-step-in-the-effort-to-combat-the-us-opioid-crisis-198497**">name brand Narcan</a>.</p>
<p>The study involved 17 participants responding to a simulated overdose. Each simulation included an untrained participant who portrayed a bystander, a box of naloxone delivered by drone, a mannequin as the overdose victim, and a panicked observer. The latter added a sense of urgency by continually shouting at the bystander throughout the simulation. </p>
<p>Via a video playing on a screen carried by the drone, the bystander received instructions on how to use the naloxone, which is administered as a nasal spray. We timed each participant on how long it took them to correctly give the medication during this crisis moment.</p>
<p>Our trial revealed that the average time for someone to remove the naloxone from the drone, view the video and administer the medication was 62 seconds. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/tc-zNiwN4Zg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Simulation of the first demonstration flight of the drone’s delivery of naloxone to an overdose victim.</span></figcaption>
</figure>
<h2>Why it matters</h2>
<p>Such a scenario could be a lifesaver, particularly in places where an emergency medical services, or EMS, team is either not available or slower than a drone delivery. This includes not only densely populated cities with traffic congestion, but more remote areas. </p>
<p>The average response time for an ambulance in rural America is <a href="https://www.hrsa.gov/sites/default/files/hrsa/advisory-committees/rural/access-to-ems-rural-communities.pdf">14 minutes</a>. Nationally, the average ambulance response time <a href="https://doi.org/10.1001/jamasurg.2017.2230">is seven minutes</a>. </p>
<p>Either way, it’s too late to help an opioid user who has stopped breathing. Brain damage occurs in about four minutes, and death in six. </p>
<p>But get a drone to an overdose victim within three minutes, and add one more minute for someone to remove and administer the drug, and there’s a chance to save their life and even prevent brain injury. </p>
<p>More than 75,000 people in the U.S. <a href="https://www.nytimes.com/2023/05/17/us/politics/drug-overdose-deaths.html">died in 2022 from an opioid overdose</a>. A drone network that could deliver naloxone fast enough to ensure quick administration of the drug could save thousands of lives every year.</p>
<p>The technology, although nascent, is here. Amazon is already using drones to <a href="https://www.aboutamazon.com/news/transportation/amazon-prime-air-drone-delivery-mk30-photos">deliver packages</a> in select U.S. cities and in other countries. Since 2011, drones have been <a href="https://doi.org/10.1503/cmaj.109-5541">delivering blood</a> to remote hospitals in Africa. </p>
<h2>What still isn’t known</h2>
<p>Deciding where to distribute drone stations across an area is the next step. But if emergency service planners can first determine how long it takes to dispense the medication, informed by our study and others, then they will know how much time a drone has to get to the scene. </p>
<p>Our trial provides a template for future studies – and it comes closer than other controlled trials to simulating the surprise and anxiety experienced by a bystander during an overdose incident. </p>
<p>To the best of our knowledge, there are two previous human trials from the U.S. using drones for medical intervention. But both studies <a href="https://doi.org/10.1016%2Fj.resuscitation.2020.10.006">used trained participants</a> who were <a href="https://doi.org/10.1016/j.ajem.2020.05.103">familiar with the interventions</a> and did not require in-the-moment training on how to use the device.</p>
<h2>What’s next</h2>
<p>As this technology matures, engineering teams will continue to improve the drone’s design and its methods of instruction.</p>
<p>Replicating this study with a diverse population and larger groups of people will be crucial to confirm the time needed to administer the drug after the drone lands. </p>
<p>Another issue for future study will be addressing community acceptance of medical drones. As they fly over houses, drones still cause <a href="https://dronesurveyservices.com/drone-statistics/">fear and uncertainty</a> in many neighborhoods. Adequate education will be needed to prepare communities for these potentially life-saving deliveries.</p>
<p><em>The <a href="https://theconversation.com/us/topics/research-brief-83231">Research Brief</a> is a short take on interesting academic work.</em></p><img src="https://counter.theconversation.com/content/219387/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Adams has received funding from the Substance Use and Mental Health Service Administration (SAMHSA), the US Department of Agriculture (USDA), the National Council of State Boards of Nursing (NCSBN), as well as internal University seed grants. </span></em></p>The study discovered that nonmedical personnel can provide the naloxone to an overdose victim in about one minute.Nicole Adams, Clinical Associate Professor of Nursing, Purdue UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/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>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/HHiN7JftdcY?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Scott McFadden, an addictions counsellor in recovery from opioid use, shares his own journey and the impact of stigma and shame.</span></figcaption>
</figure>
<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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<em>
<strong>
Read more:
<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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</em>
</p>
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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/2144392023-10-12T12:32:48Z2023-10-12T12:32:48ZPhiladelphia bans supervised injection sites – evidence suggests keeping drug users on the street could do more harm than good<figure><img src="https://images.theconversation.com/files/552844/original/file-20231009-23-6425vq.jpg?ixlib=rb-1.1.0&rect=0%2C8%2C5991%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A registered nurse treats Dominic Rodriguez for a skin injury related to xylazine use in Philadelphia in May 2023. Treatment vans are allowed in the city, but not supervised injection sites. </span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/Drug%20Overdoses%20Animal%20Drug/9c80e074d4e7453380be9404d3bcdd2c?Query=Philadelphia%20drugs&mediaType=photo&sortBy=creationdatetime:desc&dateRange=Anytime&totalCount=592&currentItemNo=21">Matt Rourke/AP Photo</a></span></figcaption></figure><p>The United States remains tightly in the grasp of an ongoing, and escalating, <a href="https://www.cdc.gov/opioids/basics/epidemic.html">crisis of deaths</a> caused by opioid overdoses. </p>
<p>With a record-high <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">109,000 people dying in 2022</a>, it is clear that something new needs to be done to reverse this trend. </p>
<p>Philadelphia is near the epicenter of the crisis. Some of the country’s <a href="https://www.dailymail.co.uk/news/article-9372555/Philadelphias-Skid-Row-Video-shows-citys-homeless-crisis-dozens-camped-trash-bin-fire.html">largest open-air drug markets</a> can be found in the Kensington neighborhood. Heroin, prescription opioids and fentanyl aren’t the only drugs of concern. Xylazine, a powerful non-opioid also known as tranq, has <a href="https://www.nytimes.com/2023/01/07/health/fentanyl-xylazine-drug.html#">an overwhelming presence</a> on the streets.</p>
<p>We are a group of <a href="https://www.med.uio.no/sustainit/english/people/aca/tjsandse/index.html">Scandinavian</a> <a href="https://www.sv.uio.no/iss/english/people/aca/synovena/index.html">and</a> <a href="https://drexel.edu/coas/faculty-research/faculty-directory/criminology-justice-studies/hyatt-jordan/">American</a> researchers who have studied drug treatment and harm reduction, and we have been watching the situation in Philadelphia from a variety of perspectives.</p>
<h2>A mixed response</h2>
<p>A record 1,413 people died in Philadelphia from <a href="https://www.phila.gov/media/20231002090544/CHARTv8e3.pdf">drug overdoses in 2022</a>. The rate of drug-related deaths for Black residents more than doubled <a href="https://www.phila.gov/2023-10-02-philadelphia-records-more-than-1400-overdose-deaths-in-2022-deaths-among-black-residents-rose-nearly-20/">between 2018 and 2022</a>, mirroring a <a href="https://doi.org/10.1007/s40615-022-01384-6">problematic national trend</a>.</p>
<p>In response, Philadelphia has adopted a multifaceted plan to <a href="https://www.phila.gov/2023-04-26-how-philadelphia-is-responding-to-the-overdose-crisis-in-2023/">stem the tide of overdoses</a>.</p>
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<p>But Philadelphia’s City Council has overwhelmingly rejected the establishment of <a href="https://whyy.org/articles/philadelphia-city-council-passes-near-total-ban-on-future-safe-consumption-overdose-prevention-sites/">supervised injection sites</a> – a potentially impactful, evidence-based tool in this fight. Overriding <a href="https://www.nbcphiladelphia.com/news/local/city-council-overturns-mayors-veto-on-safe-injection-site-ban/3655988/">the mayor’s veto</a> on Sept. 28, 2023, council members have used zoning legislation to essentially prevent the opening of sites where people can take drugs under supervision across most of the city. </p>
<p>In May 2023, the <a href="https://apnews.com/article/opioid-heroin-safe-injection-sites-pennsylvania-drugs-3c94134829464b858e02e3799ac3ae2b">Pennsylvania legislature</a> also overwhelmingly voted to ban supervised injection sites in the entire state.</p>
<p>While much of the political discourse surrounding this decision has focused on <a href="https://doi.org/10.1177/0091450921993821">protecting neighborhoods</a> where drug activity happens in parks and on the streets, ample evidence suggests that banning supervised injection sites may instead jeopardize the people and communities the policy was intended to protect.</p>
<h2>What is harm reduction?</h2>
<p>Supervised injection sites are an example of harm reduction, a general approach to addressing addiction and other public health crises. Ranging from efforts aimed at <a href="https://www.unaids.org/en/resources/presscentre/featurestories/2017/june/20170621_harm_reduction">reducing incidences of HIV</a> to encouraging the <a href="https://depts.washington.edu/harrtlab/wordpress/wp-content/uploads/2018/11/Safer-Use-Alcohol.pdf">safer consumption of alcohol</a>, the concept has become integral to many global public health initiatives. </p>
<p>The goal of <a href="https://espace.curtin.edu.au/bitstream/handle/20.500.11937/17446/18961_downloaded_stream_53.pdf?sequence=2&isAllowed=y">harm reduction</a> is to minimize the negative effects associated with drug use and other risky behaviors rather than solely focusing on eliminating the activity. This approach acknowledges the difficulty in breaking addictive behaviors and the fact that some individuals won’t – or can’t – stop regardless of policy and social efforts. </p>
<p>For drug use, harm reduction takes many forms. These include encouraging nonjudgmental approaches toward people who use drugs among social service workers and health care personnel, needle exchange programs, distribution of drugs that reverse overdoses, testing drugs for safety – and, in many parts of the world, supervised injection sites.</p>
<h2>Limitations in the United States</h2>
<p>Supervised injection sites have been a particularly <a href="https://www.inquirer.com/opinion/commentary/safe-injection-sites-safehouse-philadelphia-20200203.html">controversial approach</a> to harm reduction not just in Philadelphia but across most of the U.S. </p>
<p>Only a few officially sanctioned supervised injection sites have emerged. Two opened in <a href="https://www.nytimes.com/2021/11/30/nyregion/supervised-injection-sites-nyc.html">Manhattan in 2021</a> with support from <a href="https://www.nytimes.com/2023/08/28/nyregion/safe-injection-sites-drugs-nyc.html">the government of New York City</a>, where research suggests they could <a href="https://doi.org/10.1016/j.jsat.2019.08.010">save both lives and health care dollars</a>. <a href="https://www.wpri.com/target-12/ri-prepares-to-open-first-safe-injection-site-amid-onslaught-of-overdose-deaths/">Rhode Island plans to open</a> a third in Providence in spring 2024, permitted by state legislation. The legality of even these rare sites in the U.S. remains unclear under federal law, according to <a href="https://doi.org/10.2105/AJPH.2006.103747">a 2011 study</a>.</p>
<p>In <a href="https://lira.bc.edu/files/pdf?fileid=f11d3cc8-fb45-4fae-be8c-ee8dcc4e8384">the face of this uncertain legality</a>, scant evidence from the U.S. is available. One unsanctioned site operating in secrecy <a href="https://doi.org/10.1016/j.amepre.2017.06.010">was studied by academics</a>. They found that 90% of users reported they would otherwise have been injecting in parks, streets or public restrooms, meaning the site averted over 2,300 public injections and safely disposed of at least 1,700 needles over two years.</p>
<p>Beyond this, policymakers have limited research in the U.S. to draw upon – and so it is informative to look abroad.</p>
<p>Globally, <a href="https://doi.org/10.1016/j.drugpo.2017.12.005">over 100 supervised injection sites</a> are currently operating in 10 countries, including <a href="https://doi.org/10.1186/s12954-017-0154-1">Canada</a> and across <a href="https://www.emcdda.europa.eu/system/files/publications/2734/POD_Drug%20consumption%20rooms.pdf">Europe</a>. Researchers have looked to experiences in Denmark and Norway, in particular, to study drug consumption rooms. Despite clear differences between Scandinavia and Philadelphia, the research and evidence highlight the potential impact of this form of harm reduction.</p>
<h2>The evidence from Norway</h2>
<p>In Norway, as in the U.S., harm-reduction efforts first began with <a href="http://doi.org/10.18261/issn.2535-2512-2019-06-04">opioid substitution therapy</a>, meaning the provision of less dangerous drugs like methadone for opioid users. </p>
<p>When <a href="http://doi.org/10.1159/000346781">overdose rates</a> kept rising, supervised injection sites where people who use drugs could get clean needles and be <a href="https://www.emcdda.europa.eu/system/files/attachments/6240/Safe%20consumption%20room%202017%20SIF%20and%20overdose%20Oslo%20-%20Thomas%20Clausen%2C%20Norway.pdf">observed while using drugs</a> were piloted in 2005 and made permanent by 2009.</p>
<p>The Norwegian Institute of Public Health collected data on the impact of the supervised injection site in Oslo. Just over 150 people used the site in 2005, the first year it opened. Two years later, demand had almost quadrupled. After just six months of operation, staff were recording over 900 injections per month, each diverted from the street. People using the facility <a href="https://fhi.brage.unit.no/fhi-xmlui/bitstream/handle/11250/275861/sirusrap.7.07.pdf?sequence=3">told researchers</a> their sense of human dignity improved.</p>
<p>Staff reported that the site allowed them to directly connect more people to social and health services. Other data shows that the presence of the site has <a href="http://doi.org/10.1080/08897077.2018.1485130">reduced the use of ambulances</a> and related public services, preserving those resources for the community. </p>
<h2>Striking results in Denmark</h2>
<p>The <a href="https://www.emerald.com/insight/content/doi/10.1108/DAT-03-2015-0007/full/html?utm_campaign=Emerald_Health_PPV_Dec22_RoN">first official Danish supervised injection site</a> opened its doors in Copenhagen in 2012, though underground versions had been operating for a few years.</p>
<p>Since then, several studies have shown the Copenhagen sites not only prevented many drug-related deaths, but <a href="https://sum.dk/nyheder/2015/maj/ny-evaluering-stofindtagelsesrum-har-flyttet-fix-vaek-fra-gaden">improved overall health</a> by successfully connecting people to substance abuse treatment and other health care services. </p>
<p>Staff were also successful at educating people about more hygienic injection techniques, <a href="https://doi.org/10.1186/s12954-016-0109-y">thereby reducing infections and other drug-related complications</a> that often lead to hospitalization. After the sites were opened, <a href="https://doi.org/10.1186/1477-7517-11-29">fewer people openly used drugs</a> in Copenhagen’s parks and streets. <a href="https://doi.org/10.1111/dar.13509">Property values</a> near the injection sites were unaffected.</p>
<p>An evaluation by the Danish Ministry of Health found that the number of needles and syringes discarded in the city’s public spaces was reduced <a href="https://sum.dk/nyheder/2015/maj/ny-evaluering-stofindtagelsesrum-har-flyttet-fix-vaek-fra-gaden">by 70% to 80%</a>, and residents in surrounding neighborhoods said <a href="https://psy.au.dk/fileadmin/CRF/STOF/STOF_pdf_er/STOF_nr._30/STOF_NR_30__S._09_-_Stofmiljoeet_paa_Vesterbro_og_politikken_i_forhold_til_det.pdf">their quality of life improved</a>.</p>
<p>Copenhagen’s experience also highlights the essential fact that supervised injection sites alone aren’t a solution; they are only a part of an effective harm-reduction strategy and must be accompanied by social support and other programming. </p>
<p>For example, the Users’ Academy – or <a href="https://brugernesakademi.dk">Brugernes Akademi</a> in Danish – is a national nonprofit led by people who use drugs that offers a wide range of harm-reduction services directly to their peers. They run a needle exchange program through the mail and raise awareness regarding the legal rights of people who use drugs. They also operate a mobile health clinic that seeks to prevent diseases like <a href="https://bmjopen.bmj.com/content/10/11/e039724">hepatitis C</a> and reduce barriers to health and social services.</p>
<h2>An opportunity to investigate</h2>
<p>Even in the face of the ongoing <a href="https://www.npr.org/sections/health-shots/2021/01/14/956428659/in-philadelphia-judges-rule-against-opening-a-medical-site-to-safely-inject-hero">controversy in Philadelphia</a>, new ideas are emerging.</p>
<p>Using the infusion of <a href="https://whyy.org/articles/philadelphia-opioid-settlement-funds-spending-overdose-preventionwrap-around-services-kensington/">funding from national opioid settlements</a>, Philadelphia could explore more politically acceptable approaches to harm reduction while collecting evidence and building support for a permanent supervised injection site. </p>
