tag:theconversation.com,2011:/id/topics/heroin-1800/articlesHeroin – The Conversation2024-03-26T17:02:22Ztag:theconversation.com,2011:article/2258272024-03-26T17:02:22Z2024-03-26T17:02:22ZFor people with mental illness, drugs and alcohol can be a key survival strategy. I’ve learned they shouldn’t have to ‘get clean’ to get treatment<figure><img src="https://images.theconversation.com/files/582279/original/file-20240315-20-k4w6kp.jpg?ixlib=rb-1.1.0&rect=43%2C60%2C5708%2C3768&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-on-bottles-blurred-person-drinking-1200866920">Ground Picture/Shutterstock</a></span></figcaption></figure><p>A decade ago, while working in a women’s prison, I met a young woman whose story would leave an indelible mark on me. She had endured severe abuse at the hands of men, and I was initially concerned that, as a male social worker, my presence might rekindle her trauma. Yet, through careful and considered engagement, we were able to forge a relationship of trust.</p>
<p>Jenny* confided in me that heroin had become her refuge – the only respite that quieted the relentless storm of her thoughts. But her dependency had brought dire consequences: the removal of her children and her subsequent imprisonment for possession with intent to supply. Even so, Jenny told me that before she was imprisoned: “Heroin was the only thing that helped me to cope.”</p>
<p>While inside, she experienced regular flashbacks and profound anxiety. Her treatment regime included antipsychotic medication Seroquel and heroin replacement Subutex – but Jenny didn’t use them conventionally. “The only way they help is if I grind them together and snort them,” she explained. This method provided her a fleeting, euphoric respite from her psychological torment.</p>
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<p><em>Across the world, we’re seeing unprecedented levels of mental illness at all ages, from children to the very old – with huge costs to families, communities and economies. <a href="https://theconversation.com/uk/topics/tackling-the-mental-health-crisis-147216?utm_source=TCUK&utm_medium=ArticleTop&utm_campaign=MentalHealthSeries">In this series</a>, we investigate what’s causing this crisis, and report on the latest research to improve people’s mental health at all stages of life.</em></p>
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<p>It wasn’t Jenny’s drug revelation that struck me most profoundly, but the reaction of some of my prison colleagues. Her unconventional use of the medication was labelled substance abuse, leading to her being ostracised by the prison’s mental health service, which refused to work with her until she “sorted out” her drug issues.</p>
<p>Even though I had known Jenny for a year, it was only when she was about to be released from prison that I really understood how serious her situation was. I was shocked to see her breaking the prison’s rules on purpose because she didn’t want to leave. She started smoking in places she shouldn’t, damaged her own cell and areas everyone used, attacked another prisoner, which was not like her at all, and started using spice and hooch.</p>
<p>Jenny preferred staying in jail over facing life outside, but she was let out all the same. A week after her release, I received news that she had died from a heroin overdose.</p>
<h2>My search for answers</h2>
<blockquote>
<p>Mental health problems are experienced by the majority of drug and alcohol users in community substance use treatment. Death by suicide is also common, with a history of alcohol or drug use being recorded in 54% of all suicides in people experiencing mental health problems. (<a href="https://assets.publishing.service.gov.uk/media/5a75b781ed915d6faf2b5276/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf">Public Health England guide</a>, 2017.)</p>
</blockquote>
<p>Jenny’s tragic story left me with many questions – what were the underlying causes of mental illness? What spurred the spiral into addiction? Why did individuals turn to substance use? – that, even after six years as a mental health social worker working in prisons and psychiatric hospitals, I had neither the knowledge nor experience to answer. Talking to colleagues did not resolve them, so I sought answers by returning to academia alongside my day job.</p>
<p>A postgraduate diploma helped me better understand the theories of mental health from neuroscientific, psychiatric and pharmacological perspectives. But above all, I realised that many of the people I was now encountering in my new role, working in a crisis home treatment team (a community-based team set up to support people experiencing severe mental health issues), would never get better. Rather, they would just keep coming back with a new crisis.</p>
<p>And for a large majority of them (around four in five), substances ranging from highly addictive narcotics to potent, mind-altering chemicals would be a key part of their daily lives in addition to, or as an alternative for, their prescribed psychiatric medication.</p>
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<img alt="" src="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/288776/original/file-20190820-170910-8bv1s7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<p><strong><em>This article is part of Conversation Insights</em></strong>
<br><em>The Insights team generates <a href="https://theconversation.com/uk/topics/insights-series-71218">long-form journalism</a> derived from interdisciplinary research. The team is working with academics from different backgrounds who have been engaged in projects aimed at tackling societal and scientific challenges.</em></p>
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<p>Roger was one of many people I met who relied on <a href="https://theconversation.com/what-is-spice-and-why-is-the-drug-so-dangerous-60600">Spice</a>, a synthetic cannabinoid designed to mimic the effects of naturally occurring <a href="https://www.ncbi.nlm.nih.gov/books/NBK563174/#:%7E:text=Delta%2D9%2Dtetrahydrocannabinol%20(also,the%20class%20of%20cannabinoid%20medications.),%20the%20psychoactive%20ingredient%20in%20marijuana.%20Regular%20Spice%20users%20face%20severe%20health%20risks,%20in%20particular%20to%20their%20cognitive%20function,%20and%20an%20increased%20risk%20of%20%5Bpsychotic%20outcomes%5D(https://onlinelibrary.wiley.com/doi/full/10.1002/wps.20341">THC</a>. (In addition to consumption by smoking, there are increasing reports of synthetic cannabinoids being used in <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5398321/">e-cigarettes or vapes</a>.)</p>
<p>Nonetheless, Roger told me Spice was the “only thing that would help sort my head out”. And, after listening to a lecture from me about the dangers of these substances, he responded:</p>
<blockquote>
<p>I know how much to take – I know when I’ve taken too much or not enough. I use it in doses now. Why would I stop if it’s the only thing that works?</p>
</blockquote>
<p>It was clear that Roger knew much more about the effects of Spice than I did. Interactions like this ignited a desire in me for deeper knowledge – not from books or universities, but directly from people with co-existing mental health and addiction problems.</p>
<p>Perhaps surprisingly, in the UK we don’t know how many people are living in this combined state. Estimates have tended to focus only on people with severe mental health problems and problematic substance use. For example, a <a href="https://www.drugsandalcohol.ie/17764/">2002 Department of Health guide</a> suggested that 8-15% of its patients had a dual diagnosis – while acknowledging that it is difficult to assess exact levels of substance use, both in the general population and among those with mental health problems.</p>
<p>A decade earlier, US research had identified that for <a href="https://psycnet.apa.org/record/2005-09774-007">people with schizophrenia</a>, substance use (non-prescribed drugs) was a significant problem relative to the general population. More recently, a 2023 global review of evidence identified that the prevalence of co-existing mental health and substance use among <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9955022/">children and adolescents treated for psychiatric conditions</a> ranged between 18.3% and 54%.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Painting of Thomas De Quincey" src="https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=644&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=644&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=644&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=810&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=810&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582289/original/file-20240315-24-55mu9.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=810&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Thomas De Quincey, author of Lessons From an English Opium Eater.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Thomas_de_Quincey_by_Sir_John_Watson-Gordon.jpg">National Portrait Gallery via Wikimedia</a></span>
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</figure>
<p>But what I found particularly interesting was an analysis of the writings of Thomas De Quincey from more than 200 years ago. In his 2009 article <a href="https://www.tandfonline.com/doi/abs/10.3109/10826089009056230">Lessons From an English Opium Eater: Thomas De Quincey Reconsidered</a>, leading clinical academic, John Strang, highlighted that issues raised by De Quincey in 1821 remain causes for concern some two centuries later.</p>
<p>De Quincey was arguably the first person to document his own use of substances, in particular opium. His writing shows that he self-medicated to manage pain, including “excruciating rheumatic pains of the head and face”:</p>
<blockquote>
<p>It was not for the purpose of creating pleasure, but of mitigating pain in the severest degree, that I first began to use opium as an article of daily diet … In an hour, oh Heavens! What an upheaving, from its lowest depths, of the inner spirit! </p>
</blockquote>
<p>De Quincey’s use of non-prescribed drugs mirrors that of John, Jenny, Roger and so many other people I have met as a social worker. Clearly, we’ve known about the close relationship between mental illness and substance abuse for hundreds of years, yet are still wrestling with how best to respond.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/guide-to-the-classics-confessions-of-an-english-opium-eater-by-thomas-de-quincey-a-dense-strange-journey-through-addiction-190435">Guide to the classics: Confessions of an English Opium Eater by Thomas De Quincey – a dense, strange journey through addiction</a>
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<p>Official guidance almost always advocates for a <a href="https://www.nhsconfed.org/system/files/2022-12/NHS%20Confederation%20parliamentary%20briefing%20-%20No%20wrong%20door%20-%20a%20ten-year%20vision%20for%20mental%20health%20learning%20disability%20and%20autism%20services.pdf">“no wrong door” policy</a>, meaning that those with dual addiction and mental health issues will get help whichever service encounters them first. But from what people with lived experience were telling me, this was not the case.</p>
<p>I sent freedom of information requests to 54 mental health trusts across England, to try to discern any patterns of variation in the way their patients were being measured and treated. Some 90% of the trusts responded, of which a majority (58%) recognised the dual occurrence of mental illness and substance use. However, the estimated prevalence of this dual diagnosis varied widely – from only nine to around 1,200 patients per trust.</p>
<p>What I found most alarming was that less than 30% of the mental health trusts said they have a specialised service for addiction which accepts referrals for dual diagnosis patients. In other words, throughout England, a lot of these patients are not being appropriately supported.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Out-of-focus man holding a syringe in the foreground" src="https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582295/original/file-20240315-22-jay1uw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-addict-young-man-syringe-action-599693732">271 Eak Moto/Shutterstock</a></span>
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<h2>‘When I say I use heroin, people change’</h2>
<blockquote>
<p>I started using when I was around 18. Things weren’t good in my life at the time, and I got in with a crowd who offered me heroin. It was the most amazing experience; all my worries disappeared better than the antidepressants I had been taking. But the more I used, the more I needed it. Now I use it in stages, just before I go to work and at night.</p>
</blockquote>
<p>Carl had been using heroin for more than ten years when I interviewed him. When I asked if he wanted to stop, he shrugged and said no, explaining:</p>
<blockquote>
<p>I’ve tried so many times – I’ve been on methadone but that was worse, especially coming off it. I know how much to take, and no one knows I use gear – so, no. But, as soon as you tell a professional you take heroin, their whole attitude changes. I’ve seen it many times. I dress quite well and I have a job, but as soon as I say I use heroin, they change. It’s almost as if they don’t see the same person any more.</p>
</blockquote>
<p>Talking to Carl underlined that many users know far more than me about the substances they take and why they take them. Yet as soon as a professional (typically a nurse, social worker or doctor) hears they are taking an illegal substance, or are misusing a legal substance such as alcohol, they are stigmatised and often ostracised from service provision.</p>
<p>Suzanne was homeless and also using heroin, but for different reasons to Carl. I asked why she started using it:</p>
<blockquote>
<p>I’ve had a shit life – it numbs all of that. Now being homeless, it helps me to sleep and keeps me warm, but I only use it in the winter because I need to sleep.</p>
</blockquote>
<p>In summer, Suzanne explained, she would switch to taking “phet” – amphetamines. I asked her why:</p>
<blockquote>
<p>You need to be awake – there are lots of dickheads around. I’ve been beaten and raped in the summer when I was asleep, so you need to be awake more.</p>
</blockquote>
<p>Hearing the stories of people fighting their personal battles with mental health and substance use issues was at once haunting and cathartic for me. It was deeply moving to hear them, time and again, struggling with the most difficult aspect of their condition: the simple decision to ask for help. And sadly, far too often, when they did summon the courage, their requests would go unheard, unheeded, or they would be engulfed by a sprawling system that seemed unable to help.</p>
<p>Dave had been using alcohol for many years and had asked for support on several occasions – only to be passed from service to service:</p>
<blockquote>
<p>I was made redundant and, at 50, was finding it hard to get another job. I wasn’t drinking all of the time then. But as I started to get into more debt and the bailiffs were knocking on the door, I needed a drink to get me through it. It was not until I was charged with drunk driving that I knew I had a problem.</p>
</blockquote>
<p>Dave said he wasn’t shy about asking for help – at least, for a while. But he found himself caught in a downward spiral that led to more drinking, more suffering, and less support:</p>
<blockquote>
<p>So many times I’d stop drinking, but I couldn’t deal with the voices in my head. I’d ask for support, but the waiting lists were so long. The medication the doctor gave me did nothing, so I’d start drinking again, and because I’d start to drink again, mental health services wouldn’t touch me. All they kept saying was: ‘You should stop drinking first.’</p>
</blockquote>
<h2>The biggest barrier to getting support</h2>
<p>To expand my understanding, I also sought the perspectives of a dozen people working on the frontline of mental healthcare – from professionals in NHS mental health and substance use teams, to people working for charitable support groups. Their insights revealed a <a href="https://www.miragenews.com/northern-england-life-ups-death-risk-from-1195801/">frayed and fragmented network of services</a>, with the holes and inefficiencies obvious and crying out for attention and repair. As one nurse explained:</p>
<blockquote>
<p>The stress of trying to get services to help is unbelievable. You’ve got pressure from the person’s family because they are afraid they’ll end up dead. You’ve got pressure from managers to discharge the person. All I’d get is criticism which far outweighed encouragement or support. The stress made me so anxious that I almost gave it all up – and even considered suicide myself.</p>
</blockquote>
<p>Over 80% of the professionals I spoke to called for an integration of mental health and substance use teams, in part because of the huge cuts nationwide in funding to substance use services. One social worker in a substance use service explained the current situation:</p>
<blockquote>
<p>If you get someone with an alcohol addiction, it becomes quite apparent that they use drink as a way of coping with their mental health. But, because of massive waiting lists within mental health services or because they are told they need to stop drinking before [they can be treated], mental health support can’t be offered. So, the person just keeps drinking and eventually disengages from our services as there is no hope for them. We shouldn’t expect someone to stop using a substance that they perceive is helping without offering an alternative treatment.</p>
</blockquote>
<p>For all the professionals I interviewed, the most significant barrier to getting support for someone’s mental health issues was that they used substances and would not receive any treatment until they addressed this. As one mental health nurse told me:</p>
<blockquote>
<p>I had one chap who was using cocaine, mainly due to social anxiety. Initially, he’d use it when socialising with friends. But because it gave him confidence and he could talk to people, he started to use it all the time and got himself in debt. I wanted to address the root cause, the social anxiety, so I referred him to our Improving Access to Psychological Therapy service. But I was told he needed to be abstinent from cocaine for three months before they’d accept him. He eventually disengaged, and I haven’t seen him since.</p>
</blockquote>
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<a href="https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="The word HELP spelled out in white powder" src="https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=363&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=363&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=363&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=456&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=456&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582311/original/file-20240315-25-o9e0be.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=456&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/word-help-spelled-out-by-cocaine-2289738709">Runawayphill/Shutterstock</a></span>
</figcaption>
</figure>
<h2>A seismic shift is needed</h2>
<p>In the shadows of our society, hidden behind the walls of our prisons and in the dark corners of our streets, the experiences of Jenny and countless others bear witness to the profound failings of our healthcare system to address co-existing mental health and substance use issues. For those caught in the merciless cycle of addiction and illness, these systemic inefficiencies and administrative blockades do much to intensify their torment.</p>
<p>Their often brutally honest accounts (and the insights of those who try to support them) draw a portrait of a split and underfunded service, collapsing under the weight of its contradictions. The loud calls for integrated mental health and substance addiction treatment become muffled amid the bureaucratic din of funding cuts, lengthy waiting lists and policy neglect.</p>
<p>The evidence overwhelmingly confirms the need for a model of care that is <a href="https://theconversation.com/how-to-solve-our-mental-health-crisis-214776">holistic and integrated</a> – one that shifts the narrative from stigma and isolation to awareness and support.</p>
<p>The economic case for reshaping investment in our mental health and substance misuse services is powerful. The annual cost of mental health problems to the UK economy is a staggering £117.9 billion – equivalent to <a href="https://www.england.nhs.uk/aac/wp-content/uploads/sites/50/2022/09/B1482_research-demand-signalling-national-mental-health-programme_september-2022.pdf">5% of its annual GDP</a> – with substance misuse adding a <a href="https://www.gov.uk/government/publications/review-of-drugs-phase-two-report/review-of-drugs-part-two-prevention-treatment-and-recovery#:%7E:text=There's%20a%20strong%20'invest%20to,was%20spent%20on%20drug%20treatment.">further £20 billion</a>.</p>
<p>However, these figures tell only part of the tale. While we know that <a href="https://assets.publishing.service.gov.uk/media/5a75b781ed915d6faf2b5276/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf">70% of people in treatment for drug misuse and 86%</a> of people in treatment for alcohol misuse have a mental health diagnosis, the full financial impact of people with these co-occurring disorders is probably far greater.</p>
<p>This also includes people who often plough through a <a href="https://www.emerald.com/insight/content/doi/10.1108/ADD-11-2017-0021/full/html">punitive and bewildering series of services</a> as they navigate their intersecting problems, encountering barriers at every turn that fail to address their <a href="https://assets.publishing.service.gov.uk/media/5a75b781ed915d6faf2b5276/Co-occurring_mental_health_and_alcohol_drug_use_conditions.pdf">acute health</a> and social care needs. As their distress is amplified, the costs to <a href="https://www.emerald.com/insight/content/doi/10.1108/17570971111197175/full/html">wider society</a> escalate too – as one social worker explained to me:</p>
<blockquote>
<p>I am currently supporting a woman who is struggling with alcohol dependency, a condition that began after she endured significant domestic abuse. The cycle is devastating: her trauma cannot be effectively addressed because of her dependency on alcohol, and she cannot abandon alcohol because it’s the only solace she finds from her emotional torment. Despite several attempts at rehabilitation, none of the programmes have sufficiently tackled the mental health aspects of her trauma. Now, with cirrhosis of the liver, her health is in critical decline. It’s a heart-wrenching situation – a stark reminder of the desperate need for integrated treatment approaches that address both substance dependency and the underlying psychological trauma.</p>
</blockquote>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Out-of-focus woman with a glass of alcohol on the table in front of her" src="https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=502&fit=crop&dpr=1 754w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=502&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/582306/original/file-20240315-20-l7ky73.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=502&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
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<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/alcohol-addiction-portrait-lonely-desperate-drunk-137241875">Kamira/Shutterstock</a></span>
</figcaption>
</figure>
<h2>‘I might as well be dead’</h2>
<p>In the quiet confines of a West Midlands mental health crisis centre, I’m preparing to meet someone whose story I know only from the clinical notes on my screen. The phrase “is alcohol dependent” is highlighted in bold. Behind those words is another person whose life is unravelling in the silence of a battle fought alone.</p>
<p>John walks into the room, a man living in the grip of two relentless forces – addiction and mental illness. “It was just to stop the noises,” he says of the whisky he uses as medication for his inner turmoil. His hands are trembling. This is the moment of truth – his story is no longer trapped within the clinical pages of a case file. </p>
<p>“I’ve lost everything,” he tells me. “I might as well be dead.” </p>
<p>Then John explains why he’s given up hope:</p>
<blockquote>
<p>I’ve asked for help so many times, but all I get told is that I need to stop drinking before my mental health can be treated. However, alcohol is the only thing that works for me. I’ve gone through detox, but then I had to wait months for counselling. I just can’t cope that long without any support – antidepressants don’t do anything for me. What’s the point?</p>
</blockquote>
<p>Over the past 15 years, I have met countless “Johns”, both during my day job as a mental health social worker and, latterly, in my academic research. This has led me to conclude that the health and social care system in which I work falls catastrophically short. </p>
<p>This is no mere professional critique. It is an impassioned plea for society to rediscover its collective heart; to explore the human stories that lie hidden in statistics such as that, between 2009 and 2019, <a href="https://documents.manchester.ac.uk/display.aspx?DocID=60521">53% of UK suicides</a> were among people with comorbid diagnoses of mental health and substance use.</p>
<p>Instead of viewing people through the limiting lens of labels, we should endeavour to see their humanity. Engaging in conversation, extending empathy and showing compassion are powerful actions. A kind word, an understanding nod or a gesture of support can affirm their dignity and spark a connection that resonates with their innate human spirit. Or as John, whose journey I’ve had the privilege to witness, puts it:</p>
<blockquote>
<p>It’s not about the help offered but the meaning behind it. Knowing you’re seen as a person, not just a problem to be solved – that’s what sticks with you.</p>
</blockquote>
<p><em>*All names in this article have been changed to protect the anonymity of the interviewees.</em></p>
<p><em>If you or anyone you know require expert advice about the issues raised in this article, the NHS provides this <a href="https://www.nhs.uk/nhs-services/mental-health-services/where-to-get-urgent-help-for-mental-health/">list of local helplines and support organisations</a>.</em></p>
<hr>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=112&fit=crop&dpr=1 600w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=112&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=112&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=140&fit=crop&dpr=1 754w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=140&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/313478/original/file-20200204-41481-1n8vco4.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=140&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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</figcaption>
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<p><em>For you: more from our <a href="https://theconversation.com/uk/topics/insights-series-71218?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insights series</a>:</em></p>
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<li><p><em><a href="https://theconversation.com/insomnia-how-chronic-sleep-problems-can-lead-to-a-spiralling-decline-in-mental-health-224131?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">Insomnia: how chronic sleep problems can lead to a spiralling decline in mental health
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<li><p><em><a href="https://theconversation.com/how-music-heals-us-even-when-its-sad-by-a-neuroscientist-leading-a-new-study-of-musical-therapy-214924?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK">How music heals us, even when it’s sad – by a neuroscientist leading a new study of musical therapy
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<p><em>To hear about new Insights articles, join the hundreds of thousands of people who value The Conversation’s evidence-based news. <a href="https://theconversation.com/uk/newsletters/the-daily-newsletter-2?utm_source=TCUK&utm_medium=linkback&utm_campaign=TCUKengagement&utm_content=InsightsUK"><strong>Subscribe to our newsletter</strong></a>.</em></p><img src="https://counter.theconversation.com/content/225827/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Bratt 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>This is the moment of truth. John’s story is no longer trapped in the clinical pages of a case file. ‘I’ve lost everything,’ he says. ‘I might as well be dead.’Simon Bratt, Mental Health Social Worker and PhD Candidate, Staffordshire UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2205172024-01-12T16:12:10Z2024-01-12T16:12:10ZFour street drugs that could pose the biggest threat to UK public health in 2024<figure><img src="https://images.theconversation.com/files/569021/original/file-20240112-25-j3jcoe.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4025%2C3017&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Xanax pills</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/muncie-indiana-united-states-june-5-1416893333">gremlinworks/Shutterstock</a></span></figcaption></figure><p>As with fashion and music, illicit drugs go through peaks and troughs of popularity. There are popular staples, such as cannabis, and more disruptive and transient substances, such as <a href="https://theconversation.com/meow-hear-this-mephedrone-is-a-curious-khat-2164">mephedrone</a>. As with <a href="https://youtu.be/Ja2fgquYTCg?si=AjGVwuw92NiEPnMS">clothing fashion</a>, the drugs that most people are able to buy are <a href="https://www.emcdda.europa.eu/publications/eu-drug-markets_en">determined by</a> the choices of designers, manufacturers and logistical operations, rather than consumers. </p>
<p>Predicting how the UK drug market may change in 2024 relies not only on recent trends in drug use but also on international developments. Geopolitical events in <a href="https://geographical.co.uk/news/myanmar-becomes-worlds-biggest-producer-of-opium">south-east Asia</a> or <a href="https://www.bbc.co.uk/news/world-latin-america-67912242">South America</a> are just as important as organised crime activity in cities such as London or Liverpool. We suggest that there are four types of drugs that will be of increasing concern in 2024. </p>
<h2>1. Opioids</h2>
<p>Heroin sold in the UK is primarily sourced from opium grown in Afghanistan. Any change in the <a href="https://theconversation.com/afghanistan-what-the-conflict-means-for-the-global-heroin-trade-165995">production and distribution</a> of opium has a direct effect on the <a href="https://theconversation.com/nitazenes-synthetic-opioids-more-deadly-than-fentanyl-are-starting-to-turn-up-in-overdose-cases-212589">UK heroin market</a>. </p>
<p>After seizing power in 2022, the Taliban announced a clampdown on opium farming in Afghanistan. While other growing regions have <a href="https://www.unodc.org/roseap/en/2023/12/southeast-asia-opium-survey-report-launch/story.html#:%7E:text=Bangkok%20(Thailand)%2C%2012%20December,Asia%20released%20in%20Bangkok%20today.">increased production</a>, this has not been at the level of the Afghan crop. </p>
<p>Large stockpiles of opium and heroin stored along trafficking routes have depleted. 2024 will see the impact of this. </p>
<p>The estimated number of people who use heroin has <a href="https://www.gov.uk/government/publications/opiate-and-crack-cocaine-use-prevalence-estimates/estimates-of-opiate-and-crack-use-in-england-main-points-and-methods">increased</a> over the past decade, with an estimated 341,032 current users in England. </p>
<p>This is a highly profitable market, and suppliers are adaptable and nimble in responding to changes like these. As a consequence of the shortfall in Afghan heroin production, new, highly potent <a href="https://www.bmj.com/content/383/bmj.p2421">synthetic opioids</a> have already emerged to fill the gap. These include the group of synthetic opiates known as <a href="https://theconversation.com/nitazenes-synthetic-opioids-more-deadly-than-fentanyl-are-starting-to-turn-up-in-overdose-cases-212589">nitazenes</a>, which have contributed to the <a href="https://theconversation.com/generation-x-hardest-hit-as-drug-deaths-rise-yet-again-in-england-and-wales-220064">record levels</a> of drug-related deaths recorded in 2023 in the UK. </p>
<p>Increased market penetration of these drugs could lead to a big rise in deaths in 2024. Worryingly, <a href="https://www.bbc.co.uk/news/uk-england-manchester-67777938">misselling</a> as other products and unintentional contamination of other non-opioid drugs could increase the harms further. Government and treatment services must act now to prepare for an increase in the supply of these drugs, as the costs of not doing so might lead to a <a href="https://www.sciencedirect.com/science/article/pii/S0955395923003614?via%3Dihub">“nightmare scenario”</a>. </p>
<h2>2. Cocaine</h2>
<p>Cocaine has never been purer, more affordable and more available to those <a href="https://www.theguardian.com/commentisfree/2023/dec/23/coke-consumption-uk-millennials-generation-x">who want it in the UK</a>. While <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2023">levels of use</a> have been relatively stable over the past 20 years, <a href="https://theconversation.com/generation-x-hardest-hit-as-drug-deaths-rise-yet-again-in-england-and-wales-220064">deaths and hospitalisations</a> have increased due the nature of the product on the market and increases in the frequency and length of use. </p>
<p>Unlike other class A drugs, such as heroin, there are few effective treatments, and users tend to be more socially integrated. This means that they are less likely to come into contact with police or present to treatment services. </p>
<p>They may not identify themselves as having a drug problem, despite the effect it may be having on their lives. When disposable income continues to be squeezed as it is in the current cost of living crisis, powder cocaine (as opposed to crack cocaine) is a drug that will continue to provide good “value for money”. Sadly, we predict yet another rise in poisonings and hospitalisations in 2024.</p>
<figure class="align-center ">
<img alt="Older man snorting coke." src="https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/569019/original/file-20240112-29-ke6q5v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cocaine users tend to be more ‘socially integrated’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/old-male-writer-smoking-cigarette-2284921057">Elnur/Shutterstock</a></span>
</figcaption>
</figure>
<h2>3. Ketamine</h2>
<p>Ketamine has been used in medicine as an anaesthetic for many years, and more recently as an <a href="https://theconversation.com/how-antidepressants-ketamine-and-psychedelic-drugs-may-make-brains-more-flexible-new-research-216025">antidepressant</a>. Taken recreational at lower doses, the drug <a href="https://www.talktofrank.com/drug/ketamine">induces</a> feelings of detachment and happiness. </p>
<p>This is another drug that has become increasingly <a href="https://bjgp.org/content/73/727/87">popular</a> because it is cheap, fast-acting and easy to get hold of. </p>
<p>Around <a href="https://news.sky.com/story/student-died-after-taking-ketamine-now-her-mother-wants-to-address-naivety-among-parents-13039959">3.8% of young people</a> (aged 16 to 24) report having used the drug. This has been steadily rising over the past decade. Police report that the weight of <a href="https://www.gov.uk/government/statistics/seizures-of-drugs-in-england-and-wales-financial-year-ending-2022/seizures-of-drugs-in-england-and-wales-financial-year-ending-2022">seizures</a> of ketamine that they made increased sharply from 187kg in 2021 to 1,837kg in 2022. Drug seizures are often used as a proxy for estimating levels of supply.</p>
<p>A range of problems can develop for those using ketamine in higher doses or over a longer period, ranging from mental health problems to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4544340/">incontinence</a>. An overdose of the drug can prove to be fatal.</p>
<p>As with most illicit drugs, combining ketamine with alcohol <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9323326/">increases</a> health risks. Sadly, it is the norm for people to use more than one drug at a time – including alcohol.</p>
<p>Given the widespread availability and <a href="https://www.timeout.com/uk/nightlife/how-ketamine-became-britains-go-to-party-drug">affordability</a> of ketamine in the UK, its use will continue to rise in 2024. Use is concentrated among younger people, many of whom won’t be aware of its potential for harm until it’s too late. </p>
<p>As with cocaine, there has been a distinct lack of health messaging, advice and support for people who use ketamine. Some youth organisations that have tried to do this have faced unhelpful <a href="https://www.thetimes.co.uk/article/how-ketamine-became-the-uks-hidden-campus-killer-9mp3pm6ht">national media backlash</a>. </p>
<h2>4. Benzodiazapines</h2>
<p>Benzodiazepines, more commonly known by brand names such as Valium and Xanax, have proved to be popular and dangerous in equal measure. While medical prescriptions have <a href="https://www.england.nhs.uk/2023/03/opioid-prescriptions-cut-by-almost-half-a-million-in-four-years-as-nhs-continues-crackdown/">fallen</a> in recent years illicit <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2023">demand</a> and supply has not. </p>
<p>Although doctors have been <a href="https://www.nice.org.uk/sharedlearning/benzodiazepine-hypnotics-deprescribing">encouraged</a> to reduce prescriptions for benzodiazepines, the black market has filled the gap in demand. Unlike legitimate supply, the illicit market has no quality control or reliable information on strength – both of which lead to deaths.</p>
<p>The rapid rise in deaths from <a href="https://www.sciencedirect.com/science/article/abs/pii/S0955395921004308">these drugs</a> in Scotland shows regional differences both in the use of drugs and the risks they pose. Reversing this trend in use and fatalities will prove to be difficult in 2024 as there are few signs of a change in demand for, or supply of these drugs.</p>
<h2>Can we prevent drug harms?</h2>
<p>It is not possible to entirely prevent all the harms relating to drug use and the drugs market, but they can be reduced. 2024 may see the emergence of new drugs or new ways of taking them, but what won’t change will be the continuation of more than 20 years of increasing drug-related harm. </p>
<p>In a year of a general election in the UK, there is the danger that drugs policy will be used for political point scoring – signalling to the electorate how tough on crime one party is, or how soft on crime their opponents are. Whatever the outcome of the election, unless there is a clear commitment to long-term investment in responses to drug use, new records will be set in drug-related deaths.</p><img src="https://counter.theconversation.com/content/220517/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives and has received funding from public grant awarding bodies for alcohol and other drugs research, and consultation fees from (international) not-for-profit organisations, and government Ministries for consultation work. He is an unpaid member of the Scientific Advisory Board of the Mind Foundation.</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>Synthetic opioids called nitazenes are ones to watch in 2024.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/2200642023-12-20T14:01:10Z2023-12-20T14:01:10ZGeneration X hardest hit as drug deaths rise yet again in England and Wales<figure><img src="https://images.theconversation.com/files/566838/original/file-20231220-18278-uaocdf.jpg?ixlib=rb-1.1.0&rect=26%2C53%2C4422%2C2921&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/drug-syringe-cooked-heroin-on-spoon-355085264">one photo/Shutterstock</a></span></figcaption></figure><p>It’s another tragic record. A new report has confirmed yet another rise in drug related deaths in <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2022registrations#drug-poisonings-in-england-and-wales">England and Wales</a>. The Office for National Statistics (ONS) reports that 4,907 “drug poisoning” deaths were recorded in 2022 (84.4 deaths per 1,000,000 of the population), the highest on record.</p>
<p>While there was a slight fall in deaths in men (from 3,275 in 2021 to 3,240 in 2022), this was masked by a corresponding increase in women (from 1,584 in 2021 to 1,667 in 2022). This reflects a longer term trend of females catching up with male mortality. Drug-related suicides, <a href="https://sites.manchester.ac.uk/ncish/reports/annual-report-2023/">a topic that doesn’t usually receive much attention</a> in discussions about drug-related harms, were also higher in women than men. </p>
<p>Most deaths involved multiple substances, however opiates were detected in just under half of all deaths (2,261 cases). </p>
<p>Of concern are cocaine deaths (857 cases), which have now increased for 11 consecutive years. It’s not possible to determine whether these related to use of powder or crack cocaine. But we know there’s been an increase in the use of cocaine as well as a boost in the <a href="https://www.emcdda.europa.eu/publications/eu-drug-markets/cocaine_en">global production, supply, purity, affordability and availability</a> of the drug, despite frequent <a href="https://www.nationalcrimeagency.gov.uk/news/seven-men-charged-in-national-crime-agency-investigation-into-140m-cocaine-seizure">large seizures</a> by law enforcement agencies.</p>
<p>Cocaine has become more potent and more affordable in recent years. Both factors increase the risk of harm including fatal overdose. We’ve also lagged behind developing support for people who use cocaine compared to those who use opioids.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/566840/original/file-20231220-27-vu9xne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Actor Matthew Perry, who died of a ketamine overdose." src="https://images.theconversation.com/files/566840/original/file-20231220-27-vu9xne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/566840/original/file-20231220-27-vu9xne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=879&fit=crop&dpr=1 600w, https://images.theconversation.com/files/566840/original/file-20231220-27-vu9xne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=879&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/566840/original/file-20231220-27-vu9xne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=879&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/566840/original/file-20231220-27-vu9xne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1105&fit=crop&dpr=1 754w, https://images.theconversation.com/files/566840/original/file-20231220-27-vu9xne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1105&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/566840/original/file-20231220-27-vu9xne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1105&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">Actor Matthew Perry died after taking ketamine.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/los-angeles-aug-01-matthew-perry-71462893">DFree/Shutterstock</a></span>
</figcaption>
</figure>
<p>Surprisingly, despite its popularity <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2023">in recreational settings</a>, ketamine is not included in the data – and it is unclear why. <a href="https://pubmed.ncbi.nlm.nih.gov/34092131/">Other research</a> suggests there are around 30 deaths each year in England, which is lower than the number of ecstasy deaths (50 in 2022), despite <a href="https://www.thetimes.co.uk/article/how-ketamine-became-the-uks-hidden-campus-killer-9mp3pm6ht">being used by more people</a>. </p>
<p>As for fentanyl, there were <a href="https://nida.nih.gov/research-topics/trends-statistics/overdose-death-rates#:%7E:text=Overall%2C%20drug%20overdose%20deaths%20rose,overdose%20deaths%20reported%20in%202021.">tens of thousands of deaths</a> in the US each year. However, in England and Wales these have remained low (57) and stable. </p>
<p>That’s reassuring, but it’s important not to be complacent. There has been recent concern about the emergence of other types of <a href="https://www.gov.uk/government/news/synthetic-opioids-will-be-banned-as-government-acts-to-stop-drug-deaths">even more potent opioids</a>, with many experts predicting that these drugs will become more prevalent if opium production in Afghanistan <a href="https://www.vice.com/en/article/7kxw3b/the-talibans-opium-ban-has-become-an-existential-problem-for-the-west">continues to decline</a> – leading to fears of even greater increases in drug deaths. </p>
<p>There were also sharp geographical differences in death rates, with those in more deprived areas in the north east and north west of England much higher than other areas. While there were higher rates of <a href="https://www.gov.uk/government/publications/opiate-and-crack-cocaine-use-prevalence-estimates/estimates-of-opiate-and-crack-use-in-england-main-points-and-methods">opioid and crack use</a> in these regions, this also <a href="https://www.health.org.uk/news-and-comment/charts-and-infographics/male-healthy-life-expectancy-from-birth">reflects wider health and social inequalities</a>.</p>
<h2>Age as a risk factor</h2>
<p>The highest rate of deaths occurred in the 40- to 49-year-old age group, and the average age at death continued to rise. This is mainly the “Generation X” cohort born in the 1970s, who came of age when there was a rapid rise in the availability of heroin, and when general population rates of drug use were at their highest in the 1990s. </p>
<p>These premature deaths reflect <a href="https://nida.nih.gov/publications/drugs-brains-behavior-science-addiction/addiction-health">poorer</a> physical and psychological health, such as compromised respiratory and cardiovascular functioning, which increases the risk of dying from drugs. Many of these health problems could be <a href="https://www.emcdda.europa.eu/publications/topic-overviews/prevention-drug-related-deaths_en">treated</a> if people accessed health services, but unfortunately too few do – adding to the risk of premature death. </p>
<p>The data doesn’t reveal everything though. It is also possible that coroners may record a physical health issue as the cause of death, rather than use of drugs. This adds to an <a href="https://backup.ons.gov.uk/wp-content/uploads/sites/3/2018/08/Drug-related-deaths-deep-dive-into-coroners-records.pdf">underestimation</a> of the number of people dying from drugs.</p>
<p>Synthetic opioids, implicated in <a href="https://www.bbc.co.uk/news/uk-67589364">local spikes in deaths</a>, aren’t fully captured in the latest ONS figures either. This is because there are <a href="https://theconversation.com/drug-deaths-in-england-and-wales-rise-for-eighth-consecutive-year-145498">delays</a> between when a death occurs, when it is officially recorded by the coroner and when it is included in ONS reports. The latest report includes deaths which occurred in 2021 and 2022, and even as far back as 2017. </p>
<p>While rapid response investigatory panels have been set up in some local areas, these continuing delays hinder rapid assessment of threats to public health. </p>
<p>It may seem paradoxical that overall drug use is <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/articles/drugmisuseinenglandandwales/yearendingmarch2023#:%7E:text=1.-,Main%20points,(around%201.1%20million%20people).">declining</a> while drug-related deaths are rising. But this can be explained by the time taken to develop dependent use of drugs and the accompanying problems and risk to health. </p>
<h2>Reversing fatalities</h2>
<p>The government commissioned Dame Carol Black to advise on how the record number of drug related deaths could be reversed. <a href="https://www.gov.uk/government/publications/review-of-drugs-phase-two-report">Her report</a>, published in 2020 and 2021, provided several suggestions including increasing investment in drug treatment which the government has accepted. </p>
<p>While provision of evidence-based drug treatment reduces the risk of death, increased investment will take time to have an impact. It comes after a decade of austerity, which severely affected provision of drug services. Currently, only about <a href="https://fingertips.phe.org.uk/search/drug">half of people</a> who might benefit from formal support are accessing treatment services. </p>
<p>There is no single intervention that will reduce death rates, and the complex profile of the illicit drug market and the cocktail of drugs implicated in deaths means that a whole systems response is required. Most importantly, recent uplifts in funding of treatment services need to be maintained. This will be challenging given the economic pressure on public services. </p>
<p>The priority should be an increase in the community provision of <a href="https://theconversation.com/uk/topics/naloxone-7974">naloxone</a>, the opioid overdose reversal drug. This can already be distributed through drug services, and an increasing number of <a href="https://www.bbc.co.uk/news/uk-england-beds-bucks-herts-66293181">police officers</a> are also carrying it. Supervised drug consumption facilities, such as the one due to be <a href="https://www.bbc.co.uk/news/uk-scotland-scotland-politics-66796575">trialled</a> in Glasgow in 2024 <a href="https://www.emcdda.europa.eu/publications/technical-reports/drug-consumption-rooms_en">may reduce</a> risks in some more vulnerable groups, including those who are experiencing street homelessness.</p>
<p>City-based <a href="https://www.crew.scot/the-scottish-drug-checking-project/">drug checking services</a> and local early warning systems can also help to identify the local emergence of harmful substances. The government is also <a href="https://www.gov.uk/government/news/5-million-fund-to-tackle-fatal-drug-deaths-across-the-uk#:%7E:text=As%20part%20of%20the%20Reducing,in%20potential%20drug%2Drelated%20deaths.">funding pilot projects</a> that may provide technological and data driven innovations. </p>
<p>There remains a worrying lack of innovation in the response to non-opioid drugs such as benzodiazepines (544 deaths this year). Considering the high proportion of deaths attributed to long-term health conditions, it is essential that we continue to break down barriers to accessing timely healthcare in all its forms, including <a href="https://www.antistigmanetwork.org.uk/home">stigma</a> and poor quality care.</p><img src="https://counter.theconversation.com/content/220064/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Harry Sumnall receives and has received funding from public grant awarding bodies for alcohol and other drugs research, and consultation fees from (international) not for profit and government Ministries for consultation work. He is an unpaid member of the Scientific Advisory Board of the Mind Foundation. </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>Women are catching up with men’s drug use.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/2148952023-11-30T17:23:43Z2023-11-30T17:23:43ZBuvidal: is it really a ‘game changer’ in the treatment of problematic opioid use?<p>To overcome problematic opioid use, traditional forms of opioid substitution therapy, such as <a href="https://www.nhs.uk/medicines/methadone/">methadone</a> and <a href="https://www.nhs.uk/medicines/buprenorphine-for-pain/">oral buprenorphine</a>, have become valuable tools. <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002209.pub2/full?highlightAbstract=opioid">Research</a> shows that patients receiving substitution therapy are more likely to stay in treatment and stop using heroin than patients receiving treatments that do not involve substitutes – such as counselling or group therapy.</p>
<p>But not all those on substitute medication are able to stop using illicit opioids. Some continue to use them in addition to the substitute. One <a href="https://www.sciencedirect.com/science/article/abs/pii/S0376871621001460">barrier</a> to success is the need to attend a clinic or pharmacy every day, or every few days, to obtain the substitute. </p>
<p>In early 2019, a new form of substitute treatment, long-acting injectable buprenorphine, was approved for use in the UK. Unlike methadone and oral buprenorphine, <a href="https://www.nice.org.uk/advice/es19/evidence/evidence-review-pdf-6666819661#:%7E:text=Buprenorphine%20prolonged%2Drelease%20injection%20is,buprenorphine%20prolonged%2Drelease%20injection%20subcutaneously.">long-acting injectable buprenorphine</a> is administered via an injection either weekly or monthly. The treatment – also known by its brand names Buvidal or Sublocade – has been heralded as a “<a href="https://nation.cymru/news/welsh-university-carries-out-game-changer-drug-treatment-research/">game changer</a>” by both doctors and patients. </p>
<h2>Opioids</h2>
<p>In 2021, nearly 5,000 drug-related deaths were <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsrelatedtodrugpoisoninginenglandandwales/2021registrations">registered</a> in England and Wales. About half of those involved an opioid. </p>
<p>Opioids are a class of drugs that include substances derived from the opium poppy. They include <a href="https://www.nhs.uk/medicines/morphine/">morphine</a> and <a href="https://www.emcdda.europa.eu/publications/drug-profiles/heroin_en">heroin</a>, as well as synthetic alternatives that mimic the effects of naturally occurring opioids such as <a href="https://www.nhs.uk/medicines/tramadol/">tramadol</a> and <a href="https://bnf.nice.org.uk/drugs/fentanyl/">fentanyl</a>.</p>
<p>Opioids work in the brain to produce a variety of effects, including pain relief. They also produce feelings of euphoria, joy and pleasure. Opioids have a depressant effect on the body, so if someone overdoses, they can stop breathing and may die. Overdose is a particular risk for those who use illegally obtained opioids of unknown strength, such as heroin.</p>
<p>Often people are unable to stop using opioids despite the risk of death and the serious negative health and social consequences. Such drugs are hard to give up, partly because stopping causes painful physical and psychological withdrawal symptoms.</p>
<h2>Opioid substitution therapy</h2>
<p>An effective form of treatment for problematic opioid use is opioid substitution therapy, where illegally obtained opioids are substituted for prescribed alternatives. </p>
<p>Providing a legal substitute of known purity is useful in many ways. Most notably, it removes the need to buy and use illicit opioids. This reduces the risk of <a href="https://www.bmj.com/content/357/bmj.j1550">overdose</a> and the need to commit crimes like <a href="https://academic.oup.com/bjc/article-abstract/49/4/513/2747197">theft and shoplifting</a> to get money to pay for drugs.</p>
<p>But while daily attendance and supervised consumption may help to minimise the risk of misuse, it also has its drawbacks. For example, it can bring patients into regular contact with their former drug-using networks and can require time-consuming journeys that interfere with employment, education and other responsibilities.</p>
<p>Long-acting injectable buprenorphine does not have these drawbacks. It is not unlike <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8369037/">long-acting</a> forms of contraception, in that the medicine releases slowly over time, thereby avoiding the peaks and troughs associated with oral formulations.</p>
<p>When the pandemic broke and the UK went into lockdown, <a href="https://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs_en">concerns</a> were raised by experts that daily attendance at clinics or pharmacies for opioid substitution medication might increase the risk of COVID transmission. </p>
<p>Keen to stop the spread of the virus while also providing safe and continuous treatment to patients, the Welsh government <a href="https://committees.parliament.uk/writtenevidence/107535/pdf/">agreed</a> to fund the roll-out of long-acting injectable buprenorphine to drug services across Wales. </p>
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<figcaption><span class="caption">Two doctors discuss Buvidal from the perspective of lived experience.</span></figcaption>
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<p>That decision was supported by <a href="https://pilotfeasibilitystudies.biomedcentral.com/articles/10.1186/s40814-023-01348-5">emerging evidence</a> of the effectiveness of the medication from a drug service in south Wales that had been piloting the medicine before the pandemic. </p>
<h2>Results</h2>
<p>While the primary aim at that time was to stop the spread of COVID, it quickly became clear that the medication was benefiting patients in many other ways. </p>
<p>Patients taking part in a <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">survey</a> about the new medication reported reductions in cravings, lower levels of anxiety, reductions in offending and abstinence from illicit opioids. They described rebuilding their lives, getting jobs, reconnecting with family members and heralded long-acting injectable buprenorphine as a “game changer”, “life changing” and even a “miracle”. </p>
<p>Positive results have also been reported in <a href="https://www.jsatjournal.com/article/S0740-5472(22)00058-7/fulltext">systematic reviews</a> that summarise the findings of the currently small, and not very robust, body of evidence on the effectiveness of the medication.</p>
<p>However, alongside the reports of success, less positive <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">stories</a> have emerged suggesting that the treatment may not be a silver bullet. Some patients have found the transition onto the medication challenging because it required them to be in full withdrawal before their first dose. </p>
<p>Others have been overwhelmed with emotions because the medication made them feel so clear-headed that their past traumas – suppressed by years of illicit opioid use – had begun to resurface. There have also been <a href="https://kaleidoscope68.org/app/uploads/2022/05/Kaleidoscope-Peer-led-Buvidal-Review..pdf">reports</a> of an increase in crack cocaine use among some patients and concerns about the reduced amount of contact (from daily to monthly) with drug services.</p>
<p>Even though there is a “<a href="https://pubmed.ncbi.nlm.nih.gov/16764215/">ceiling effect</a>” that reduces the risk of overdose, this medication still carries a risk of respiratory depression. This risk is <a href="https://pubmed.ncbi.nlm.nih.gov/15957155/">greater</a> among those using alcohol, benzodiazepines or other opioids such as heroin.</p>
<p>Long-acting injectable buprenophine is still in its infancy worldwide, so the evidence for its effectiveness is slim. To determine if it really is a “game changer”, experts will need to look at its impact across a wider range of outcomes, over longer periods and with larger samples than have been considered to date.</p><img src="https://counter.theconversation.com/content/214895/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katy Holloway receives funding from Welsh Government and is a member of Welsh Government's National Implementation Board for Drug Poisoning Prevention. </span></em></p><p class="fine-print"><em><span>Fabrizio Schifano receives funding from Welsh Government. Currently a World Health Organization (WHO) member of the Expert Committee on Drug Dependence (ECDD; 2023). Previously, Schifano was a member of the ACMD UK and an expert advisor of the European Medicines Agency (EMA) for Psychiatry. </span></em></p>Long-acting injectable buprenorphine is also known by the brand names Buvidal or Sublocade.Katy Holloway, Professor of Criminology, University of South WalesFabrizio Schifano, Chair in Clinical Pharmacology and Therapeutics, University of HertfordshireLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2137162023-10-16T21:49:31Z2023-10-16T21:49:31ZThe roots of the North American opioid crisis, and 3 key strategies for stopping it<figure><img src="https://images.theconversation.com/files/554088/original/file-20231016-21-1blzbh.jpg?ixlib=rb-1.1.0&rect=31%2C7%2C4866%2C3210&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Approaching the opioid crisis from a public health perspective includes massively increasing access to care and treatment for patients experiencing substance use disorder.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><iframe style="width: 100%; height: 100px; border: none; position: relative; z-index: 1;" allowtransparency="" allow="clipboard-read; clipboard-write" src="https://narrations.ad-auris.com/widget/the-conversation-canada/the-roots-of-the-north-american-opioid-crisis-and-3-key-strategies-for-stopping-it" width="100%" height="400"></iframe>
<p>The Netflix series <em><a href="https://www.netflix.com/ca/title/81095069">Painkiller</a></em> recently depicted how the over-prescribing of the medicine OxyContin wreaked havoc on American society. </p>
<p>Today the grim reality is that opioid-related deaths in North America reached a record level in 2022, with more than <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">109,000 fatalities in the United States</a>. The same year in Canada, <a href="https://www.statista.com/statistics/812260/number-of-deaths-from-opioid-overdose-canada-province/">deaths exceeded 7,400</a>, a number equivalent to 20 opioid-related deaths every day, and this is <a href="https://www.thelancet.com/infographics-do/opioid-crisis-north-america">likely to continue to increase over the coming years</a>.</p>
<p>The opioid overdose crisis has been ongoing for over two decades in Canada and the U.S. The current mortality rate is greater than the <a href="https://www.cdc.gov/mmwr/preview/mmwrhtml/mm5021a2.htm">worst years</a> of the <a href="https://www.jstor.org/stable/41994093">HIV/AIDs epidemic</a> in these <a href="https://doi.org/10.14745%2Fccdr.v43i12a01">countries</a>. </p>
<p><a href="https://www.canada.ca/en/health-canada/services/opioids.html">Opioids</a> are drugs primarily used to treat severe pain, such as after surgery. When prescribed responsibly they are an effective medication, but if over-prescribed or used recreationally they can lead to an addiction (known as <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">opioid use disorder</a>) that can result in overdose death and wider community problems.</p>
<h2>The roots of the crisis</h2>
<p>After introduction of the opioid painkiller OxyContin in 1996, <a href="https://doi.org/10.2105%2FAJPH.2007.131714">Purdue Pharma marketed the drug aggressively</a>, underplaying its potential for addiction. Prescriptions increased and many patients became addicted. Purdue Pharma eventually <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">pleaded guilty to criminal charges in 2020</a>.</p>
<p>To address addiction, <a href="https://store.samhsa.gov/sites/default/files/d7/priv/sma16-4997.pdf">prescription monitoring programs</a> aimed to limit supply but many patients then sought illicit opioids, leading to large heroin markets in the 2010s. </p>
<p>From 2015 onwards, illegally made <a href="https://www.canada.ca/en/health-canada/services/substance-use/controlled-illegal-drugs/fentanyl.html">fentanyl</a> — a very strong opioid that is easy to manufacture — became widely available, and rapidly replaced the heroin market. Fentanyl is extremely toxic — up to 100 times stronger than heroin — and is largely responsible for the increase in overdose deaths. </p>
<p>Now North Americans face an urgency on how to end the suffering. There is no single solution given the complexity of the problem, but we explain three potential strategies for treating patients and managing this epidemic.</p>
<h2>1. Treat substance use disorders as a public health problem</h2>
<p>The traditional “<a href="https://www.lse.ac.uk/ideas/publications/reports/ending-drugs">war on drugs</a>” approach that focuses only on criminalization has been unsuccessful. In reality the data shows that illegal drug prices have fallen whilst purity and deaths have increased. <a href="https://www.themarshallproject.org/2021/07/15/inside-the-nation-s-overdose-crisis-in-prisons-and-jails">Overdose deaths have also increased in prisons</a> showing that places with even the highest level of security are vulnerable to drug smuggling.</p>
<p>Focusing on the opioid crisis through a public-health approach includes massively increasing access to care and treatment for patients experiencing substance use disorder. It requires more evidence-based services such as addiction clinics, psychotherapy harm reduction strategies and education for both patients and families about treatments that are available to them. </p>
<p>Beyond initial treatment there should be continued professional social support and a wider national effort to address the <a href="https://doi.org/10.2105%2FAJPH.2017.304187">socioeconomic causes</a> in disadvantaged communities. </p>
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<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>
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<p>Just as there is <a href="https://www.youtube.com/watch?v=HHiN7JftdcY">stigma associated with addiction</a> that stops people from seeking help, there also appears to be stigma at the political and community level, as there is reluctance to fully acknowledge community drug problems. This <a href="https://doi.org/10.1371/journal.pmed.1002969">stigma needs to be reduced</a> so patients can get help.</p>
<h2>2. Find better treatments through research</h2>
<p>There are currently three main medicines approved for <a href="https://www.canada.ca/en/health-canada/services/opioids/opioids-use-disorder-treatment.html">treating patients with opioid use disorder</a> in Canada and the U.S.: methadone, buprenorphine/naloxone and extended-release naltrexone.</p>
<p>Although these are effective when used, there are barriers to access and long-term engagement with these treatments. <a href="https://thetyee.ca/News/2023/10/06/Catastrophe-No-Sense-Crisis/">Less than 10 per cent of overdose survivors have access to meaningful care.</a> The limited number of medications available does not work for everyone. We need more innovation to rapidly increase access to care and to find better therapies that suit the needs of different patients.</p>