<p>In some European cities, mobile supervised injection sites have been adopted first. In Copenhagen, <a href="http://fixerum.dk/">Fixelancen</a>, an old ambulance, has been refurnished as a low-cost supervised injection site. It can service different areas of the city as the drug scene rapidly evolves, avoiding the focus and burden on a particular neighborhood. Such an approach could easily complement <a href="https://www.inquirer.com/health/opioid-addiction/south-philadelphia-upenn-buprenorphine-van-addiction-treatment-opioid-crisis-20191227.html%5D">other mobile</a> <a href="https://doi.org/10.1370/afm.256">harm-reduction efforts</a> already operating in Philadelphia.</p><img src="https://counter.theconversation.com/content/214439/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jannet van der Veen has received income from Brugernes Akademi.</span></em></p><p class="fine-print"><em><span>Synøve Nygaard Andersen received funding from The Research Council of Norway (grant #288083).</span></em></p><p class="fine-print"><em><span>Jordan Hyatt and Tony Joakim Ananiassen Sandset 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>A group of academics look at the global evidence to examine the potential impact of supervised injection sites in Philadelphia and the US.Jordan Hyatt, Associate Professor of Criminology and Justice Studies, Drexel UniversityJannet van der Veen, Visiting Fellow at the Center for Public Policy, Drexel UniversitySynøve Nygaard Andersen, Postdoctoral Fellow in Sociology, University of OsloTony Joakim Ananiassen Sandset, Researcher Fellow at the Centre for Sustainable Healthcare Education, University of OsloLicensed 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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<figcaption><span class="caption">What happens to you when you take opioids.</span></figcaption>
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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/2070092023-09-07T20:01:43Z2023-09-07T20:01:43ZWhat is cognitive functional therapy? How can it reduce low back pain and get you moving?<figure><img src="https://images.theconversation.com/files/533074/original/file-20230621-25-swu29c.jpg?ixlib=rb-1.1.0&rect=8%2C186%2C5414%2C3430&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.pexels.com/photo/man-watering-his-plants-7658808/">Pexels/Kampus Production</a></span></figcaption></figure><p>If you haven’t had lower back pain, it’s likely you know someone who has. It affects <a href="https://pubmed.ncbi.nlm.nih.gov/22231424/">around 40% of adults</a> in any year, ranging from adolescents to those in later life. While most people recover, <a href="https://pubmed.ncbi.nlm.nih.gov/29112007/">around 20%</a> go on to develop chronic low back pain (lasting more than three months).</p>
<p>There is a <a href="https://bjsm.bmj.com/content/54/12/698">common view</a> that chronic low back pain is caused by permanent tissue damage including “wear and tear”, disc degeneration, disc bulges and arthritis of the spine. This “damage” is often described as resulting from injury and loading of the spine (such as bending and lifting), ageing, poor posture and weak “core” muscles. </p>
<p>We’re often told to “protect” our back by sitting tall, bracing the core, keeping a straight back when bending and lifting, and avoiding movement and activities that are painful. Health practitioners often <a href="https://theconversation.com/having-good-posture-doesnt-prevent-back-pain-and-bad-posture-doesnt-cause-it-183732">promote and reinforce these messages</a>.</p>
<p>But this is <a href="https://bjsm.bmj.com/content/54/12/698">not based on evidence</a>. An emerging treatment known as <a href="https://pubmed.ncbi.nlm.nih.gov/29669082/">cognitive functional therapy</a> aims to help patients undo some of these unhelpful and restrictive practices, and learn to trust and move their body again. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/having-good-posture-doesnt-prevent-back-pain-and-bad-posture-doesnt-cause-it-183732">Having ‘good’ posture doesn't prevent back pain, and 'bad' posture doesn't cause it</a>
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</p>
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<h2>People are often given the wrong advice</h2>
<p>People with chronic back pain are often referred for imaging scans to detect things like disc degeneration, disc bulges and arthritis. </p>
<p>But these findings are very common in people <em>without</em> low back pain and research shows they <a href="https://pubmed.ncbi.nlm.nih.gov/24276945/">don’t accurately predict</a> a person’s current or future experience of pain. </p>
<p>Once serious causes of back pain have been ruled out (such as cancer, infection, fracture and nerve compression), there is <a href="https://pubmed.ncbi.nlm.nih.gov/27745712/">little evidence</a> scan findings help guide or improve the care for people with chronic low back pain. </p>
<p>In fact, scanning people and telling them they have arthritis and disc degeneration can <a href="https://pubmed.ncbi.nlm.nih.gov/33748882/">frighten them</a>, resulting in them avoiding activity, worsening their pain and distress.</p>
<p>It can also lead to potentially harmful treatments such as <a href="https://pubmed.ncbi.nlm.nih.gov/27213267/">opioid</a> pain medications, and invasive treatments such as spine <a href="https://pubmed.ncbi.nlm.nih.gov/19127161/">injections</a>, spine <a href="https://pubmed.ncbi.nlm.nih.gov/12709856/">surgery</a> and battery-powered electrical stimulation of spinal nerves. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioids-dont-relieve-acute-low-back-or-neck-pain-and-can-result-in-worse-pain-new-study-finds-203244">Opioids don't relieve acute low back or neck pain – and can result in worse pain, new study finds</a>
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</em>
</p>
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<h2>So how should low back pain be treated?</h2>
<p>A complex range of factors <a href="https://pubmed.ncbi.nlm.nih.gov/29112007/">typically contribute</a> to a person developing chronic low back pain. This includes over-protecting the back by avoiding movement and activity, the belief that pain is related to damage, and negative emotions such as pain-related fear and anxiety. </p>
<p>Addressing these factors in an individualised way is <a href="https://pubmed.ncbi.nlm.nih.gov/29573871/">now considered</a> best practice.</p>
<figure class="align-center ">
<img alt="Physio touches woman's back" src="https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/533071/original/file-20230621-30-v4sxij.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">
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<span class="caption">Treatment for back pain needs to be individualised.</span>
<span class="attribution"><a class="source" href="https://www.pexels.com/photo/physiotherapist-touching-womans-back-5793653/">Pexels/Yan Krukau</a></span>
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<p><a href="https://pubmed.ncbi.nlm.nih.gov/15936976/">Best practice care</a> also needs to be person-centred. People suffering from chronic low back pain want to be heard and validated. They <a href="https://pubmed.ncbi.nlm.nih.gov/35384928/">want</a> to understand why they have pain in simple language. </p>
<p>They want care that considers their preferences and gives a safe and affordable pathway to pain relief, restoring function and getting back to their usual physical, social and work-related activities.</p>
<p>An example of this type of care is cognitive functional therapy.</p>
<h2>What is cognitive functional therapy?</h2>
<p><a href="https://pubmed.ncbi.nlm.nih.gov/29669082/">Cognitive functional therapy</a> is about putting the person in the drivers’ seat of their back care, while the clinician takes the time to guide them to develop the skills needed to do this. It’s led by physiotherapists and can be used once serious causes of back pain have been ruled out. </p>
<p>The therapy helps the person understand the unique contributing factors related to their condition, and that pain is usually not an accurate sign of damage. It guides patients to relearn how to move and build confidence in their back, without over-protecting it. </p>
<p>It also addresses other factors such as sleep, relaxation, work restrictions and engaging in physical activity based on the <a href="https://www.restorebackpain.com/patient-journey">person’s preferences</a>.</p>
<p>Cognitive functional therapy usually involves longer physiotherapy sessions than usual (60 minutes initially and 30-45 minute follow-ups) with up to seven to eight sessions over three months and booster sessions when required.</p>
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Read more:
<a href="https://theconversation.com/ouch-the-drugs-dont-work-for-back-pain-but-heres-what-does-72283">Ouch! The drugs don't work for back pain, but here's what does</a>
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<h2>What’s the evidence for this type of therapy?</h2>
<p>Our recent clinical trial of cognitive functional therapy, published in <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00441-5/fulltext">The Lancet</a>, included 492 people with chronic low back pain. The participants had pain for an average of four years and had tried many other treatments. </p>
<p>We first trained 18 physiotherapists to competently deliver cognitive functional therapy across Perth and Sydney over six months. We compared the therapy to the patient’s “usual care”.</p>
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<img alt="Woman lays in bed, comfortable" src="https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/543156/original/file-20230817-21-bs2zp0.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">
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<span class="caption">Participants in our study had low back pain for years and tried many other treatments.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/photo-young-woman-lying-bed-night-2142343367">Shutterstock</a></span>
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<p>We found large and sustained improvements in function and reductions in pain intensity levels for people who underwent the therapy, compared with those receiving usual care. </p>
<p>The effects remained at 12 months, which is unusual in low back pain trials. The effects of most recommended interventions such as exercise or psychological therapies are <a href="https://pubmed.ncbi.nlm.nih.gov/34580864/">modest in size</a> and tend to be of <a href="https://pubmed.ncbi.nlm.nih.gov/32794606/">short duration</a>.</p>
<p>People who underwent cognitive functional therapy were also more confident, less fearful and had a more positive mindset about their back pain at 12 months. They also liked it, with 80% of participants satisfied or highly satisfied with the treatment, compared with 19% in the usual care group.</p>
<p>The treatment was as safe as usual care and was also cost-effective. It saved more than A$5,000 per person over a year, largely due to increased participation at work. </p>
<h2>What does this mean for you?</h2>
<p>This trial shows there are safe, relatively cheap and effective treatments options for people living with chronic pain, even if you’ve tried other treatments without success. </p>
<p><a href="https://www.restorebackpain.com/cft-clinicians">Access to clinicians</a> trained in cognitive functional therapy is currently limited but will expand as training is scaled up.</p>
<p>The costs depend on how many sessions you have. Our studies show some people improve a lot within two to three sessions, but most people had seven to eight sessions, which would cost around A$1,000 (aside from any Medicare or private health insurance rebates). </p>
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Read more:
<a href="https://theconversation.com/why-does-my-back-get-so-sore-when-im-sick-the-connection-between-immunity-and-pain-207222">Why does my back get so sore when I'm sick? The connection between immunity and pain</a>
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<img src="https://counter.theconversation.com/content/207009/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter O'Sullivan is a Director and consults at bodylogic.physio. He receives funding from the National Health and Medical Research Council. </span></em></p><p class="fine-print"><em><span>JP Caneiro is a Director and consults at bodylogic.physio. He has received funding from the National Health and Medical Research Council.</span></em></p><p class="fine-print"><em><span>Mark Hancock received NHMRC funding for grants paid to his university, including for the RESTORE study of cognitive functional therapy.</span></em></p><p class="fine-print"><em><span>Peter Kent's employing institution (Curtin University) received funding from Australian National Health and Medical Research Council (grant number 1145271) for the clinical trial mentioned in this article.</span></em></p>A new therapy aims to undo some of the harmful and restrictive patterns patients have been taught to ‘protect’ their back from pain. Instead, they’re learning to trust and move their body again.Peter O'Sullivan, Professor of Musculoskeletal Physiotherapy, Curtin UniversityJP Caneiro, Research Fellow in physiotherapy, Curtin UniversityMark Hancock, Professor of Physiotherapy, Macquarie UniversityPeter Kent, Adjunct Associate Professor of Physiotherapy, Curtin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2124352023-08-30T21:16:09Z2023-08-30T21:16:09ZDecriminalization: How police drug seizure, even without arrest, can create harms<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/decriminalization-how-police-drug-seizure-even-without-arrest-can-create-harms" width="100%" height="400"></iframe>
<p><a href="https://www.overdoseday.com/">International Overdose Awareness Day</a>, an annual campaign to end overdose and drug poisonings while also remembering those who have died, is Aug. 31. Events are being held in <a href="https://www.momsstoptheharm.com/ioad23">communities across Canada</a>, a sign of a worsening crisis that has taken more than <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/">36,000 lives since 2016</a>.</p>
<p>The day also represents an opportunity to discuss much-needed policy changes. The <a href="https://drugpolicy.org/issue/decriminalize-drugs-invest-in-health-services/">decriminalization of people who use drugs</a> has long been one of the proposed solutions, an approach that is currently being piloted in British Columbia.</p>
<p>On Jan. 31, 2023, B.C. began a first-in-Canada <a href="https://www.canada.ca/en/health-canada/services/health-concerns/controlled-substances-precursor-chemicals/policy-regulations/policy-documents/exemption-personal-possession-small-amounts-certain-illegal-drugs-british-columbia.html">pilot “decriminalization” policy</a>, in which criminal sanctions for the possession of small amounts of certain illegal drugs for personal use were removed for adults aged 18 or above.</p>
<p>Seven months into this experiment, the impact of this policy remains unclear. Because <a href="https://vancouverisland.ctvnews.ca/data-on-b-c-s-drug-decriminalization-plan-to-be-publicly-available-on-dashboard-1.6252744">a dashboard</a> of policy impact indicator data has not yet been published at the time of writing, it is difficult to weigh <a href="https://vancouversun.com/news/local-news/six-months-into-b-c-s-decriminalization-experiment-whats-working-and-whats-not">the initial effects of the policy</a>.</p>
<p>However, in the city of Vancouver, a policy of <a href="https://doi.org/10.1177/1477370819887514">depenalization</a> (also referred to as de facto decriminalization) has been in place since 2006, providing an opportunity to understand how the provincial pilot may be working — or even improved.</p>
<h2>Depenalization in Vancouver</h2>
<p>Seventeen years ago, the Vancouver Police Department (VPD) launched <a href="https://vpd.ca/wp-content/uploads/2021/06/vpd-policy-drug.pdf">its drug policy</a> to promote <a href="https://doi.org/10.1177/1477370819887514">the depenalization</a> of simple possession offences. Under this policy, VPD officers were encouraged to not arrest or charge people for simple drug possession for personal use except for certain circumstances.</p>
<p>The VPD’s policy differed from B.C.’s pilot decriminalization in several important ways. For example, the VPD’s policy did not specify the class or threshold quantity of drugs to define simple possession. VPD officers were given broad enforcement discretion with respect to drug possession.</p>
<p>Although publicly available VPD data are limited, <a href="https://vpd.ca/wp-content/uploads/2021/06/cleared-drug-charges-january-2014-to-present.pdf">available data</a> indeed indicated low and declining numbers of simple possession charges recommended by the VPD to Crown counsel from 2016 to 2019. These numbers have often <a href="https://vancouversun.com/news/drug-possession-charges-vary-widely-by-police">been cited</a> as the indicator of success of the VPD’s depenalization policy: fewer people are sent to the criminal justice system for the sake of personal drug use.</p>
<p>However, <a href="https://www.straight.com/news/1213101/vancouver-police-stats-suggest-softer-touch-drugs-users-say-its-different-story-streets">anecdotal reports</a> and <a href="https://doi.org/10.1016/j.drugpo.2021.103471">previous qualitative research</a> suggested that police officers might not arrest people for simple possession, but they would still seize drugs. Local communities of people who use drugs and public health advocates in Vancouver expressed concern about the harm created by this policing behaviour.</p>
<p>We undertook <a href="https://doi.org/10.1186/s12954-023-00833-7">surveys involving more than 1,800 people</a> who used drugs on a daily basis in Vancouver to investigate this often undocumented discretionary policing practice.</p>
<h2>Police drug seizures without arrest</h2>
<p>During a 16-month study period in 2019-2021, we found that six per cent of 995 people who used drugs daily in Vancouver (60 per cent residing in the Downtown Eastside neighbourhood that is known for high rates of marginalization and drug use) had had their drugs seized by police without arrest at least once in the past six months. Of those, more than one in four experienced it more than once during the same six-month period.</p>
<p>Of particular concern, 68 per cent of our study participants who had their drugs taken by police without arrest reported having obtained new drugs immediately after the seizure. This portion of the data was collected from the same study population between 2009 and 2012.</p>
<p><a href="https://www.pivotlegal.org/project_inclusion_full">Previous qualitative research</a> documented that acquiring drugs this way could put health and safety at risk in multiple ways. For example, it can put people at a higher risk of drug market violence by creating drug debts.</p>
<p>Some users may also be compelled to acquire new drugs in a rush from an unknown supplier, especially when experiencing painful withdrawal. <a href="https://app.powerbi.com/view?r=eyJrIjoiOGFhMTkwOTktYWQ1My00MzQ4LThlNzItMzVhOWY3NGFmOWQ4IiwidCI6IjZmZGI1MjAwLTNkMGQtNGE4YS1iMDM2LWQzNjg1ZTM1OWFkYyJ9">Amid the ongoing drug toxicity crisis</a>, increasing the frequency of buying drugs in the unregulated drug market, especially through an unknown source, increases risk of drug poisoning.</p>
<p>This is contrary to <a href="https://doi.org/10.1016/j.drugpo.2021.103471%22%22">a belief held among some police officers</a> that seizing drugs would prevent harms, including drug poisoning.</p>
<h2>The role of police in the toxic drug crisis</h2>