<p>For example, our <a href="https://www.bccsu.ca/about/">research centre in Vancouver</a>, is evaluating a slow-release formulation of morphine compared to methadone, which has been the dominant treatment for the past 40 years. This study will generate real-world evidence on the effectiveness of novel treatments in contexts of increasing fentanyl use.</p>
<p>Other research is exploring <a href="https://classic.clinicaltrials.gov/ct2/show/NCT05985850">cannabis-based therapy</a> and the <a href="https://www.bccsu.ca/road-to-recovery-study/">best pathways patients can access for recovery</a>. These research initiatives aim to increase the number of evidence-based treatments that can be used to enhance patient recovery and quality of life.</p>
<h2>3. Stop the international spread of the epidemic</h2>
<p>Currently the epidemic is contained within North America but there is the real <a href="https://doi.org/10.1007/s40429-018-0231-x">concern of the crisis spreading</a> to other countries. There is a steady <a href="https://theconversation.com/over-the-counter-opioids-does-britain-have-a-codeine-problem-205331">increase in prescription</a> and illicit opioid use in the United Kingdom and other European countries, which should be an early warning sign that they do not follow the same trajectory. Clinicians must remain actively vigilant on how they prescribe these drugs. </p>
<p>There should be <a href="https://doi.org/10.1016/S0140-6736(21)02252-2">greater international regulation</a> in the marketing and operational strategies of pharmaceuticals, and oversight of the “<a href="https://www.science.org/content/article/fda-s-revolving-door-companies-often-hire-agency-staffers-who-managed-their-successful">revolving door</a>” between industry and regulator employment. There is a potential conflict of interest when pharma companies hire the government employees who oversee their applications. As shown in <em>Painkiller</em>, the FDA regulator who initially had issues with the drug’s approval, and then later approved it, subsequently went on to work for Purdue.</p>
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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>
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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/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>
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<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>
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<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/1994822023-03-28T12:15:09Z2023-03-28T12:15:09ZWhat is xylazine? A medical toxicologist explains how it increases overdose risk, and why Narcan can still save a life<figure><img src="https://images.theconversation.com/files/517430/original/file-20230324-20-vu2ybd.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5444%2C3627&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Although xylazine is not an opioid, naloxone can reverse the effects of the fentanyl and heroin it is often mixed with.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/PhotoEssayFentanylsScourge/6b522b7eb85b4bf3aca36ae6cb30ed2a">AP Photo/Jae C. Hong</a></span></figcaption></figure><p>The White House officially designated fentanyl adulterated with xylazine as an <a href="https://www.whitehouse.gov/ondcp/briefing-room/2023/04/12/biden-harris-administration-designates-fentanyl-combined-with-xylazine-as-an-emerging-threat-to-the-united-states/">emerging threat to the U.S.</a> on Apr. 12, 2023. Earlier, the U.S. Drug Enforcement Administration <a href="https://www.dea.gov/alert/dea-reports-widespread-threat-fentanyl-mixed-xylazine">issued a warning</a> on Mar. 21, 2023, about an increase in trafficking of fentanyl adulterated with xylazine, which can increase the risk of overdosing on an <a href="https://theconversation.com/what-is-fentanyl-and-why-is-it-behind-the-deadly-surge-in-us-drug-overdoses-a-medical-toxicologist-explains-182629">already deadly drug</a>. Xylazine is <a href="https://doi.org/10.1016/j.drugalcdep.2022.109380">increasingly appearing</a> within the U.S. supply of illicit opioids like fentanyl and heroin. The agency noted that it has seized mixtures of xylazine and fentanyl in 48 of 50 states.</p>
<p>Xylazine, commonly referred to as <a href="https://khn.org/news/article/xylazine-tranq-drugs-dangerous/">tranq</a>, is a <a href="https://www.drugsandalcohol.ie/13119/">drug adulterant</a> – a substance intentionally added to a drug product to <a href="https://theconversation.com/rat-poison-is-just-one-of-the-potentially-dangerous-substances-likely-to-be-mixed-into-illicit-drugs-163568">enhance its effects</a>. Illicit drugmakers may include xylazine to <a href="https://doi.org/10.1016/j.drugalcdep.2022.109380">prolong opioid highs</a> or prevent withdrawal symptoms. </p>
<p>As a <a href="https://scholar.google.com/citations?user=X55PT8EAAAAJ&hl=en">physician who cares for people who use fentanyl</a>, I worry about the ways xylazine increases their risk for overdose. I worry even more that misunderstandings about xylazine can make bystanders less likely to <a href="https://umasstox.com/narcan/">administer the lifesaving drug naloxone (Narcan)</a> during an overdose. If you suspect an overdose, calling emergency medical services and administering naloxone are still the critical first steps to saving a life.</p>
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<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>
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<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>
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<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/1991992023-03-05T19:20:04Z2023-03-05T19:20:04ZA neighbourhood ‘war zone’ and a garden-gate overdose sparked Judy Ryan’s fight for Victoria’s first safe injecting room<figure><img src="https://images.theconversation.com/files/512360/original/file-20230227-4956-vp2k3n.JPG?ixlib=rb-1.1.0&rect=0%2C2%2C1528%2C971&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p>Most of us don’t have people overdosing on drugs in our front garden. Judy Ryan did. In July 2016, Ryan found a young man slumped at her gate: one of her “regulars”, who often injected drugs in or around her Richmond property.</p>
<p><a href="https://scribepublications.com.au/books-authors/books/you-talk-we-die-9781922585851">You Talk, We Die</a> describes her involvement, as an community activist, in the battle for Melbourne’s first safe injecting facility (and Australia’s second). </p>
<hr>
<p><em>Review: You Talk, We Die the battle for Victoria’s first safe injecting facility – Judy Ryan (Scribe Publications)</em></p>
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<p>North Richmond Community Health’s <a href="https://nrch.com.au/services/medically-supervised-injecting-room/#whatismsir">medically supervised injecting room</a> opened in June 2018: initially for a two-year trial, <a href="https://www.yarracity.vic.gov.au/the-area/community-safety-and-wellbeing/medically-supervised-injecting-room">since extended</a> for a further three years, until June 2023. </p>
<p>Melbourne is set to have a second medically supervised injecting facility, most likely in the CBD.</p>
<p>Ryan describes the situation in her community prior to the safe injecting facility as something akin to a war zone:</p>
<blockquote>
<p>I regularly walked south along Lennox Street to Richmond station. It was common to see people injecting, “on the nod”, or overdosed in the playground of Richmond West Primary School or next door in the carpark of North Richmond Community Health. As these incidents had been common place in this area for decades, both establishments had well-honed drills. </p>
</blockquote>
<p>Ryan’s book describes, in meticulous detail, what it took for the Victorian government to trial Richmond’s safe injecting facility, through the lens of a local resident. It shows change is not always linear; it can be messy, and involves multiple systems. </p>
<p>And it shows Judy Ryan was the right person, at the right time, to help leverage change.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/512361/original/file-20230227-2428-v17nrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman smiling in front of a busy main road. She wears glasses, a red scarf and a black jacket." src="https://images.theconversation.com/files/512361/original/file-20230227-2428-v17nrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512361/original/file-20230227-2428-v17nrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=435&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512361/original/file-20230227-2428-v17nrt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=435&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512361/original/file-20230227-2428-v17nrt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=435&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512361/original/file-20230227-2428-v17nrt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=547&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512361/original/file-20230227-2428-v17nrt.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=547&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512361/original/file-20230227-2428-v17nrt.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=547&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Judy Ryan’s story shows change can be messy, and it involves multiple systems.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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<h2>Safe injecting facilities reduce harm</h2>
<p>Safe injecting facilities are health centres where registered nurses and health-education officers supervise “drug injecting that would otherwise happen elsewhere – often in public and under dangerous conditions”, as Ryan writes. They provide emergency medical care if needed, and can refer clients to other services, including mental health support, addiction treatment, wound care and blood testing.</p>
<p>There is <a href="https://link.springer.com/article/10.1007/s11904-017-0363-y">good evidence</a> safe injecting facilities reduce drug-related harms.</p>
<p>Ryan writes that safe injecting facilities around the world:</p>
<blockquote>
<p>have been found to reduce the number of fatal and non-fatal drug overdoses and the spread of blood borne viral infections (including HIV and hepatitis B and C) both among people who inject drugs and in the wider community.</p>
</blockquote>
<p>North Richmond Community Health lists vital statistics for its safe injecting facility (recorded between June 30 2018 and September 30 2022) on its website. They include: 346,598 visits, 6,355 overdoses safely managed, and more than 112,000 health and social support services provided onsite.</p>
<p>Despite the available evidence, it’s been very challenging to get safe injecting facilities and other harm-reduction strategies (such as pill testing) trialled in Australia. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-goes-on-inside-a-medically-supervised-injection-facility-87341">What goes on inside a medically supervised injection facility?</a>
</strong>
</em>
</p>
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<h2>Windows for change</h2>
<p>Drug policy reform, such as the implementation of a safe injecting facility, typically requires “<a href="https://openresearch-repository.anu.edu.au/bitstream/1885/36921/2/01_Ritter_Models_of_policy-making_and_2010.pdf">windows</a>” of opportunity. </p>
<p>Such windows can open following specific events such as a spike in drug-related deaths, or a change in government. Or even due to emerging evidence about the medical uses of prohibited drugs, like we have recently seen with <a href="https://theconversation.com/legalising-medicinal-cannabis-is-a-leap-forward-for-compassion-14297">cannabis</a> and now <a href="https://theconversation.com/the-tga-has-approved-certain-psychedelic-treatments-the-response-from-experts-is-mixed-199290">psychedelics</a>. </p>
<p>In the 1990s, there was a “<a href="https://onlinelibrary.wiley.com/doi/pdf/10.1080/0959523021000002778">glut</a>” in the supply of heroin. More Australians were using it and there was a significant increase in overdose deaths. Some Australian newspapers were publishing the daily death toll. </p>
<p>This concern led to the establishment of Australia’s first safe injecting facility in May 2001, in Sydney. Sadly, no similar service was established in Melbourne – despite significant political will. In 1999, the Bracks government sought to establish a safe injecting facility there, but in 2000 the proposal was rejected by the upper house of Victorian parliament. </p>
<p>These different local outcomes to the same national public health crisis highlight how successful drug policy reform requires more than just windows for change. </p>
<p>Drug policy reform requires advocacy. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/more-australians-back-legalising-cannabis-and-57-support-pill-testing-national-survey-shows-142720">More Australians back legalising cannabis and 57% support pill testing, national survey shows</a>
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</em>
</p>
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<h2>Humanity and tenacity make a great advocate</h2>
<p>Not everyone would help a stranger who is overdosing in public. But, remarkably, Judy Ryan tried to help her “regulars”. Her book shows how another resident adapted to the situation:</p>
<blockquote>
<p>I am ashamed to say this, but […] I had become immune to people being overdosed in our area, slumped in the streets. I’d literally step over them because it was so commonplace. I am horrified reflecting on what I had become: a person lacking humanity.</p>
</blockquote>
<p>A successful drug policy reform advocate needs more than humanity though: they need tenacity, and to trust their instincts. </p>
<p>In 2016, Ryan helped her fellow residents gain a voice by running to represent them as a councillor, at Yarra City Council. She was given the following unsolicited advice:</p>
<blockquote>
<p>That I must have a strong presence on Facebook and Twitter and that I must not campaign with a single policy. On the first point, I was concerned about receiving abusive comments and dealing with trolls, and so I decided not to bother with online platforms.</p>
</blockquote>
<p>Ryan won 579 primary votes and at least 791 second-preference votes on the single issue of trialling a safe injecting centre in the area – with no social media presence.</p>
<p>While Ryan did not secure a position on the council, her campaign allowed her to connect with other residents who supported a safe injecting facility. Together, they formed <a href="https://www.vicstreetdrugsolutions.org/">Residents for Victoria Street Drug Solutions</a>.</p>
<p>She has since stood as the Reason Party candidate in the Victorian state electorate of Richmond in 2018, and the federal electorate of Melbourne in 2019.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/512359/original/file-20230227-2316-q8zjre.jpg?ixlib=rb-1.1.0&rect=0%2C14%2C3215%2C2209&q=45&auto=format&w=1000&fit=clip"><img alt="A woman wearing sunglasses and speaking into a megaphone" src="https://images.theconversation.com/files/512359/original/file-20230227-2316-q8zjre.jpg?ixlib=rb-1.1.0&rect=0%2C14%2C3215%2C2209&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/512359/original/file-20230227-2316-q8zjre.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=490&fit=crop&dpr=1 600w, https://images.theconversation.com/files/512359/original/file-20230227-2316-q8zjre.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=490&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/512359/original/file-20230227-2316-q8zjre.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=490&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/512359/original/file-20230227-2316-q8zjre.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=615&fit=crop&dpr=1 754w, https://images.theconversation.com/files/512359/original/file-20230227-2316-q8zjre.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=615&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/512359/original/file-20230227-2316-q8zjre.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=615&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Judy Ryan helped her fellow Richmond residents gain a voice.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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</figure>
<h2>Politics and the media</h2>
<p>Through my work with the <a href="https://www.aodmediawatch.com.au/">Alcohol and Other Drugs Media Watch</a> project, I’ve observed how the Herald Sun and the Age would often ask local Richmond traders for their views on the best “solution” to the drug problems in their area. The voices of residents were conspicuously absent. </p>
<p>Ryan notes that the “solutions” proposed by local traders (such as CCTV and policing) “don’t address drug activity; they relocate it” – to Ryan’s home and those of her neighbours.</p>
<p>Ryan’s group, Residents for Victoria Street Drug Solutions, was able to ensure the local residents’ views were reflected in media stories. In particular, she notes the important role journalist Ian Royall played to provide Richmond residents with a voice. </p>
<p>Their advocacy meant the Richmond safe injecting facilities became a Victorian election issue. </p>
<p>Royall’s work regarding the Richmond safe injecting facilities has been <a href="https://www.aodmediawatch.com.au/behind-the-headlines-the-herald-suns-ian-royall-on-the-campaign-for-richmonds-safe-injecting-centre/">acclaimed</a> by Alcohol and Other Drugs Media Watch, and he has received journalism awards for his work. However, soon after the safe injecting facility was opened by the Andrews government in 2018, Royall’s reporting – and that of his publication, the Herald Sun – took a 180-degree turn. </p>
<p>Instead of publishing stories about residents rallying for a safe injecting facility, Royall published stories about how <a href="https://www.aodmediawatch.com.au/whose-more-against-the-richmond-medically-supervised-injection-room-residents-or-the-herald-sun/">residents were opposed</a> to the newly opened facility. In a statement to Alcohol and Other Drugs Media Watch, Royall said </p>
<blockquote>
<p>Yes, the Herald Sun supported the trial of the injection room. But we reserve the right to pose the question of whether it’s working effectively, and the numbers using it suggest it is. But that does not preclude us from reporting what else is happening in the suburb and wonder if relocation might be appropriate.</p>
</blockquote>
<p>The Herald Sun began publishing pictures of people injecting drugs near the Richmond safe injecting facility. It even ran a video interview with a man who had overdosed and would have been unable to consent to his face being broadcast. </p>
<p>This reporting became so bad that in 2020, Alcohol and Other Drugs Media Watch <a href="https://www.aodmediawatch.com.au/more-poor-reporting-from-the-herald-sun-on-the-melbourne-medically-supervised-injecting-room-to-whom-are-they-accountable/">made a complaint</a> to the Australian Press Council. </p>
<p>Ultimately the Press Council, which is primarily funded by industry members (such as the Herald Sun), sided with the newspaper. Making a complaint to the Press Council about a newspaper is a bit like making a complaint to Drinkwise about a beer advertisement.</p>
<p>I believe the Herald Sun was only supportive of the Richmond safe injecting facility while the Andrews government was opposed to it: that the Herald Sun’s editorial policy was about the Andrews government, not the safe injecting facility itself. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-mental-disorder-not-a-personal-failure-why-now-is-the-time-for-australia-to-rethink-addiction-151686">A mental disorder, not a personal failure: why now is the time for Australia to rethink addiction</a>
</strong>
</em>
</p>
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<h2>Not in my back yard</h2>
<p>Additional criticisms of the safe injecting facility have included fears property prices would decline and concern for the welfare of the children attending adjacent Richmond West Primary School. </p>
<p>But Ryan writes that parent opposition to the facility’s location is not, despite media reports, “widespread”, but instead mixed; parent support is given “quietly for fear of repercussions”. In an appendix, she compiles anonymous comments from school parents, both for and against the facility.</p>
<blockquote>
<p>Drugs have always been around North Richmond. In the eight years since my kids have gone to RWPS, I have not experienced an increase in drug use. I’ve always spoken to my kids about what’s going on for drug users and my kids have never had a problem negotiating their way to and from school.</p>
</blockquote>
<p>And:</p>
<blockquote>
<p>The problem has grown since the injecting room has been established. It does support a very vulnerable part of our community and they do need it but don’t put it next to our kids’ school.</p>
</blockquote>
<p>In the afterword, Ryan notes a story published in the Herald Sun about a man who was arrested at the local school and “changed with trespass, possessing a controlled weapon and breach of bail”. However, the Herald Sun failed to reported he was also charged with public drunkenness, presumably since this would limit their ability to frame him as a potential consumer of the Richmond safe injecting room.</p>
<p>Just as the media played an important role in helping secure a trial of Melbourne’s first safe injecting facility, irresponsible reporting could jeopardise new efforts to reduce drug-related harm. </p>
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<a href="https://images.theconversation.com/files/511253/original/file-20230220-18-mid27o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/511253/original/file-20230220-18-mid27o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/511253/original/file-20230220-18-mid27o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/511253/original/file-20230220-18-mid27o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/511253/original/file-20230220-18-mid27o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/511253/original/file-20230220-18-mid27o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/511253/original/file-20230220-18-mid27o.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/511253/original/file-20230220-18-mid27o.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Judy Ryan’s activism was able to ensure local Richmond residents’ views were reflected in media stories. Here, she’s leading the March to Save Lives protest.</span>
<span class="attribution"><span class="license">Author provided</span></span>
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<h2>On the shoulders of giants</h2>
<p>As she became increasingly involved in advocating for a trial of a safe injecting facility in Victoria, Ryan read three seminal books on drug policy: Johann Hari’s <a href="https://www.bloomsbury.com/au/chasing-the-scream-9781526608369/">Chasing the Scream</a>, Matt Noffs’ <a href="https://www.harpercollins.com.au/9781460707029/breaking-the-ice/">Breaking the Ice</a> and Ingrid van Beek’s <a href="https://www.goodreads.com/book/show/439640.In_the_Eye_of_the_Needle">In the Eye of a Needle: Diary of a Medically Supervised Injecting Facility</a>.</p>
<p>In her work, Ryan says, she stood on the shoulders of such giants, who’d forged similar paths to drug policy reform before her. Her book is also likely to become a seminal text: it so clearly documents the timeline of events leading up to the establishment of Victoria’s first safe injecting room, and what happened in the immediate aftermath.</p>
<p>Drug policy scholars might use this timeline to compare and contrast different models of drug policy reform.</p><img src="https://counter.theconversation.com/content/199199/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Stephen Bright 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>Judy Ryan’s book describes, in meticulous detail, what it took for the Victorian government to trial the state’s first safe injecting facility, through the lens of a local Richmond resident.Stephen Bright, Senior Lecturer of Addiction, Edith Cowan UniversityLicensed 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>
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<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/1855442022-07-03T08:10:53Z2022-07-03T08:10:53ZPlasma gangs: how South Africans’ fears about crime created an urban legend<figure><img src="https://images.theconversation.com/files/470312/original/file-20220622-3417-d2mg4a.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Photo by Rushay Booysen/EyeEm via Getty Images</span></span></figcaption></figure><p>Around the middle of 2013 a series of <a href="https://www.iol.co.za/news/plasma-tv-powder-drug-craze-1570154">stories</a> appeared in the South African press about a new phenomenon called ‘plasma gangs’, presented as the latest iteration of the country’s <a href="https://www.gov.za/speeches/minister-bheki-cele-release-quarter-four-crime-statistics-202122-3-jun-2022-0000">crime crisis</a>. Journalists, broadcasters, police and government spokespeople, social media users and local residents shared tales online and in mainstream media of the frightening <a href="https://www.iol.co.za/news/xenophobia-erupts-over-plasma-tv-gang-1571182">exploits</a> of these gangs, said to be located in Alexandra (Alex) township in the north of Johannesburg. </p>
<p><a href="https://www.sahistory.org.za/place/alexandra-township-johannesburg">Alex</a>, like other South African townships, is an underdeveloped and sometimes precarious area, blighted by the inequality and racial segregation that were central to apartheid spatial engineering. Developed in the early 20th century to house around 30,000 people, it is now home to an estimated <a href="https://www.sowetanlive.co.za/news/south-africa/2019-10-18-waiting-to-exhale-the-story-of-alexandra-township/">700,000</a>. This density creates intense pressure on infrastructure and resources, as well as a powerful community culture that lends itself to the transmission of urban legends.</p>
<h2>Plasma gangs</h2>
<p>Plasma gangs were not like “normal” robbers, who stole anything of value. They had very specific modus operandi. They were said to break into Alex homes with the express purpose of stealing plasma televisions. According to the stories, the gangs used various technologies to achieve this aim, such as hypermodern electronic devices that could tell from outside which homes contained the TVs. Another method involved techniques of <a href="http://edition.cnn.com/2002/WORLD/europe/04/19/mandela.muti/index.html">muti</a>, indigenous magic, that sent residents to sleep while their homes were plundered.</p>
<p>They were extremely violent and often caused death or harm. But rather than selling the desirable consumer goods they stole, as one might expect from criminal syndicates, the gangs were said to dismantle them and break them open. Then they extracted a mysterious white powder that was used to make <a href="https://www.newframe.com/nyaope-the-drug-that-never-lets-go/">nyaope</a>, a street drug otherwise known as wonga or <a href="http://www.kznhealth.gov.za/mental/Whoonga.pdf">whoonga</a>. Depending on which story one heard, the gangs were either nyaope addicts themselves or professional dealers of the drug.</p>
<h2>Nyaope</h2>
<p>Nyaope is <a href="https://www.youtube.com/watch?v=Mfn9o_Aqn6k">notorious</a> in South African cities. It is extremely destructive and the subject of a large body of urban mythology. Experts generally agree that it is comprised of a mix of substances, usually a base of cheap heroin with additions like asbestos, rat poison, milk powder, bicarbonate of soda and even swimming pool cleaner. As is common with drug-related panics, stories about nyaope pull a range of other social anxieties into their axis. </p>
<p>There is no mysterious powder in plasma televisions that can <a href="https://ewn.co.za/2013/09/25/Plasma-gang-myth-busted">be used</a> to get high. Plasma is a descriptor for a technology rather than a substance. The powder contained in these devices is magnesium oxide, a small amount of which coats the display electrodes in a thin layer. Magnesium oxide is easily purchased at health food stores. It has never been shown to have any psychotropic effects. </p>
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<a href="https://theconversation.com/anxiety-in-johannesburg-new-views-on-a-global-south-city-147517">Anxiety in Johannesburg: new views on a global south city</a>
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<p>Concerns about drug users and dealers played powerfully into the plasma gangs narrative. The nyaope connection is part of what set this story aside from “normal, everyday” crime and helped it morph into an urban legend that continues to be disseminated as one of the risks of living in South Africa. </p>
<h2>Social anxiety</h2>
<p>The plasma gangs story shows the way in which <a href="https://www.encyclopedia.com/social-sciences/applied-and-social-sciences-magazines/townships">township</a> residents’ narratives about their own precarity are both hypermodern and related to globalised and transnational anxieties about status, consumption, belonging and identity. It combines the local and the global, the historical and the contemporary, to reveal the social utility of urban legends. </p>
<p>The fact that plasma gangs are not empirically ‘real’ is almost beside the point. The story condenses fears about security and crime, drug dealers and drug users, police failures and corruption, dangerous foreigners, unruly youth, the intersection between crime, witchcraft and technology and the insecurity and visibility of township life. It illustrates the way in which certain South Africans develop and transmit stories and rumours that helped them to make sense of the world they live in. </p>
<p>In considering the plasma gangs we can see how myth, uncertainty, rumour and strangeness inform South African cultures of fear: crime is not just frightening in and of itself but also because it connotes the presence of hidden forces that undermine the predictability of everyday life. This kind of “crime talk” is endemic in South Africa but oddly quiet in academic literature, which often associates fear of crime with whiteness and wealth.</p>
<h2>Making sense of fear</h2>
<p>The plasma gang scare is a compelling example of the power of narrative to condense and codify collective anxieties. A series of existing fears, spurred by the experiences of people living in a place that is both insecure and community-minded, both high risk and aspirational, layered on top of each other to produce a story that had a peculiar amount of social power. </p>
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<a href="https://images.theconversation.com/files/470304/original/file-20220622-25-wqnjag.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A book cover in black and white showing ominous clouds and metal structures. In red, the title Worrier State." src="https://images.theconversation.com/files/470304/original/file-20220622-25-wqnjag.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/470304/original/file-20220622-25-wqnjag.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=867&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470304/original/file-20220622-25-wqnjag.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=867&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470304/original/file-20220622-25-wqnjag.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=867&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470304/original/file-20220622-25-wqnjag.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1089&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470304/original/file-20220622-25-wqnjag.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1089&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470304/original/file-20220622-25-wqnjag.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1089&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="attribution"><span class="source">Wits University Press</span></span>
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<p>A tale of gangster criminality, personal danger, magic, violence and fear offered a way to foreground the contradictions that come with living in the South African township, a place that both defines residents as aspirational global citizens and imposes conditions of insecurity upon them. </p>