<p>A broader question is: Are there any circumstances where police drug seizures are beneficial in preventing drug poisoning? <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2023.307291">A recent study from the United States</a> highlighted that police efforts to reduce the unregulated drug supply may worsen the drug toxicity crisis by showing a consistent pattern. As police seizures of drugs increased, drug poisoning cases also increased.</p>
<p>Several scholars noted that <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2023.307328">police drug seizures would not address the toxic drug supply</a>, that <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2023.307329">the narrow mission of police may exacerbate drug-related harms</a> and that <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2023.307320">more harm reduction interventions to address the toxic drug supply are needed</a>.</p>
<p><a href="https://doi.org/10.1186/s12954-023-00833-7">Findings from our study</a> indicate that the VPD’s depenalization policy essentially “<a href="https://d3n8a8pro7vhmx.cloudfront.net/pivotlegal/pages/3494/attachments/original/1639066365/Decriminalization_Report_Final_Revised.pdf">mimics the health and safety harms associated with criminalization</a>” and likely undermines overdose prevention efforts.</p>
<p>Under B.C.’s pilot decriminalization policy, police officers can no longer seize drugs from an adult who possesses up to 2.5 grams of certain illegal drugs. However, the threshold quantity of drugs that defined simple possession has been shown to be <a href="https://doi.org/10.1016/j.drugpo.2023.104126">too low</a> to fulfil the policy objectives. Some people who use drugs, particularly those more marginalized and engaging in high-intensity drug use, may carry more than 2.5 grams of drugs. They may get arrested or experience police drug seizures without arrest.</p>
<p>The annual International Overdose Awareness Day compels us to reckon with ongoing toxic drug deaths and what we can do to reverse this worsening crisis. If decriminalization is going to contribute to positive change, police need to stop seizing drugs from people who use them.</p><img src="https://counter.theconversation.com/content/212435/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kanna Hayashi holds the St. Paul's Hospital Chair in Substance Use Research and is supported in part by a U.S. National Institute on Drug Abuse (NIDA) grant (U01DA038886) and the St. Paul’s Foundation. For the research work presented here, she received funding through a NIDA grant (U01DA038886), a Michael Smith Health Research BC Scholar Award and the William and Ada Isabelle Steel Fund through Simon Fraser University. She also receives funding from the Canadian Institutes of Health Research and the Social Sciences and Humanities Research Council to support her ongoing research in this area. She is also affiliated with the Vancouver Coastal Health Authority as research staff and the Division of Social Medicine, Department of Medicine, University of British Columbia as an affiliate assistant professor. </span></em></p>A police policy of not making arrests for simple possession is a way to essentially decriminalize personal drug use. However, confiscating drugs — even without arrests — can be harmful in many ways.Kanna Hayashi, Research Scientist at the British Columbia Centre on Substance Use & St. Paul's Hospital Chair in Substance Use Research and Associate Professor, Faculty of Health Sciences, Simon Fraser UniversityLicensed 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">
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<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>
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<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/2076822023-07-13T12:37:25Z2023-07-13T12:37:25ZMyths about will power and moral weakness keep people with opioid use disorder from receiving effective medications like methadone, buprenorphine and naltrexone<figure><img src="https://images.theconversation.com/files/534714/original/file-20230628-17-b8qav.jpg?ixlib=rb-1.1.0&rect=8%2C4%2C2986%2C1989&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A nurse dispenses liquid Methadose, an FDA-approved medication that helps people addicted to opioids.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/vanessa-leavitt-dispenses-a-dosage-of-the-liquid-form-of-news-photo/462014722">Whitney Hayward/Portland Press Herald via Getty Images</a></span></figcaption></figure><p>The <a href="https://store.samhsa.gov/sites/default/files/pep21-02-01-002.pdf">most effective science-based treatment</a> for opioid use disorder is medication. Methadone and buprenorphine prevent intense cravings and other symptoms of withdrawal, while naltrexone works by blocking <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">the effects of opioids</a>. </p>
<p>Despite <a href="https://doi.org/10.1001/jamanetworkopen.2020.29676">abundant research</a> <a href="https://doi.org/10.1016/j.jsat.2021.108447">showing these medications reduce the risk</a> <a href="https://doi.org/10.1001/jamanetworkopen.2023.14925">of relapse and overdose</a>, many people, no matter their relationship with opioids or with people who use them, are still <a href="https://doi.org/10.1177/19367244231159096">hesitant to support the use of these medications</a>. And the majority of people who would benefit from such treatments <a href="https://doi.org/10.1016/j.drugpo.2022.103786">do not have access to them</a>.</p>
<p><a href="https://scholar.google.com/citations?user=NKKkSF8AAAAJ&hl=en">We</a> <a href="https://scholar.google.com/citations?user=fZr3zoUAAAAJ&hl=en">study</a> opioid use disorder and the attitudes that surround it. To better understand hesitancy around the use of medication to treat opioid use disorder, we <a href="https://scholar.google.com/citations?hl=en&user=D4mtQ3IAAAAJ">and</a> <a href="https://scholar.google.com/citations?hl=en&user=_VuWPDAAAAAJ">our</a> <a href="https://www.lifespringhealthsystems.org/">colleagues</a> <a href="https://www.ecommunity.com/locations/community-fairbanks-recovery-center">conducted</a> focus groups with three populations intimately involved in the opioid crisis – those in recovery, their friends and family and their health care providers – as well as with community members with no direct connection to opioid use disorder. We spoke with 101 people in all across rural and urban locations in Indiana. </p>
<p>We asked what they thought about using medication to treat opioid use disorder. We found all four groups had negative opinions about using medication. No matter who they were, <a href="https://doi.org/10.1177/19367244231159096">participants voiced</a> an underlying belief that opioid use disorder results from moral weakness that can be overcome with willpower and commitment to behavior change, despite research-based evidence that overwhelmingly shows that opioid use disorder is a <a href="https://www.ncbi.nlm.nih.gov/books/NBK541390/">chronic brain disease best managed with medication</a>. </p>
<p>Across all four groups, we heard three myths about using medication for opioid use disorder. Research reveals these stigmatizing beliefs are counter to reality.</p>
<h2>Medication isn’t trading one drug for another</h2>
<p>Many of our participants expressed the belief that using medication is the same as using opioids to get high. This misperception is likely rooted in the outdated idea that recovery is defined by <a href="https://nida.nih.gov/research-topics/recovery">total abstinence from all substances</a>, except perhaps caffeine and nicotine. As one service provider working with people in recovery declared, “If you’re on Suboxone or you’re on methadone and you’re not being tapered down, you’re using.” </p>
<p>The truth is, taking medication is not the same as using prescription or street opioids to get high. These medications <a href="https://nida.nih.gov/publications/research-reports/medications-to-treat-opioid-addiction/how-do-medications-to-treat-opioid-addiction-work">do not produce the same experience of euphoria or high</a> as heroin, morphine or other opioids. <a href="https://www.pewtrusts.org/en/research-and-analysis/fact-sheets/2020/12/medications-for-opioid-use-disorder-improve-patient-outcomes">In different ways</a>, methadone, buprenorphine and naltrexone all reduce cravings and <a href="https://www.recoveryanswers.org/research-post/better-down-the-road-the-long-term-outcomes-of-opioid-use-disorder-patients-treated-with-medication/">allow people to remain sober</a> and to work, raise their children and engage in activities of healthy productive living – all challenges for people to do well when using opioids to get high. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up photo of a woman's hands holding two small packages labeled Suboxone." src="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/536144/original/file-20230706-17-grkola.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">Suboxone is a medicine containing buprenorphine and naltrexone. It is most often taken under the tongue.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/susan-stevens-shows-off-a-prescription-for-suboxone-her-news-photo/1134203790">Eamon Queeney/The Washington Post via Getty Images</a></span>
</figcaption>
</figure>
<h2>Medication is an important part of long-term recovery</h2>
<p>We found that people’s overall discomfort with the idea of using medication to treat opioid use disorder led to a belief that such treatment should be used only as a steppingstone on the way to sobriety. A community member we spoke with said, “It’s a way of weaning them off everything. I think that’s just one of the steps they have to take to get clean.” </p>
<p>The belief that medication should be used for only a short time runs counter to <a href="https://doi.org/10.1001/jama.1977.03270390032021">research showing</a> <a href="https://doi.org/10.1016/0002-9343(78)90691-5">higher rates of relapse</a> <a href="https://doi.org/10.1080/10550490701860971">after tapering</a>. <a href="https://www.cms.gov/about-cms/story-page/cdcs-tapering-guidance.pdf">Guidelines from the U.S. Department of Health and Human Services</a> discourage rapid tapers and affirm that long-term use is the best way to prevent relapse, overdose and death.</p>
<h2>Long-term treatment counts as success</h2>
<p>Many of our study participants voiced the belief that long-term use of medication means the treatment did not work. As one family member put it, “If you’re on it for 10 or 15 years, then that’s not really helping you.” </p>
<p>The myth that long-term use of medication means the medicine is ineffective – or has failed – runs counter to both the <a href="https://doi.org/10.1001/jama.283.10.1303">life outcomes of those on maintenance treatment</a> and the <a href="https://doi.org/10.1080/10550490701860971">physiological reality</a> that such drugs may remain <a href="https://doi.org/10.1016/j.jsat.2009.05.003">necessary to normalize brain function</a> for the person in recovery. </p>
<p>Just as those with high blood pressure or diabetes may need to remain on medications for the long term, so might some people with opioid use disorder. Keeping people in treatment and alive through use of medications is treatment success, not failure.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man walks in a peaceful demonstration carrying a sign saying 'Treatment is Effective #recoverymatters.'" src="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/534712/original/file-20230628-19-8eykmp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Marchers celebrate National Recovery Month in Grand Rapids, Mich.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/sacredheartrehab/15173561710/in/photolist-p7QtfW-27rXxBC-pnimPN-pp41Va-S3zEL3-CbHjig-2h4m9TE-D96W66-27rXxAL-CFYWwb-2h4oKL5-R9cAic-2h4oL3h-pninfh-2h4nZHE-2h4oKRR-2h4m9ED-R9cESH-pnimDh-2h4m9mN-QXFtr2-pp3ZGt-2h4oL1D-2h4nZTz-2oAQSr8-QyZHBY-LZNzgj-R9cD2i-2cqYiND-PUxY8p-f7izxQ-HRdXWU-R9cFd2-QXB1ix-2ojTUQi-2h4kKJb-2hQGWS3-CbHkg8-2ojUFCF-qsmpB6-D1PbJg-2ojPTAR-uRqk2e-vNhxTz-nCKoZG-2hQLtBT-D6Mppq-pqeL95-9TckNM-QXFtEZ">Sacred Heart/flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>An <a href="https://www.ncbi.nlm.nih.gov/books/NBK448203/">estimated 3 million Americans</a> have had or currently struggle with opioid use disorder. The latest data from the U.S. Centers for Disease Control and Prevention <a href="https://blogs.cdc.gov/nchs/2023/05/18/7365/">estimates nearly 83,000 deaths in 2022</a> involved opioids.</p>
<p>Methadone, buprenorphine and naltrexone are lifesaving medications. Myths associated with their use cause avoidable relapse, overdose and death by keeping people from using the most effective tool for entering into and maintaining recovery.</p><img src="https://counter.theconversation.com/content/207682/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Melissa S. Fry receives funding from Indiana University Addictions Grand Challenge Program, and provides evaluation services to Substance Abuse and Mental Health Services Administration funded programs. </span></em></p><p class="fine-print"><em><span>Melissa Cyders receives funding from Indiana University Addictions Grand Challenge Program and the National Institutes of Alcohol Abuse and Alcoholism.</span></em></p>Prescription medications can help people with opioid use disorder avoid the risks of relapse and overdose. But stigma based on misperceptions about addiction limits their use.Melissa S. Fry, Director, Applied Research and Education Center & Associate Professor of Sociology, Indiana UniversityMelissa Cyders, Professor of Psychology, Indiana 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/2032442023-06-28T22:35:43Z2023-06-28T22:35:43ZOpioids don’t relieve acute low back or neck pain – and can result in worse pain, new study finds<figure><img src="https://images.theconversation.com/files/532128/original/file-20230615-15-n0wdqe.jpg?ixlib=rb-1.1.0&rect=40%2C70%2C6669%2C4396&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/old-man-back-pain-705668263">Shutterstock</a></span></figcaption></figure><p>Opioids are the one of the most prescribed pain-relief for people with low back and neck pain. In Australia, around <a href="https://link.springer.com/article/10.1007/s00586-017-5178-4">40% of people</a> with low back and neck pain who present to their GP and <a href="https://qualitysafety.bmj.com/content/28/10/826">70% of people</a> with low back pain who visit a hospital emergency department are prescribed opioids such as oxycodone. </p>
<p>But our <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)00404-X/fulltext">new study</a>, published today in the Lancet medical journal, found opioids do not relieve “acute” low back or neck pain (lasting up to 12 weeks) and can result in worse pain.</p>
<p>Prescribing opioids for low back and neck pain can also cause <a href="https://www.healthdirect.gov.au/taking-opioid-medicines-safely">harms</a> ranging from common side effects – such as nausea, constipation and dizziness – to <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/summary">misuse, dependency, poisoning and death</a>.</p>
<p>Our findings show opioids should <em>not</em> be recommended for acute low back pain or neck pain. A change in prescribing for low back pain and neck pain is urgently needed in <a href="https://www.tga.gov.au/resources/publication/publications/addressing-prescription-opioid-use-and-misuse-australia">Australia</a> and <a href="https://www.thelancet.com/commissions/opioid-crisis">globally</a> to reduce opioid-related harms. </p>
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<em>
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Read more:
<a href="https://theconversation.com/2-200-deaths-32-000-hospital-admissions-15-7-billion-dollars-what-opioid-misuse-costs-australia-in-a-year-137712">2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year</a>
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<h2>Comparing opioids to a placebo</h2>
<p>In our trial, we randomly allocated 347 people with acute low back pain and neck pain to take either an opioid (oxycodone plus naloxone) or <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/placebo-effect">placebo</a> (a tablet that looked the same but had no active ingredients). </p>
<p>Oxycodone is an opioid pain medicine which can be given orally. <a href="https://www.nps.org.au/radar/articles/oxycodone-with-naloxone-controlled-release-tablets-targin-for-chronic-severe-pain">Naloxone</a>, an opioid-reversal drug, reduces the severity of constipation while not disrupting the pain relieving effects of oxycodone. </p>
<p>Participants took the opioid or placebo for a maximum of six weeks.</p>
<p>People in the both groups also received <a href="https://www.sciencedirect.com/science/article/pii/S1836955321000941">education and advice</a> from their treating doctor. This could be, for example, advice on returning to their normal activities and avoiding bed rest.</p>
<p>We assessed their outcomes over a one-year period. </p>
<h2>What did we find?</h2>
<p>After six weeks of treatment, taking opioids did not result in better pain relief compared to the placebo.</p>
<p>Nor were there benefits to other outcomes such as physical function, quality of life, recovery time or work absenteeism.</p>
<p>More people in the group treated with opioids experienced nausea, constipation and dizziness than in the placebo group.</p>
<p>Results at one year highlight the potential long-term harm of opioids even with short-term use. Compared to the placebo group, people in the opioid group experienced slightly worse pain, and reported a higher risk of <a href="https://academic.oup.com/painmedicine/article/20/1/113/4728236#129780622">opioid misuse</a> (problems with their thinking, mood or behaviour, or using opioids differently from how the medicines were prescribed).</p>
<p>More people in the opioid group reported pain at one year: 66 people compared to 50 in the placebo group.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/ouch-the-drugs-dont-work-for-back-pain-but-heres-what-does-72283">Ouch! The drugs don't work for back pain, but here's what does</a>
</strong>
</em>
</p>
<hr>
<h2>What will this mean for opioid prescribing?</h2>
<p>In recent years, international low back pain guidelines have shifted the focus of treatment from drug to non-drug treatment due to <a href="https://www.thelancet.com/article/S0140-6736(18)30489-6/fulltext">evidence</a> of limited treatment benefits and concern of medication-related harm. </p>
<p>For acute low back pain, <a href="https://link.springer.com/article/10.1007/s00586-018-5673-2">guidelines</a> recommend patient education and advice, and if required, anti-inflammatory pain medicines such as ibuprofen. Opioids are <a href="https://link.springer.com/article/10.1007/s00586-018-5673-2">recommended only</a> when other treatments haven’t worked or aren’t appropriate. </p>
<p>Guidelines for <a href="https://pubmed.ncbi.nlm.nih.gov/33064878/">neck</a> pain similarly discourage the use of opioids. </p>
<figure class="align-center ">
<img alt="Woman holds neck in pain" src="https://images.theconversation.com/files/532146/original/file-20230615-25-sbzt66.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/532146/original/file-20230615-25-sbzt66.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/532146/original/file-20230615-25-sbzt66.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/532146/original/file-20230615-25-sbzt66.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/532146/original/file-20230615-25-sbzt66.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/532146/original/file-20230615-25-sbzt66.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/532146/original/file-20230615-25-sbzt66.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">Guidelines discourage opioids for neck and low back pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/fatigued-indian-woman-student-office-worker-1606121236">Shutterstock</a></span>
</figcaption>
</figure>
<p>Our latest research clearly demonstrates the benefits of opioids do not outweigh possible harms in people with acute low back pain and neck pain.</p>
<p>Instead of advising opioid use for these conditions in selected circumstances, opioids should be discouraged without qualification.</p>
<h2>Change is possible</h2>
<p>Complex problems such as opioid use need smart solutions, and another study we recently conducted provides convincing data opioid prescribing can be successfully reduced. </p>
<p>The <a href="https://qualitysafety.bmj.com/content/30/10/825">study</a> involved four hospital emergency departments, 269 clinicians and 4,625 patients with low back pain. The intervention comprised of:</p>
<ul>
<li>clinician education about <a href="https://aci.health.nsw.gov.au/networks/musculoskeletal/resources/low-back-pain">evidence-based management</a> of low back pain</li>
<li>patient education using posters and handouts to highlight the benefits and harms of opioids </li>
<li>providing heat packs and anti-inflammatory pain medicines as alternative pain-management treatments</li>
<li>fast-tracking referrals to outpatient clinics to avoid long waiting lists</li>
<li>audits and feedback to clinicians on information about opioid prescribing rates.</li>
</ul>
<p>This intervention reduced opioid prescribing from <a href="https://qualitysafety.bmj.com/content/30/10/825">63% to 51% of low back pain presentations</a>. The <a href="https://emj.bmj.com/content/early/2023/04/02/emermed-2022-212874">reduction was sustained for 30 months</a>. </p>
<p>Key to this successful approach is that we worked with clinicians to develop suitable pain-management treatments without opioids that were feasible in their setting. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-does-my-back-get-so-sore-when-im-sick-the-connection-between-immunity-and-pain-207222">Why does my back get so sore when I'm sick? The connection between immunity and pain</a>
</strong>
</em>
</p>
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<p>More work is needed to evaluate this and other interventions aimed at reducing opioid prescribing in other settings including GP clinics. </p>
<p>A nuanced approach is often necessary to avoid causing <a href="https://theconversation.com/opioid-script-changes-mean-well-but-have-left-some-people-in-chronic-pain-156753">unintended consequences</a> in reducing opioid use. </p>
<p>If people with low back pain or neck pain are using opioids, especially at higher doses over an extended period of time, it’s important they seek advice from their doctor or pharmacist before stopping these medicines to avoid <a href="https://www.healthdirect.gov.au/opioid-withdrawal-symptoms">unwanted effects when the medicines are abruptly stopped</a>. </p>
<p>Our research provides compelling evidence opioids have a limited role in the management of acute low back and neck pain. The challenge is getting this new information to clinicians and the general public, and to implement this evidence into practice.</p><img src="https://counter.theconversation.com/content/203244/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christine Lin receives funding from the National Health and Medical Research Council. She is affiliated with the Australia and New Zealand Musculoskeletal (ANZMUSC) Clinical Trials Network and the Australia and New Zealand Low Back Pain (ANZBACK) Centre of Research Excellence. She is a registered physiotherapist and serves on the editorial board of Journal of Physiotherapy and British Journal of Sports Medicine.</span></em></p><p class="fine-print"><em><span>Andrew McLachlan receives research funding from the NHMRC and the Sydney Pharmacy School receives research scholarship funding from GSK for a PhD student under his supervision. Andrew has served as a paid consultant on Australian government committees related to medicines regulation.</span></em></p><p class="fine-print"><em><span>Christopher Maher received funding for the OPAL trial from Australia’s National Health and Medical Research Council; University of Sydney Faculty of Medicine and Health; and SafeWork SA.</span></em></p><p class="fine-print"><em><span>Caitlin Jones 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>Opioids are the one of the most prescribed pain-relief for people with low back and neck pain. But new research shows they don’t effectively relieve low back or neck pain and can result in worse pain.Christine Lin, Professor, University of SydneyAndrew McLachlan, Head of School and Dean of Pharmacy, University of SydneyCaitlin Jones, Postdoctoral Research Associate in Musculoskeletal Health, University of SydneyChristopher Maher, Professor, Sydney School of Public Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2076792023-06-27T21:21:32Z2023-06-27T21:21:32ZLet evidence, not opinion, guide harm reduction policy and practice in Canada’s drug poisoning crisis<p>The poisoning of the unregulated drug supply, especially in Canada, is a public health crisis that deserves a high priority for the integration of evidence into policy and practice. </p>
<p>The <a href="https://www.cbc.ca/news/health/drug-poisoning-deaths-language-1.6457834">drug poisoning crisis</a> is often referred to as the opioid crisis, but it is all illicit substances, including stimulants, that are tainted with fentanyl, benzodiazepines and other dangerous ingredients, <a href="https://doi.org/10.1111/add.15844">increasing the risk of harm, especially overdose</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<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>
</strong>
</em>
</p>
<hr>
<p>It is still an ongoing battle for those in positions of power to submit to the rigorous evidence supporting harm reduction, despite strategies like <a href="https://doi.org/10.1186/s12954-017-0154-1">supervised consumption sites</a> and the distribution of drug equipment <a href="https://www.phs.ca/insite-an-anniversary-of-hope/">being more than two decades old</a>. </p>
<p>For example, North America’s first formal supervised consumption site, <a href="https://www.phs.ca/program/insite/">Insite</a>, has been in operation for 20 years showcasing what its founding organization, PHS Community Services, calls a “<a href="https://www.phs.ca/insite-an-anniversary-of-hope/">pragmatic and humane approach to the risks of drug use</a>.” </p>
<p>Thorough evaluation of harm reduction strategies has shown they can <a href="https://doi.org/10.1186/s12954-017-0154-1">save money, save lives and promote health</a> at an individual and population level. Furthermore, denial of access to supervised consumption is a <a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do">violation of Section 7 of the Canadian Charter of Rights and Freedoms</a>, which protects an individual’s right to life, liberty and security of the person.</p>
<h2>Stigma and ideology</h2>
<p>Recently, Canada’s leader of the Opposition Pierre Poilievre had his motion to defund safer supply voted down in Parliament. His reference to a “<a href="https://www.ourcommons.ca/DocumentViewer/en/44-1/house/sitting-200/hansard">tax-funded drug supply</a>” as fuelling addiction rather than recovery is not supported by evidence and follows the <a href="https://www.cbc.ca/news/politics/conservative-motion-safe-supply-fails-1.6858551">failed prejudicial ideology of the war on drugs era</a>. </p>
<p>Poilievre’s actions mirror the sentiments of former federal health minister Rona Ambrose, whose opinion also superseded evidence while in a position of influence. In 2013 she attempted to deny access to heroin assisted treatment (HAT) — an <a href="https://doi.org/10.1136/bmj.327.7410.310">opioid substitution treatment using diamorphine/diacetylmorphine (medical grade heroin</a>) — for persons with substance use disorder in Vancouver. </p>
<p><a href="https://www.providencehealthcare.org/sites/default/files/Supreme%20Court%20of%20British%20Columbia%20Decision.pdf">Ambrose publicly stated that</a> “Our policy is to take heroin out of the hands of addicts, not to put it into their arms.”</p>
<p>Ambrose made this public declaration <a href="https://doi.org/10.1016/j.jsat.2006.04.007">despite evidence</a> from both <a href="https://doi.org/10.1056/NEJMoa0810635">Canada</a> and <a href="https://doi.org/10.1136/bmj.317.7150.13">Europe</a> that <a href="https://doi.org/10.1192/bjp.bp.106.026112">showcased the efficacy</a> of HAT in six <a href="https://doi.org/10.1016/S0140-6736(10)60349-2">randomized controlled trials</a> with over 1,500 patients.</p>
<h2>What is evidence?</h2>
<p>What is considered evidence, especially regarding public health? From an epistemological (justified belief, as opposed to opinion) perspective, we may think evidence equals truth. However <a href="https://global.oup.com/academic/product/population-health-science-9780190459376?cc=ca&lang=en&">causation cannot be observed, only inferred</a>. While evidence may be viewed as more of a confirmation, truly <a href="https://doi.org/10.1046/j.1365-2753.2000.00244.x">definitive scientific evidence is rare due to its ever-changing and evolving nature</a>. </p>
<p>Evidence comes in many forms, and although it may not constitute absolute “proof,” it is reliable.</p>
<p>In harm reduction, best practices are grounded in evidence that comes from several facets including peer-reviewed literature, unpublished reports or grey literature, and the experiential knowledge of persons who use drugs themselves. </p>
<p>The way <a href="https://doi.org/10.1016/j.drugpo.2020.103015">harm reduction has progressed in Canada</a> tells us that <a href="https://doi.org/10.1186/s13011-021-00406-6">people who use drugs are key informants at the table</a> as they articulate their own experience of what it is like to use substances from an unregulated supply and to navigate the health and social services system. <a href="https://doi.org/10.1111/add.158441196COMMENTARIES">Their voice in the conversation</a> helps to reduce stigma, support client-centred essential services and policies, and prioritize the needs of people who use substances.</p>
<h2>Barriers to progress</h2>
<p>The question still remains as to why government policies across Canada, public stigma, and ignorance towards the use of substances and the people who use them, are still able to create barriers to the promotion of strategies that fight the current drug poisoning crisis. </p>
<p>During the COVID-19 pandemic, <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline">public health strategies were implemented at a rapid pace</a>, but this same urgency is not translating to our community of people who use unregulated drugs. One would think that <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants">the loss of nearly 40,000 Canadians to opioid overdoses since 2016</a> would be impetus for not just change, but bold action.</p>
<p>Has government not learned its lessons about taking all aspects of evidence into consideration while also considering the urgency of action required in crisis situations? After public health failures during the 2001 SARS crisis, <a href="https://doi.org/10.1098/rsfs.2021.0079">Justice Archie Campbell recommended in his report</a>: </p>
<blockquote>
<p>“Where there is reasonable evidence of an impending threat to public harm, it is inappropriate to require proof of causation beyond a reasonable doubt before taking steps to avert the threat…that reasonable efforts to reduce risk need not await scientific proof.” </p>
</blockquote>
<p>The ultimate question that needs to be asked to those who have the power to move harm reduction forward is: If they want to be a part of ending the drug toxicity crisis, then why and for whom? Is their primary objective more votes? Or is it to value all members of our community, and not just keep people who use drugs alive, but to help them thrive? </p>
<p>If the goal is wanting to be a part of ending this crisis for the betterment of the persons experiencing it, then the approach must include weighing evidence from a variety of sources and triumphing over public and political ideology and stigma. </p>
<p><a href="https://plato.stanford.edu/entries/egalitarianism/#Pri">Prioritarianism</a>, as a principle of justice, puts the focus on the population most in need, whether it be in terms of health, resources, opportunities or access. The moral and ethical values of this approach intend to maximize overall well-being for those who need it the most. </p>
<p>Movement forward requires collaboration that builds on existing strengths and capacities, with the guiding principle being to <a href="https://healthydebate.ca/2021/09/topic/encampments-pandemic-covid/">put the needs of the persons living this experience first</a>. Bioethicist Anita Ho describes epistemic humility — the ability to challenge one’s preconceived and biased assumptions — as “<a href="https://doi.org/10.2979/intjfemappbio.4.2.102">characterized by a commitment to mutual collaboration and trust with those they serve</a>.” </p>
<p>A healthy public includes us all.</p><img src="https://counter.theconversation.com/content/207679/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ross Upshur receives funding from Health Canada, CIHR, Atlas Institute for Veterans and Families</span></em></p><p class="fine-print"><em><span>Karla Ghartey 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>Harm reduction is grounded in evidence. But policies, stigma and ignorance about substance use still create barriers in battling Canada’s drug poisoning crisis.Karla Ghartey, Doctor of Public Health (DrPH) student, University of TorontoRoss Upshur, Professor, Dalla Lana School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2053312023-06-13T12:20:53Z2023-06-13T12:20:53ZOver-the-counter opioids: does Britain have a codeine problem?<p>Earlier this year, the NHS announced that it had cut opioid prescriptions by almost <a href="https://www.england.nhs.uk/2023/03/opioid-prescriptions-cut-by-almost-half-a-million-in-four-years-as-nhs-continues-crackdown/">half a million in four years</a>. But opioids aren’t just available on prescription in the UK. They can be bought over the counter at pharmacies in the form of co-codamol – pills that contain codeine and paracetamol.</p>
<p>Each co-codamol pill contains a fixed amount of 500mg of paracetamol and between 8mg and 12.8mg of codeine, depending on the product. (Co-codamol with more than 12.8mg of codeine is only available on prescription.)</p>
<p>Co-codamol is the <a href="https://www.statista.com/statistics/377895/top-ten-analgesic-drugs-dispensed-by-item-in-england/">second most dispensed painkiller</a> in England after paracetamol – with over 15 million packs sold in 2021. In 2023, the UK was estimated to be the third largest <a href="https://www.incb.org/documents/Narcotic-Drugs/Status-of-Estimates/2023/EstApr23.pdf">consumer of codeine</a> at over 28 tonnes after India and Italy (75 tonnes and 33.5 tonnes, respectively). </p>
<figure class="align-center ">
<img alt="Leading analgesic drugs dispensed in England by item." src="https://images.theconversation.com/files/530370/original/file-20230606-19-psgkb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/530370/original/file-20230606-19-psgkb.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=446&fit=crop&dpr=1 600w, https://images.theconversation.com/files/530370/original/file-20230606-19-psgkb.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=446&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/530370/original/file-20230606-19-psgkb.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=446&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/530370/original/file-20230606-19-psgkb.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=560&fit=crop&dpr=1 754w, https://images.theconversation.com/files/530370/original/file-20230606-19-psgkb.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=560&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/530370/original/file-20230606-19-psgkb.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=560&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Leading analgesic drugs dispensed in England by item.</span>
<span class="attribution"><a class="source" href="https://www.statista.com/statistics/377895/top-ten-analgesic-drugs-dispensed-by-item-in-england/">Matej Mikulic/Statista</a></span>
</figcaption>
</figure>
<p>Codeine is considered a “weak opioid” – 10mg of codeine is <a href="https://bnf.nice.org.uk/medicines-guidance/prescribing-in-palliative-care/">equal</a> to 1mg of oral morphine. Once ingested, a liver enzyme called CYP2D6 converts codeine into morphine. However, some ethnic groups, such as people from north Africa, <a href="https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/019429s035lbl.pdf">produce more of the CYP2D6 enzyme</a> (so-called ultra-rapid metabolisers) and so are at greater risk of harm, even at regular doses.</p>
<p>Co-codamol is meant to be used to treat mild to moderate pain – such as period pain or toothache – but because it can also create a euphoric effect, it is at risk of being abused. </p>
<p>Codeine can cause <a href="https://medlineplus.gov/druginfo/meds/a682065.html">serious harm</a>, including dizziness, confusion, difficulty breathing and even death. These risks are especially great among ultra-rapid metabolisers, and among people who use other medications, such as benzodiazepines.</p>
<p>Some people buy co-codamol to treat their craving for heroin when there are local heroin shortages. But anecdotal reports suggest that this drug may be abused by people who start taking the pills to treat pain and <a href="https://www.independent.co.uk/life-style/health-and-families/features/confessions-of-an-opiateeater-932932.html">end up being addicted</a>.</p>
<h2>Cold-water extraction</h2>
<p>In theory, the paracetamol in the pills should prevent people from abusing them.</p>
<p>A maximum single dose of paracetamol for an adult should not exceed 1,000mg (two co-codamol pills) as it can harm the liver. However, online groups share a simple method called “cold water extraction” for removing the paracetamol. </p>
<p>Clinical toxicologists at Guys’ and St Thomas’ Hospital in London <a href="https://www.tandfonline.com/doi/abs/10.1080/15563650.2019.1612069?journalCode=ictx20">found case studies</a> which suggest that the method is fairly effective at removing paracetamol from the pills, and a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5130903/">laboratory test</a> backs this up.</p>
<p>It is not clear how widespread this form of tampering is, but a YouTube clip (now removed) showing viewers how to perform the procedure had been watched <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5130903/">more than half a million times</a>.</p>
<p>Pharmaceutical firms have yet to come up with an adequate way to prevent this kind of tampering. </p>