<p><em>This is an edited extract from the author’s book Worrier State: Risk, anxiety and moral panic in South Africa <a href="https://witspress.co.za/catalogue/worrier-state/">available</a> from Wits University Press</em></p><img src="https://counter.theconversation.com/content/185544/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Nicky Falkof receives funding from the University of the Witwatersrand and the South African National Research Foundation</span></em></p>In 2013 stories emerged of gangs stealing plasma TV screens to use to make street drugs. It’s a myth, but it tells us something about South Africa’s social anxieties.Nicky Falkof, Associate professor, University of the WitwatersrandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1851612022-06-23T11:07:24Z2022-06-23T11:07:24ZDiamorphine shortage could be more than just a problem for drug users<p>The UK has experienced <a href="https://theconversation.com/hrt-crisis-whats-causing-the-shortages-of-menopause-treatments-182391">many shortages</a> of essential medicines, especially since the <a href="https://theconversation.com/learning-from-covid-how-to-improve-future-supplies-of-medical-equipment-and-vaccines-161054">beginning of the pandemic</a>. The latest shortage is of diamorphine, a painkiller that can be prescribed to drug users who have not responded well to other treatments.</p>
<p>While only around 200 people in England are prescribed diamorphine as a treatment for drug addiction, these shortages could have dire consequences for those who rely on it to help them <a href="https://www.bbc.co.uk/news/health-61699960">live a normal life</a>, hold down jobs and be part of society. </p>
<p>Diamorphine is also used as a painkiller in surgery and even for severe cancer pain. As a result, these current shortages might affect thousands of people in the UK. </p>
<p>The shortage also highlights a greater issue affecting people in both the UK and around the world when it comes to being able to access essential medicines.</p>
<h2>Understanding shortages</h2>
<p>While diamorphine (laboratory-made heroin) is used as a painkiller, Britain was the first country in the world to prescribe it to street-heroin users as a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7610880/">treatment for opioid dependency</a>. In most countries, the medicinal use of diamorphine is banned because of the <a href="https://patient.info/medicine/diamorphine-for-pain-relief">risks</a> and potential for <a href="https://www.who.int/news-room/fact-sheets/detail/opioid-overdose">misuse</a>. It is <a href="https://www.cancer.gov/publications/dictionaries/cancer-terms/def/diamorphine-hydrochloride">illegal</a> to use or sell in the US. </p>
<p>While most users of street heroin will be offered oral methadone or buprenorphine as substitutes, diamorphine is offered when these substitutes are ineffective. <a href="https://www.bbc.co.uk/news/uk-england-tees-59591133.amp">UK-based schemes</a> that help drug users access products such as diamorphine have seen <a href="https://www.glasgow.gov.uk/article/25326/Scotlands-First-Heroin-Assisted-Treatment-Unveiled">drug-related crimes and deaths fall</a>. But for the small number of diamorphine users in the UK, when this treatment isn’t available it could lead to relapse, putting them at <a href="https://www.bbc.co.uk/news/health-61699960">risk of harm</a> if they turn to street heroin.</p>
<p>This isn’t the first time there have been shortages of diamorphine in the UK. In 2021, supply shortages meant some NHS trusts had to purchase <a href="https://pharmaceutical-journal.com/article/news/nhs-trusts-forced-to-use-expensive-pre-filled-diamorphine-syringes-to-manage-ongoing-supply-issues">more expensive pre-filled vials</a> of the drug for patients. This is one reason why <a href="https://psnc.org.uk/our-news/medicine-supply-notification-diamorphine-100mg-and-500mg-powder-for-solution-for-injection-ampoules">morphine is now recommended</a> for pain relief, as it’s cheaper and there’s greater supply. However, morphine is not authorised for use in drug addiction.</p>
<p>Diamorphine shortages worsened in March 2022. The main reason for this is because of England’s reliance on two main suppliers – <a href="https://www.bbc.co.uk/news/health-61699960">Wockhardt and Accord Healthcare</a>, generic drug manufacturers who both have bases in India – who are experiencing stock issues. In fact, this product has had <a href="https://hospitalpharmacyeurope.com/news/editors-pick/diamorphine-the-return-of-an-old-friend/">intermittent availability issues as far back as 2004</a> that have not been resolved. Manufacturing problems were cited as causing some of these issues.</p>
<p>In January 2022, 5mg and 10mg vials were reported as unavailable, with concerns that demand for other dosages (such as 30mg vials) <a href="https://psnc.org.uk/our-news/medicine-supply-notification-diamorphine-5mg-powder-for-solution-for-injection-ampoules/">would cause further shortages</a>. This is now the case, with diamorphine injections in varying strengths <a href="https://pharmaceutical-journal.com/article/news/diamorphine-shortage-causing-former-heroin-users-to-relapse-for-first-time-in-a-decade-charities-warn">out of stock</a> in England.</p>
<p>Northern Ireland has also reported supply shortages. But Scotland has not reported any shortages – probably because they get their supply from a <a href="https://www.bbc.co.uk/news/health-61699960">source in Switzerland</a>, which is also used by one clinic in England. Wales has also not experienced supply disruptions, as diamorphine use is <a href="https://pubmed.ncbi.nlm.nih.gov/16203431/#:%7E:text=Prescription%20of%20diamorphine%2C%20dipipanone%20and%20cocaine%20in%20England,subject%20to%20the%201971%20Misuse%20of%20Drugs%20Act">extremely limited</a>, and <a href="https://gov.wales/wales-roll-out-once-month-injection-recovering-heroin-addicts-help-protect-nhs-staff">other drugs are prescribed </a>for recovering heroin addicts. </p>
<h2>Looking forward</h2>
<p>The supply shortages mostly affect people who use single-use diamorphine vials at home – including former heroin users and palliative-care patients. </p>
<p>Alternative drugs are available for most patients, such as morphine in cancer care. GPs and healthcare workers are being advised to encourage patients to use other drugs that have more stable supply. But for recovering heroin users who haven’t found success with methadone or buprenorphine, diamorphine may be their only option. This is why decisions about changing treatments need to <a href="https://www.drinkanddrugsnews.com/pushed-to-the-brink/">be made with patients</a>, instead of for them.</p>
<p>Hospitals, hospices and palliative-care teams have already stopped using diamorphine, and newly referred street heroin users are instead prescribed a different treatment to help them. This means that shortages are likely only to be a significant problem for people already prescribed diamorphine. </p>
<p>It’s not clear how the current shortages can be reduced or if other companies may wish to manufacture this product for the UK market. But to lessen its impact, and avoid a situation like this in the future, the following actions should be considered:</p>
<ol>
<li><p><strong>Switch to alternatives.</strong> A recent study asserts that other products can be successful in <a href="https://www.frontiersin.org/articles/10.3389/fpsyt.2022.882299/full">helping patients with opioid dependency</a>. But again, if a patient is already taking diamorphine, they will need to be carefully consulted over decisions to change their treatment. </p></li>
<li><p><strong>Responsible prescribing</strong>. This means <a href="https://pubmed.ncbi.nlm.nih.gov/33979300/">not prescribing opioids</a>, such as diamorphine, unnecessarily (such as for <a href="https://pharmaceutical-journal.com/article/news/a-day-in-the-life-of-a-chronic-pain-pharmacist">chronic pain</a>) as there’s a risk of becoming addicted. </p></li>
<li><p><strong>Reduce over-reliance on a few sources.</strong> The UK depends largely on <a href="https://pharmaceutical-journal.com/article/feature/india-and-china-spark-concerns-for-uk-drug-supplies">India and China</a> for the supply of many drugs – not just diamorphine. Developing manufacturing capacity within the UK or sourcing from other countries should make medicines more accessible. </p></li>
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<p>While diamorphine shortages may only affect a small segment of the UK’s population, it highlights the wider medication supply shortage that the UK has been experiencing for years – which has only been worsened as a <a href="https://theconversation.com/medicine-shortages-are-already-a-reality-but-a-no-deal-brexit-could-make-it-worse-102218">result of Brexit</a> and the pandemic. The war in Ukraine may only further contribute to drug shortages. This is why the UK government needs to find alternative ways of supplying essential medicines to the population and further invest in <a href="https://www.gov.uk/government/publications/uk-life-sciences-support/medicines-manufacturing">UK manufacturing capacity</a> to ensure this doesn’t happen – or at least happens less often.</p><img src="https://counter.theconversation.com/content/185161/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Current supply shortages may also be a problem for people in palliative care or receiving cancer treatment.Liz Breen, Director of the Digital Health Enterprise Zone (DHEZ), University of Bradford, Professor in Health Service Operations, University of BradfordJonathan Silcock, Associate Professor in Pharmacy Practice, University of BradfordZoe Edwards, Research Fellow in Medicines Optimisation, University of BradfordLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1733672021-12-13T13:10:13Z2021-12-13T13:10:13ZAfghanistan: heroin and human trafficking are the only two sectors of the economy still thriving<figure><img src="https://images.theconversation.com/files/436945/original/file-20211210-141979-gccmxy.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5184%2C3445&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Cash crop: poppy cultivation and heroin trafficking vie with people smuggling as some of the most lucrative ways of making money in Afghanistan.</span> <span class="attribution"><span class="source">EPA-EFE/Ghulamullah Habibi</span></span></figcaption></figure><p>In the frontier town of Zaranj on Afghanistan’s border with Iran, young men jostle one another as they cram into pickups that leave at regular intervals to be smuggled across the border. Human trafficking is one of the few sectors of the Afghan economy <a href="https://www.politico.eu/article/uk-braces-for-human-trafficking-surge-from-afghanistan/">that is thriving</a>. Another <a href="https://www.theguardian.com/global-development/2021/nov/11/its-our-lifeline-the-taliban-are-back-but-afghans-say-opium-is-here-to-stay">is drugs</a>. </p>
<p>Some 950km to the east of Zaranj, on a remote and cold mountain pass, men with backpacks follow the narrow path to the border-crossing at Tabai, before beginning their descent into the “tribal areas” of Pakistan. Hidden in their loads are bags of heroin, bound for markets in Peshawar and Karachi, with much of it ending up on the streets of the UK. </p>
<p>The trade in drugs and people are growing in importance as other sectors of the economy <a href="https://www.reuters.com/world/asia-pacific/afghanistans-economic-collapse-could-prompt-refugee-crisis-imf-2021-10-19/">contract or shut down</a> and poverty deepens.</p>
<p>Both illicit economies involve complex logistics, infrastructure and networks of brokerage to enable and funnel flows of people or illegal drugs out of the country. Both have responded with remarkable speed and agility to the political rupture marked by the <a href="https://theconversation.com/the-taliban-what-could-its-return-to-power-mean-for-afghanistan-164531">Taliban takeover</a>. </p>
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Read more:
<a href="https://theconversation.com/the-taliban-what-could-its-return-to-power-mean-for-afghanistan-164531">The Taliban: what could its return to power mean for Afghanistan?</a>
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<p>In Zaranj, prior to the change of regime, people told us that 2014–15 was the high point of the people smuggling industry, when the labour market contracted and the economy slowed down in response to the international military draw down. Now, the business is booming again, and <a href="https://www.infomigrants.net/en/post/36331/what-else-can-we-do-increasing-numbers-engage-smugglers-to-flee-afghanistan">so are prices</a>. </p>
<p>A report by the <a href="https://mixedmigration.org/wp-content/uploads/2020/10/138_covid_snapshot_smuggling_Asia.pdf">Danish Refugee Council</a> found that even before the crisis Afghans were being asked for an average of $1,710 to be transported from Afghanistan to Turkey. It has been estimated that the numbers crossing the border have doubled in recent weeks. Before the Taliban takeover there were around 400 vehicles taking migrants via Pakistan into Iran every day. This rose to some 1,200 in September-October and has now dropped to around 600 vehicles. Fees for the longer Mashkel route via Pakistan initially increased four to sixfold during this period. Official border crossings with Iran are closed for most migrants.</p>
<p>The economic significance of the drugs trade has also grown. When the Taliban took over, drug prices increased significantly. In Nangarhar, dry opium increased from PKR20,000 (Pakistani Rupee – the equivalent of about £86) to PKR33,000 (£141) per Afghan seer, equivalent to about 1.25kgs. In Nimroz, opium increased from PKR10,000 (£43) to PKR28,000 (£120) per kilo. The spike in prices was driven by traders buying product at a time of uncertainty. </p>
<p>But prices went down and stabilised once it became apparent that the Taliban would consolidate their power swiftly. One sign of confidence in the market has been the opening up of opium bazaars in formerly government-controlled areas. The Taliban’s new monopoly on taxing the drugs trade is manifest in districts such as Durbaba in Nangarhar, where they charge taxes of PKR1,000 (£4.28) per seer of opium, PKR500 (£2.14) per kilo of hashish and PKR2,000 (£8.56) per kilo of heroin.</p>
<h2>The Taliban and the drug economy</h2>
<p>Under pressure and under conditions of economic decline and an escalating crisis, the Taliban is unlikely to move against the drug economy. The exception is <a href="https://www.france24.com/en/live-news/20211018-under-taliban-kabul-s-drug-addicts-forced-into-withdrawal">often draconian measures</a> against drug users in Kabul.</p>
<p>There are no signs yet that the Taliban will target other parts of the drug business, such as cultivation, refining, trade and cross-border trafficking. Unlike ISIS-K (Islamic State Khorasan), drug cultivation and trafficking are not an ideological matter for the Taliban – but more likely a bargaining chip in their negotiations with the west around funding and recognition.</p>
<p>At the same time, those involved in the trade are hedging their bets by stockpiling in case the Taliban’s laissez-faire policy changes.</p>
<p>While the underlying drivers of the drug economy – instability, bad governance and widespread poverty – remain so strong, there is no credible or humane way to achieve sustained reductions in poppy cultivation. Billions of pounds invested in counter narcotics efforts by international actors over the last 20 years failed to do this and the Taliban have neither the resources nor the inclination to enforce drug bans now. To do so would further impoverish a population already in dire straits, and at the same time undermine the Taliban’s core support base in the poppy-growing areas of the Pashtun south. It would also cut off an important source of revenue to the regime.</p>
<h2>Borderland businesses</h2>
<p>Most of Afghanistan’s illicit drug production and trafficking happens in the borderlands, building on longstanding trading networks and societal connections that predate the modern Afghan state and that have been reinforced and rejuvenated by more than four decades of war.</p>
<p>The sudden withdrawal of western funding has exposed an economy, polity and society heavily shaped by – and dependent on – external financial support, technical assistance and military capacity. In the current context, the Taliban government is going to struggle to support any public sector activity, including the provision of basic health and education services. The possibilities of survival in the borderlands of rural Afghanistan are already severely limited by declining farm sizes and high levels of landlessness, and the repeated droughts wrought by the climate emergency.</p>
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<a href="https://theconversation.com/afghanistan-what-the-conflict-means-for-the-global-heroin-trade-165995">Afghanistan: what the conflict means for the global heroin trade</a>
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<p>People smuggling and drugs are two borderland economies that can be understood as responses to a context of radical uncertainty. Border regions are places of improvisation and innovation, often the first regions to react to moments of rupture and transition. While the licit economy has been hit hard by the banking crisis, the people smuggling and drugs industries continue to be funded by “halwaldars”, the informal money exchange system. </p>
<p>Unfortunately the international response has been ponderous and dogmatic. An indefinite “wait-and-see” approach by western governments, megaphone diplomacy with the Taliban, or efforts to “quarantine” Afghanistan’s illicit flows will all exacerbate a growing humanitarian, financial, and security crisis with regional and global ramifications. Humanitarian and development funding have to be delivered now, and at scale.</p><img src="https://counter.theconversation.com/content/173367/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Goodhand receives funding from UKRI Global Challenges Research Fund, award no. eS/ P011543/1</span></em></p><p class="fine-print"><em><span>Jan Koehler receives funding from UKRI Global Challenges Research Fund, award no. eS/ P011543/1</span></em></p>As the Afghan economy collapses, drugs and people smuggling are booming.Jonathan Goodhand, Professor in Conflict and Development Studies, SOAS, University of LondonJan Koehler, Research Associate, School of Development Studies, SOAS, University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671002021-09-16T12:11:03Z2021-09-16T12:11:03ZOxyContin created the opioid crisis, but stigma and prohibition have fueled it<figure><img src="https://images.theconversation.com/files/421389/original/file-20210915-17-1lvjamv.jpg?ixlib=rb-1.1.0&rect=6%2C12%2C997%2C597&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People around the world mourned loved ones on International Overdose Awareness Day on Aug. 31, 2021.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/edmontonians-pose-wooden-crosses-with-roses-on-news-photo/1234986137?adppopup=true"> NurPhoto/Getty Images</a></span></figcaption></figure><p>The <a href="https://theconversation.com/how-the-purdue-opioid-settlement-could-help-the-public-understand-the-roots-of-the-drug-crisis-166701">highly contentious</a> <a href="https://www.npr.org/2021/09/01/1031053251/sackler-family-immunity-purdue-pharma-oxcyontin-opioid-epidemic">Purdue Pharma settlement</a> announced Sept. 1, 2021, comes at a pivotal time for the U.S. overdose crisis: 2020 was the worst year on record, with over <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">93,000 Americans</a> losing their lives to fatal drug overdose. The drug overdose epidemic, now more than two decades long, has claimed the lives of <a href="https://www.cdc.gov/opioids/data/index.html">more than 840,000</a> people since 1999. Current estimates suggest that some <a href="https://www.rand.org/content/dam/rand/pubs/research_reports/RR3100/RR3140/RAND_RR3140.pdf">2.3 million people</a> in the U.S. use heroin and <a href="https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis">1.7 million people</a> use pharmaceutical opioids without a prescription. </p>
<p>Since 2016, I’ve <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">studied the overdose crisis</a> with an eye to understanding its roots as well as its ramifications. As a <a href="https://www.holycross.edu/academics/programs/sociology-and-anthropology/faculty/emily_b_campbell">sociologist</a>, I came to this area of research in my own quest for meaning, as each year brought more funerals of former classmates and friends. What I found was an increasingly dangerous drug environment for people who use drugs, often exacerbated by policies not founded in research and by attitudes that harm those affected.</p>
<h2>How prohibition fuels dangerous markets</h2>
<p>Research shows that <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">the illicit drug market adapts</a> to both demand and drug enforcement efforts. </p>
<p>The first consequence of increased demand is that drugs become <a href="https://doi.org/10.1016/j.drugpo.2007.11.016">cheaper over time</a>. For example, the price of heroin and cocaine have been falling for decades. Political economists explain that demand, coupled with globalization, increases efficiency and competition. The result is that there are more drugs on the illicit market, which in turn lowers prices. </p>
<p>Second, as a response to drug prohibition, <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">drugs become more potent</a>. A stronger product in a smaller package is easier to transport and harder to detect. The American overdose crisis has become <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">a case study</a> in the devastating interplay of demand and prohibition. </p>
<p>OxyContin was released in 1996 and <a href="https://doi.org/10.2105/AJPH.2007.131714">mass-marketed as a revolutionary intervention</a> in the medical treatment of pain. Purdue Pharma, its maker, <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html?smid=url-share">knowingly downplayed</a> its addictive potential. As an opioid and central nervous depressant, <a href="https://doi.org/10.1300/J069v23n04_01">OxyContin has effects</a> similar to those of morphine or heroin. Not surprisingly, studies show that prescription patterns of opioids from 1999 to 2008 were <a href="https://pubmed.ncbi.nlm.nih.gov/22048730/">directly linked to a surge in overdose deaths</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pill bottle and pills of OxyContin prescription-only pain medication" src="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Oxycontin prescription-only pills were aggressively promoted to primary care physicians as a safe and effective pain control method for patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/oxycontin-pills-oxycodone-hydrochloride-prescription-only-news-photo/563590877?adppopup=true">Lawrence K. Ho/Los Angeles Times via Getty Images</a></span>
</figcaption>
</figure>
<p>As concern over opioid overdose grew, doctors’ prescribing practices <a href="https://doi.org/10.1007/s11013-016-9496-5">came under scrutiny</a>. In 2010, Purdue Pharma replaced the original OxyContin with an <a href="https://doi.org/10.1001/jamapsychiatry.2014.3043">“abuse deterrent” formulation</a> that was more difficult to crush and inhale. As a result, many people who were addicted to OxyContin turned to heroin, which was <a href="https://doi.org/10.1162/rest_a_00755">cheaper and easier to get</a>. This spurred a surge in heroin-related fatal overdoses, which is often termed the <a href="https://doi.org/10.1016/j.drugpo.2019.01.010">second wave of the overdose crisis</a>.</p>
<p>The growing market for heroin paved the way for the <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">introduction of fentanyl</a> into the illicit U.S. drug market. Fentanyl, a drug used in medical settings for severe pain, is <a href="https://www.drugabuse.gov/publications/drugfacts/fentanyl">50 times more potent than heroin</a>. From the standpoint of efficiency for shipping and trafficking, fentanyl is easier to transport and sell than heroin. Fentanyl’s entry into the illicit drug market, in particular in combination with heroin, <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">led to a doubling and tripling </a>of overdose deaths around 2012 to 2013. </p>
<p><a href="https://journals.lww.com/co-psychiatry/fulltext/2021/07000/the_rise_of_illicit_fentanyls,_stimulants_and_the.4.aspx">Since then, fentanyl</a> <a href="https://doi.org/10.1016/j.drugpo.2021.103353">has contaminated</a> the U.S. illicit drug supply: It is often found in not just heroin but cocaine, MDMA – commonly known as Ecstasy – methamphetamine and counterfeit prescription pills. The result is that most people <a href="https://doi.org/10.1016/j.drugpo.2019.07.008">do not know the potency or contents</a> of what they are using. </p>
<p>As the overdose crisis evolves, <a href="https://doi.org/10.1007/s40615-021-01007-6">communities of color</a> in particular have experienced a surge in fatal overdoses – deaths that are often preventable. And most recently, COVID-19 supply chain disruptions led people to use whatever was available, causing <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2021.306256">a surge in overdoses</a> from drug mixing. </p>
<h2>Barriers to treatment</h2>
<p>Too often, people who use drugs are bombarded with messages that are not supported by research and that deepen the harm. </p>
<p>Public health officials and community leaders urge people to seek treatment and highlight that recovery is within reach. Yet, roughly 70% of people who seek treatment are <a href="https://www.rcorp-ta.org/sites/default/files/2020-06/Improving-Access-to-Evidence-Based-Medical-Treatment-for-OUD_FINAL.pdf">unable to access it</a>. <a href="https://doi.org/10.1080/10826084.2017.1363238">Barriers to treatment</a> include health care costs, lack of available treatment options and social stigma. Research also demonstrates that some people are not ready for treatment or <a href="https://doi.org/10.1080/10826084.2017.1310247">do not want to be sober</a>.</p>
<p>Sobriety is touted as the ultimate goal for people who use drugs. Yet research shows that addiction is a <a href="https://doi.org/10.1038/s41386-020-00950-y">recurring brain disease</a>, and relapse is highly likely. Most people who use drugs do so in a <a href="https://www.ucpress.edu/book/9780520293472/hurt">sporadic way</a> that features bouts of controlled and uncontrolled use as well as sobriety. It is also well documented that fear of arrest and shame encourages people to hide their drug use in ways that <a href="https://doi.org/10.1080/10826084.2020.1790008">increase their risk</a> of a fatal overdose. This is because when people use alone, there is no one there to call 911 or perform CPR should an overdose occur. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding up phone with image of brother and son who died after taking fentanyl-laced drugs" src="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Laurie Restivo’s brother, David Restivo, 47 (left on phone image), died from fentanyl-laced heroin, and her son, Jason Fisher Jr., 25 (right), died from fentanyl-laced cocaine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/fentanyl-overdose-restivo-johnson-laurie-restivo-displays-a-news-photo/1315873058?adppopup=true">Reading Eagle/MediaNews Group via Getty Images</a></span>
</figcaption>
</figure>
<p>In terms of effective treatment, <a href="https://doi.org/10.1176/appi.ps.201300256">medically assisted treatments</a> are considered the gold standard for opioid use disorder, yet they are still <a href="https://doi.org/10.1111/jrh.12328">underutilized</a>. <a href="https://doi.org/10.1001/jama.2021.1741">Buprenorphine</a> is an opioid with a “ceiling effect,” meaning it does not intoxicate like morphine or heroin but instead satiates an opioid craving. Buprenorphine assists people in transitioning away from uncontrolled use and mitigates physical cravings. People who are prescribed it are often able to work, attend therapy and regain enjoyment of day-to-day life. </p>
<p>Nonetheless, buprenorphine’s availability <a href="https://doi.org/10.1002/pds.4984">varies widely by state</a>, and people of color are <a href="https://doi.org/10.1377/hlthaff.2020.02261">persistently underprescribed</a> this lifesaving medication. Methadone has been used as a treatment for opioid use disorder since the 1950s, yet it is persistently <a href="https://doi.org/10.1007/s11606-018-4801-3">hard to access</a> long term. Researchers point to the <a href="https://doi.org/10.1080/08897077.2019.1640833">ongoing role of stigma</a> in the underuse of both of these medications. </p>
<h2>Better paths forward</h2>
<p>Public health officials, harm reduction activists and concerned citizens across the U.S. are working to secure <a href="https://doi.org/10.1097/01.NPR.0000534948.52123.fb">safer injection sites</a> where people can use drugs in the presence of medical staff. Such sites facilitate the prevention of fatal overdose by assuring an adequate and timely medical response and open a pathway for further health care and addiction-related treatment. In response to the pandemic’s strains on inpatient care facilities, <a href="https://doi.org/10.1016/j.jsat.2021.108552">take-home methadone</a> availability was expanded in new ways – a change that some treatment experts <a href="https://doi.org/10.1016/j.jsat.2020.108246">hope will be permanent</a>. </p>
<p>For people who use drugs, the <a href="https://doi.org/10.1016/j.jhealeco.2019.01.001">potency and contents of their drugs are often unknown</a>. <a href="https://doi.org/10.1016/j.drugpo.2018.10.001">Drug-checking programs</a> allow people to inspect the <a href="https://doi.org/10.1016/j.drugpo.2018.09.009">contents of their drugs for fentanyl</a> at home with a simple test strip. Such programs have recently gained traction with <a href="https://www.cdc.gov/media/releases/2021/p0407-Fentanyl-Test-Strips.html">federal support</a>. States also continue to expand <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5049966/">access to naloxone</a>, an overdose reversal nasal spray that is simple to administer. People who use drugs or have loved ones who use drugs are encouraged to receive training on how to administer naloxone and to carry the nasal spray on them. </p>
<p>Those who argue for a <a href="https://doi.org/10.1503/cmaj.201618">safer supply</a> and <a href="https://doi.org/10.1016/j.socscimed.2021.113986">decriminalization of drugs</a> point to success abroad. <a href="https://www.rand.org/content/dam/rand/pubs/working_papers/WR1200/WR1263/RAND_WR1263.pdf">Heroin-assisted treatment</a> is shown to be effective in keeping people away from an unpredictable drug market, thus lowering the risk of overdose. Germany’s use of <a href="https://doi.org/10.1111/j.1360-0443.2008.02185.x">heroin-assisted treatment</a> improved patients’ physical and mental health while dramatically reducing illicit drug use. In the early 2000s, <a href="https://doi.org/10.1177/2050324516683640">Portugal decriminalized</a> all drugs in response to consistently having the highest fatal overdose rates in Western Europe. With diversion of funds away from prohibition to education and treatment, Portugal saw a drop in overall drug use and now boasts among the lowest fatal overdose rates in Western Europe.</p>
<p>Americans are the world’s <a href="https://doi.org/10.1111/add.14234">largest consumers</a> of drugs and consistently have among the highest rates of opioid and cocaine dependence globally. In <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">my own research</a>, I’ve found that people often describe drug use as a battle between sobriety and death. But the heartbreaking surge in accidental, fatal overdose deaths tells a much more complex story. Ignoring the evidence will surely cost many more lives.</p>
<p><em>If you or someone you care about has a substance use disorder and wants help, you can call SAMHSA’s National Helpline: 1-800-662-HELP (4357). Immediate emotional support is available from the National Suicide Prevention Hotline 800-273-8255.</em> </p>
<p>[<em>Get our best science, health and technology stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-best">Sign up for The Conversation’s science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/167100/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Emily B. Campbell does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>False narratives about drug addiction and policies that are not supported by research are deepening the overdose epidemic in the US.Emily B. Campbell, Visiting Assistant Professor of Sociology, College of the Holy CrossLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1635682021-08-16T12:29:11Z2021-08-16T12:29:11ZRat poison is just one of the potentially dangerous substances likely to be mixed into illicit drugs<figure><img src="https://images.theconversation.com/files/415548/original/file-20210810-17-n2r4rx.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2121%2C1412&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Impurities are often added to recreational drugs to mask poor quality.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/midsection-of-man-holding-cocaine-royalty-free-image/1076137624">Sebastian Leesch/EyeEm via Getty Images</a></span></figcaption></figure><p>Over 150 people in Illinois started <a href="https://doi.org/10.1056/NEJMoa1807652">bleeding uncontrollably</a> after using <a href="https://www.drugabuse.gov/publications/drugfacts/synthetic-cannabinoids-k2spice">synthetic cannabis-based products</a> – including fake marijuana, Spice and K2 – that contained the rat poison brodifacoum in March and April 2018. By the end of July 2021, these banned products were still being sold in <a href="https://www.usatoday.com/story/news/nation/2018/07/20/fda-warning-synthetic-marijuana-rat-poison/802585002/">10 states and the District of Columbia</a>, resulting in hundreds of severe bleeds and several deaths.</p>
<p>Illicit drug use was responsible for <a href="https://ourworldindata.org/illicit-drug-use#direct-deaths-drug-overdoses">an estimated 166,613 deaths worldwide in 2017 due to overdose</a>. The increased risk of disease and injury associated with illicit drug use caused an <a href="https://ourworldindata.org/illicit-drug-use#indirect-deaths-drug-use-as-a-risk-factor-for-premature-death">additional estimated 585,348 premature deaths</a>. And it’s impossible to tease out whether people were harmed by the drugs themselves or by the myriad impurities added to them.</p>
<p>I am a <a href="https://scholar.google.com/citations?user=lWAD9d8AAAAJ&hl=en">clinical pharmacologist</a> and guest editor for a <a href="https://doi.org/10.1002/jcph.1921">special supplement</a> in the Journal of Clinical Pharmacology on commonly abused substances. I also <a href="https://doi.org/10.1002/jcph.1860">surveyed the research</a> in 2021 on what’s known about illicit drug adulteration. The research is clear: Adding impurities to, or adulterating, illicit drugs is a longstanding and widespread practice with harmful consequences. </p>
<h2>You seldom get what you pay for</h2>
<p>Drugmakers <a href="https://doi.org/10.1002/dta.220">include other ingredients for a few reasons</a>, whether to cut costs by bulking up their product with cheaper nonactive ingredients or to achieve particular effects by adding other drugs to mask poor product quality or imitate the desired effect of the drug itself.</p>
<p>Prior to the 2000s, drugs including cocaine and heroin were being “cut,” or diluted, with <a href="https://doi.org/10.1002/jcph.1860">inactive ingredients like sugars</a> to enlarge supply and increase profits. Since then, buyers of cocaine and heroin products frequently receive a cocktail of adulterants that mimic the product’s intended effects or mask side effects due to poor quality.</p>
<p>For example, the active ingredient of ecstasy, MDMA, is what produces the product’s intended effects. However, a 2004 study assessing ecstasy tablets from drug seizures at raves found that <a href="https://doi.org/10.1007/s00213-003-1712-7">20% of the products contained no MDMA</a>, and dosage varied widely in products that did. Cheaper and more dangerous <a href="https://doi.org/10.1002/jcph.266">stimulants and psychedelics</a> like <a href="https://doi.org/10.1002/jcph.742">synthetic bath salts</a> and LSD are frequently swapped for MDMA without alerting the buyer.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415555/original/file-20210810-17-1rzlf8u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Five ecstasy tablets on a white background." src="https://images.theconversation.com/files/415555/original/file-20210810-17-1rzlf8u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415555/original/file-20210810-17-1rzlf8u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415555/original/file-20210810-17-1rzlf8u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415555/original/file-20210810-17-1rzlf8u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415555/original/file-20210810-17-1rzlf8u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415555/original/file-20210810-17-1rzlf8u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415555/original/file-20210810-17-1rzlf8u.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">Some drugs are so adulterated that they contain little to none of the active ingredient that buyers seek.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/ecstasy-pills-royalty-free-image/508919350">portokalis/iStock via Getty Images Plus</a></span>
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<h2>Drugs added to intensify effects</h2>
<p><a href="https://doi.org/10.1111/1556-4029.13968">Over 70% of cocaine products</a> contain <a href="https://doi.org/10.1038/clpt.2010.156">levamisole</a>, a drug for worm infections that increases the intensity and duration of stimulant effects. It was <a href="https://doi.org/10.1016/j.psym.2013.02.012">banned in the U.S. in 1999</a> because it <a href="https://doi.org/10.1111/1556-4029.13968">suppresses red and white blood cell production</a> and increases the risk of life-threatening infections and anemia. These side effects are seen at doses over 150 milligrams, and <a href="https://doi.org/10.1111/1556-4029.13968">35% of seized cocaine products in the U.S.</a> exceed that level.</p>
<p>Other additives are commonly added to cocaine to intensify effects. <a href="https://doi.org/10.1016/j.ijcard.2011.06.105">Aminorex</a>, a stimulant and appetite suppressant, was <a href="https://doi.org/10.1016/j.ijcard.2011.06.105">withdrawn by the FDA in 1972</a> after it caused a number of <a href="https://go.gale.com/ps/i.do?id=GALE%7CA181301396&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=1082801X&p=AONE&sw=w&userGroupName=anon%7E1f297428">pulmonary hypertension</a> cases that resulted in heart failure and death. Similarly, <a href="https://doi.org/10.1001/jama.291.2.216">caffeine</a> is <a href="https://jppres.com/jppres/pdf/vol8/jppres19.638_8.2.146.pdf">frequently added</a> to intensify the adrenaline rush. While safe when taken alone in lower doses, higher doses of caffeine in combination with other stimulants can induce <a href="https://doi.org/10.1001/jama.291.2.216">seizures and heart rhythm problems</a>.</p>
<p>For heroin, <a href="https://doi.org/10.1111/j.1556-4029.2007.00648.x">veterinary anesthetic xylazine</a> is commonly added to intensify its relaxing effect. And <a href="https://doi.org/10.1111/j.1556-4029.2007.00648.x">fentanyl is increasingly being used as a substitute</a>. Because fentanyl is <a href="https://www.statnews.com/2016/09/29/why-fentanyl-is-deadlier-than-heroin/">50 times more potent</a> than heroin, a smaller amount of total product can produce similar effects. But adding even just a slightly larger amount of fentanyl than expected can easily result in an overdose.</p>
<h2>Covering up adulteration and poor manufacturing quality</h2>
<p>Manufacturers also add impurities to compensate for lost effects due to adulteration. Anesthetics like <a href="https://doi.org/10.1111/1556-4029.13968">lidocaine and benzocaine</a> are added to adulterated products to reproduce the tingling sensation on the gums or tongue that drug dealers look for to assess cocaine quality. While these anesthetics are FDA approved, they can cause seizures and heart rhythm problems with the wrong dose.</p>
<p>A similar technique is used for heroin. Manufacturers commonly add <a href="https://doi.org/10.1007/s11606-012-2089-2">malaria drug quinine</a> to mimic heroin’s bitter taste and the initial drop in blood pressure when it’s administered.</p>
<figure class="align-center zoomable">
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<span class="caption">Adulterants may be added to mimic the expected effects of a particular drug.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/drug-grams-and-tabs-royalty-free-image/482857483">KatarzynaBialasiewicz/iStock via Getty Images Plus</a></span>
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<p>Poor heroin production also creates a lot of impurities that can cause <a href="https://doi.org/10.1002/jcph.1860">severe chills and pain at the injection site</a>. To get around these side effects, manufacturers frequently add antihistamines like Benadryl and pain relievers like Tylenol. The pain reliever metamizole, which was recalled in 1977 for health risks, is sometimes used instead of Tylenol.</p>
<h2>The double-edged sword of field testing</h2>
<p>Adulterants can lead to dangerous side effects. But because additives aren’t disclosed to the buyer and most of them have been banned by the FDA, clinicians might not recognize or even suspect that an adulterant is the cause of a patient’s symptoms. </p>
<p>While consumer-based methods to test for drug impurities may help, they aren’t foolproof. Volunteers at music festivals in the 2010s offered <a href="https://www.hopkinsmedicine.org/news/media/releases/on_site_ecstasy_pill_testing_services_may_reduce_user_risks_at_concerts_and_raves">MDMA purity testing</a> so attendees could decide whether they wanted to use the drugs they had. If they were injured, attendees could alert emergency personnel about potential adulterants they were exposed to. Unfortunately, over 40% of the adulterated samples were missed by those field testing kits and discovered days later only with sophisticated laboratory equipment.</p>
<p>With illicit drugs, the difference between what you believe you are buying and what is actually in the product can be the difference between life and death. If you are suffering from drug addiction, <a href="https://www.samhsa.gov/find-help/national-helpline">resources are available</a> to help you manage your addiction and achieve sobriety.</p><img src="https://counter.theconversation.com/content/163568/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>In an effort to reduce costs, drugmakers and dealers often cut, or adulterate, recreational drugs with substances that have been banned by the FDA.C. Michael White, Professor of Pharmacy Practice, University of ConnecticutLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1659952021-08-12T13:47:35Z2021-08-12T13:47:35ZAfghanistan: what the conflict means for the global heroin trade<p>The long war in Afghanistan reached a potential watershed on August 6 when Taliban fighters <a href="https://www.voanews.com/south-central-asia/zaranj-becomes-first-afghan-provincial-capital-fall-taliban">took over Zaranj</a>, a dusty frontier town with a population of some 63,000 on the Afghan-Iranian border. Though geographically and politically marginal, Zaranj was the first provincial centre to fall during a month of rapid advances. </p>
<p>In the preceding weeks, the Taliban’s advances had been largely confined to the countryside, taking control of more than half of the country’s 421 districts. But emboldened by these successes and the plummeting morale of the Afghan armed forces, the Taliban turned to major population centres. Since their breakthrough in Zaranj, <a href="https://www.aljazeera.com/news/2021/8/10/infographic-taliban-captures-afghan-provincial-capitals">they have</a> taken over nearby Farah and seven other provincial capitals in the north. </p>
<p>The speed and success of this offensive has taken many by surprise, but the balance of power has shifted since the <a href="https://www.auswaertiges-amt.de/en/newsroom/news/us-taliban-agreement/2315872">2020 agreement</a> between the US and the Taliban, which committed the US to withdraw its troops from the country. This has been aided by <a href="https://www.lowyinstitute.org/the-interpreter/pakistan-fuelling-taliban-takeover">Pakistani support</a> for the Taliban, as well as the Afghan government’s <a href="https://www.nytimes.com/2020/08/09/world/asia/afghanistan-taliban-prisoners-peace-talks.html">release of 5,000</a> imprisoned Taliban fighters, a condition of the US-Taliban agreement. Subsequent <a href="https://www.aa.com.tr/en/asia-pacific/afghan-taliban-peace-talks-fail-to-reach-breakthrough/2308518">peace talks</a>, supported by international and regional powers, have failed to stem the recent violence or come up with a credible peace plan. </p>
<p>But while most commentary has focused on this ailing peace process and the military dimension, far less has been said about how economic factors are shaping unfolding events, including the trade in opium and heroin. </p>
<h2>History repeats itself</h2>
<p>This takes us back to Zaranj. It is not coincidental that the Taliban has focused on border towns, since these have huge importance economically, which translates into military and political advantage. The Taliban now control some ten international crossing points. In addition to Zaranj, they have Spin Baldak, a gateway to Pakistan; Islam Qala, the main crossing point to Iran; and Kunduz, which confers control of the routes north to Tajikistan. </p>
<p>The importance of these trading cities has been demonstrated by recent history. When the warring factions in Afghanistan stopped receiving military and financial aid mainly from the Russians and Americans after the Russians withdrew in the late 1980s, control of trade became very important. This included the drug economy, which <a href="https://documents1.worldbank.org/curated/en/158651468767124612/pdf/311490PAPER0AF100SASPR0no051Dec0171.pdf">expanded massively</a> from the early 1990s. </p>
<p>This is playing out again. In the 1990s, for example, Zaranj was a wild west kind of place that grew as an illicit trading hub, drawing on longstanding cross-border connections between Baluch tribes who specialised in smuggling fuel, drugs and people. Similar activities continue there today: opium and heroin, derived from the poppy fields of Farah and Helmand provinces, are smuggled across the border, alongside the booming business in human trafficking. </p>
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<p><a href="https://drugs-and-disorder.org/2020/09/21/catapults-pickups-and-tankers/">Yet Zaranj</a> has also become a gateway town for legitimate trade, including in fuel, construction materials, consumer goods and foodstuffs. Located on a key corridor connecting Kabul to the Iranian port of Chabahar, the Afghan government has invested in roads and border infrastructure as part of a wider effort to cement relations with Iran and decrease its dependence on trade with Pakistan. This mix of licit and illicit trade has unlocked inward investment and attracted a growing population from surrounding areas, as well as being an important source of tax. </p>
<p>Across the country, <a href="https://www.bloomberg.com/news/articles/2021-08-05/taliban-seizes-border-posts-draining-key-afghan-income-source">import duties account</a> for around half of the Afghan government’s domestic revenue. <a href="https://www.bbc.co.uk/news/world-asia-57773120">Islam Qala alone</a> generates more than US$20 million (£14 million) per month. So taking control of these key crossing points fills the Taliban coffers while denying the government an important source of revenue, at a time when external funding from international donors <a href="https://www.aljazeera.com/news/2021/3/16/aid-cuts-by-us-others-could-imperil-afghanistan-govt-watchdog">is declining</a>. </p>
<p>The Taliban now control many of the key parts of the economy – the main poppy growing regions, as well as markets and trading routes to Pakistan, Iran and Tajikistan – enabling them to systematically tax different points along commodity chains.</p>
<p>Control of borders also enables the Taliban to impose economic restrictions on imported goods such as petrol and gas, providing them with further leverage over Kabul. Disruption to the flow of imports and exports has already affected the prices of fuel and foodstuffs. Housing rents in Kabul <a href="https://www.thenationalnews.com/world/asia/2021/08/09/kabul-rents-rise-as-taliban-offensive-sends-afghans-fleeing-to-capital/">have gone up</a> in recent days, with many of those displaced by the recent fighting seeking accommodation in the capital. At the same time, property prices have plummeted as desperate Kabulis seek to sell up and leave the country.</p>
<h2>Heroin and opium</h2>
<p>In 2020 according to the <a href="https://www.unodc.org/unodc/en/frontpage/2021/May/afghanistan_-37-per-cent-increase-in-opium-poppy-cultivation-in-2020--while-researchers-explore-novel-ways-to-collect-data-due-to-covid-19.html">latest survey</a> from the UN Office on Drugs and Crime, there was a 37% increase in the amount of land allocated to poppy cultivation. This was linked to a range of factors including political instability and conflict, devastating droughts, high seasonal floods, the declining international funding and employment opportunities. This is likely to continue as the structural drivers of the opium economy – armed conflict, poor governance and widespread poverty – are all moving in a negative direction. </p>
<p>In both the countryside and the border towns, the opium economy provides an important lifeline for Afghans, many of whom were already living through a humanitarian crisis. The uptick in conflict comes as the <a href="https://www.rescue.org/press-release/millions-risk-displacement-afghanistan-faces-extreme-drought-warns-irc">severe drought</a> has driven up food prices, while there has also been a surge in the <a href="https://www.voanews.com/covid-19-pandemic/afghan-officials-delta-variant-accounts-nearly-60-new-infections">delta variant</a>, and <a href="https://rusi.org/explore-our-research/publications/commentary/uk-foreign-aid-cuts-and-afghan-refugee-crisis">some 360,000 people</a> have been displaced since the start of the year in response to all the trouble in the country.</p>
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<p>Whichever scenario plays out – a Taliban victory, a civil war or a negotiated settlement – there is unlikely to be a transformation of Afghanistan’s illicit drug economy any time soon. Both the Taliban and government make pronouncements about addressing illicit drugs, but the underlying drivers remain too strong. </p>
<p>The drug trade is simply too deeply embedded in the accumulation and survival strategies of the Taliban, the state, the militias currently being stood up to fight the Taliban, and the wider population. This will unfortunately drive the global heroin market, as well as feeding the growing drug problem within Afghanistan and neighbouring countries.</p><img src="https://counter.theconversation.com/content/165995/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jonathan Goodhand receives funding from ESCR Global Challenges Research Fund</span></em></p>Having taken charge of multiple vital border trading posts, the Taliban is now increasingly in control of the Afghan drug trade.Jonathan Goodhand, Professor in Conflict and Development Studies, SOAS, University of LondonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1508062020-12-10T13:36:42Z2020-12-10T13:36:42ZOregon just decriminalized all drugs – here’s why voters passed this groundbreaking reform<figure><img src="https://images.theconversation.com/files/374023/original/file-20201209-21-1aik374.jpg?ixlib=rb-1.1.0&rect=30%2C7%2C5111%2C3423&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">According to Oregon law, possessing a small amount of drugs for personal consumption is now a civil – rather than criminal – offense. </span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/teenage-schoolgirl-reaching-for-cocaine-in-her-back-royalty-free-image/1132980785?adppopup=true">Peter Dazeley via Getty</a></span></figcaption></figure><p>Oregon became the first state in the United States to decriminalize the possession of all drugs on Nov. 3, 2020. </p>
<p><a href="https://ballotpedia.org/Oregon_Measure_110,_Drug_Decriminalization_and_Addiction_Treatment_Initiative_(2020)">Measure 110</a>, a ballot initiative <a href="https://www.klcc.org/post/election-preview-measure-110-would-make-oregon-1st-state-decriminalize-drug-use">funded by the Drug Policy Alliance, a nonprofit advocacy group backed in part by Facebook’s Mark Zuckerberg</a>, passed with more than 58% of the vote. Possessing heroin, cocaine, methamphetamine and other drugs for personal use is no longer a criminal offense in Oregon. </p>
<p>Those drugs are still against the law, as is selling them. But possession is now a civil – not criminal – violation that may result in a fine or court-ordered therapy, not jail. Marijuana, which Oregon legalized in 2014, remains fully legal.</p>
<p>Oregon’s move is radical for the United States, but several European countries <a href="https://www.loc.gov/law/help/decriminalization-of-narcotics/decriminalization-of-narcotics.pdf">have decriminalized drugs to some extent</a>. There are three main arguments for this major drug policy reform. </p>
<h2>#1. Drug prohibition has failed</h2>
<p>In 1971, President Richard Nixon declared drugs to be “public enemy number one” and launched a “<a href="https://www.theatlantic.com/health/archive/2012/03/the-war-on-drugs-how-president-nixon-tied-addiction-to-crime/254319/">war on drugs</a>” that continues today.</p>
<p>The ostensible rationale for harshly punishing drug users is to deter drug use. But decades of research – including <a href="http://tupress.temple.edu/book/20000000009196">our own on marijuana</a> and <a href="https://us.sagepub.com/en-us/nam/drugs-and-drug-policy/book258916">drugs generally</a> – has found the <a href="https://www.vera.org/publications/for-the-record-prison-paradox-incarceration-not-safer">deterrent effect of strict criminal punishment to be small</a>, if it exists at all. This is especially true among young people, who <a href="http://www.monitoringthefuture.org/pubs/monographs/mtf-vol2_2019.pdf">are the majority of drug users</a>. </p>
<p>This is partly due to the nature of addiction, and also because <a href="https://nij.ojp.gov/topics/articles/five-things-about-deterrence">there are simply limits to how much punishment can deter crime</a>. As a result, the U.S. has both <a href="https://www.sentencingproject.org/criminal-justice-facts/">the world’s highest incarceration rate</a> and <a href="http://www.espad.org/sites/espad.org/files/TD0116475ENN.pdf">among the highest rates of illegal drug use</a>. Roughly <a href="https://www.prisonpolicy.org/reports/pie2020.html">1 in 5 incarcerated people in the United States is in for a drug offense</a>. </p>
<p><a href="https://books.google.com/books?hl=en&lr=&id=dNcNUjn4UQEC&oi=fnd&pg=PP9&dq=Crime+in+the+Making:+Pathways+and+Turning+Points+Through+Life.&ots=UfXRYQfehU&sig=jAyUyb68tCm1Bw9dXXtlyUlXPro#v=onepage&q=Crime%20in%20the%20Making%3A%20Pathways%20and%20Turning%20Points%20Through%20Life.&f=false">Criminologists find</a> that other consequences of problematic drug use – such as harm to health, reduced quality of life and strained personal relationships – are more effective deterrents than criminal sanctions. </p>
<p>Because criminalizing drugs does not really prevent drug use, <a href="https://www.jstor.org/stable/3342518?seq=1">decriminalizing does not really increase it</a>. Portugal, <a href="https://time.com/longform/portugal-drug-use-decriminalization/">which decriminalized the personal possession of all drugs in 2001</a> in response to high illicit drug use, has <a href="https://www.emcdda.europa.eu/system/files/publications/11331/portugal-cdr-2019_0.pdf">much lower rates of drug use than the European average</a>. Use of cocaine among young adults age 15 to 34, for example, is 0.3% in Portugal, compared to 2.1% across the EU. <a href="https://www.emcdda.europa.eu/system/files/publications/11331/portugal-cdr-2019_0.pdf">Amphetamine and MDMA consumption is likewise lower in Portugal</a>. </p>
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<a href="https://images.theconversation.com/files/373956/original/file-20201209-13-1k3fxx5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman with a dog waits at a white van while a man drinks from a tiny cup" src="https://images.theconversation.com/files/373956/original/file-20201209-13-1k3fxx5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/373956/original/file-20201209-13-1k3fxx5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/373956/original/file-20201209-13-1k3fxx5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/373956/original/file-20201209-13-1k3fxx5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/373956/original/file-20201209-13-1k3fxx5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=492&fit=crop&dpr=1 754w, https://images.theconversation.com/files/373956/original/file-20201209-13-1k3fxx5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=492&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/373956/original/file-20201209-13-1k3fxx5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=492&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">A mobile drug-services van in Lisbon gives out methadone, a medication for people with opioid use disorder, in 2017.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/patient-rita-pestana-holds-her-puppy-while-her-husband-news-photo/857614826?adppopup=true">Horacio Villalobos - Corbis/Corbis via Getty Images</a></span>
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<h2>2. Decriminalization puts money to better use</h2>
<p>Arresting, prosecuting and imprisoning people for drug-related crimes is expensive. </p>
<p>The Harvard economist Jeffrey Miron estimates that all government drug prohibition-related expenditures <a href="https://www.cato.org/publications/tax-budget-bulletin/budgetary-effects-ending-drug-prohibition">were US$47.8 billion nationally</a> in 2016. Oregon spent about $375 million on drug prohibition in that year. </p>
<p>Oregon will now divert some the money previously used on drug enforcement to pay for <a href="https://www.statesmanjournal.com/story/news/politics/2020/10/16/oregon-2020-election-ballot-measure-110-decriminalize-drug-possession/3620146001/%22%22">about a dozen new drug prevention and treatment centers</a> statewide, which has been <a href="http://www.justicepolicy.org/uploads/justicepolicy/documents/04-01_rep_mdtreatmentorincarceration_ac-dp.pdf">found to be a significantly more cost-effective</a> strategy. Some tax revenue from <a href="https://www.bizjournals.com/portland/news/2019/07/25/oregon-cannabis-tax-revenue-gets-higher-and-higher.html">recreational marijuana sales</a>, which exceeded $100 million in 2019, will also go to addiction and recovery services. </p>
<p>Oregon <a href="https://www.oregonlegislature.gov/citizen_engagement/Reports/2019-OCJC-SB1041-Report.pdf">spent about $470 million on substance abuse treatment</a> between 2017 and 2019.</p>
<p>Not everyone who uses drugs needs treatment. Decriminalization makes help accessible to those who do need it – and keeps both those users and recreational users out of jail.</p>
<h2>3. The drug war targets people of color</h2>
<p>Another aim of decriminalization is to mitigate the significant <a href="https://www.sentencingproject.org/wp-content/uploads/2016/01/Disparity-by-Geography-The-War-on-Drugs-in-Americas-Cities.pdf">racial and ethnic disparities associated with drug enforcement</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/373973/original/file-20201209-17-i30jco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Black and whit image of police arresting a Black man in a New York subway station; no faces are seen" src="https://images.theconversation.com/files/373973/original/file-20201209-17-i30jco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/373973/original/file-20201209-17-i30jco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=339&fit=crop&dpr=1 600w, https://images.theconversation.com/files/373973/original/file-20201209-17-i30jco.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=339&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/373973/original/file-20201209-17-i30jco.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=339&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/373973/original/file-20201209-17-i30jco.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=426&fit=crop&dpr=1 754w, https://images.theconversation.com/files/373973/original/file-20201209-17-i30jco.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=426&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/373973/original/file-20201209-17-i30jco.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=426&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">New York’s ‘stop and frisk’ policing most often resulted in marijuana possession charges and targeted young Black men. It was declared unconstitutional in 2013.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/saw-this-young-man-being-stopped-in-nyc-subway-by-two-news-photo/185494998?adppopup=true">Third Eye Corporation/Getty</a></span>
</figcaption>
</figure>
<p>Illegal drug use is <a href="https://www.samhsa.gov/data/sites/default/files/cbhsq-reports/NSDUHNationalFindingsReport2018/NSDUHNationalFindingsReport2018.pdf">roughly comparable across race</a> in the U.S. But people of color are significantly more likely to be <a href="https://ag.ny.gov/pdfs/OAG_REPORT_ON_SQF_PRACTICES_NOV_2013.pdf">searched</a>, <a href="https://www.drugabuse.gov/about-nida/noras-blog/2020/06/message-director-racially-motivated-violence">arrested and imprisoned for a drug-related offense</a>. Drug crimes can incur long prison sentences.</p>
<p>Discretion in drug enforcement and sentencing means prohibition is among the <a href="https://newjimcrow.com/">leading causes of incarceration of people of color in the United States</a> – an injustice <a href="https://www.cato.org/multimedia/daily-podcast/bipartisan-drug-policy-reform">many Americans on both sides of the aisle</a> increasingly recognize. </p>
<p>Freed up from policing drug use, departments may redirect their resources toward crime prevention and solving <a href="https://thecrimereport.org/2015/06/24/2015-06-reinventing-american-policing-a-seven-point-blueprin/">violent crimes like homicide and robbery</a>, which are time-consuming to investigate. That could help restore some trust between law enforcement and Oregon’s communities of color. </p>
<h2>Risks of decriminalization</h2>
<p>One common concern among Oregonians <a href="https://www.opb.org/article/2020/10/15/measure-110-oergon-politics-decriminalize-drugs/">who voted against decriminalization</a> was that lessening criminal penalties would endanger children. </p>
<p>“I think it sends a really bad message to them, and influences their perception of the risks,” James O’Rourke, a defense attorney who helped organize the opposition to measure 110, <a href="https://www.opb.org/article/2020/10/15/measure-110-oergon-politics-decriminalize-drugs/">told Oregon Public Broadcasting in October</a>.</p>
<p>But U.S. states that legalized marijuana haven’t seen adolescent use rise significantly. In fact, marijuana consumption among teens – <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/add.14939">though not among college-aged Americans</a> – actually <a href="https://jamanetwork.com/journals/jamapediatrics/fullarticle/2737637">declined in some states with legal marijuana</a>. This may be because legal, regulated marijuana is more difficult for minors to get than black-market drugs. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/373955/original/file-20201209-13-pm4j84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman browses various types of marijuana in glass jars on shelves, in well-lit, upscale setting" src="https://images.theconversation.com/files/373955/original/file-20201209-13-pm4j84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/373955/original/file-20201209-13-pm4j84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/373955/original/file-20201209-13-pm4j84.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/373955/original/file-20201209-13-pm4j84.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/373955/original/file-20201209-13-pm4j84.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/373955/original/file-20201209-13-pm4j84.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/373955/original/file-20201209-13-pm4j84.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Customers must be 21 or older to purchase marijuana from dispensaries like Oregon’s Finest, in Portland.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/woman-shops-at-oregons-finest-a-marijuana-dispensary-in-news-photo/491438512?adppopup=true">Josh Edelson/AFP via Getty Images</a></span>
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</figure>
<p>Research also shows that for some people, particularly the young, banning a behavior <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4675534/">makes it more alluring</a>. So defining drugs as a health concern rather than a crime could actually make them less appealing to young Oregonians.</p>
<p>Another worry about decriminalization is that it will attract people looking to use drugs. </p>
<p>So-called “drug tourism” <a href="https://www.economist.com/europe/2009/08/27/treating-not-punishing">hasn’t really been a problem for Portugal</a>, but it happened in Switzerland after officials in the 1980s and 1990s began officially “ignoring” heroin in Zurich’s Platzspitz Park. People came from across the country to <a href="https://theculturetrip.com/europe/switzerland/articles/a-brief-history-of-zurichs-needle-park/">inject heroin in public, leaving discarded needles on the ground</a>. </p>
<p>The local government shut down Platzspitz Park. But rather than chase off or arrest those who frequented it, it began offering methadone and prescription heroin to <a href="https://ssir.org/articles/entry/inside_switzerlands_radical_drug_policy_innovation">help people with opioid use disorder</a>. Public injection, HIV rates and overdoses – which had all become a problem in Zurich – <a href="https://www.northcarolinahealthnews.org/2019/01/21/switzerland-couldnt-stop-drug-users-so-it-started-supporting-them/">plummeted</a>. </p>
<p>Certain parts of Oregon already have higher rates of public drug consumption, namely Portland and Eugene. Because public drug use is still illegal in Oregon, however, we don’t expect a Platzspitz Park-style open drug scene to emerge.