<h2>Twenty-five countries have banned over-the-counter codeine</h2>
<p>Given the pills’ potential for abuse, at least <a href="https://www.sciencedirect.com/science/article/pii/S0033350615002504?via%3Dihub">25 countries</a>, including Germany, Japan and the US have banned over-the-counter codeine sales.</p>
<p>Australia also implemented a ban in February 2018, despite warnings that people would switch to stronger opioids. However, researchers at the University of Sydney found that a year after the ban was implemented, there was a <a href="https://onlinelibrary.wiley.com/doi/10.1111/add.14798">51% drop in codeine overdoses overall</a> (including high-strength codeine). And there was a 79% drop in overdoses from low-strength codeine, the type now only available on prescription.</p>
<p>In the UK, the drugs regulator, the Medicines and Healthcare products Regulatory Agency (MHRA), <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/852388/Codeine_and_dihydrocodeine_minimising_the_risk_of_addiction.pdf">intervened in 2009</a> to reduce harms from over-the-counter opioids, such as limiting pack sizes to 32 pills per pack and adding prominent warnings on packs to not take the pills for more than three days.</p>
<p>In 2019, the MHRA conducted a review and decided against making co-codamol a prescription-only product.</p>
<p>While codeine-related <a href="https://www.statista.com/statistics/470902/death-by-codeine-drug-poisoning-in-england-and-wales/">deaths in England and Wales</a> are fairly low, they have increased from 24 deaths in 1993 to 200 deaths in 2021 (200 deaths). It’s not clear if these deaths relate to over-the-counter codeine, prescription codeine or illicit codeine (say, bought on the “dark web”). Nevertheless, if codeine-related deaths continue to rise, the government may wish to reconsider its position on over-the-counter sales of codeine.</p><img src="https://counter.theconversation.com/content/205331/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amira Guirguis 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>Many countries have banned over-the-counter sale of codeine. The UK is not one of them.Amira Guirguis, Swansea UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2013892023-06-11T20:52:50Z2023-06-11T20:52:50ZWhat’s a TENS machine? Can it help my period pain or endometriosis?<figure><img src="https://images.theconversation.com/files/529235/original/file-20230531-17-nf3bmd.jpg?ixlib=rb-1.1.0&rect=1%2C0%2C997%2C667&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/cropped-close-view-girl-touch-stomach-1354368302">Shutterstock</a></span></figcaption></figure><p>If you’ve been on social media recently you might have noticed sponsored posts and ads for a variety of small, portable electrical devices. These claim to manage period or <a href="https://www.endometriosisaustralia.org/about-endo">endometriosis</a> pain safely and without drugs.</p>
<p>Most devices have a small box that generates an electrical pulse, and wires connected to sticky pads, which go on your tummy.</p>
<p>So how are these devices supposed to stop your pain? Are they safe? Do they actually work?</p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CT7o8DnPaXs","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p>
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Read more:
<a href="https://theconversation.com/health-check-are-painful-periods-normal-62290">Health Check: are painful periods normal?</a>
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<h2>They’re mini TENS machines</h2>
<p>These devices use “transcutaneous electrical nerve stimulation”, better known as TENS. In other words, they apply small electrical pulses across the skin to stimulate certain types of nerves.</p>
<p>TENS machines are not new. They’ve been around since the <a href="https://patents.google.com/patent/US3817254">1970s</a> and have been used for a <a href="https://www.healthdirect.gov.au/tens">variety of painful conditions</a>, from muscular injuries to pain relief in labour. </p>
<p>However, these latest devices are compact and easy to wear discretely compared to the older models. They’re fairly simple to use, portable, you can use them at home, and they cost around A$50-200. </p>
<p>It’s easy to see why devices like these might be popular. <a href="https://doi.org/10.1016/j.jpag.2020.11.007">Half</a> of people with period pain say over-the-counter medication such as ibuprofen doesn’t get rid of their period pain. Most people with endometriosis <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/imj.15494">report</a> major issues with getting adequate pain relief.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/from-sharp-butt-pains-to-period-poos-5-lesser-known-menstrual-cycle-symptoms-191352">From sharp butt pains to period poos: 5 lesser-known menstrual cycle symptoms</a>
</strong>
</em>
</p>
<hr>
<h2>How might TENS work?</h2>
<p>All TENS-based devices generate small electrical pulses that feel a little like <a href="https://patient.info/treatment-medication/painkillers/tens-machines">mild electrical shocks</a>. These pulses are transmitted through the surface of the skin via the sticky pads. </p>
<p>You generally place these pads where the pain is. So for period pain that’s usually at or below the level of the belly button but above the pubic region. You can also place the pads on your lower back or even on your tailbone (sacrum). This is because some nerves near your tailbone also affect the pelvic area.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Sticky pad of TENS machine on skin" src="https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529236/original/file-20230531-21-4m3nnt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">You place two sticky pads on your tummy or lower back.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/tens-electrodes-positioned-back-pain-treatment-466080803">Shutterstock</a></span>
</figcaption>
</figure>
<h2>Here’s what we know so far</h2>
<p>The exact mechanisms of how TENS works to reduce pain is still unclear. There are likely <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011890.pub3/full">many different pathways</a>. </p>
<p>First, we need to first talk about different types of nerves. <a href="https://www.ncbi.nlm.nih.gov/books/NBK10965/">Nociceptors</a> are nerves that send “danger” impulses about actual or potential tissue damage. Sensory nerves in your skin transmit information about things such as touch and pressure.</p>
<p>The <a href="https://www.science.org/doi/10.1126/science.150.3699.971">gate control theory of pain</a> says the spinal cord has “gates” that can be open or closed. When these gates are open, nerves can transmit these danger impulses up the spinal cord to the brain where they may be interpreted as “pain”. If these gates are closed, these impulses can’t reach the brain as easily.</p>
<p>TENS machines, especially at high frequency (greater than 50 pulses per second), tend to stimulate <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011890.pub3/full">sensory nerves</a> (the ones in your skin). These sensory nerves also send signals to your brain, but faster than the danger ones.</p>
<p>These sensory signals can close the “gates” at certain parts of the spinal cord. So if the TENS machine can stimulate enough of these sensory nerves in your skin, it will block at least some of these danger impulses from reaching the brain. The fewer danger impulses that reach the brain, the less pain you are likely to feel.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Closed farm gate across dirt track" src="https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=399&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=399&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=399&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=501&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=501&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529241/original/file-20230531-27-4m3nnt.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"></a>
<figcaption>
<span class="caption">TENS machines may close the ‘gates’ at certain parts of the spinal cord so fewer ‘danger’ impulses reach the brain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-iron-farm-field-gate-red-2260337685">Shutterstock</a></span>
</figcaption>
</figure>
<p>Then there’s the concept of <a href="https://www.news-medical.net/health/What-are-Endogenous-Opioids.aspx">endogenous opioids</a> as pain relief. These are pain relieving chemicals the body makes itself. </p>
<p>TENS machines stimulate the release of these chemicals, with different types of endogenous opioids released depending on the frequency of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027071/">stimulation</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-pain-and-what-is-happening-when-we-feel-it-49040">Explainer: what is pain and what is happening when we feel it?</a>
</strong>
</em>
</p>
<hr>
<h2>So does TENS work?</h2>
<p><strong>For period pain</strong></p>
<p>A systematic <a href="https://www.sciencedirect.com/science/article/pii/S155083072030286X">review</a> in 2022 found four studies looking at TENS to manage primary dysmenorrhea (period pain that occurs without any physical changes in the pelvis).</p>
<p>There was a significant reduction in period pain when high-frequency TENS (more than 50 pulses per second) was compared to sham TENS (where the machine looks the same but doesn’t deliver a pulse). </p>
<p>This is in line with an older <a href="https://www.cochrane.org/CD002123/MENSTR_transcutaneous-electrical-nerve-stimulation-for-primary-dysmenorrhoea">Cochrane review</a> that found similar benefits. </p>
<p>Pain relieving effects only tend to last while the device is active.</p>
<p><strong>For endometriosis</strong></p>
<p>Endometriosis is where tissue similar to the lining of the uterus is found outside the uterus, commonly in the pelvis. There is only <a href="https://doi.org/10.1016/j.ejogrb.2015.07.009">one</a> study of TENS for pelvic pain due to endometriosis. </p>
<p>This study compared two types of TENS – one using a higher frequency for 20 minutes twice a day, and one using a lower frequency for 30 minutes once per week. Both types used pads placed on the tailbone, and women were told to make the pulses “strong, but comfortable”. </p>
<p>Both types improved pelvic pain, pain after sex, and quality of life, but not period pain. This was a very small study (11 women in each group) and there was no control or placebo group. So we need larger studies with a proper control group before we can be sure if TENS works for endometriosis pain.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-have-painful-periods-could-it-be-endometriosis-101026">I have painful periods, could it be endometriosis?</a>
</strong>
</em>
</p>
<hr>
<h2>Is it safe?</h2>
<p>Most <a href="https://www.sciencedirect.com/science/article/pii/S155083072030286X">studies</a> report no side effects when the pads are used on the abdomen or lower spine.</p>
<p>However, if you turn up the intensity too high it <a href="https://www.tandfonline.com/doi/full/10.2147/IJWH.S220523">can be uncomfortable</a>. You could also get a rash from the adhesive on the pads.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/first-periods-can-come-as-a-shock-5-ways-to-support-your-kid-when-they-get-theirs-177920">First periods can come as a shock. 5 ways to support your kid when they get theirs</a>
</strong>
</em>
</p>
<hr>
<h2>Which one to buy?</h2>
<p>All TENS machines should allow you to change the <em>intensity</em> (how strong the pulse feels). Some also allow you to change the <em>frequency</em> (how often the pulses happen).</p>
<p>If you are going to use the device occasionally (less than 4-5 days per month) you may just need a device that allows you to change the <a href="https://doi.org/10.2522/ptj.20120281">intensity</a>.</p>
<p>To get the best relief, the machine should be turned up high enough so it delivers noticeable pulses, but is not painful. So you need to find your own comfort level.</p>
<p>For period pain, <a href="https://www.tandfonline.com/doi/full/10.2147/IJWH.S220523">high frequency</a> (more than 50 pulses per second) shows better results than low frequency (usually 2-5 pulses per second). So make sure the device you’re thinking of buying is either set to a high frequency or you can change the frequency.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman clutching tummy and head lying on sofa" src="https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/529242/original/file-20230531-15-mlq5gp.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">Many people find it hard to manage period pain. So would TENS help?</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/sick-muslim-woman-hijab-having-acute-1616145232">Shutterstock</a></span>
</figcaption>
</figure>
<p>For people with endometriosis, it’s a little more tricky. You’ll probably going to want to use the device more often than a few days a month. </p>
<p>Unfortunately, like with taking regular opioid painkillers, with regular TENS use people can become <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3027071/">tolerant</a> to its pain-relieving effect, which means it doesn’t work as well as it did when you first started using it.</p>
<p>One possible solution to tolerance is to use <a href="https://academic.oup.com/ptj/article/93/10/1397/2735589">mixed-frequency TENS</a> where both high and low frequencies are alternated. You can also slowly increase the intensity level over time. </p>
<p>TENS also doesn’t work well when people are regular <a href="https://pubmed.ncbi.nlm.nih.gov/6965549/">opioid users</a>. This is important as people with endometriosis are often using <a href="https://www.jmig.org/article/S1553-4650(20)30291-0/fulltext">opioid medications</a> to manage their pain. If you are using opioids regularly, high-frequency TENS is likely to be a <a href="https://academic.oup.com/ptj/article/93/10/1397/2735589">better choice</a>.</p><img src="https://counter.theconversation.com/content/201389/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mike Armour 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>TENS machines for period pain are all over social media. But what are they? And do they work?Mike Armour, Associate Professor at NICM Health Research Institute, Western Sydney UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2045222023-05-30T12:24:11Z2023-05-30T12:24:11ZYour body naturally produces opioids without causing addiction or overdose – studying how this process works could help reduce the side effects of opioid drugs<figure><img src="https://images.theconversation.com/files/528436/original/file-20230525-27-cw53qp.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2309%2C1299&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Opioid neurotransmitters are located in many areas of the body, including the brain, spine and gut.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/neurotransmitter-release-mechanisms-royalty-free-image/1396888608">ALIOUI Mohammed Elamine/iStock via Getty Images Plus</a></span></figcaption></figure><p>Opioid drugs such as morphine and fentanyl are like the two-faced Roman god Janus: The kindly face delivers pain relief to millions of sufferers, while the grim face drives an opioid abuse and overdose crisis that <a href="https://www.cdc.gov/drugoverdose/deaths/index.html">claimed nearly 70,000 lives</a> in the U.S. in 2020 alone. </p>
<p><a href="https://scholar.google.com/citations?user=LXVL7f0AAAAJ&hl=en">Scientists like me who study pain and opioids</a> have been seeking a way to separate these two seemingly inseparable faces of opioids. Researchers are trying to design drugs that deliver effective pain relief without the risk of side effects, including addiction and overdose.</p>
<p>One possible path to achieving that goal lies in understanding the molecular pathways opioids use to carry out their effects in your body.</p>
<h2>How do opioids work?</h2>
<p>The <a href="https://pubmed.ncbi.nlm.nih.gov/16082232/">opioid system in your body</a> is a set of neurotransmitters your brain naturally produces that enable communication between neurons and activate protein receptors. These neurotransmitters include small proteinlike molecules like <a href="https://doi.org/10.1124/mol.120.119388">enkephalins and endorphins</a>. These molecules regulate a tremendous number of functions in your body, including pain, pleasure, memory, the movements of your digestive system and more.</p>
<p>Opioid neurotransmitters activate receptors that are <a href="https://www.ncbi.nlm.nih.gov/books/NBK546642/">located in a lot of places</a> in your body, including pain centers in your spinal cord and brain, reward and pleasure centers in your brain, and throughout the neurons in your gut. Normally, opioid neurotransmitters are released in only small quantities in these exact locations, so your body can use this system in a balanced way to regulate itself.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/NDVV_M__CSI?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The opioids your body produces and opioid drugs bind to the same receptors.</span></figcaption>
</figure>
<p>The problem comes when you take an opioid drug like morphine or fentanyl, especially at high doses for a long time. These drugs <a href="https://theconversation.com/how-do-drugs-know-where-to-go-in-the-body-a-pharmaceutical-scientist-explains-why-some-medications-are-swallowed-while-others-are-injected-182488">travel through the bloodstream</a> and can activate every opioid receptor in your body. You’ll get pain relief through the pain centers in your spinal cord and brain. But you’ll also get a euphoric high when those drugs hit your brain’s reward and pleasure centers, and that could <a href="https://doi.org/10.1016%2FS2215-0366(16)00104-8">lead to addiction</a> with repeated use. When the drug hits your gut, you may develop constipation, along with other common <a href="https://www.asahq.org/madeforthismoment/pain-management/opioid-treatment/what-are-opioids/">opioid side effects</a>.</p>
<h2>Targeting opioid signal transduction</h2>
<p>How can scientists design opioid drugs that won’t cause side effects?</p>
<p>One approach my research team and I take is to understand how cells respond when they receive the message from an opioid neurotransmitter. Neuroscientists call this process <a href="https://doi.org/10.1097%2FALN.0b013e318238bba6">opioid receptor signal transduction</a>. Just as neurotransmitters are a communication network within your brain, each neuron also has a communication network that connects receptors to proteins within the neuron. When these connections are made, they trigger specific effects like pain relief. So, after a natural opioid neurotransmitter or a synthetic opioid drug activates an opioid receptor, it activates proteins within the cell that carry out the effects of the neurotransmitter or the drug.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/FQFBygnIONU?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Cells communicate with one another in multiple ways.</span></figcaption>
</figure>