These places should benefit from the expansion of methadone programs and other medication-assisted treatment, which is endorsed by the <a href="https://www.ama-assn.org/delivering-care/opioids/ama-push-better-access-opioid-use-disorder-treatments">American Medical Association</a>.</p>
<p><a href="https://www.theolympian.com/opinion/editorials/article247180921.html">If neighboring Washington state decriminalizes drugs</a>, which it is considering, the chances of drug tourism would drop further. </p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p>
<h2>Upside – and downside</h2>
<p>There are risks with any major policy change. The question is whether the new policy results in a net benefit. </p>
<p>In Portugal, full decriminalization has proven more humane and effective than criminalization. Because drug users don’t worry about facing criminal charges, those who need help are more likely to seek it – and <a href="https://www.opensocietyfoundations.org/uploads/52ff6eb9-76c9-44a5-bc37-857fbbfedbdd/drug-policy-in-portugal-english-20120814.pdf">get it</a>. </p>
<p>Portugal’s <a href="https://www.emcdda.europa.eu/system/files/publications/11364/20191724_TDAT19001ENN_PDF.pdf%22%22">overdose death rate is five times lower than the EU average</a> – which is itself <a href="https://www.cdc.gov/nchs/products/databriefs/db356.htm">far lower than the United States’</a>. HIV infection rates among injection drug users also <a href="https://www.emcdda.europa.eu/system/files/publications/11331/portugal-cdr-2019_0.pdf">dropped massively</a> since 2001.</p>
<p>These policies show that problem drug use is a public health challenge to be managed, not a war that can be won.</p><img src="https://counter.theconversation.com/content/150806/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Possessing heroin, cocaine, meth and other drugs for personal use is no longer a criminal offense in Oregon. The idea is to get people with problem drug use help, not punishment.Scott Akins, Professor, Sociology Department, Oregon State UniversityClayton Mosher, Professor, Sociology Department, Washington State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1444222020-08-30T20:02:02Z2020-08-30T20:02:02ZOpioids continue to be the leading cause of overdose deaths in Australia. What else can we do?<figure><img src="https://images.theconversation.com/files/354808/original/file-20200826-16-qnyqwt.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C6000%2C3961&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In 2018, more than 2,000 people <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2016%7EMain%20Features%7EDrug%20Induced%20Deaths%20in%20Australia%7E6">died from drug overdoses</a> in Australia — about five each day.</p>
<p>That’s according to the Penington Institute’s <a href="https://www.penington.org.au/publications/2020-overdose-report/">annual overdose report</a>, released today.</p>
<p>The largest number of overdose deaths (more than 1,000) involved opioids (for example, heroin, morphine, oxycodone, fentanyl), followed by benzodiazepines (for example, Valium).</p>
<p>Opioid-related deaths in Australia have been on an upward trend in recent years, having <a href="https://tinyurl.com/yyscg788">doubled since 2006</a>. This means we’re now not far off numbers recorded in the late 1990s, when opioid-related deaths <a href="https://tinyurl.com/yyscg788">were highest</a>. There’s more we could be doing to curb this problem. </p>
<h2>What kind of opioids are causing harm?</h2>
<p>Unlike North America, where illicitly manufactured fentanyl has been involved in <a href="https://www.cdc.gov/drugoverdose/data/fentanyl.html">many opioid deaths</a>, most opioid deaths in Australia involve <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Drug%20Induced%20Deaths%20December%202019%20Bulletin_1.pdf">pharmaceutical opioids</a>. </p>
<p>That said, heroin deaths have <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2018%7EMain%20Features%7EOpioid-induced%20deaths%20in%20Australia%7E10000">increased over the past five years</a>. </p>
<p>Among all opioid deaths, just over <a href="https://pubmed.ncbi.nlm.nih.gov/31704378/">half of people overdosing</a> have a history of injecting drugs, and substance use problems. We know people with chronic non-cancer pain are becoming dependent <a href="https://pubmed.ncbi.nlm.nih.gov/26011277/">on pharmaceutical opioids</a> and are also among these <a href="https://pubmed.ncbi.nlm.nih.gov/31704378/">statistics</a>.</p>
<p>Some 80% of opioid deaths are accidental, while 16% are <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2018%7EMain%20Features%7EOpioid-induced%20deaths%20in%20Australia%7E10000">intentional overdoses</a> (the remaining 4% we don’t know). Intentional overdoses are <a href="https://pubmed.ncbi.nlm.nih.gov/31704378/">twice as common</a> with pharmaceutical opioids.</p>
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<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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<h2>Current strategies</h2>
<p>A large driver of increasing opioid deaths internationally has been the <a href="https://pubmed.ncbi.nlm.nih.gov/26852264/">increase in prescribing and use</a> of pharmaceutical opioids. Australia <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(19)32229-9/fulltext#supplementaryMaterial">ranks tenth worldwide</a>.</p>
<p>Australia has introduced a range of strategies to manage and restrict supply, including <a href="https://www.tga.gov.au/codeine-info-hub">re-scheduling codeine</a> to prescription-only, introducing <a href="https://theconversation.com/smaller-pack-sizes-from-today-could-new-opioid-restrictions-stop-leftover-medicines-causing-harm-139558">smaller pack sizes</a>, and setting up <a href="https://theconversation.com/prescription-monitoring-is-here-but-we-need-to-tread-carefully-to-avoid-unintended-harms-114969">systems to track prescribing</a>. </p>
<p>As many of these changes have only been implemented recently, it’s too early to know whether or not they’re having a positive effect.</p>
<p>But regulatory responses run the risk of unintended consequences. We saw this in Australia with the re-formulation of oxycodone tablets to a product that’s more difficult to inject. Heroin-related ambulance call-outs and emergency department presentations <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/add.14784">increased significantly</a> in Victoria after this change was introduced. </p>
<p>In North America, restricted opioid prescribing was associated with <a href="https://substanceabusepolicy.biomedcentral.com/articles/10.1186/s13011-020-0256-8">dramatic increases</a> in heroin and illicitly manufactured fentanyl deaths.</p>
<figure class="align-center ">
<img alt="Man sits against the wall with his head in his hand." src="https://images.theconversation.com/files/354809/original/file-20200826-7049-36ocr7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/354809/original/file-20200826-7049-36ocr7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/354809/original/file-20200826-7049-36ocr7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/354809/original/file-20200826-7049-36ocr7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/354809/original/file-20200826-7049-36ocr7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/354809/original/file-20200826-7049-36ocr7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/354809/original/file-20200826-7049-36ocr7.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">Restricting the availability of pharmaceutical opioids can steer people towards illicit opioids.</span>
<span class="attribution"><span class="source">Shutterstock</span></span>
</figcaption>
</figure>
<p>One key response to opioid overdose has been providing <a href="https://theconversation.com/opioid-dependence-treatment-saves-lives-so-why-dont-more-people-use-it-122537">opioid agonist treatment</a> (for example, methadone or buprenorphine) to opioid dependent people, typically those with a history of injecting drugs.</p>
<p>But only around <a href="https://www.thelancet.com/action/showPdf?pii=S2214-109X%2817%2930373-X">half take up this treatment</a>, and Australians with pharmaceutical opioid dependence are <a href="https://pubmed.ncbi.nlm.nih.gov/21545560/">unlikely to seek this type of help</a>. </p>
<p>Barriers to treatment include critical shortages of prescribers (addiction medicine specialists and trained GPs), <a href="https://pubmed.ncbi.nlm.nih.gov/29762767/">stigma</a>, and the requirement to attend a clinic or pharmacy daily at the start of treatment.</p>
<p>We need to double treatment capacity to meet the demand for people who may benefit from opioid agonist treatment.</p>
<h2>What else can we do?</h2>
<p>We can make opioid use safer.</p>
<p>The <a href="https://theconversation.com/what-goes-on-inside-a-medically-supervised-injection-facility-87341">two supervised injecting facilities</a> in Australia play an important role in reducing public injecting, and responding to overdoses on site. Neither service (in <a href="https://adf.org.au/insights/medically-supervised-injecting-centres/">Sydney</a> or <a href="https://www.parliament.vic.gov.au/file_uploads/Review_of_the_Medically_Supervised_Injecting_Room_June_2020_WsP785dN.pdf">Melbourne</a>) has had a death since opening.</p>
<p>The Victorian government has <a href="https://www2.health.vic.gov.au/alcohol-and-drugs/aod-treatment-services/injecting-room/second-supervised-injecting-room">approved</a> a second Melbourne facility, and a <a href="https://www.burnet.edu.au/projects/438_feasibility_study_for_a_potential_medically_supervised_injecting_centre_drug_consumption_service_for_the_act">study</a> currently underway is looking at whether a facility would be useful in Canberra.</p>
<p>Establishing these facilities requires a lot of planning as well as changes to legislation, and scaling them up to reach more Australians who inject drugs has proven difficult. There has been no movement on calls made <a href="https://theconversation.com/drug-users-in-outer-sydney-need-another-medically-supervised-consumption-room-96463">several years ago</a> to set up a second service in Sydney. </p>
<p>But we know these services <a href="https://www.parliament.vic.gov.au/file_uploads/Review_of_the_Medically_Supervised_Injecting_Room_June_2020_WsP785dN.pdf">save lives</a> and help get people into treatment, so we need to keep scaling them up. In the past three years Canada has opened <a href="https://www.hri.global/files/2019/03/29/drug-consumption-room-brief-2018.pdf">24 new supervised injecting facilities</a>, while Australia has opened just one.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/what-goes-on-inside-a-medically-supervised-injection-facility-87341">What goes on inside a medically supervised injection facility?</a>
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<p>We also need to consider innovations to ensure safer opioid supply.</p>
<p>In <a href="https://www.emcdda.europa.eu/system/files/publications/11287/20191061_TD0119176ENN_PDF.pdf">Europe</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/30359110/">North America</a> drug researchers monitor the heroin supply for dangerous contaminants, and we’ve seen early work like this <a href="https://pubmed.ncbi.nlm.nih.gov/32145660/">in Australia</a>, including at Sydney’s safe injecting centre.</p>
<p>These monitoring services provide critical information on opioid supply and can help people using opioids make informed decisions. </p>
<h2>What about the pandemic?</h2>
<p>We don’t yet know how COVID-19 will affect opioid deaths in Australia. We’ll need to continually monitor how the pandemic affects <a href="https://harmreductionjournal.biomedcentral.com/articles/10.1186/s12954-020-00370-7">access to treatment for opioid dependence</a>, and any <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/dar.13079">disruptions to opioid supply</a>.</p>
<p>But one thing is clear: the pandemic has shown we can respond quickly to implement change. Treatment services have <a href="https://www.pabn.org.au/covid-19/">rapidly adapted</a> to COVID-19 restrictions, for example by making it possible for people to receive methadone and buprenorphine without having to visit a clinic or pharmacy every day.</p>
<p>As well as making treatment more flexible, the pandemic has addressed broader needs for some people who are dependent on opioids, such as <a href="https://theconversation.com/if-australia-really-wants-to-tackle-mental-health-after-coronavirus-we-must-take-action-on-homelessness-139840">providing temporary accommodation</a>. Hopefully these changes will provide longer-term benefits, including encouraging people to remain in treatment.</p>
<hr>
<p>
<em>
<strong>
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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<p>In addressing opioid overdose deaths in Australia, we need to follow the best evidence, extend our vision to responses implemented internationally, and evaluate them locally. </p>
<p>Importantly, responses should be formulated within the frame of good clinical care, rather than relying on punitive responses, such as <a href="https://www.dss.gov.au/benefits-payments/drug-testing-trial">mandatory drug testing for welfare recipients</a>. This creates further problems, such as stigma, for people who use drugs.</p><img src="https://counter.theconversation.com/content/144422/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amanda Roxburgh is the current recipient of an NHMRC Investigator Grant.</span></em></p><p class="fine-print"><em><span>Paul Dietze is a National Health and Medical Research Council (NHMRC) Senior Research Fellow (grant no. 1136908) and receives NHMRC funding across a range of projects. He has received investigator-driven funding from the Victorian Department of Health and Human Services, the Australian Government Department of Health, the Colonial Foundation Trust, Gilead Science and Indivior. </span></em></p><p class="fine-print"><em><span>Suzanne Nielsen is the recipient of an NHMRC Fellowship (#1163961), and has received research funding from Indivior and Seqirus. </span></em></p>Opioid-related deaths in Australia have been on an upward trend in recent years, having doubled since 2006.Amanda Roxburgh, NHMRC Research Fellow, Burnet InstitutePaul Dietze, Head of Alcohol and other Drug Research, Centre for Population Health; Burnet Principal for Alcohol, other drugs and harm reduction, Burnet InstituteSuzanne Nielsen, Associate Professor and Deputy Director, Monash Addiction Research Centre, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1377122020-05-13T20:05:27Z2020-05-13T20:05:27Z2,200 deaths, 32,000 hospital admissions, 15.7 billion dollars: what opioid misuse costs Australia in a year<figure><img src="https://images.theconversation.com/files/334556/original/file-20200513-82403-l35x3e.jpg?ixlib=rb-1.1.0&rect=26%2C0%2C5964%2C3988&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In a single year, extra-medical opioid use caused more than 2,200 deaths, 32,000 hospital admissions and resulted in the loss of over 70,000 years of life in Australia. </p>
<p>“Extra-medical” opioid use includes both the illegal use of opioids such as heroin, and the misuse of pharmaceutical opioids – that is, when they’re not used as prescribed or intended.</p>
<p>In a <a href="http://ndri.curtin.edu.au/NDRI/media/documents/publications/T277.pdf">report released today</a>, we’ve quantified the social costs of pharmaceutical opioid misuse and illicit opioid use in Australia over the financial year 2015-16.</p>
<p>We found extra-medical opioid use came at a cost of an estimated A$15.7 billion.</p>
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<h2>The scope of the problem</h2>
<p>An <a href="https://www.aihw.gov.au/getmedia/15db8c15-7062-4cde-bfa4-3c2079f30af3/21028a.pdf.aspx?inline=true">Australian survey</a> showed more than 645,000 people used extra-medical opioids in the previous year.</p>
<p>But because of the stigma around opioid use, estimates from <a href="https://www.aihw.gov.au/getmedia/15db8c15-7062-4cde-bfa4-3c2079f30af3/aihw-phe-214.pdf.aspx?inline=true">national surveys</a> of how many people use extra-medical opioids or how many people would be classified as “dependent” may be underestimates.</p>
<p>We used results from the <a href="https://vizhub.healthdata.org/gbd-compare/">Global Burden of Disease study</a> to estimate more than 104,000 people in Australia were opioid-dependent in 2015-16, putting them at high risk of harms associated with their drug use.</p>
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Read more:
<a href="https://theconversation.com/opioid-dependence-treatment-saves-lives-so-why-dont-more-people-use-it-122537">Opioid dependence treatment saves lives. So why don't more people use it?</a>
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<p>While Australia has so far avoided the pharmaceutical opioid crisis seen elsewhere, especially in the United States, the number of Australian deaths due to pharmaceutical opioids outstrip those from <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/Drug%20Induced%20Deaths%20July%202019%20Drug%20Trends%20Bulletin_Final_0.pdf">heroin</a>. </p>
<p>In 2017, only 28% of opioid deaths involved illicit opioids alone. Some 63% involved pharmaceutical opioids and the remainder involved both.</p>
<h2>Let’s break down the costs</h2>
<p>Premature deaths accounted for about 80% of the costs of opioids to society, both in tangible and intangible costs. </p>
<p>As the average age of death from opioids is quite young (<a href="http://ndri.curtin.edu.au/NDRI/media/documents/publications/T277.pdf">43 years</a>), each death results in many potential years of life being lost. We calculated 70,000 years of life were lost as a result of premature deaths from opioids in 2015-16. </p>
<p>The intangible cost is the value society is willing to pay to prevent pain and suffering or premature death, which we come to through a variety of modelling techniques. </p>
<p>The tangible costs are the economic contributions the deceased person would have made through employment and unpaid household work, as well as the costs to employers in replacing an employee.</p>
<p>Making up the tangible costs, we also found crime accounted for $940 million, workplace costs such as from absenteeism and injury were $460 million, hospital inpatient care $250 million, and costs to other health services were $830 million. </p>
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<p>Typically, economic modelling doesn’t include any “harms” to the consumer, as those harms are part of a rational decision to consume. But for someone who has a drug dependence, that decision may be affected by the dependence and related consequences such as withdrawal. </p>
<p>As including those costs is controversial, we calculated them, but did not add them to our total. Based on data from the <a href="https://www.sciencedirect.com/science/article/pii/S0140673613615305">Global Burden of Disease study</a> we estimated the value of the lost quality of life for the 104,000 people dependent on opioids at $14.9 billion. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/fixing-pain-management-could-help-us-solve-the-opioid-crisis-90919">Fixing pain management could help us solve the opioid crisis</a>
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<p>We also looked at lost quality of life for partners and children living with a person dependent on opioids. We calculated there were more than 41,000 adults and 70,000 children living in these households in 2015-16. </p>
<p>Based on <a href="https://www.ncbi.nlm.nih.gov/pubmed/16244100">research</a> on the impact of living with an alcohol dependent person, we estimated the value of their lost quality of life at $12 billion. </p>
<p>These tentative estimates were also omitted from the overall total.</p>
<h2>Tackling the problem</h2>
<p>Since a low point of <a href="https://www.sciencedirect.com/science/article/abs/pii/S0376871617304040">529 deaths</a> in 2006, we’ve seen an increasing trend in deaths from extra-medical opioid use in Australia. But recent initiatives could serve to reduce deaths and other costs. </p>
<p>In Australia, “<a href="https://link.springer.com/content/pdf/10.1007/s40265-019-01154-5.pdf">take home naloxone</a>”, a drug that can reverse the effects of an opioid overdose, is increasingly available with support from the federal and state and territory governments.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
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<p>While most deaths documented in our report were due to drug toxicity (overdose), liver disease and liver cancer due to hepatitis C virus (HCV) accounted for 39% of extra-medical opioid deaths. </p>
<p>In March 2016, the Pharmaceutical Benefits Scheme subsidised <a href="https://kirby.unsw.edu.au/sites/default/files/kirby/report/ANSPS_National-Data-Report-2013-2017.pdf">a new treatment</a> for HCV.</p>
<p>This development has the potential to markedly reduce HCV related-disease and death for people dependent on opioids. A study in New South Wales has already noted a <a href="https://www.sciencedirect.com/science/article/abs/pii/S0168827819302752">significant decline</a> in HCV-related deaths and ill health in a broader population.</p>
<p>Needle and syringe programs remain important in preventing <a href="https://www.acon.org.au/wp-content/uploads/2015/04/Evaluating-the-cost-effectiveness-of-NSP-in-Australia-2009.pdf">blood borne viruses</a> for people who inject opioids. Along with access to opioid treatment (both pharmacological and psycho-social) these programs are central to our efforts to prevent and reduce opioid-related disease and deaths.</p>
<p>We’ve also seen regulatory changes. Between 2000 and 2013, 1,437 deaths involved <a href="https://www.mja.com.au/system/files/issues/203_07/10.5694mja15.00183.pdf">codeine</a>. So in 2018 increased restrictions were placed on over-the-counter medications containing codeine. </p>
<p>Initial findings are <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/add.14798">promising</a> but we look forward to evidence about the longer-term effects of this approach.</p>
<h2>There’s more we could be doing</h2>
<p>It’s important to recognise costs are typically estimated, for example the amount of time a general practitioner spends treating opioid-related conditions. </p>
<p>There are also other costs we know occurred, but where we can’t attribute a specific amount to opioids, such as efforts at our borders to address drug importation. So overall expenditure is the best approximation rather than a definitive figure.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-new-hepatitis-c-drugs-could-tackle-liver-cancer-too-73455">How new hepatitis C drugs could tackle liver cancer, too</a>
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<p>Social cost studies like this one provide a focus on the overall harms associated with a condition that can drive debate, policy reform and the allocation of health resources. </p>
<p>It’s critical we continue to enhance access to a range of treatments for opioid dependence and continue with other strategies already in place to tackle this tragic loss of life. </p>
<p>In addition, we need to focus on examining the impact of online supply of “counterfeit” and other pharmaceuticals outside of medical regulation, and develop targeted responses where indicated.</p><img src="https://counter.theconversation.com/content/137712/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Robert Tait works for the National Drug Research Institute, Curtin University which has received Australian Government funding to undertake alcohol and other drug research and related activities and in particular funding to support the work reported in this article. Robert Tait has received funding from Australian and state government agencies to undertake alcohol and other drug work and NHMRC research funding. He has also received funding from 'not-for-profit' organisations for work in the alcohol and other drug field. He is affiliated with the Australasian Professional Society Alcohol and Other Drug Research (member, state representative, director). </span></em></p><p class="fine-print"><em><span>Aqif Mukhtar works for NDRI which has received Australian Government funding to undertake alcohol and other drug research and related activities and in particular funding to support the work reported in this article. He is also works with WA Department of Health. </span></em></p><p class="fine-print"><em><span>Steve Allsop works for the National Drug Research Institute Curtin University which has received Australian Government funding to undertake alcohol and other drug research and related activities and in particular funding to support the work reported in this article.
Steve Allsop has received funding from Australian and state government agencies to undertake alcohol and other drug work and NHMRC research funding.
Steve Allsop is Chair of the WA Network of ALcohol and other Drug Agencies and Deputy Chair of the Australian National Advisory Council on Alcohol and other Drugs. </span></em></p><p class="fine-print"><em><span>Steve Whetton receives funding from the Australian Government to undertake alcohol and other drug research, through a research collaboration with Curtin University. He has also received funding from state and territory governments to undertake research into the impacts of alcohol and other drugs, including being called by the NSW Crown Solicitor's office as an expert witness in NCAT hearings on appeals against liquor licensing decisions.</span></em></p>A new report counts the social costs of pharmaceutical opioid misuse and illegal opioid use in Australia for 2015/2016. The numbers are fairly grim.Robert Tait, Senior Research Fellow, National Drug Research Institute, Curtin UniversityAqif Mukhtar, Research Associate, Curtin UniversitySteve Allsop, Professor, National Drug Research Institute, Curtin UniversitySteve Whetton, Deputy Director, SA Centre for Economic Studies, University of AdelaideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1239622020-04-21T12:47:47Z2020-04-21T12:47:47ZPharmacists could be front-line fighters in battle against opioid epidemic<figure><img src="https://images.theconversation.com/files/315053/original/file-20200212-61929-1m6slzs.jpg?ixlib=rb-1.1.0&rect=48%2C24%2C5400%2C3564&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">On average, more than 130 Americans die from an opioid overdose every day.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/19331187675272/">AP Photo/Keith Srakocic</a></span></figcaption></figure><p>When you stop at your local pharmacy to pick up a toothbrush or an antacid, soon you may also be able to buy an over-the-counter drug to reverse an opioid overdose. The lifesaving drug, naloxone, currently requires a prescription, but it may become available as an over-the-counter purchase in 2020. </p>
<p>Despite the <a href="https://www.cdc.gov/vitalsigns/opioids/index.html">national decrease in opioid prescriptions</a> since 2012, the <a href="https://www.cdc.gov/drugoverdose/data/prescribing.html">opioid crisis</a> continues. Access to prescription opioids have decreased due to <a href="https://doi.org/10.1111/add.14394">stricter legislation</a>, insurance regulations and the Centers for Disease Control Guideline for Prescribing Opioids for Chronic Pain. At the same time, the use of heroin and illegally manufactured synthetic opioids, such as fentanyl and counterfeit prescription opioids, has <a href="https://www.cdc.gov/nchs/data/databriefs/db356-h.pdf">escalated</a>. </p>
<p>In addition, <a href="https://doi.org/10.1001/jama.2018.2844">nearly 80% of opioid overdoses</a> involve multiple substances, compounding the risk of a fatal overdose. This reinforces the need for widespread, convenient naloxone access accompanied by <a href="https://doi.org/10.1097/ADM.0000000000000223">training on how to administer</a> this reversal drug. </p>
<p>As a <a href="https://cphs.wayne.edu/profile/ai6726">professor of pharmacy</a> and pharmacist, I believe that many more pharmacists can be engaged in providing naloxone for their patients.</p>
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<img alt="" src="https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308474/original/file-20200103-11900-49bqho.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Communities demand attention for the damage caused by the opioid crisis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/new-york-nyusa-0831-overdose-awareness-1168887157">Shutterstock.com/SCOOTERCASTER</a></span>
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<h2>Essential medication to save a life</h2>
<p>An opioid overdose can depress a person’s respiratory center to the point where breathing stops, resulting in death. Naloxone can reverse this effect within minutes. With minimal training, anyone can safely administer naloxone in various forms – nasal spray, auto-injector or intramuscular injection – to effectively buy more time and get medical help for someone who has overdosed. </p>
<p>Naloxone has been used in hospitals for more than 40 years to reverse excess sleepiness and respiratory depression from opioid anesthesia and pain medication or to treat overdoses in the emergency room. During the 1990s, naloxone use expanded <a href="https://www.drugabuse.gov/related-topics/opioid-overdose-reversal-naloxone-narcan-evzio">into communities</a> to first responders, laypersons and, most importantly, to people who use drugs to reverse opioid overdoses. </p>
<p>The U.S. surgeon general issued an <a href="https://www.surgeongeneral.gov/priorities/opioid-overdose-prevention/naloxone-advisory.html">advisory</a> in April 2018 encouraging family, friends and individuals at risk for an opioid overdose to carry naloxone and be trained to administer it. <a href="http://doi.org/10.1001/jamainternmed.2019.0272">Research shows</a> that wider access to naloxone is associated with fewer deaths. Naloxone could <a href="https://doi.org/10.1186/s12954-019-0352-0">successfully reverse</a> every witnessed opioid overdose, but only if naloxone is in the hands of a trained bystander. The challenge has been how to get naloxone to the people who need it.</p>
<p>In 48 states and the District of Columbia, pharmacists are now able to dispense naloxone under a standing order that does not require a physician’s prescription, or they can <a href="https://ldi.upenn.edu/brief/expanding-access-naloxone-review-distribution-strategies">directly prescribe naloxone</a>. But people may still be hesitant to ask for naloxone.</p>
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<img alt="" src="https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308476/original/file-20200103-11896-6y7ecx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Pharmacies may one day dispense naloxone as an over-the-counter drug.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-vector/naloxone-medicine-used-block-effects-opioids-1591052014">PureRadiancePhoto/Shutterstock.com</a></span>
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<h2>Why community pharmacists are key</h2>
<p><a href="https://www.psychiatry.org/patients-families/addiction/opioid-use-disorder/opioid-use-disorder">Opioid use disorder</a> is a chronic, relapsing, lifelong condition. Managing opioid use disorder requires sustained treatment and support, similar to other chronic conditions, such as diabetes and heart disease. But opioid use disorder often carries a social stigma, which can make people hesitant about seeking help through traditional health care channels. </p>
<p>People may be afraid to request a prescription for naloxone because they may be accused of misusing drugs. Others may not know how or where to obtain naloxone, particularly if they don’t have a regular health care provider. People who use drugs report <a href="https://doi.org/10.1007/s11606-015-3394-3">feeling stigmatized</a>, while <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6082708/">providers including pharmacists may be uncomfortable</a> starting a conversation with patients about the importance of carrying naloxone. </p>
<p>Yet the greater the access to naloxone, the more likely this lifesaving drug will be administered to reverse an overdose. I believe that pharmacists in the community are ideally positioned as a local resource to obtain naloxone. Community pharmacies have evolved into <a href="https://www.michiganpharmacists.org/Portals/0/patients/communitypharmacy.pdf">neighborhood health centers</a> where individuals can access a variety of services outside a traditional clinical setting including immunizations, health screenings and lab monitoring. </p>
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<a href="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/308472/original/file-20200103-11909-19koiog.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Vial of naloxone.</span>
<span class="attribution"><a class="source" href="http://www.Shutterstock.com/418417357">PureRadiancePhoto/Shutterstock.com</a></span>
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<p><a href="https://doi.org/10.1097/ADM.0000000000000223">Pharmacists</a> can recommend and provide naloxone, opioid education and overdose prevention information to high-risk individuals and their support network. Pharmacists can make their pharmacy a safe and nonjudgmental resource, where people obtain and learn to administer naloxone, seek self-care advice and reduce harm from drug use, including clean needles and syringes. And pharmacists are well positioned to provide connections to local programs for recovery and support. They can make referrals to supportive health care providers and provide “whole person” care for vulnerable individuals. </p>
<h2>Federal support to halt deadly overdoses</h2>
<p>The U.S. Department of Health and Human Services recognizes the importance of addressing opioid use disorder and the opioid crisis with a <a href="https://www.hhs.gov/opioids/about-the-epidemic/hhs-response/index.html">5-point strategy</a>. This includes better access to opioid use disorder treatment, research funding, improved pain management and expanded naloxone availability in health care and community settings. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=365&fit=crop&dpr=1 600w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=365&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=365&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=459&fit=crop&dpr=1 754w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=459&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/325856/original/file-20200406-96658-1qy7sdo.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=459&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Emergency overdose kit.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Drug-Abuse-Treatment/3c546feaea4d4b1a827a397a9aece342/115/0">AP Photo/Jim Cole</a></span>
</figcaption>
</figure>
<p>While naloxone is not yet available for purchase over the counter, the U.S. Food and Drug Administration supports this simple access and has developed a “drug facts naloxone label” with pictures making it easy for anyone to effectively administer the correct dose. Manufacturers can apply for over-the-counter status, and naloxone is expected to become available as an over-the-counter drug <a href="https://doi.org/10.1111/1475-6773.13125">this year</a>. The availability to purchase naloxone without a prescription and over the counter can remove the perceived stigma of having to request it from a health care provider or pharmacist. </p>
<p>Naloxone alone will not mitigate the opioid crisis. Yet the ability to reverse a fatal overdose – having someone nearby who carries and can administer naloxone – allows the survivor another chance to enter <a href="https://doi.org/10.2105/AJPH.2017.304187">treatment that addresses</a> the social, structural, genetic, behavioral and individual factors of opioid use disorder. Pharmacists have an important role in helping to remove the stigma associated with requesting and carrying naloxone by openly discussing its benefits and making naloxone available to all patients. </p>
<p>[<em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>.]</p><img src="https://counter.theconversation.com/content/123962/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Victoria Tutag Lehr has received funding from MDHHS, BCBSMF, Amerisource-Bergen.
</span></em></p>Pharmacists are well positioned to provide communities with a lifesaving drug.Victoria Tutag Lehr, Professor of Pharmacy, Wayne State UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1347532020-03-26T13:59:19Z2020-03-26T13:59:19ZHow coronavirus is changing the market for illegal drugs<figure><img src="https://images.theconversation.com/files/323280/original/file-20200326-132995-tgg5v0.png?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Reading between the lines. </span> <span class="attribution"><a class="source" href="https://www.wallpaperflare.com/closeup-photography-of-rolled-banknote-with-cocaine-addiction-wallpaper-zecyl">Wallpaper flare</a></span></figcaption></figure><p>The illicit drug market in the UK <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/868404/Review_of_Drugs_Evidence_Pack_-_FINAL_PUBLICATION_VERSION_1.pdf">turns over</a> more than £10 billion tax-free a year. Unlike the wider economy, we have limited intelligence about how it operates. But like the wider economy, it is certainly not immune to the disruption being caused by the COVID-19 virus. </p>
<p>As borders close, the supply and distribution of most drugs is being restricted – but <a href="https://www.vice.com/en_uk/article/dygebq/drug-dealers-how-coronavirus-affecting-business">particularly</a> those that rely on ingredients <a href="https://www.vice.com/en_uk/article/bvgazz/sinaloa-cartel-drug-traffickers-explain-why-coronavirus-is-bad-for-business">sourced</a> in China. We are already hearing reports of reductios in the supplies of “<a href="http://www.emcdda.europa.eu/publications/drug-profiles/synthetic-cannabinoids">Spice</a>”, for example, the synthetic cannabinoid which is often imported from that part of the world. There are also bound to be problems further down the distribution network. The edict to stay at home will be affecting the ability of city-based dealers to carry out “<a href="https://www.nationalcrimeagency.gov.uk/what-we-do/crime-threats/drug-trafficking/county-lines">county lines dealing</a>”, where they push their product into smaller towns and rural areas. </p>
<p>Previous heroin “droughts” in <a href="https://www.gov.uk/government/publications/reducing-opioid-related-deaths-in-the-uk">the UK</a> and <a href="https://substanceabusepolicy.biomedcentral.com/articles/10.1186/1747-597X-1-11">Australia</a> have been accompanied by temporary falls in deaths, as people reduced their use or substituted with alternatives that were less lethal in an overdose. But more recently, we have seen significant increases in deaths from the <a href="https://www.gov.uk/government/publications/misuse-of-fentanyl-and-fentanyl-analogues">synthetic opioid fentanyl</a> in North America, so we must be alert to the possibility that UK dealers and users will turn to this dangerous substance as heroin supplies dry up. As fentanyl is significantly stronger than heroin it is easier to store and move around due to the smaller quantity required.</p>
<p>Even where a user knows they have bought fentanyl rather than heroin, titrating a safe dose is challenging and this might only become apparent when it’s too late. The UK already has <a href="https://theconversation.com/uk-drug-deaths-continue-to-rise-time-for-action-120449">the highest</a> rate of drug-related deaths in Europe, and the danger now is that the rate may climb even higher. </p>
<p>The government is <a href="https://www.theguardian.com/world/2020/mar/16/government-response-to-coronavirus-led-by-science-grant-shapps">continually stressing</a> that it is led by research evidence in tackling the COVID-19 pandemic, but this doesn’t extend to acting on its advisers’ <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/699825/Letter_from_Victoria_Atkins_MP_to_OBJ.pdf">own recommendation</a> that it should set up drug consumption rooms to reduce the number of deaths from overdoses. It’s difficult to imagine a more important time to heed this advice. </p>
<h2>Another kind of panic buying</h2>
<p>Now that we are all self-isolating, a perfect set of ingredients come together: anxiety, boredom, escapism and loneliness. All of these are candidates for self-medicating with more drugs – as are the abrupt change of routine and being cooped up with family.</p>
<p>Just as we’ve seen <a href="https://theconversation.com/coronavirus-why-people-are-panic-buying-loo-roll-and-how-to-stop-it-133115">people panic buying</a> toilet rolls and paracetamol, consumers of recreational drugs will, if they have the means, stockpile their drug of choice. More than 1.5 million people are <a href="https://www.gov.uk/government/statistics/drug-misuse-findings-from-the-2018-to-2019-csew">regular users</a> of drugs in England and Wales alone, and the surge in demand has <a href="https://www.vice.com/en_uk/article/dygebq/drug-dealers-how-coronavirus-affecting-business">already seen reports</a> of the price of drugs escalating.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1242796149603524610"}"></div></p>
<p>Stockpiling might lead people to take more drugs than usual. If they are dependent and subsequently can’t source the drug, they could suddenly end up with a withdrawal problem. This increases the risk that they will try a substitute drug, which again makes it more likely that they will come to harm since they may not be used to the drug or know what a safe dose should be. </p>
<p>The European Monitoring Centre for Drugs and Drug Addiction recently issued some <a href="http://www.emcdda.europa.eu/publications/topic-overviews/covid-19-and-people-who-use-drugs">general advice</a> to users on reducing harm during the spread of coronavirus. This was welcome, but it didn’t say anything about the risks from drugs themselves at this time. </p>
<p>We are talking about a market without any quality control or regulation, in which consumers have no idea of the strength of their drug from dose to dose or which chemicals they are exposing themselves to. Mirroring the lack of testing for COVID-19, there’s no routine testing for drugs in the UK and many other countries – other than, say, at <a href="https://theconversation.com/festival-drug-checking-is-here-but-it-now-needs-to-be-expanded-across-the-country-63065">certain music festivals</a>.</p>
<h2>The growing threat</h2>
<p>Public Health England has asked frontline agencies to alert them to examples of drug substitution or contaminated product. Gathering this intelligence makes sense, but is of little benefit unless it is communicated directly to those at risk. This could be viewed by some as a government agency condoning drug use, so it is unlikely to do so directly.</p>
<p>There is already a <a href="https://www.gov.uk/drug-safety-update">similar process</a> for problems with prescribed drugs, as the Medicines and Healthcare Products Regulatory Agency alerts pharmacists, general practitioners and others involved in prescribing or dispensing these drugs to any hazards or emerging risks.</p>
<p>In the case of illegal drugs, the obvious network for feeding back equivalent information is the specialist drug treatment services. Unfortunately, that network <a href="https://transformdrugs.org/we-need-to-support-the-vulnerable-as-covid-19-spreads/">has shrunk</a> significantly over the last decade because the government has <a href="https://theconversation.com/drug-deaths-increase-as-fewer-people-access-treatment-84784">savagely cut</a> the treatment budget. Even then, this network doesn’t reach the majority of people with drug problems, as they are not in treatment. For obvious reasons, such people guard their identity. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/323289/original/file-20200326-133001-szmzlb.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">‘Much obliged’.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/drug-trafficking-crime-addiction-sale-concept-519449383">Syda Productions</a></span>
</figcaption>
</figure>
<p>The bottom line is that we need to be smarter and better informed about this large but hidden part of our economy. The pandemic is exposing how little we know, and our inability to protect the significant number of people involved in it. There are persuasive grounds to change our policy approach to drugs, including the potential to <a href="https://journals.sagepub.com/doi/full/10.1177/1477370819887514">reduce the harms done</a> by either no longer criminalising users or even <a href="https://blogs.lse.ac.uk/politicsandpolicy/the-costs-and-benefits-of-a-licensed-taxed-and-regulated-cannabis-market/">legalising sales</a> and reaping the tax revenues. </p>
<p>“Doing what it takes to protect people” has to include everyone – not just those we morally approve of.</p><img src="https://counter.theconversation.com/content/134753/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alex Stevens is a member of the DrugScience committee, of the board of the International Society for the Study of Drug Policy, and of the Green Party</span></em></p><p class="fine-print"><em><span>Ian Hamilton does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Prices are surging amid shortages and panic-buying – and we could soon be facing a public health disaster. Ian Hamilton, Associate Professor, Addiction and Mental Health, University of YorkAlex Stevens, Professor in Criminal Justice and Faculty Director of Public Engagement, University of KentLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1293922020-01-30T12:44:41Z2020-01-30T12:44:41ZThe highs and lows of the opium trade in southern Africa<figure><img src="https://images.theconversation.com/files/311814/original/file-20200124-81336-1d1c10h.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>The reach of European empires and of Indian Ocean trade networks drew southern Africa into the global politics of opium around the turn of the twentieth century. Between the late 1880s and early 1920s and there was a shift from economies of supply to regimes of control. </p>
<p>The colonies of Mozambique and South Africa were caught up in these big changes. </p>
<p>In a <a href="https://www.tandfonline.com/doi/full/10.1080/02582473.2019.1627402">recent paper</a> I highlight how official and unofficial actors shaped and responded to the global politics of opium and, in different ways, worked to benefit from these developments. </p>
<p>With a focus on Mozambique and, especially, South Africa, I demonstrate how the changing global politics of drug supply and suppression influenced local colonial social and political processes. </p>
<p>I also show how these histories influenced events worldwide, including the first efforts to use the League of Nations to control the international cannabis trade.</p>
<h2>Opium cultivation in Mozambique</h2>
<p>In July 1877 an unpleasant surprise greeted British Imperial consul, Captain James Frederick Elton, as he led an expedition through the Zambezi valley in <a href="https://www.britannica.com/place/Mozambique">Mozambique</a>. An agricultural experiment was underway, and it seemed to be thriving. The enterprise was Portuguese; the crop was <a href="https://www.history.com/topics/crime/history-of-heroin-morphine-and-opiates">opium</a>. </p>
<p>This was a problem for him because there was open contestation between European countries hungry to <a href="https://www.newworldencyclopedia.org/entry/Scramble_for_Africa">colonise the continent</a>. Elton recognised that active farming in this region was bad news for British interests and claim-making. </p>
<p>Worse, the healthy crop of <em>Papaver somniferum</em> heralded a new source of competition with <a href="https://www.britannica.com/topic/Opium-Wars">British Indian opium</a> that monopolised the lucrative Chinese market.</p>
<p>In 1874, the Mozambique Opium Cultivation and Trading Company launched its experiment with £180,000, a concession of 50,000 acres of Portuguese crown land and exclusive rights to duty-free export for 12 years. </p>
<p>In fact, growing opium in the Zambezi valley proved a short-lived venture. </p>
<p>In 1884, poppy cultivation was ended by an anti-colonial uprising. Although the violence had broader aims and targets, African workers were motivated to destroy the opium plantation because of the company’s extortion of workers through taxes and forced recruitment. </p>
<p>Quests to profit from opium were taken up in a different way further south. </p>
<h2>The South African leg</h2>
<p>By the early 1900s the consumption of opium and its alkaloids, like morphine, were well established in southern Africa. A common ingredient in over-the-counter <a href="https://americanhistory.si.edu/collections/object-groups/balm-of-america-patent-medicine-collection/history">patent medicines</a>, opiates were distributed by shopkeepers, pharmacists and missionaries. </p>
<p>Because of disproportionate access, white citizens were most at risk of forming a ‘habit’. Afrikaans poet <a href="https://www.uj.ac.za/library/informationsources/special-collections/Online-Exhibitions/Eugene-Marais/Pages/Eugene-Marais-Early-Life.aspx">Eugene Marais</a> was famously a life-long morphine injector. At least one historian has argued that the writing career of <a href="https://digitalcollections.lib.uct.ac.za/humanitec/schreiner">Olive Schreiner</a> was, for a time, hampered by over-consumption of opiated Chlorodyne. </p>
<p>Opium also figured in labour control. Early in the century, until 1910, the Transvaal legally imported tons of opium for the use of migrant Chinese workers recruited to the gold mines. It legislated a <a href="https://www.cambridge.org/core/journals/journal-of-african-history/article/poppies-and-gold-opium-and-law-making-on-the-witwatersrand-190410/7F346245184D53E8B084CE30C1F772B7">formal system of opium provision</a> for these workers and farmed the revenue through a customs act.</p>
<p>Opium consumption was entirely legal. Nevertheless, especially from 1910, the South African government sought to <a href="https://mh.bmj.com/content/44/4/253.full">regulate all forms of opium sales</a>. Police showed most interest in opium used for smoking and occasionally raided ‘opium dens’. In 1910, police reported six such venues in Cape Town. All were in fact just rooms in private homes. Salon owners supplied opium, along with the pipes and lamps used to smoke it. </p>
<p>Their patrons were a small and eclectic community. There was, for example, William Birch, a ‘Coloured’ Pierrot troupe player, small time drug dealer and police informant; Daisy Harris, a ‘European’ hotel barmaid; Mr Kong Lee, who ran a laundry with his wife, a ‘St Helena woman’; Hamat Rajap, a Muslim tailor; and Richardson (alias ‘Country’), a black American traveller.</p>
<p>In Cape ports, sailors brought opium. Train stewards were known to move it inland. Some medical professionals also profited from a sideline supplying opium. In Johannesburg, risk-takers could try their luck smuggling Indian opium from up the coast and the port at Lourenço Marques (now Maputo).</p>
<h2>Colonial rule</h2>
<p>After 1910, quantities of opium in circulation remained relatively small. Yet, international opium conferences held in the <a href="https://www.unodc.org/unodc/en/frontpage/the-1912-hague-international-opium-convention.html">Hague in 1912</a> and in 1914 identified the Union of South Africa as a critical region for controlling ‘dangerous drugs’. Bordered by two oceans, with multiple ports and a growing pharmaceutical manufacturing sector, the Union was instructed to embrace the protocols being drafted. </p>
<p>But South Africa dragged its feet. That is until the 1920s when government officials such as <a href="https://www.sahistory.org.za/people/general-jan-christiaan-smuts">Jan Smuts</a>, who served as prime minister of the Union, promoted restrictive legislation. </p>
<p>Smuts was also one of the architects of the <a href="https://www.unog.ch/80256EDD006B8954/(httpAssets)/36BC4F83BD9E4443C1257AF3004FC0AE/%24file/Historical_overview_of_the_League_of_Nations.pdf">League of Nations</a>. He soon recognised that the international campaigns against ‘dangerous drugs’ could suit local political aims. </p>
<p>The government led by Smuts sought to control the consumption and production of cannabis (known as ‘dagga’ locally) within its borders. Cannabis had been used as medicine and recreational intoxicant by indigenous communities for at least 500 years. But the British <a href="https://theconversation.com/south-african-court-frees-cannabis-from-colonial-and-apartheid-past-103644">colonial view</a> of the plant became woven into narratives that fed white panic about crime and racial control. </p>
<p>South Africa requested that international bodies add cannabis to the ‘dangerous drugs’ list. With support from Egypt and other nations, cannabis was – along with opium, heroin, and cocaine – criminalised internationally in 1925.</p>
<p>The South African government also set about putting rigorous controls in place on the Mozambican border. The drive to control ‘dangerous drugs’ therefore also bolstered its capacity for territorial sovereignty.</p>
<p><em>This is the second article in a <a href="https://theconversation.com/africa/search?utf8=%E2%9C%93&q=DRSA">series</a> on drug regimes in southern Africa. They are based on research done for a special edition for the <a href="https://www.tandfonline.com/toc/rshj20/current">South African Historical Journal</a>. Read the full paper over <a href="https://www.tandfonline.com/doi/full/10.1080/02582473.2019.1627402">here</a>.</em></p><img src="https://counter.theconversation.com/content/129392/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thembisa Waetjen receives funding from the National Research Foundation (NRF).</span></em></p>Opium played a fascinating role in southern African colonial politics, conflict and social change - from the poppy fields of Mozambique to the early days of Johannesburg city.Thembisa Waetjen, Associate Professor of History, University of JohannesburgLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1282462020-01-29T12:41:41Z2020-01-29T12:41:41ZSecret histories of drugs – legal and illegal – in southern Africa<figure><img src="https://images.theconversation.com/files/311110/original/file-20200121-117907-1k57lih.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>If you want to score heroin in some of the historically black suburbs, or townships, of Johannesburg, South Africa, you need to find yourself a ‘Snyman’. A ‘Snyman’ is a drug dealer. The word is used in <a href="https://link.springer.com/chapter/10.1057/978-1-137-01593-8_18">tsotsitaal</a>, the creole, urban dialect that emerged during the colonial and apartheid eras of segregation. </p>
<p>‘Snyman’ entered this lexicon in the late 1960s and early 1970s. It was around this time that cannabis smugglers supplying the gold mining compounds and nearby settlements began to diversify into pharmaceuticals. One drug of choice was methaqualone, also known as Mandrax. </p>
<p>Today, most young people who rely on a Snyman to supply them with a
bit of a heroin admixture locally known as <a href="https://www.sciencedirect.com/science/article/pii/S037907381830481X">nyaope</a> aren’t aware that they are invoking the name of a mid-century professor of medicine at the University of Pretoria, Dr HW Snyman. In 1961 Snyman headed a governmental commission that bore his name. Its recommendations led to the Medicines and Related Substances <a href="https://www.nda.agric.za/vetweb/Legislation/Other%20acts/R_Medicines_and_related_substances.htm">Control Act</a> of 1965.</p>
<p>This means that, at the height of the apartheid era, black entrepreneurs trading in illicit pharmaceuticals adopted and repurposed the name of a white medical expert who enacted the state’s vision of drug regulation. In calling themselves ‘Snyman’, they showed a hefty dose of defiance as well as ironic humour.</p>
<p>The anecdote may be read as a metaphor of grassroots challenges to apartheid statecraft. But it also confirms growing, global evidence that drug prohibitions have never been far from the workings of ‘shadow’ economies. Indeed, chemically and socially, the <a href="https://www.strath.ac.uk/humanities/schoolofhumanities/history/centreforthesocialhistoryofhealthhealthcare/beyondthemedicinesdrugsdichotomyhistoricalperspectivesongoodandevilinpharmacy/">dichotomies</a> historically crafted between (legitimated) medicines and (illicit) drugs just don’t hold in practice. </p>
<p>We see this currently, for example, in the rapidly <a href="https://www.economist.com/international/2019/08/29/a-global-revolution-in-attitudes-towards-cannabis-is-under-way">shifting legal status</a> of cannabis (including in <a href="http://theconversation.com/south-african-court-frees-cannabis-from-colonial-and-apartheid-past-103644">South African law</a>) and its speedy absorption into <a href="https://www.marketwatch.com/story/10-largest-marijuana-companies-2019-01-02">corporate commerce</a>; in <a href="https://www.theguardian.com/us-news/2019/oct/04/purdue-pharma-oxycontin-sacklers-opioid-lawsuits">painkiller</a> ‘opioid crises’ and <a href="https://www.cdc.gov/nchs/pressroom/podcasts/20190911/20190911.htm">fentanyl overdose deaths</a> in the US; in the <a href="https://www.unodc.org/nigeria/en/key-findings-of-unodc-study-on-tramadol-trafficking-in-west-africa-discussed-at-regional-meeting.html">illicit trade</a> in the painkiller Tramadol in West Africa; and in clandestine exports of Chinese Xanax into the hands of South African <a href="https://www.newframe.com/prescription-drug-poses-new-threat-to-youths/">school kids</a>.</p>
<p>A special issue of the <a href="https://www.tandfonline.com/toc/rshj20/current">South African Historical Journal</a>, Drug Regimes in Southern Africa, showcases research about some of the ‘secret’ histories of drugs from the southern region of the African continent. These range from Cape Town’s opium dens to cannabis experiments on cats; from big pharma bio-prospecting to the politics of synthetic sedatives and controversial cow vaccines.</p>
<p>But why spend time reading about the past when today’s drug dilemmas seem so urgent?</p>
<h2>Why history matters</h2>
<p>Historical research can offer critical perspectives that help make sense of current dilemmas. Historians don’t generally set out to inform policy. Nevertheless complex understandings of the past are key to sound decision-making in both legislative and medical practices. Historians know that debates about substances commonly called ‘drugs’ are far from new. As was pointed out by organisers of a recent <a href="https://www.strath.ac.uk/humanities/schoolofhumanities/history/changingmindssocietiesstatesthesciencesandpsychoactivesubstancesinhistory/">history conference</a> held in Shanghai:</p>
<blockquote>
<p>After all, experts offering definitive accounts of psychoactive substances, vacillating bureaucrats and politicians, unyielding moralists and fickle consumers are all among the figures familiar to historians from other periods and a range of places.</p>
</blockquote>
<p>Historical research on ‘drugs’, whether defined as <a href="https://www.intoxicatingspaces.org/">intoxicants</a> or medicines, is an established field among scholars in the global North. This is shown in the work of the <a href="https://alcoholanddrugshistorysociety.org/about/">Alcohol and Drugs History Society</a> and its excellent journal, <a href="https://www.journals.uchicago.edu/toc/shad/current">Social History of Alcohol and Drugs</a>. </p>
<p>But drugs history scholarship from and about the global South grows ever more vibrant. Histories of <a href="https://uncpress.org/book/9780807859056/andean-cocaine/">cocaine </a> in South America and <a href="https://www.strath.ac.uk/humanities/schoolofhumanities/history/centreforthesocialhistoryofhealthhealthcare/ourresearch/theasiancocainecrisis/">Asia</a>, <a href="https://uncpress.org/book/9781469613727/home-grown/">cannabis in Mexico </a> and <a href="https://www.cambridge.org/core/journals/journal-of-modern-african-studies/article/politics-of-law-enforcement-in-nigeria-lessons-from-the-war-on-drugs/8B56707532B2902B3C2A26354C97966B">Nigeria</a>, <a href="https://brill.com/view/title/13754">khat in Kenya</a> and the politics of <a href="https://www.cambridge.org/core/books/drugs-politics/E2EFB2A2A59AC5C2D6854BC4C4501558">drug use in Iran</a> are a few examples. </p>
<p><a href="https://www.palgrave.com/gp/book/9781137321893">Histories of drugs in Africa</a> are of growing interest worldwide.</p>
<p>Since the late 19th century especially, global flows of neurochemical substances and products have deepened the entanglements of consumers in Africa in networks of legal and illicit drugs production, flow, profit and risk. Historical perspectives bring to light the social processes through which bioactive plants, manufactured pharmaceuticals and techniques of treatment come to figure in diverse and changing human experiences. </p>
<p>In the 20th century, the contexts of colonialism, apartheid and democracy shaped <a href="https://mh.bmj.com/content/44/4/253">drug control, provision and regulation</a> in South Africa.</p>
<p>Today media reports on drug issues in this country often invite panicked responses. Journalism frequently reproduces the hyperbole and moralism that have – for over a century – shaped public opinion here. Narratives that sometimes exaggerate or even mislead the public about new forms of substances, coming across borders, or the behaviours they allegedly cause, have had very negative consequences. These have included fuelling <a href="https://www.theguardian.com/world/2019/sep/10/we-are-a-target-wave-of-xenophobic-attacks-sweeps-johannesburg">xenophobic sentiments</a> as well as <a href="https://www.hsrcpress.ac.za/books/opioids-in-south-africa">the stigma</a> attached to people using drugs. </p>
<p>At the same time, there are hopeful signs of change in public opinion. And there are positive indications of a quest for evidence-based policy and treatment solutions. An example is the case of <a href="https://www.hsrcpress.ac.za/books/opioids-in-south-africa">harm reduction approaches</a> to opioid addiction.</p>
<h2>What’s needed</h2>
<p>The promises of pharmaceutical technologies are evident. So are the challenges. In today’s global world, we need the evidence offered by history to develop more informed, nuanced and less reactionary responses.</p>
<p>The <a href="https://www.tandfonline.com/toc/rshj20/current">special issue</a> ‘Drug Regimes in Southern Africa’ is proof of a growing body of work on the histories of drugs – illegal and legal – across the continent. </p>
<p><em>The information that ‘Snyman’ is used as a word for drug dealer was provided by Msawenkosi Gibson Nzimande, a University of Johannesburg Masters student currently doing research on substance use in Johannesburg.</em></p>
<p><em>This is the first article in a <a href="https://theconversation.com/africa/search?utf8=%E2%9C%93&q=DRSA">series</a> on drug regimes in southern Africa. They are based on research done for a special edition for the <a href="https://www.tandfonline.com/toc/rshj20/current">South African Historical Journal</a>. Read the full paper over <a href="https://www.tandfonline.com/doi/full/10.1080/02582473.2019.1681073">here</a>.</em></p><img src="https://counter.theconversation.com/content/128246/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thembisa Waetjen receives funding from the National Research Foundation (NRF).</span></em></p><p class="fine-print"><em><span>Julie Parle receives funding from the National Research Council (NRF).</span></em></p><p class="fine-print"><em><span>Rebecca Hodes receives funding from the Medicines Research Council and the Human Sciences Research Council of South Africa, the Medical Research Council of the United Kingdom, the Fogarty International Centre and the National Institute of Mental Health at the National Institutes of Health, United States, the European Research Council, and the Desmond Tutu HIV Foundation.</span></em></p>From colonial poppy fields to pharmatrash, southern Africa offers a fascinating history of drug regimes – one that helps us make sense of drug policies and legislation today.Thembisa Waetjen, Associate Professor of History, University of JohannesburgJulie Parle, Honorary Professor in History, University of KwaZulu-NatalRebecca Hodes, Director, AIDS and Society Research Unit, University of Cape TownLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1225372019-11-03T18:55:46Z2019-11-03T18:55:46ZOpioid dependence treatment saves lives. So why don’t more people use it?<figure><img src="https://images.theconversation.com/files/299607/original/file-20191031-187898-1v815y4.jpg?ixlib=rb-1.1.0&rect=0%2C16%2C5597%2C3709&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">To reduce opioid-related harms, we must ensure treatments for opioid dependence are accessible to those who need them. </span> <span class="attribution"><span class="source">From shutterstock.com</span></span></figcaption></figure><p>In Australia last year, <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/3303.0%7E2018%7EMain%20Features%7EOpioid-induced%20deaths%20in%20Australia%7E10000">1,123 people</a> died from opioids – illicit drugs such as heroin, and pain relievers such as codeine, oxycodone and morphine. If used regularly, physical and psychological dependence can develop.</p>
<p>In recent years most deaths have been due to <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/contents/table-of-contents">pharmaceutical opioids</a> – that is, overdoses of strong pain medicines. Though heroin-related deaths are <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/data">increasing rapidly</a>, so we need evidence-based responses for both.</p>
<p>One key approach to reducing these deaths is treatment for opioid dependence. Although the evidence shows treatments such as methadone and buprenorphine <a href="https://www.ncbi.nlm.nih.gov/pubmed/24500948">are effective</a>, people who are dependent on opioids continue to face barriers to accessing them.</p>
<p>These include cost, stigma, restrictiveness of the treatment regime, and a lack of places to go to receive treatment. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-naloxone-how-to-save-a-life-from-opioid-overdose-63459">Weekly Dose: Naloxone, how to save a life from opioid overdose</a>
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</em>
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<h2>Opioid dependence treatment</h2>
<p>The dependence treatment backed by the strongest evidence is called “opioid agonist treatment”. An opioid “agonist” means a drug that produces opioid effects in the body.</p>
<p>Opioid agonist treatment is when a known and legal opioid medicine (the opioid “agonist”) is provided in a therapeutic setting, like a clinic or pharmacy, in a regular dose. This removes the need for using additional opioids by reducing craving and withdrawal.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=785&fit=crop&dpr=1 600w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=785&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=785&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=986&fit=crop&dpr=1 754w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=986&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/299822/original/file-20191101-102186-s1nsbo.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=986&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="attribution"><span class="source">The Conversation</span>, <a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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<p>Staying in treatment <a href="https://www.ncbi.nlm.nih.gov/pubmed/7259424">longer</a> is associated with better outcomes, with best results seen when treatment is continued <a href="https://ndarc.med.unsw.edu.au/sites/default/files/ndarc/resources/FAQ%20Pharmacetuical%20Opioid%20Dependence%20Treatment_0.pdf">for 12 months or more</a>. So this is a longer-term treatment providing an opportunity to make sustainable changes, as opposed to a short-term detox.</p>