<p>Opioid signal transduction is complex, and scientists are just starting to figure out how it works. However, one thing is clear: Not every protein involved in this process does the same thing. Some are more important for pain relief, while some are more important for side effects like <a href="https://theconversation.com/pain-and-anxiety-are-linked-to-breathing-in-mouse-brains-suggesting-a-potential-target-to-prevent-opioid-overdose-deaths-174187">respiratory depression</a>, or the decrease in breathing rate that makes overdoses fatal.</p>
<p>So what if we target the “good” signals like pain relief, and avoid the “bad” signals that lead to addiction and death? Researchers are tackling this idea in different ways. In fact, in 2020 the U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-new-opioid-intravenous-use-hospitals-other-controlled-clinical-settings">approved the first opioid drug based on this idea</a>, oliceridine, as a painkiller with fewer respiratory side effects.</p>
<p>However, relying on just one drug has downsides. That drug might not work well for all people or for all types of pain. It could also have other side effects that show up only later on. Plenty of options are needed to treat all patients in need.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="drawing depicting a tangle of red, blue and yellow curly and straight lines" src="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=800&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=800&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=800&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1006&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1006&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528435/original/file-20230525-23265-15id3l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1006&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This figure shows the structure of Hsp90.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/heat-shock-protein-90-chaperone-complex-royalty-free-illustration/185759601">Laguna Design/Science Photo Library via Getty Images</a></span>
</figcaption>
</figure>
<p>My research team is targeting a protein called <a href="https://doi.org/10.1007/128_2012_356">Heat shock protein 90, or Hsp90</a>, which has many functions inside each cell. Hsp90 has been a hot target in the <a href="https://doi.org/10.3390/ijms221910317">cancer field</a> for years, with researchers developing Hsp90 inhibitors as a treatment for many cancer types. </p>
<p>We’ve found that Hsp90 is also really important in regulating opioid signal transduction. <a href="https://doi.org/10.1074/jbc.m116.769489">Blocking Hsp90 in the brain</a> blocked opioid pain relief. However, <a href="https://doi.org/10.1126/scisignal.aaz1854">blocking Hsp90 in the spinal cord</a> increased opioid pain relief. Our recently published work uncovered more details on exactly how <a href="https://doi.org/10.1126/scisignal.ade2438">inhibiting Hsp90 leads to increased pain relief</a> in the spinal cord.</p>
<p>Our work shows that manipulating opioid signaling through Hsp90 offers a path forward to improve opioid drugs. Taking an Hsp90 inhibitor that targets the spinal cord along with an opioid drug could improve the pain relief the opioid provides while decreasing its side effects. With improved pain relief, you can take less opioid and reduce your risk of addiction. We are <a href="https://reporter.nih.gov/search/zF-FuD_ZC0CFwl6deU7tQw/project-details/10294366">currently developing</a> a new generation of Hsp90 inhibitors that could help realize this goal. </p>
<p>There may be many paths to developing an improved opioid drug without the burdensome side effects of current drugs like morphine and fentanyl. Separating the kindly and grim faces of the opioid Janus could help provide pain relief we need without addiction and overdose.</p><img src="https://counter.theconversation.com/content/204522/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>John Streicher receives funding from the National Institutes of Health, the Arizona Biomedical Research Commission, the Flinn Foundation, and the University of Arizona. He is an equity holder in Teleport Pharmaceuticals, LLC, and Botanical Results, LLC, however, no company products or interests were discussed in this article. </span></em></p>Unlike opioid drugs like morphine and fentanyl that travel throughout the body, the opioids your body produces are released in small quantities to specific locations.John Michael Streicher, Associate Professor of Pharmacology, University of Arizona Health SciencesLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2053782023-05-17T12:40:39Z2023-05-17T12:40:39ZBarbara Kingsolver’s ‘Demon Copperhead’ and the enduring devastation of the opioid crisis<figure><img src="https://images.theconversation.com/files/526588/original/file-20230516-35975-5ps8gu.jpg?ixlib=rb-1.1.0&rect=453%2C590%2C3095%2C2057&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Barbara Kingsolver's protagonist, Demon, is much more than his drug habit.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/child-lying-on-the-waterfall-royalty-free-image/537292087">SergioZacchi/iStock via Getty Images</a></span></figcaption></figure><p><a href="http://barbarakingsolver.net">Barbara Kingsolver’s</a> literary honors range from the National Book Prize of South Africa to the PEN/Faulkner Award. </p>
<p>On May 8, 2023, she added a <a href="https://www.pulitzer.org/winners/barbara-kingsolver">Pulitzer Prize</a> to her accolades. </p>
<p>Her winning novel, “<a href="https://www.harpercollins.com/products/demon-copperhead-barbara-kingsolver?variant=40073146204194">Demon Copperhead</a>,” is more than just a reimagining of Charles Dickens’ “<a href="https://www.gutenberg.org/files/766/766-h/766-h.htm">David Copperfield</a>.” Casting an opioid-addicted Appalachian orphan as her protagonist, Kingsolver sheds new light on one of America’s greatest health crises. </p>
<p>Understandably, the COVID-19 pandemic eclipsed media coverage of and national concern over the opioid epidemic; nevertheless, opioids remain a massive public health problem, and I think the author’s attention to it is both welcome and necessary. </p>
<p>In taking up the topic, she joins artists with ties to Appalachia, such as bluegrass guitar phenom <a href="https://www.billystrings.com/">Billy Strings</a>, the late singer-songwriter <a href="https://www.johnprine.com/">John Prine</a> and photographer <a href="https://www.stacykranitz.com/">Stacy Kranitz</a>, all of whom have used their art to highlight the ravaging effects of these drugs on their region.</p>
<h2>How artists can reclaim a place</h2>
<p><a href="https://www.middlebury.edu/college/people/william-nash">As an American Studies professor</a> who teaches courses on both country music and images of rural America, I see this groundbreaking work through the lens of <a href="https://researchguides.dartmouth.edu/human_geography/cultural">cultural geography</a>, which explores the relationship between culture and place.</p>
<p>A region can inspire unique forms of art, music, literature and architecture, and the work of geographer <a href="https://www.aag.org/memorial/edward-w-soja/">Edward Soja</a> helped show how this work can push back against stereotypes. </p>
<p>In 1996, Soja published “<a href="https://geography.ruhosting.nl/geography/index.php?title=Thirdspace">Thirdspace: Journeys to Los Angeles and Other Real-and-Imagined Places</a>.” </p>
<p>In it, he argued that stereotypes of a region’s people and landscape could lead to damaging politics and policies. For example, outsiders’ views of “the inner city” as hotbeds for poverty, crime and broken families led to the implementation of racist <a href="https://www.blackpast.org/african-american-history/moynihan-report-1965/">public housing policies in the 1960s</a>.</p>
<p>Soja’s book was a call to arms for artists and the marginalized: In what he called “thirdspace” – a place that exists at the intersection of the real and the imagined – they can reclaim and reframe visions of their region, showcasing <a href="https://theconversation.com/how-black-poets-and-writers-gave-a-voice-to-affrilachia-155706">different identities and experiences</a>. </p>
<p>Appalachia is a region that, for generations, has been subjected to <a href="https://qz.com/1167671/the-100-year-capitalist-experiment-that-keeps-appalachia-poor-sick-and-stuck-on-coal">economic oppression</a>, <a href="https://www.npr.org/sections/codeswitch/2014/04/03/298892382/stereotypes-of-appalachia-obscure-a-diverse-picture">classist stereotyping</a> and environmental and medical recklessness. <a href="https://www.justice.gov/opa/speech/assistant-attorney-general-brian-benczkowski-gives-remarks-west-virginia-and-appalachian">The pumping of opioids into rural communities</a> represents just another chapter in this story of exploitation. </p>
<p>Yet artists and writers like Kingsolver are able to show that the people in the region are more than just backward, powerless victims – that they are complicated people with the same goals, longings and fears as the rest of us. </p>
<h2>More than an addict</h2>
<p>Kingsolver, who was raised in rural Kentucky and who currently resides in Virginia, had a keen vision for Copperhead. She weaves the history of the economic fallout from the tobacco industry and coal mining into her protagonist’s backstory.</p>
<p>Her central concern, though, was always the opioid crisis. </p>
<p><a href="https://www.nytimes.com/2022/10/14/books/barbara-kingsolver-demon-copperhead.html?smid=nytcore-ios-share&referringSource=articleShare">As she told The New York Times in October 2022</a>, “I wanted to say, ‘Look, it’s still here, and this got done to us and we didn’t deserve it.’”</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Book cover of 'Demon Copperhead.'" src="https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=774&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=774&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=774&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=973&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=973&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=973&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">‘Demon Copperhead’ won the 2023 Pulitzer Prize for fiction.</span>
<span class="attribution"><a class="source" href="https://cdn.shopify.com/s/files/1/0570/7209/1326/products/33274BCF-6D06-40F3-B603-2C8F57086E36.jpg?v=1669761668">Black Bird Bookstore and Cafe</a></span>
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</figure>
<p>That’s the story of Demon’s life. An orphan who experiences poverty, an abusive foster home and social isolation, he finds freedom and glory on the football field, only to experience a devastating knee injury. </p>
<p>Pressured by his coach and the townspeople to play through his pain, he blindly takes the OxyContin that the local Dr. Feelgood prescribes, only to find himself crippled physically, psychologically and emotionally by his addiction.</p>
<p>And yet, through all of that, Demon is much more than his habit. Kingsolver foregrounds his humanity, his humor and his potential for goodness in a way that makes him more than “just an addict.” </p>
<p>In doing so, Kingsolver uses her connection to the region, her empathy for its residents and her awareness of stereotypes about Appalachians and addicts to avoid what could have easily been a reductive portrayal. Instead, she crafts a realistic and still-not-despairing vision from the inside.</p>
<p>This approach – an example of Soja’s thirdspace – is, in my view, the most powerful tool that artists have at their disposal to counteract the impulse to move on from grappling with this ongoing epidemic.</p>
<h2>Filling the void</h2>
<p>What Kingsolver does in prose, Billy Strings and John Prine do in song. </p>
<p>Strings, whose breakout hit, “<a href="https://outsider.com/entertainment/music/country-music/billy-strings-dust-in-a-baggie-lyrics-story-behind-song/">Dust in a Baggie</a>,” is a portrait of methamphetamine addiction, takes on opioids in “<a href="https://americansongwriter.com/billy-strings-enough-to-leave-video-jason-isbell-tour-announcement/">Enough to Leave</a>,” a track from his album “Home.” </p>
<p>Written to commemorate two friends who overdosed on fentanyl-laced heroin within the same week, <a href="https://lyrics.lol/artist/1431433-billy-strings/lyrics/4694970-enough-to-leave">the song</a> is a <a href="https://jambands.com/news/2020/02/20/billy-strings-shares-in-studio-video-of-enough-to-leave/">haunting evocation of grief</a> for those left behind when addiction takes its toll:</p>
<pre class="highlight plaintext"><code> Enough to kill ya, enough to put you down
Seems like every way you turned was like a hard wind comin' down
Enough to leave me, enough to leave me here
And though the room is empty now I can almost feel you near
</code></pre>
<p>The same is true for Prine’s “Summer’s End,” a track from his last album, 2018’s “The Tree of Forgiveness.”</p>
<p>The video for that song, directed by West Virginia filmmakers Kerrin Sheldon and Elaine McMillan Sheldon, <a href="https://www.rollingstone.com/music/music-news/how-john-prines-summers-end-video-addresses-the-opioid-crisis-776514/">portrays an aging grandfather and his young granddaughter</a> going about the mundanities of daily life in the wake of their daughter and mother’s death. A single frame depicts a news headline about the opioid crisis, illuminating the source of their suffering without overshadowing the regularity of their routines.</p>
<p>The video brings to mind a line from Samuel Beckett’s 1953 novel “<a href="https://www.britannica.com/topic/The-Unnamable">The Unnamable</a>”: “You must go on. I can’t go on. I’ll go on.”</p>
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<figcaption><span class="caption">The music video for ‘Summer’s End.’</span></figcaption>
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<h2>Upending a theory of ‘genetic decline’</h2>
<p>Words, music and pictures – all have become powerful tools in this thirdspace reading of opioid-afflicted Appalachia. </p>
<p>Like the Sheldons, Kentucky-born photographer Stacy Kranitz offers gritty, complex and beautiful photographic portraits of Appalachia.</p>
<p><a href="https://www.readingthepictures.org/2014/02/stacy-kranitz-the-rape-of-appalachia/">She has written</a> about how she wants her work to provide a corrective to the negative portraits of Appalachia penned by Kentuckian <a href="https://en.wikipedia.org/wiki/Night_Comes_to_the_Cumberlands">Harry Caudill</a> and New York Times reporter <a href="https://en.wikipedia.org/wiki/Homer_Bigart">Homer Bigart</a> in the 1960s. </p>
<p>Caudill, who emphasized the economic exploitation of Appalachia, also came to embrace William Shockley’s <a href="https://www.splcenter.org/fighting-hate/extremist-files/individual/william-shockley">theory of dysgenics</a>, arguing that “genetic decline” among the people of Appalachia played a contributing role in the perpetuation of their suffering.</p>
<p>Their work brought Appalachia to the <a href="http://acsc.lib.udel.edu/exhibits/show/legislation/appalachian">Johnson administration’s awareness</a>. But it also amplified the national perception of the region and its people as backward, helpless and ripe for exploitation. </p>
<p>Kranitz’s engagement with Appalachia – particularly her refusal to let Caudill’s stereotypical views of its inhabitants as backward and regressive stand – offers a thirdspace revision of the region and its residents. Her series “<a href="https://www.stacykranitz.com/as-it-was-given-to-me">As It Was Given to Me</a>” juxtaposes a burning cross at a Klan rally with an image of a lovely, innocent girl holding a lit sparkler. Unafraid to illustrate the ugliness of the region, Kranitz is equally insistent on finding its beauty. </p>
<p>Like these artists and musicians, Kingsolver set out in “Demon Copperhead” to wrestle with the region’s complex history and its current social ills. </p>
<p>In that, she succeeded. </p>
<p>Hopefully the Pulitzer committee’s recognition of the novel will lead others to not only educate themselves about Appalachia, but also participate in the work needed to undo the damage that these drugs have done – and continue to do. </p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CQtOSdzMXDr","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p><img src="https://counter.theconversation.com/content/205378/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Nash does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Pulitzer Prize-winning author is just one of many artists from Appalachia who are probing the crisis in their work, while taking pains to ensure that it doesn’t define the region and its people.William Nash, Professor of American Studies and English and American Literatures, MiddleburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1984972023-03-29T19:21:16Z2023-03-29T19:21:16ZFDA approval of over-the-counter Narcan is an important step in the effort to combat the US opioid crisis<figure><img src="https://images.theconversation.com/files/515985/original/file-20230317-22-wo4sgg.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The use of naloxone administered by nasal spray can be a lifesaving drug with minimal side effects.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/demonstration-of-a-drug-nebulizer-for-intranasal-royalty-free-image/1457667344?phrase=naloxone&adppopup=true">TG23/iStock via Getty Images Plus</a></span></figcaption></figure><p>On March 29, 2023, the U.S. Food and Drug Administration <a href="https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray">approved Narcan</a> for <a href="https://apnews.com/article/business-medication-opioids-health-38ae986009788501bc418fe108593632">over-the-counter sale</a>. Narcan is the 4-milligram nasal spray version of naloxone, a medication that can quickly counteract an opioid overdose.</p>
<p>The FDA’s greenlighting of over-the-counter naloxone means that it will be available for purchase without a prescription at more than 60,000 pharmacies nationwide. That means that, for 90% of Americans, naloxone nasal spray will be accessible at a pharmacy <a href="https://doi.org/10.1016/j.japh.2022.07.003">within 5 miles from home</a>. It will also likely be available at gas stations, supermarkets and convenience stores. The transition from prescription to over-the-counter status is expected to take a few months.</p>
<p><a href="https://scholar.google.com/citations?user=9Np7_DYAAAAJ&hl=en">We are</a> <a href="https://scholar.google.com/citations?user=84WOMGkAAAAJ&hl=en">pharmacists</a> and <a href="https://www.pharmacy.pitt.edu/directory/profile.php?profile=99">public health experts</a> who seek to increase public acceptance of and access to naloxone. </p>
<p>We think that making naloxone available over the counter is an essential step in reducing deaths due to overdose and destigmatizing <a href="https://www.cdc.gov/dotw/opioid-use-disorder/index.html#">opioid use disorder</a>. Over-the-counter access to naloxone will permit more people to carry and administer it to help others who are overdosing. Moreover, increasing naloxone’s over-the-counter availability will convey the message that risks associated with substance use disorder warrant a pervasive intervention much as with other illnesses.</p>
<p>Deaths from opioid overdoses across the U.S. have <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">increased nearly threefold since 2015</a>.
Between October 2021 and October 2022, approximately 77,000 people died <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">from opioid overdoses in the U.S</a>. Since 2016, the synthetic opioid fentanyl has been responsible for most of the <a href="https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates">drug-involved overdose deaths in America</a>. </p>
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<figcaption><span class="caption">Naloxone can be a lifesaving intervention from opioids and other drugs that are laced with the synthetic opioid fentanyl.</span></figcaption>
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<h2>What is naloxone?</h2>
<p>Naloxone reverses overdose from prescription opioids like fentanyl, oxycodone and hydrocodone and recreational opioids like heroin. Naloxone works by competitively binding to the same receptors in the central nervous system that opioids bind to for euphoric effects. When naloxone is administered and reaches these receptors, it can block the euphoric effects of opioids and reverse respiratory depression when opioid overdose occurs. </p>
<p>There are two common ways to administer naloxone. One is through the prepackaged nasal sprays, such as <a href="https://www.narcan.com/">Narcan</a> and <a href="https://kloxxado.com/">Kloxxado</a> or generic versions of the drug. The other method is via auto-injectors, like <a href="https://zimhi.com/">ZIMHI</a>, which deliver naloxone through injection, similar to the way epinephrine is delivered by an EpiPen as an emergency treatment for life-threatening allergic reactions. </p>
<p>The FDA will review a second over-the-counter application for <a href="https://www.fda.gov/news-events/press-announcements/fda-announces-preliminary-assessment-certain-naloxone-products-have-potential-be-safe-and-effective">naloxone auto-injectors at a later date</a>. Although no interaction with a health care provider will be needed to purchase over-the-counter naloxone, when naloxone is purchased at a pharmacy, a knowledgeable pharmacist will be able to help people choose a product and explain instructions for use.</p>
<p>Research shows that when people who are likely to witness or respond to opioid overdoses have naloxone, <a href="https://www.cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf">they can save patients’ lives</a>. This also includes bystanders as well as first responders like police officers and paramedics. </p>
<p>But until now, people in those situations could intervene only if they were carrying prescription naloxone or knew where to retrieve it quickly. Friends and family of people who use opioids are often given prescriptions for naloxone for emergency use. Over-the-counter naloxone will help make the drug more accessible to members of the general public. </p>
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<figcaption><span class="caption">Naloxone works on a variety of opioids, including fentanyl.</span></figcaption>
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<h2>Reducing stigma and saving lives</h2>
<p>Naloxone <a href="https://www.cdc.gov/drugoverdose/featured-topics/naloxone.html">is a safe medication</a> with minimal side effects. It works only for those with opioids in their system, and it’s unlikely to cause harm if given by mistake to someone who’s not actively overdosing on opioids.</p>
<p>Since approximately 40% of overdoses <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html#:">occur in the presence of someone else</a>, we believe public access to naloxone is extremely important. People may wish to have naloxone on hand if someone they know is at an <a href="https://www.cdc.gov/stopoverdose/naloxone/index.html">increased risk for opioid overdose</a>, including people who have opioid use disorder or people who take high amounts of prescribed opioid medications.</p>
<p>Community centers and recreational facilities may also keep naloxone on hand, similar to the placement of automated external defibrillators in public spaces for emergency use when someone has a heart attack. </p>
<p>There’s a long-held public stigma that suggests addiction is a moral failing rather than a <a href="https://www.cdc.gov/stopoverdose/stigma/index.html">chronic yet treatable health condition</a>. Those who request naloxone or who have an opioid use disorder <a href="https://doi.org/10.1186/s13722-018-0116-2">experience stigma and often aren’t comfortable</a> disclosing their drug use to others, or seeking medical treatment. Removing naloxone’s prescription requirements by making it over the counter could decrease the stigma experienced by individuals since they no longer must request it from a health care provider or behind the pharmacy counter. </p>
<p>In addition, we encourage health care providers and members of the general public to <a href="https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction">use less stigmatizing language</a> when discussing addiction.</p>
<h2>Questionable accessibility</h2>
<p>Often, medications switched from prescription to over the counter are <a href="https://doi.org/10.4103/2279-042X.185706">not covered by insurance</a>. It remains unclear if this will be the case with Narcan. If so, the costs will shift to the patient, highlighting the reason continued support of <a href="https://www.samhsa.gov/find-help/harm-reduction">programs that offer naloxone free of charge</a> remains important.</p>
<p>What’s more, over-the-counter access could paradoxically cause a decrease in the drug’s availability. A rise in purchases could make it harder to buy naloxone if manufacturer supply does not keep up with increased consumer demand. The U.S. experienced such <a href="https://www.cnn.com/2022/12/28/health/flu-covid-rsv-medications-tests/index.html">shortages of over-the-counter drugs</a> in late 2022 during the nationwide surges in flu, respiratory syncytial virus and COVID-19. </p>
<p>Federal and state governments could lessen these potential barriers by subsidizing the cost of over-the-counter naloxone and working with drug manufacturers to provide production incentives to meet public demand.</p>
<p>The effects of nationwide access to over-the-counter naloxone on opioid-related deaths remain to be seen, but making this medication more widely available is an important next step in our nation’s response to the opioid crisis.</p><img src="https://counter.theconversation.com/content/198497/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lucas Berenbrok is part owner of the consulting company, Embarx, LLC. </span></em></p><p class="fine-print"><em><span>Janice L. Pringle is affiliated with C4 Recovery. </span></em></p><p class="fine-print"><em><span>Joni Carroll receives grant funding from the Centers for Disease Control and Prevention Overdose Data to Action. </span></em></p>The Food and Drug Administration’s approval of Narcan will make the lifesaving drug more widely available, especially to those who might be likely to witness or respond to opioid overdoses.Lucas A. Berenbrok, Associate Professor of Pharmacy and Therapeutics, University of PittsburghJanice L. Pringle, Professor of Pharmacy and Therapeutics, University of PittsburghJoni Carroll, Assistant Professor of Pharmacy and Therapeutics, University of PittsburghLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1994822023-03-28T12:15:09Z2023-03-28T12:15:09ZWhat is xylazine? A medical toxicologist explains how it increases overdose risk, and why Narcan can still save a life<figure><img src="https://images.theconversation.com/files/517430/original/file-20230324-20-vu2ybd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5444%2C3627&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Although xylazine is not an opioid, naloxone can reverse the effects of the fentanyl and heroin it is often mixed with.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/PhotoEssayFentanylsScourge/6b522b7eb85b4bf3aca36ae6cb30ed2a">AP Photo/Jae C. Hong</a></span></figcaption></figure><p>The White House officially designated fentanyl adulterated with xylazine as an <a href="https://www.whitehouse.gov/ondcp/briefing-room/2023/04/12/biden-harris-administration-designates-fentanyl-combined-with-xylazine-as-an-emerging-threat-to-the-united-states/">emerging threat to the U.S.</a> on Apr. 12, 2023. Earlier, the U.S. Drug Enforcement Administration <a href="https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine">issued a warning</a> on Mar. 21, 2023, about an increase in trafficking of fentanyl adulterated with xylazine, which can increase the risk of overdosing on an <a href="https://theconversation.com/what-is-fentanyl-and-why-is-it-behind-the-deadly-surge-in-us-drug-overdoses-a-medical-toxicologist-explains-182629">already deadly drug</a>. Xylazine is <a href="https://doi.org/10.1016/j.drugalcdep.2022.109380">increasingly appearing</a> within the U.S. supply of illicit opioids like fentanyl and heroin. The agency noted that it has seized mixtures of xylazine and fentanyl in 48 of 50 states.</p>
<p>Xylazine, commonly referred to as <a href="https://khn.org/news/article/xylazine-tranq-drugs-dangerous/">tranq</a>, is a <a href="https://www.drugsandalcohol.ie/13119/">drug adulterant</a> – a substance intentionally added to a drug product to <a href="https://theconversation.com/rat-poison-is-just-one-of-the-potentially-dangerous-substances-likely-to-be-mixed-into-illicit-drugs-163568">enhance its effects</a>. Illicit drugmakers may include xylazine to <a href="https://doi.org/10.1016/j.drugalcdep.2022.109380">prolong opioid highs</a> or prevent withdrawal symptoms. </p>
<p>As a <a href="https://scholar.google.com/citations?user=X55PT8EAAAAJ&hl=en">physician who cares for people who use fentanyl</a>, I worry about the ways xylazine increases their risk for overdose. I worry even more that misunderstandings about xylazine can make bystanders less likely to <a href="https://umasstox.com/narcan/">administer the lifesaving drug naloxone (Narcan)</a> during an overdose. If you suspect an overdose, calling emergency medical services and administering naloxone are still the critical first steps to saving a life.</p>
<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>
<p><iframe id="ypnUN" class="tc-infographic-datawrapper" src="https://datawrapper.dwcdn.net/ypnUN/5/" height="400px" width="100%" style="border: none" frameborder="0"></iframe></p>
<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>
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<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/2006182023-02-27T13:24:07Z2023-02-27T13:24:07ZCan eating poppy seeds affect drug test results? An addiction and pain medicine specialist explains<figure><img src="https://images.theconversation.com/files/512239/original/file-20230224-1769-g9ij77.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Eating culinary poppy seeds won’t get you high, but they could lead to a failed drug test.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/midsection-of-woman-holding-bagels-in-plate-royalty-free-image/691138209">Linda Caldwell/EyeEm via Getty Images</a></span></figcaption></figure><p><em>The U.S. Defense Department <a href="https://media.defense.gov/2023/Feb/21/2003164614/-1/-1/1/POPPY-SEEDS-WARNING-MEMO-SIGNED-CONTACT-REDACTED.PDF">issued a memo</a> on Feb. 17, 2023, warning service members to avoid eating poppy seeds because doing so may result in a positive urine test for the opiate codeine. Addiction and pain medicine specialist <a href="https://psychiatry.ufl.edu/profile/reisfield-gary/">Gary Reisfield</a> explains what affects the opiate content of poppy seeds and how they could influence drug tests.</em></p>
<h2>What are poppy seeds?</h2>
<p>Poppy seeds come from a species of poppy plant called <a href="https://www.britannica.com/plant/opium-poppy"><em>Papaver somniferum</em></a>. “Somniferum” is Latin for “<a href="https://www.mcgill.ca/oss/article/drugs-health-history-quirky-science/what-drug-may-have-been-detected-had-dorothys-and-cowardly-lions-urine-been-tested-they-entered">sleep-bringing</a>,” which hints that it might contain opiates – powerful compounds that depress the central nervous system and can induce drowsiness and sleep.</p>
<p>There are two main uses for the opium poppy. It is a source of the opiates used in painkillers, the most biologically active of which are morphine and codeine. Its seeds are also used for cooking and baking.</p>
<p>Poppy seeds themselves don’t contain opiates. But during harvesting, the seeds can <a href="https://www.deadiversion.usdoj.gov/drug_chem_info/unwashed_poppy_seed.pdf">become contaminated</a> with opiates contained in the milky latex of the seed pod covering them.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/512234/original/file-20230224-1815-nrztn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of opium poppy heads with drops of opium milk latex leaking from the pod." src="https://images.theconversation.com/files/512234/original/file-20230224-1815-nrztn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512234/original/file-20230224-1815-nrztn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=473&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512234/original/file-20230224-1815-nrztn1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=473&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512234/original/file-20230224-1815-nrztn1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=473&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512234/original/file-20230224-1815-nrztn1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=594&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512234/original/file-20230224-1815-nrztn1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=594&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512234/original/file-20230224-1815-nrztn1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=594&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 milky latex of poppy seed pods contains opiates.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/opium-poppy-heads-papaver-somniferum-drops-milk-royalty-free-image/1445043432">Daniel Prudek/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<h2>What affects opiate content in poppy seeds?</h2>
<p>Many factors determine the opiate concentrations and ratios of poppies. As with wine grapes, the opiate profile of the poppy plant – and thus its seeds – is <a href="https://doi.org/10.1042/bj0140618">affected by its terroir</a>: climate, soil, amount of sunshine, topography and time of harvest.</p>
<p>Another factor is the variety or cultivar of the plant. For example, there are genetically engineered opium poppies that produce no <a href="https://www.abc.net.au/science/articles/2004/09/23/1203133.htm">morphine or codeine</a> and others that produce <a href="https://doi.org/10.1111/ppl.12086">no opium latex</a> at all.</p>
<h2>Can you get high from eating poppy seeds?</h2>
<p>Practically speaking, you cannot eat enough poppy seeds to get you high. Furthermore, processing dramatically decreases opiate content – for example, by <a href="https://doi.org/10.1021/acs.jafc.0c01681">washing</a> or <a href="https://doi.org/10.3389/fchem.2020.00737">cooking or baking</a> the seeds.</p>
<h2>Do poppy seeds affect drug tests?</h2>
<p>Poppy seeds don’t have nearly enough opiates to intoxicate you. But because drug tests are exquisitely sensitive, consuming certain poppy seed food products can lead to <a href="https://doi.org/10.1016/j.forsciint.2014.04.042">positive urine drug test results for opiates</a> – specifically for morphine, codeine or both. </p>
<p>Under most circumstances, opiate concentrations in the urine are too low to produce a positive test result. But <a href="https://doi.org/10.1093/jat/bkac079">certain food products</a> – and it’s generally impossible to know which ones, because opiate content does not appear on food labels – contain enough opiates to produce positive test results. Moreover, because of overlap in opiate concentrations and morphine-to-codeine ratios, it can sometimes be <a href="https://doi.org/10.1093/jat/bkac079">challenging to distinguish</a> test results that are due to the consumption of poppy seeds from those that are due to the use of opiate drugs. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/512229/original/file-20230224-1687-j2ktnx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Bowl and scoop of poppy seeds" src="https://images.theconversation.com/files/512229/original/file-20230224-1687-j2ktnx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512229/original/file-20230224-1687-j2ktnx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512229/original/file-20230224-1687-j2ktnx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512229/original/file-20230224-1687-j2ktnx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512229/original/file-20230224-1687-j2ktnx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512229/original/file-20230224-1687-j2ktnx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512229/original/file-20230224-1687-j2ktnx.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">Processing poppy seeds decreases the opiate content that may be on the seed.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/poppy-seeds-royalty-free-image/1257842791">Burcu Atalay Tankut/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>This is not a problem with most <a href="https://www.ecfr.gov/current/title-49/subtitle-A/part-40#40.137">workplace drug testing</a>. Test results are reviewed by a specially trained physician called a medical review officer. Unless the physician finds evidence of unauthorized opiate use, such as needle marks or signs of opiate intoxication or withdrawal, even relatively high concentrations of opiates in the urine that produce positive test results are generally ruled to be negative.</p>
<p>It turns out, though, that <a href="https://www.washingtonpost.com/nation/2023/02/22/poppy-seeds-drug-test-military/">drug testing in the military</a> is different, and poppy seeds pose potential problems. One such problem, as highlighted in recent news reports, concerns service members who test positive for codeine and assert a “poppy seed defense.” They are still regarded as having taken codeine, sometimes with <a href="https://www.defense.gov/News/News-Stories/Article/Article/3306336/service-members-should-avoid-foods-with-poppy-seeds/">serious consequences</a>, such as a disciplinary action or discharge from the service.</p><img src="https://counter.theconversation.com/content/200618/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gary Reisfield 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>Poppy seeds can become contaminated with opiates during harvesting. For the US Defense Department, invoking a ‘poppy seed defense’ may not be enough to rule out a positive drug test result.Gary Reisfield, Associate Professor of Psychiatry, University of FloridaLicensed 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/1975932023-01-16T19:45:25Z2023-01-16T19:45:25ZSupervised consumption sites reduce drug overdoses and disease transmission — and deserve government support<figure><img src="https://images.theconversation.com/files/504716/original/file-20230116-22-olk3l0.jpg?ixlib=rb-1.1.0&rect=66%2C41%2C5492%2C3192&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A wall at a supervised consumption site in Ottawa is decorated with notes written in chalk.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Adrian Wyld</span></span></figcaption></figure><p><a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/">Since 2016, more than 32,000 Canadians have died from drug overdoses</a>. In response to this overdose epidemic, several provinces have established <a href="https://www.canada.ca/en/health-canada/services/substance-use/supervised-consumption-sites/explained.html">Supervised Consumption Sites (SCS)</a>, which provide people who use drugs with a safe space to administer drugs under the supervision of trained staff. </p>
<p>The term people who use drugs is used to affirm people’s humanity instead of defining them by their drug use. Person-centred language helps <a href="http://www.globalcommissionondrugs.org/wp-content/uploads/2018/01/GCDP-Report-2017_Perceptions-ENGLISH.pdf">reduce stigma and discrimination</a> which in turn can encourage people who use drugs to seek out harm reduction services. </p>
<p>SCSs have proven to <a href="https://harmreduction.org/issues/supervised-consumption-services/">reduce drug overdoses, disease transmission and public drug use</a>. By 2020, there were <a href="https://health-infobase.canada.ca/datalab/supervised-consumption-sites-blog.html?=undefined&wbdisable=true">39 supervised consumption sites across Canada</a>. Yet despite the evidence, some governments continue to oppose safe consumption on ideological grounds. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/504717/original/file-20230116-16-swbvcu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A man wearing a black jumper standing outside a building next to a large yellow bin labelled: needle drop box." src="https://images.theconversation.com/files/504717/original/file-20230116-16-swbvcu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504717/original/file-20230116-16-swbvcu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=364&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504717/original/file-20230116-16-swbvcu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=364&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504717/original/file-20230116-16-swbvcu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=364&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504717/original/file-20230116-16-swbvcu.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=457&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504717/original/file-20230116-16-swbvcu.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=457&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504717/original/file-20230116-16-swbvcu.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=457&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 man waits to enter the Safeworks supervised consumption site in Calgary.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jeff McIntosh</span></span>
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</figure>
<p>Alberta is a prime example of how policy shifts away from public health approaches have tangible effects for the well-being of people who use drugs. <a href="https://doi.org/10.1016/j.drugpo.2022.103934">Our research</a> with marginalized drug users in Lethbridge, Alta. demonstrates that the closure of SCSs can increase drug-related harms and negatively impact the safety and welfare of people who use drugs.</p>
<h2>Lethbridge’s SCS</h2>
<p>Prior to the province approving a supervised consumption site in Lethbridge, the city had long contended with <a href="https://www.thestar.com/edmonton/2019/08/18/a-small-alberta-city-is-home-to-the-busiest-drug-consumption-site-in-north-america-we-spent-12-hours-inside.html">high numbers of drug overdoses</a>. Opened in 2018, Lethbridge’s site quickly became the <a href="https://www.thestar.com/edmonton/2019/08/18/a-small-alberta-city-is-home-to-the-busiest-drug-consumption-site-in-north-america-we-spent-12-hours-inside.html">busiest in North America</a>. This was in part because it offered a range of crucial social, mental and health service resources to marginalized community members.</p>