<p>The two most common medicines used in Australia are methadone and buprenorphine. Both are available through general practitioners and community pharmacies, as well as specialist clinics. Newer forms such as <a href="https://www1.racgp.org.au/newsgp/clinical/advocates-hail-game-changing-pbs-listing-of-long-a">long-acting buprenorphine</a> have also recently entered the market. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-we-can-reduce-dependency-on-opioid-painkillers-in-rural-and-regional-australia-79896">How we can reduce dependency on opioid painkillers in rural and regional Australia</a>
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<p>Methadone is what we call a “full opioid agonist”. It mimics the effects of other opioids, such as codeine or morphine, and it can remove the need to take other opioids by preventing opioid withdrawal and craving. Taken in daily oral doses methadone does not produce euphoria, or a “high”. At higher doses, methadone also blocks the effects of other opioids, helping to prevent return to other opioid use.</p>
<p>Buprenorphine (often provided in combination with naloxone, a medicine used to reverse the effects of an opioid overdose) is referred to as a “partial opioid agonist”. It’s less sedating and, unlike methadone and other opioids, is less likely to cause <a href="https://academic.oup.com/bja/article/100/6/747/303263">breathing difficulties</a> and overdose. </p>
<h2>Treatment is effective</h2>
<p>High-quality <a href="https://www.ncbi.nlm.nih.gov/pubmed/24500948">evidence</a> shows these treatments work. They help reduce opioid use, improve health, prevent the spread of blood borne viruses by reducing the likelihood people continue to inject, are cost effective, and reduce crime. </p>
<p>The most profound effects of these treatments is their ability to save lives. Risk of death while in treatment is <a href="https://www.bmj.com/content/357/bmj.j1550">substantially reduced</a>, by around half compared to when a person is dependent on opioids and not receiving treatment.</p>
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<img alt="" src="https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/296840/original/file-20191014-135501-1plj142.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Opioids include pain relievers like codeine, oxycodone and morphine, and illicit drugs like heroin.</span>
<span class="attribution"><span class="source">From shutterstock.com</span></span>
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<p>These treatments have been shown to <a href="https://ndarc.med.unsw.edu.au/resource/frequently-asked-questions-opioid-agonist-treatment-pharmaceutical-opioid-dependence">work just as well</a> for people who develop dependence to prescribed opioids and people who use heroin. </p>
<p>In 2005 the World Health Organisation put methadone and buprenorphine on their list of <a href="https://www.who.int/substance_abuse/activities/treatment_opioid_dependence/en/">essential medicines</a>, recognising their importance in treating opioid dependence.</p>
<p>So it might be surprising to learn many people in Australia who could benefit from these treatments choose not to use them, or are not able to access them.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/weekly-dose-methadone-the-most-effective-treatment-for-heroin-dependence-59814">Weekly Dose: methadone, the most effective treatment for heroin dependence</a>
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<h2>4 barriers to treatment</h2>
<p><strong>Cost</strong></p>
<p>Opioid agonist treatments attract some subsidies, but their dispensing fees are not covered by Australia’s <a href="http://www.pbs.gov.au/info/about-the-pbs">Pharmaceutical Benefits Scheme</a>, which subsidises prescription drugs. Where treatment usually adds up to A$35-A$70 a week, cost can be a <a href="https://creidu.edu.au/policy_briefs_and_submissions/10-opioid-pharmacotherapy-fees-a-long-standing-barrier-to-treatment-entry-and-retention">key barrier</a> to access.</p>
<p><strong>Stigma</strong></p>
<p>Some people choose not to access these treatments because they see them <a href="https://www.ncbi.nlm.nih.gov/pubmed/29762767">as being for people who use heroin</a>, or don’t want to <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/dar.12859">attend services seen as being for people who use illicit drugs</a>. </p>
<p>Other people believe these treatments are just replacing one opioid with another, and are not aware of their strong scientific support. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/fixing-pain-management-could-help-us-solve-the-opioid-crisis-90919">Fixing pain management could help us solve the opioid crisis</a>
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<p><strong>Restrictiveness of the treatment regime</strong></p>
<p>The need to attend a pharmacy daily for dosing at the start of treatment can affect work, study or family commitments. </p>
<p><strong>Nowhere to go</strong></p>
<p>Finally, treatment access is limited in some regions because there are not enough GPs who prescribe these treatments. This is despite a change from many state governments in recent years to reduce barriers to prescribing. </p>
<p>In <a href="https://www2.health.vic.gov.au/public-health/drugs-and-poisons/pharmacotherapy/buprenorphine-and-naloxone-prescribing-guidelines">Victoria</a> and New South Wales, for example, all GPs can prescribe buprenorphine treatment without additional training. Nonetheless, prescriber numbers have been slow to increase, with some GPs remaining hesitant to offer these treatments.</p>
<h2>People turning to short-term treatments instead</h2>
<p>As a result of these barriers, many people who are dependent on opioids choose not to seek help, or are not able to access the treatment they need. </p>
<p>Some choose to access shorter-term treatments such as a “detox”, where over the course of seven to ten days they cease opioids while their withdrawal symptoms are treated with medications.</p>
<p>This is concerning because the rates of relapse from short-term treatment are high, and research shows the risk of non-fatal or fatal opioid overdose increases <a href="https://www.ncbi.nlm.nih.gov/pubmed/17280803">following short-term treatment</a>. This means these short-term treatments contribute to opioid-related deaths rather than preventing them. </p>
<p>To stem the loss of life from opioid use in Australia, it’s critical we break down the barriers to the opioid dependence treatments we know are most effective. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/heres-what-happened-when-codeine-was-made-prescription-only-no-the-sky-didnt-fall-in-124169">Here's what happened when codeine was made prescription only. No, the sky didn't fall in</a>
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<img src="https://counter.theconversation.com/content/122537/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Suzanne Nielsen has received funding from Indivior and Seqirus, and is the current recipient of an NHMRC Research Fellowship (#1163961) </span></em></p>Treatments for opioid dependence, such as methadone and buprenorphine, are effective. But some people who stand to benefit are missing out.Suzanne Nielsen, Associate Professor and Deputy Director, Monash Addiction Research Centre, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1231322019-10-24T11:50:16Z2019-10-24T11:50:16ZWhen Halloween became America’s most dangerous holiday<figure><img src="https://images.theconversation.com/files/294450/original/file-20190926-51425-1bq8ynj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Halloween can also be a time of expression of cultural and social anxieties.</span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Hollywood-Halloween-Parade/c585c99599264bcd90e9ce19347ab6f0/132/0">AP Photo/Richard Vogel</a></span></figcaption></figure><p>The unquiet spirits, vampires and the omnipresent zombies that <a href="https://nrf.com/media-center/press-releases/halloween-spending-reach-9-billion">take over</a> American streets every October 31 may think Halloween is all about spooky fun. But what Halloween masqueraders may not realize is that in the early 1970s and well into the next decade, real fear took over.</p>
<p>The media, police departments and politicians began to tell a new kind of Halloween horror story – about poisoned candy. </p>
<p>No actual events explained this fear: It was driven by social and cultural anxieties. And there is a lesson in that about the power of rumors on this day of dark fantasy.</p>
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<h2>Poison candy fear</h2>
<p>The Halloween candy scare began in 1970. An op-ed on Oct. 28, 1970, in <a href="https://www.nytimes.com/1970/10/28/archives/those-treats-may-be-tricks.html">The New York Times</a> suggested the possibility of strangers using Halloween’s “trick-or treat” tradition to poison children.</p>
<p>The editorial mentioned two unconfirmed incidents in upstate New York and offered a series of frightening rhetorical questions. The author, Judy Klemesrud, wondered, for example, if that “plump red apple” from the “kindly old lady down the block…may have a razor blade hidden inside.” </p>
<p>Some readers accepted her questions as definitive fact.</p>
<p>Two days later, <a href="https://www.nytimes.com/1970/11/10/archives/boy-5-who-died-of-heroin-may-have-taken-a-capsule.html">a five-year-old child died on Halloween</a> in Detroit after consuming heroin. Early media reports of his death cited his uncle’s claim that he had been exposed to the drug in tainted holiday treats. </p>
<p>By mid-November 1970, newspaper reportage showed that the child had in fact found the heroin at his uncle’s home – not in his bag of Halloween candy, as investigators had at first been told. </p>
<p>But on Oct. 31, 1974, <a href="https://www.nytimes.com/1975/05/29/archives/wife-a-takes-stand-at-husbands-trial-in-sons-poisoning.html">another child died</a> in Houston. This time, the death was a result of eating poisoned candy: The child’s father had murdered his own son by placing cyanide in a pixie stick.</p>
<p>This story of the Houston “candyman killer” quickly metastasized. Though it had no evidence, Newsweek magazine <a href="https://academic.oup.com/socpro/article-abstract/32/5/488/1640225?redirectedFrom=PDF">asserted</a> in a 1975 article that “over the past several years, several children have died and hundreds have narrowly escaped injury from razor blades, sewing needles and shards of glass put into their goodies by adults.” </p>
<p>By the 1980s, some communities <a href="https://www.nytimes.com/1982/10/31/nyregion/new-warnings-of-tainted-candy-heighten-worries-over-halloween.html">banned</a> “trick-or-treating” while hospitals in some metropolitan areas offered to X-ray Halloween candy. Parent-teacher associations encouraged fall festivals to replace Halloween, and on Long Island a community group gave prizes to children who stayed home altogether for Halloween 1982. </p>
<p>In 1982 the governor of New Jersey <a href="https://www.nytimes.com/1982/10/31/nyregion/new-warnings-of-tainted-candy-heighten-worries-over-halloween.html">signed a bill</a> requiring a jail term for those tampering with candy. </p>
<p>Worries of parents and community leaders drove the fear. In a popular nationally syndicated newspaper advice column called “Ask Ann Landers,” Landers warned in 1983 of “<a href="https://news.google.com/newspapers?nid=896&dat=19951031&id=8CUOAAAAIBAJ&sjid=k30DAAAAIBAJ&pg=6927,4432593">twisted strangers</a>” who had been “putting razor blades and poison in taffy apples and other Halloween candy.” </p>
<h2>Social tensions and fear</h2>
<p>However, a comprehensive 1985 study of the of <a href="https://academic.oup.com/socpro/article-abstract/32/5/488/1640225?redirectedFrom=PDF">30 years of alleged poisoning</a> did not find even a single confirmed incident of a child’s death, or even serious injury. </p>
<p>Sociologist <a href="https://www.joelbest.net/">Joel Best</a> at the University of Delaware, who led the study, called it an “urban legend.” Most reports of poisoned Halloween candy that appeared in print were editorials written by authoritative voices in politics and media rather than actual events. However, police all over the country <a href="https://timesmachine.nytimes.com/timesmachine/1982/10/31/259232.html?pageNumber=45">urged parents</a> to accompany their children while trick-or-treating. In 1982, annual Halloween festivities at the governor’s mansion in Hartford, Connecticut were canceled.</p>
<p>Why did a series of rumors, very loosely based on a a small number of tragic crimes, convince so many people in authority and led to such panic? </p>
<p>In his book “<a href="https://wwnorton.com/books/9780393951691">The Vanishing Hitchhiker</a>,” folklorist <a href="http://people.westminstercollege.edu/faculty/dstanley/folklore/FINAL%20FINAL%20Docs/fiu12thursby.htm">Jan Harold Brunvand</a> argues that while urban legends may be grounded in actual incidents, they often come to stand in for real-world fears. </p>
<p>In the case of poisoned candy, my own <a href="https://www.baylorpress.com/9781481308823/">research into American politics and horror tales</a> suggests that those fears might have been driven in part by the multitude of problems facing the United States at the time. The years from 1970 to 1975 were marked by cultural upheaval, both domestic and geopolitical. </p>
<p>In 1974, President Richard Nixon <a href="http://www.washingtonpost.com/wp-srv/politics/special/watergate/part3.html">resigned</a> following the Watergate scandal. The scandal exposed the abuse of power and a criminal cover-up under his administration.</p>
<p>Americans had much more to worry about than Watergate in the mid-1970s. Scholar of the Vietnam era <a href="https://www.umass.edu/history/member/christian-appy">Christian G. Appy</a>, in his 2015 book “American Reckoning,” <a href="https://www.penguinrandomhouse.com/books/307777/american-reckoning-by-christian-g-appy/9780143128342/">described the era</a> as one in which defeat in Vietnam combined with “stagnant economic growth and soaring inflation” caused many Americans to see the country itself as “a victim of forces beyond its control.” This sense of victimization drove the sense that American society had become deeply unsafe.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/294451/original/file-20190926-51425-1569lqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/294451/original/file-20190926-51425-1569lqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=427&fit=crop&dpr=1 600w, https://images.theconversation.com/files/294451/original/file-20190926-51425-1569lqm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=427&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/294451/original/file-20190926-51425-1569lqm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=427&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/294451/original/file-20190926-51425-1569lqm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=537&fit=crop&dpr=1 754w, https://images.theconversation.com/files/294451/original/file-20190926-51425-1569lqm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=537&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/294451/original/file-20190926-51425-1569lqm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=537&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Young people in the streets of Harvard Square, with one of them wearing a President Nixon mask, after he resigned.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Nixon-Resignation-Reaction/f4a75ebddfd54c21b4eb8fcbe76c4d0f/6/0">AP Photo/Peter Bregg</a></span>
</figcaption>
</figure>
<p>All the social change in the 1970s fed the creation of urban legends, argues sociologist <a href="https://secularhumanism.org/authors/jeffrey-s-victor/">Jefferey S. Victor</a>. A brutal story about strangers with poison candy seemed <a href="https://rowman.com/isbn/9780742561724/satan-in-america-the-devil-we-know">a preferable national fantasy to historical reality in the 1970s and 1980s</a>. </p>
<p>Horror at the state of the world can take the form of parody or simple scary stories. Americans had become so <a href="https://www.simonandschuster.com/books/The-Invisible-Bridge/Rick-Perlstein/9781476782423">disenchanted</a>, according to the journalist and historian <a href="https://www.rickperlstein.net/">Rick Perlstein</a>, that bleak and frightening films such as 1974’s “The Exorcist” captured the national mood. </p>
<p>The false case of the poisoned candy legend is another way that American fears manifested: as an easily understood threat to innocence. </p>
<p>Scholar <a href="http://www.monstershow.net/">David J. Skal</a> in his book, “<a href="https://books.google.com/books/about/Death_Makes_a_Holiday.html?id=Aip2HAAACAAJ">Death Makes a Holiday</a>,” argues Halloween, throughout its history, has provided a moment for people to unleash their political and cultural fears. As an example, Skal notes, Richard Nixon became the first president satirized by a rubber Halloween mask in the autumn of 1974, just two months after his resignation. </p>
<h2>Fears today</h2>
<p>Today a majority of Americans, of all ages, see Halloween as an opportunity to celebrate excess, <a href="https://vinepair.com/articles/halloween-drinking-holiday/">a kind of a dark Mardi Gras</a>. </p>
<p>But some Christian churches, especially those attended by conservative evangelicals, continue to declare a kind of “<a href="https://www.christianexaminer.com/article/evangelicals-deeply-divided-on-celebrating-halloween-new-poll-says/49702.htm">war on Halloween</a>” every year. Many evangelicals, in their own description, see the holiday <a href="https://www.christiantoday.com/article/five-things-evangelicals-get-wrong-about-halloween/42290.htm">as a celebration of the occult</a>, often viewed in their religious worldview as connected to a very literal Satan.</p>
<p>Halloween, with its association with the powers of darkness, can allow many legends to flourish – tales of dangerous outsiders, poisoned candy and other alleged threats to American life. </p>
<p>Social media <a href="https://theconversation.com/misinformation-on-social-media-can-technology-save-us-69264">may serve that role</a> the rest of the year. But on Halloween, dark rumors may actually knock at the door.</p>
<p>[ <em>Insight, in your inbox each day.</em> <a href="https://theconversation.com/us/newsletters?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=insight">You can get it with The Conversation’s email newsletter</a>. ]</p><img src="https://counter.theconversation.com/content/123132/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>W. Scott Poole is the author "Wasteland: The Great War and the Origin of Modern Horror."</span></em></p>In the early 1970s, rumors about poisoned candy on Halloween led to mass paranoia. A historian explains why such fears emerge – and what, in reality, feeds them.W. Scott Poole, Professor of History, College of CharlestonLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1219282019-10-18T11:20:42Z2019-10-18T11:20:42ZThis overdose-reversal medicine could reduce opioid deaths – so why don’t more people carry it?<figure><img src="https://images.theconversation.com/files/297547/original/file-20191017-98661-f386zs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naloxone, available as a nasal spray called Narcan or in injectable form, resuscitates 100% of people who overdose if administered quickly. </span> <span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Overdose-Drug/25e6e79fdb614993a29ae319310ae4b4/31/0">AP Photo/Patrick Semansky</a></span></figcaption></figure><p>Forty-seven thousand Americans <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6334822/">died of opioid-related overdoses</a> in 2017 – similar to the number of deaths from <a href="https://www.cdc.gov/nchs/fastats/accidental-injury.htm">car accidents</a> and <a href="https://www.cdc.gov/nchs/fastats/injury.htm">gun violence</a>. </p>
<p>That number <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/add.13265">could have been much lower</a> had more people received naloxone, a medication that reverses opioid-related overdose.</p>
<p>Naloxone is <a href="https://injepijournal.biomedcentral.com/articles/10.1186/s40621-015-0041-8">safe, non-addictive and highly effective</a>. And it does more than save lives: When used <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5005759/">shortly after overdose</a>, naloxone reduces the likelihood of long-term brain damage from diminished blood flow. </p>
<p>Available as an injection or nasal spray, naloxone can <a href="https://www.ncbi.nlm.nih.gov/pubmed/18422830">be administered</a> by <a href="https://www.tandfonline.com/doi/abs/10.1080/10903127.2017.1371262">anyone trained to do so</a> - assuming, that is, that someone has it on hand at the scene of the overdose.</p>
<h2>Restricted access</h2>
<p><a href="https://www.washingtonpost.com/local/dc-politics/dc-police-officers-to-carry-opioid-overdose-antidote-naloxone/2019/01/18/b76de64a-1b44-11e9-8813-cb9dec761e73_story.html">Police</a>, firefighters and medical first responders are increasingly <a href="http://www.nchrc.org/law-enforcement/us-law-enforcement-who-carry-naloxone/">equipped with naloxone</a>. </p>
<p>However, the true first responders to an overdose often aren’t professionals but the friends, family and peers of people who <a href="https://www.mdmag.com/medical-news/public-drug-users-are-most-likely-to-reverse-peer-overdoses">use heroin and other opioids</a>. Relatively few of these “laypeople” have access to naloxone, which is available via <a href="https://www.golead.co/naloxone/">community distribution</a>, a doctor’s prescription or, <a href="https://www.japha.org/article/S1544-3191(16)30890-1/fulltext">in states that allow naloxone to be sold without a prescription</a>, from a pharmacy.</p>
<p>While <a href="https://journals.lww.com/journaladdictionmedicine/Fulltext/2019/08000/Naloxone_Availability_and_Pharmacy_Staff_Knowledge.5.aspx">at least 41 states</a> allow pharmacists to dispense the medicine without a prescription, many pharmacies <a href="https://jamanetwork.com/journals/jama/fullarticle/2714519">fail to actually stock it</a>. In California, <a href="https://jamanetwork.com/journals/jama/fullarticle/2714519">only a quarter of all pharmacies</a> carried naloxone last year.</p>
<p>As opioid-related deaths have soared, there’s <a href="https://www.scopus.com/record/display.uri?eid=2-s2.0-84931827775&origin=inward">been an increase</a> in programs working to get naloxone into the community. Health centers like <a href="https://www.pppgh.org">Prevention Point Pittsburgh</a>, for example, train people likely to witness overdose on how to recognize the signs and give them free naloxone.</p>
<p>However, the <a href="https://www.sciencedirect.com/science/article/pii/S0955395917303468">most recent available data suggest</a> that relatively few communities with high rates of opioid-related deaths actually have such programs. </p>
<p>Even emergency medical personnel, or EMS, may not have naloxone when they need it. </p>
<p>Most U.S. states <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/acem.12485">only authorize</a> intermediate- and advanced-level EMS to carry and administer the drug. But in many parts of the country – particularly <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2014.302520">rural and tribal areas</a> – EMS with basic training <a href="https://ajph.aphapublications.org/doi/10.2105/AJPH.2014.302520">are often the only medical first responders</a> immediately available in emergencies.</p>
<h2>‘Moral hazard’</h2>
<p>One impediment to increased naloxone access is the argument that reviving overdose victims will encourage opioid use.</p>
<p>Naloxone critic Dr. Harold Jonas, founder of the website Sober.com, has <a href="https://www.elitecme.com/resource-center/health-systems-management/narcan-saving-lives-or-enabling-addicts">warned health care providers</a> that naloxone creates a safety net, making people think “they don’t need treatment for substance abuse and … continue using at will.”</p>
<p>The fear that life-saving interventions encourage reckless behavior – a concern historically used to oppose everything from <a href="https://www.bmj.com/content/332/7541/605.short">condoms</a> to <a href="https://journals.sagepub.com/doi/abs/10.1177/001872088202400105">seat belts</a> – is called “<a href="http://static.stevereads.com/papers_to_read/the_economics_of_moral_hazard.pdf">moral hazard</a>.” </p>
<p>There is <a href="https://www.ncbi.nlm.nih.gov/pubmed/29610001">no peer-reviewed, empirical evidence</a> that naloxone use encourages opioid use. But this argument remains <a href="https://www.nytimes.com/2016/07/28/us/naloxone-eases-pain-of-heroin-epidemic-but-not-without-consequences.html">pervasive</a>. </p>
<p>Often, politicians combine moral hazard with budgetary arguments to oppose broader naloxone distribution. </p>
<p>The prices of some naloxone products have been <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1609578">rising</a>. Between 2009 and 2016, naloxone manufactured by Amphastar <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1609578">almost doubled</a> in price, from US$20.34 to $39.60 per dose. </p>
<p>In 2017, the city of Middletown, Ohio, <a href="https://www.journal-news.com/news/the-overdose-epidemic-comes-massive-cost-middletown-millions/6GRKXqaDortkhgLwqdxHHP/">spent</a> almost $35,000 on naloxone administered by EMS in 966 opioid overdose calls – <a href="https://www.journal-news.com/news/middletown-opioid-crisis-staggering-numbers-for-2017/BXcNXOEd88a8mAN7qBGc9I/">up from</a> $11,000 and 532 calls in 2016.</p>
<p>Citing cost, <a href="https://www.washingtonpost.com/news/to-your-health/wp/2017/06/28/a-council-members-solution-to-his-ohio-towns-overdose-problem-let-addicts-die/">Middletown Councilmember Dan Picard</a> has said the city should refuse to resuscitate people who overdose repeatedly. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=488&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=488&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=488&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=613&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=613&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297548/original/file-20191017-98653-hicrf0.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=613&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Tess Nishida, a pain pharmacist at the University of Washington, holding a vial of naloxone, Oct. 7, 2016.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Washington-Opioids/73792f4373aa4ef29f43f1745c60ae28/50/0">AP Photo/Ted S. Warren</a></span>
</figcaption>
</figure>
<h2>Naloxone is cost-effective</h2>
<p>Since the opioid crisis <a href="https://www.brookings.edu/research/pinpointing-opioid-in-most-impacted-communities/">disproportionately hurts low-income communities</a> like Middletown, our team of <a href="https://sph.umich.edu/hmp/phdstudents/townsend-tarlie.html">health policy</a> and <a href="https://sph.umich.edu/epid/phdstudents/blostein-freida.html">epidemiology</a> researchers at the University of Michigan conducted a study to determine whether naloxone is a good use of the scarce resources available to reduce opioid-related deaths. </p>
<p>Our study, published in <a href="https://www.sciencedirect.com/science/article/pii/S0955395919302099">International Journal of Drug Policy</a>, found that naloxone is extremely cost-effective. </p>
<p>We analyzed the cost-effectiveness of giving naloxone to three different groups: laypeople, police and firefighters and EMS. </p>
<p>When all three groups have naloxone, it costs about $16,000 per year of “high-quality” year of life saved. We accounted for quality of life as well as quantity, since problematic substance use increases the risk of <a href="https://www.sciencedirect.com/science/article/pii/S1473309916303255">hepatitis, HIV and other illnesses</a>.</p>
<p>As life-saving interventions go, $16,000 per high-quality year of life is <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/215852">an excellent deal</a>. The public defibrillators used to revive people in cardiac arrest <a href="https://www.sciencedirect.com/science/article/pii/">come out to around $53,797</a>. And a breakthrough class of new cancer drugs <a href="https://www.tandfonline.com/doi/full/10.1080/14737167.2018.1467270">run $100,000 to $150,000</a> per high-quality year of life saved. </p>
<p>Naloxone actually saves society money when we take the lost economic productivity from fatal overdoses into account, we found. Hard-hit communities may see naloxone as an expense – but they’re actually saving the city money by keeping more of its workforce alive. </p>
<p>This finding holds even when we add in a city’s criminal justice costs associated with opioid use.</p>
<p>Naloxone would remain cost-effective even if the “moral hazard” concerns were true. We found that overdose rates would have to rise 20% for lay distribution of naloxone to cease being cost-effective – a large margin of error for an <a href="https://www.sciencedirect.com/science/article/pii/S0306460318301382">unsubstantiated</a> worry.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/297549/original/file-20191017-156314-13xbn44.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Surgeon General Jerome Adams, right, directs a session on naloxone administration, Jackson, Mississippi, May 17, 2018.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Surgeon-General-Opioids/e1b532220f88482ca57f39d695ab367e/12/0">AP Photo/Rogelio V. Solis</a></span>
</figcaption>
</figure>
<h2>Moral imperative</h2>
<p>Our research determined that the most cost-effective strategy is to distribute naloxone to all three groups: laypeople, police and firefighters, and EMS. </p>
<p>If low-income communities can’t afford that much naloxone, however, the next-best scenario is to give the medicine to laypeople plus at least one first responder group – either police and fire or EMS.</p>
<p>Getting naloxone into lay hands is so critical because many overdose witnesses hesitate to call 911 due to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5825210/">fear of arrest</a>, stigma or loss of government benefits like subsidized housing. No matter how many first responders have naloxone, the victims in those cases cannot benefit from it. They need someone close by, like another person using opioids, to revive them. </p>
<p>But emergency responders should have naloxone as well since overdose witnesses may not always have naloxone or be <a href="https://www.ncbi.nlm.nih.gov/pubmed/19268564">able and willing to use it</a>. </p>
<p>Sometimes, a single naloxone dose can save two lives.</p>
<p>In 2018, clinicians in North Carolina <a href="https://www.publichealthpost.org/viewpoints/is-there-a-risk-to-naloxone/">treated a pregnant patient</a> who had recently overdosed. Friends had used naloxone to reverse the overdose, allowing her to enter treatment for substance use.</p>
<p>A few months later, she gave birth to a healthy baby. </p>
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<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Opioid overdoses killed 47,000 Americans in 2017 — more than gun violence. Many fewer would have died if they’d been treated with the life-saving drug naloxone, also called Narcan.Tarlise Townsend, Joint PhD Student, Health Policy and Sociology, University of MichiganFreida Blostein, Epidemiological Science PhD Candidate, University of MichiganLicensed as Creative Commons – attribution, no derivatives.