<p>But the site’s success was short-lived. The provincial government <a href="https://lethbridgenewsnow.com/2020/07/16/province-pulling-funding-from-lethbridges-scs/">defunded</a> and replaced it with an <a href="https://lethbridgenewsnow.com/2020/08/17/lethbridges-overdose-prevention-site-now-operating-as-replacement-for-scs/">Overdose Prevention Site (OPS)</a> just two years later. The OPS, while well intentioned, provides limited social, mental and health resources as compared to the SCS. </p>
<p>Moreover, while the former SCS was in the city’s downtown core, the new overdose prevention site was placed in an industrial area, about a 10-minute walk away from where many local people who use drugs spend time. Those interviewed as part of our research experienced this new location as less safe. </p>
<p>In Lethbridge, the SCS’s closure and replacement with an overdose prevention site meant reduced access to harm reduction services. In addition, the site’s closure stripped local people who use drugs of access to essential community connections and services.</p>
<p>Most people we spoke with felt overdoses and drug-related deaths had increased because of the SCS’s closure, with many having lost loved ones. As one of the participants told us: “There’s too many people dying now.” </p>
<p>Supporting participants’ views, <a href="https://healthanalytics.alberta.ca/SASVisualAnalytics/?reportUri=%2Freports%2Freports%2F1bbb695d-14b1-4346-b66e-d401a40f53e6&sectionIndex=0&sso_guest=true&reportViewOnly=true&reportContextBar=false&sas-welcome=false">provincial health data</a> demonstrates that the average number of deaths from drug poisoning doubled in Lethbridge following the site’s dismantling. </p>
<p>If the goal is to extend harm reduction services to as many people as possible, it is imperative to illuminate what prevents some people who use drugs from routinely accessing the OPS. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/504703/original/file-20230116-20-89gt6t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Syringes in plastic wrapping." src="https://images.theconversation.com/files/504703/original/file-20230116-20-89gt6t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/504703/original/file-20230116-20-89gt6t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=404&fit=crop&dpr=1 600w, https://images.theconversation.com/files/504703/original/file-20230116-20-89gt6t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=404&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/504703/original/file-20230116-20-89gt6t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=404&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/504703/original/file-20230116-20-89gt6t.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=507&fit=crop&dpr=1 754w, https://images.theconversation.com/files/504703/original/file-20230116-20-89gt6t.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=507&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/504703/original/file-20230116-20-89gt6t.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=507&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">SCSs provide a safe space to consume drugs. They also offer a range of crucial social, mental and health service resources to marginalized community members.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Paul Chiasson</span></span>
</figcaption>
</figure>
<h2>How policy change can affect people who use drugs</h2>
<p>In spring 2022, we spent time in downtown Lethbridge, getting to know those who identified as people who use drugs and expressed interest in talking to us. We interviewed 50 houseless people, asking them about their experiences of street life in Lethbridge, whether or not they access the new OPS and why. </p>
<p>Our research provides early evidence that recent provincial policy shifts have negatively impacted people who use drugs in Lethbridge. The majority of those we spoke with who routinely accessed the SCS prior to its closure chose <em>not</em> to access the new OPS. </p>
<p>Participants listed several barriers to accessing the overdose prevention site.</p>
<p>First, the new site does not have a supervised smoking room. This means that those who smoke illicit substances, or who want to replace safe injection with safe smoking, cannot do so in the facility. This is further concerning because, while smoking drugs carries a number of risks, <a href="https://doi.org/10.1016/j.drugalcdep.2021.109003">smoking instead of injecting drugs can decrease skin infections and exposure to blood-borne viruses</a>.</p>
<p>Second, many participants stated that they were fearful of accessing the OPS and spending time in the area. To get from the downtown core to the OPS, they must cross a high-traffic bridge where participants stated people driving by sometimes harass or assault them. There have also been <a href="https://lethbridgeherald.com/news/lethbridge-news/2022/08/04/alpha-house-installs-fencing-at-shelter/">reported concerns over conflict and violence</a> in the vicinity of the overdose prevention site. Accordingly, some people who use drugs often avoided the OPS, opting to consume in “safer,” usually public, areas. </p>
<p>Finally, people who use drugs reported that they often frequented the old SCS because it offered them with wraparound services, social connections and activities beyond supervised consumption. But the OPS lacks these diverse and critical benefits. Because of this, participants felt the OPS was not as responsive to their broader needs. </p>
<p>Undeniably, Lethbridge’s overdose prevention site is providing important health benefits. However, our findings suggest that harm reduction sites that provide marginalized community members with broad community services and connections are more likely to draw local people who use drugs in, encourage uptake and reduce drug-related harms. </p>
<p>Given Lethbridge’s continued challenges with drug-related harms and deaths, it is essential to build safe, accessible and comprehensive harm reduction resources that provide critical care to the city’s most marginalized.</p><img src="https://counter.theconversation.com/content/197593/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carolyn Greene receives funding from the Social Sciences and Humanities Research Council. </span></em></p><p class="fine-print"><em><span>Katharina Maier receives funding from the Social Sciences and Humanities Research Council. </span></em></p><p class="fine-print"><em><span>Marta-Marika Urbanik receives funding from the Social Sciences and Humanities Research Council and Killam Trusts. </span></em></p>Supervised consumption sites provide essential community connections and services for those who use them. By closing them, governments are risking the welfare of people who use drugs.Carolyn Greene, Associate Professor, Criminology, Athabasca UniversityKatharina Maier, Assistant Professor, Criminal Justice, University of WinnipegMarta-Marika Urbanik, Assistant Professor, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1896922023-01-11T01:27:58Z2023-01-11T01:27:58ZHow does methadone work as a heroin-replacement therapy? And what about the longer-acting buprenorphine?<figure><img src="https://images.theconversation.com/files/492493/original/file-20221031-21-8ulmrb.jpg?ixlib=rb-1.1.0&rect=53%2C472%2C5890%2C3484&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/eBW1nlFdZFw">Tbel Abuseridze</a></span></figcaption></figure><p>Around <a href="https://www.aihw.gov.au/reports/alcohol/alcohol-tobacco-other-drugs-australia/contents/drug-types/illicit-opioids-including-heroin#consumption">1%</a> of Australian adults have tried heroin in their lifetime and <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/national-drug-strategy-household-survey-2019/contents/summary">2.7%</a> have used pharmaceutical opioids for non-medical purposes in the past 12 months.</p>
<p>These drugs attach to the <a href="https://theconversation.com/explainer-how-do-drugs-work-48665">opioid receptors</a> in the brain, creating feelings of relaxation, wellbeing and reduced pain.</p>
<p>Heroin has a short <a href="https://www.mind.org.uk/information-support/drugs-and-treatments/medication/explaining-the-half-life/">half life</a>, meaning it doesn’t stay in the body for very long, so it has a high potential for dependence. If you’re dependent, you may need to use several times a day to maintain the effect.</p>
<p><a href="https://www.betterhealth.vic.gov.au/health/servicesandsupport/alcohol-and-drugs--dependence-and-addiction">Dependence</a> is when you use a drug regularly and your body and brain become used to it. When you stop, withdrawal symptoms occur, which in the case of opioids can include symptoms such as muscle aches, strong cravings and hot or cold flushes. These symptoms can be so uncomfortable that they sometimes lead to using opioids again, which will stop the withdrawal symptoms. </p>
<p>Around <a href="https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2681168#:%7E:text=When%20observed%20within%20approximately%201,have%20become%20dependent%20on%20heroin.">one in three people</a> who try heroin become <a href="https://www.betterhealth.vic.gov.au/health/servicesandsupport/alcohol-and-drugs--dependence-and-addiction">dependent</a>, and around <a href="https://pubmed.ncbi.nlm.nih.gov/26963848/">one in five</a> people who use opioids long-term for pain become dependent.</p>
<p>Research shows the most effective treatment for heroin dependence is to replace it with a similar but longer-acting opioid – such as methadone – in a controlled dose to reduce the need to use heroin. This is called “opioid agonist treatment”.</p>
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Read more:
<a href="https://theconversation.com/weekly-dose-methadone-the-most-effective-treatment-for-heroin-dependence-59814">Weekly Dose: methadone, the most effective treatment for heroin dependence</a>
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<h2>How does methadone work?</h2>
<p><a href="https://theconversation.com/weekly-dose-methadone-the-most-effective-treatment-for-heroin-dependence-59814">Methadone</a> was the first medication trialled as a “replacement therapy”. It’s a long-acting opioid, with similar effects to heroin. </p>
<p>It’s usually swallowed as a solution or a syrup. Because it maintains its action for so long, it only needs to be taken once a day.</p>
<figure class="align-right ">
<img alt="Syrup bottle and in cup" src="https://images.theconversation.com/files/492494/original/file-20221031-12-cwuxzv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/492494/original/file-20221031-12-cwuxzv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=820&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492494/original/file-20221031-12-cwuxzv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=820&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492494/original/file-20221031-12-cwuxzv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=820&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492494/original/file-20221031-12-cwuxzv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1030&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492494/original/file-20221031-12-cwuxzv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1030&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492494/original/file-20221031-12-cwuxzv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1030&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Methadone is usually taken as a solution or syrup.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cough-syrup-isolated-on-white-234373261">Shutterstock</a></span>
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<p>When the dose is high enough, methadone blocks the brain’s natural opioid receptors. So if someone uses heroin while on methadone they won’t feel the effects of the heroin because the receptors are already full with methadone.</p>
<p>Methadone treatment was first tested in the 1960s in New York, in a groundbreaking trial at The Rockefeller University by Vincent Dole, a physician, and Marie Nyswander, a psychiatrist. </p>
<p>The first <a href="https://jamanetwork.com/journals/jama/article-abstract/656315">trial of 22 people</a> who were given daily doses of methadone was highly successful and laid the foundation for decades of <a href="https://www.cochrane.org/CD002209/ADDICTN_methadone-maintenance-therapy-versus-no-opioid-replacement-therapy">research demonstrating its effectiveness</a>. </p>
<p>By removing the need to regularly take other opioids, and stabilising opioid withdrawal and cravings, methadone reduces <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002209.pub2/abstract">drug use</a>, reduces <a href="https://www.sciencedirect.com/science/article/abs/pii/S0306460313000816">criminal activity</a>, and improves <a href="https://journals.sagepub.com/doi/abs/10.1177/1010539511404396">health</a>. </p>
<p>Once a person is on a steady dose, which often takes up to six to eight weeks, and they no longer feel withdrawal symptoms, they are better able to work or study. When a person is on a steady dose (that is, that they are not <a href="https://www.australianpolice.com.au/main-drug-index-section/methadone-drug-info/#driving">intoxicated or feeling “under the influence”</a> after their normal daily dose) they are allowed to drive a car, although <a href="https://www.nps.org.au/australian-prescriber/articles/psychoactive-drugs-and-driving">driving is not recommended</a> when undergoing dose changes or at the start of treatment.</p>
<p>Methadone works for people who use heroin or <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD011117.pub3/full">prescription opioids</a>. In Australia, the proportion of people in opioid agonist treatment for dependence to prescription opioids has grown significantly.</p>
<p>Opioid agonist treatment, such as methadone, is an effective treatment for prescription opioid dependence, and is also an effective analgesic (painkiller) for those with both chronic pain and opioid dependence. </p>
<h2>So what is buprenorphine?</h2>
<p><a href="https://adf.org.au/drug-facts/buprenorphine/">Buprenorphine</a> is the other medicine commonly used for opioid dependence. </p>
<p>Buprenorphine works for even longer than methadone and in some cases can be taken every second or third day. It comes in a film or a tablet that dissolves under the tongue. </p>
<p>It is a partial agonist, so it binds to the opioid receptor but doesn’t have a full opioid effect.</p>
<p>Buprenorphine is usually combined with <a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">naloxone</a>: the medicine that reverses heroin overdoses. Naloxone is inactive when taken orally (or sublingually, or under the tounge) with buprenorphine, but if it is injected it causes unpleasant side effects. Combining the two reduces the likelihood someone will inject their medication intravenously (into a vein), as it’s not intended to be used in this way.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-do-painkillers-actually-kill-pain-from-ibuprofen-to-fentanyl-its-about-meeting-the-pain-where-its-at-173804">How do painkillers actually kill pain? From ibuprofen to fentanyl, it's about meeting the pain where it's at</a>
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<p>A <a href="https://adf.org.au/drug-facts/buprenorphine-long-acting-injectable">long-acting buprenorphine</a> that is injected subcutaneously (under the skin) and slowly released over time is also now available in Australia. It can be used as infrequently as once a month, and makes treatment much more accessible. </p>
<p>Some people prefer buprenorphine as it can be less sedating, but others find the full opioid effects of methadone is more effective.</p>
<h2>But it can be costly and difficult to access</h2>
<p>Methadone and buprenorphine are not expensive medicines, and in Australia they are paid for in full by the government. </p>
<p>Methadone and buprenorphine are usually taken under supervision by a community pharmacist. However, the <a href="https://creidu.edu.au/policy_briefs_and_submissions/10-opioid-pharmacotherapy-fees-a-long-standing-barrier-to-treatment-entry-and-retention">cost for the pharmacist</a> to provide methadone or buprenorphine is not subsidised by the government. It has to be paid for by the patient. </p>
<p>The medicine has to be taken daily or, for buprenorphine, at least several times a week. A fee is charged for each dose supplied and the <a href="https://pubmed.ncbi.nlm.nih.gov/34649203/">costs can add up</a>.</p>
<figure class="align-center ">
<img alt="Woman leans against a building at night, her head dipped" src="https://images.theconversation.com/files/492495/original/file-20221031-19-pyvm0b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492495/original/file-20221031-19-pyvm0b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492495/original/file-20221031-19-pyvm0b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492495/original/file-20221031-19-pyvm0b.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492495/original/file-20221031-19-pyvm0b.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492495/original/file-20221031-19-pyvm0b.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492495/original/file-20221031-19-pyvm0b.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">Other costs can push drug replacement therapies out of reach.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/akT1bnnuMMk">Eric Ward/Unsplash</a></span>
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</figure>
<p>Some people also need to pay to see a doctor to get a prescription.</p>
<p>All these costs can be a <a href="https://pubmed.ncbi.nlm.nih.gov/35130368/">disincentive</a> to stay in the program, even though the outcomes are very good.</p>
<h2>There’s still a lot of stigma</h2>
<p>One of the key barriers to treatment is stigma. This occurs across <a href="https://pubmed.ncbi.nlm.nih.gov/35115860/">all levels of the treatment system</a>.</p>
<p>When patients are worried about the stigma of being identified as someone on an opioid pharmacotherapy program, they may wait a long time to seek treatment.</p>
<p>Some treatment providers also hold <a href="https://theconversation.com/wild-butterfly-film-review-claire-murrays-story-gives-a-human-face-to-trauma-drug-use-and-blame-culture-132596">prejudices against people</a> who use heroin and other drugs and may treat them poorly, compounding the problem.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioid-dependence-treatment-saves-lives-so-why-dont-more-people-use-it-122537">Opioid dependence treatment saves lives. So why don't more people use it?</a>
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<p>There is also judgement from people in the community about being on treatments like methadone. Many people have the incorrect idea that methadone is “just replacing one drug for another”.</p>
<p>But compared to using street heroin, methadone treatment is better for the individual, their families and the community. </p>
<p>Think of methadone and buprenorphine treatment in a similar way to insulin for diabetes or daily medications that are needed to manage high blood-pressure. Opioid agonist treatment is usually needed long term and to be taken regularly to be effective. </p>
<figure class="align-center ">
<img alt="Man reaches into medicine cabinet" src="https://images.theconversation.com/files/492499/original/file-20221031-22-omt2q6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/492499/original/file-20221031-22-omt2q6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/492499/original/file-20221031-22-omt2q6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/492499/original/file-20221031-22-omt2q6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/492499/original/file-20221031-22-omt2q6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/492499/original/file-20221031-22-omt2q6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/492499/original/file-20221031-22-omt2q6.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">Methadone and buprenorphine are long-term therapies to treat a health condition.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/view-through-bathroom-cabinet-man-taking-1649734756">Shutterstock</a></span>
</figcaption>
</figure>
<h2>What replacement therapies might come next?</h2>
<p>Several other forms of opioid agonist treatment are available in Canada and Europe, but not yet in Australia. These include <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4226326/">slow-release oral morphine</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/33067836/">injectable opioid agonist treatments</a>. </p>
<p>With injectable opioid agonist treatments, short acting opioids like <a href="https://www.healthdirect.gov.au/hydromorphone">hydromorphone</a> are self-injected under medical supervision multiple times per day. This treatment is usually only when methadone or buprenorphine have been ineffective.</p>
<p>Although these are now well-established treatments <a href="https://edition.cnn.com/2016/09/14/health/prescription-heroin-canada/index.html">in countries such as Canada</a>, it is not clear if or when injectable opioid agonist treatments will become widely available in Australia.</p>
<p>Heroin dependence is a health condition and there is very good evidence that receiving any form of opioid agonist treatment <a href="https://www.bmj.com/content/357/bmj.j1550">saves lives</a>, so it is critical that people can access it when they need it.</p>
<p><em>If you’re worried about your own or someone else’s drug use you can call the National Alcohol and other Drug Hotline on 1800 250 015 for advice, counselling or help finding a treatment provider.</em></p><img src="https://counter.theconversation.com/content/189692/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicole Lee works as a consultant in the alcohol and other drug sector and a psychologist in private practice. She has previously been awarded funding by Australian and state governments, NHMRC and other bodies for evaluation and research into alcohol and other drug prevention and treatment.</span></em></p><p class="fine-print"><em><span>Suzanne Nielsen receives funding from the National Health and Medical Research Council (NHMRC) as a current recipient of an NHMRC Career Development Fellowship. In the past she has received research grants from Seqirus to investigator harms from prescription opioids. She was a named investigator on a trial of buprenorphine depot funded by Indivior but she did not receive funding, nor did her institution. </span></em></p>The best treatment for heroin dependence is opioid agonist treatment, where a similar but longer-acting opioid is provided in a regular dose, often with counselling or other support.Nicole Lee, Professor at the National Drug Research Institute (Melbourne), Curtin UniversitySuzanne Nielsen, Professor and Deputy Director, Monash Addiction Research Centre, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.