tag:theconversation.com,2011:/id/topics/opioid-crisis-41093/articlesOpioid crisis – The Conversation2024-02-27T17:35:27Ztag:theconversation.com,2011:article/2235392024-02-27T17:35:27Z2024-02-27T17:35:27ZGovernments must avoid policies that stigmatize those recovering from addiction<p>British Columbia is experiencing an <a href="https://app.powerbi.com/view?r=eyJrIjoiMmIzN2UyYTItNmM0Yi00MGZhLWI1NDUtOTRhZGNjYTBhZDJlIiwidCI6IjZmZGI1MjAwLTNkMGQtNGE4YS1iMDM2LWQzNjg1ZTM1OWFkYyJ9">unprecedented opioid crisis</a>. Drug overdoses are the <a href="https://www.timescolonist.com/bc-news/overdoses-the-leading-cause-of-death-in-bc-for-those-aged-for-10-to-59-coroner-7908352#:%7E:text=Opinion-,Overdoses%20the%20leading%20cause%20of%20death%20in%20B.C.%20for%20those,ten%20months%20of%20this%20year">leading cause of death</a> in the province for those aged 10 to 59. B.C., and all of Canada, are <a href="https://www.canada.ca/en/health-canada/services/substance-use/canadian-drugs-substances-strategy.html">trying hard to help</a> those with substance abuse problems and addictions. </p>
<p>Among the responses are <a href="https://www2.gov.bc.ca/gov/content/overdose/reducing-stigma">calls to destigmatize addiction</a>. Mostly, these calls encourage us to consider how the language we use can stigmatize people struggling with addiction. Language does of course have a powerful impact, but not as powerful as policy.</p>
<p>I am the executive director of a <a href="https://www.fraserhealth.ca/Service-Directory/Services/mental-health-and-substance-use/substance-use/bed-based-treatment-services">bed-based treatment facility</a> in Metro Vancouver. We help people dealing with substance abuse get better. My doctoral research is on addiction stigma. It gives me a unique perspective on the roadblocks to getting out of addiction. </p>
<p>In my work, we often come across B.C. government policies requiring a minimum amount of sobriety, usually a year, before enrolment. Most commonly, these are associated with educational programs for those doing work connected to mental health and addictions. It also occurs in provincial programs aimed at employment or re-training. </p>
<p>We say we want to destigmatize addictions. But if we are refusing to help people in recovery get back to work or school, what are we actually doing?</p>
<h2>Policies discouraging recovery</h2>
<p>These policies <a href="https://doi.org/10.1080/07347324.2021.1917323">stigmatize</a> people in <a href="https://doi.org/10.1080/1556035X.2010.523364">early recovery</a> by essentially telling them they aren’t sober enough to invest in. This discourages them from staying in recovery. We are saying they aren’t good enough and, in some cases, they hear that they’ll <a href="https://doi.org/10.1007/s11673-017-9784-y">never be good enough</a>.</p>
<p>These policies are, in part, about risk aversion. Why put money into helping someone re-train if they are at high risk of relapsing? The average taxpayer may even agree that we should restrict who can access government programs along these lines. However, these policies are <a href="https://doi.org/10.1097/yco.0000000000000351">rooted in stigma</a>. They <a href="https://doi.org/10.1177/0261018319839158">fundamentally change how people experience the programs</a>, and risk aversion does more harm than good.</p>
<p>Let’s say, on average, the policy is that someone needs to be clean and sober for a year before they can access certain government services. This means the people who access the services will generally be pretty successful in completing those programs, considering they already have been sober a year. People get to school or work, agencies get a completion statistic, and we all get to feel good for helping someone get back on their feet. The policy means that people with a year sober get the help they deserve.</p>
<p>It also means <a href="https://doi.org/10.1080/10826080701681473">fewer people</a> will reach that year mark. <a href="https://doi.org/10.1080/10826080802289762">Recovery capital</a> is a concept that says having more support makes overcoming addiction easier. These supports are holistic and can include things like counsellors or mental health supports, but also hobbies, friends, and life fulfilment. School and work are big parts of recovery capital. People in recovery want to <a href="https://doi.org/10.1080/02791072.2018.1517909">feel like they are moving forward</a>. A rolling stone gathers no moss.</p>
<p>If someone is unable to count in their recovery capital the social support and life-meaning that school and work provide, they are less likely to succeed. We weaken people’s recovery capital when we exclude them from pursuing fulfilment. It can mean the difference between someone staying in recovery and <a href="https://doi.org/10.1080/16066359.2022.2039912">going back to their old ways</a>. </p>
<h2>Destigmatizing language</h2>
<p>B.C.’s strategy for destigmatizing addiction focuses on considering the language that we use. Stigmatizing language is damaging. It is mean and <a href="https://doi.org/10.1097/yco.0000000000000351">stops people from asking for help</a>. But part of my doctoral research asks: what is the worst of the worst? The answer I have so far is that stigmatization is at its worst when it <a href="https://doi.org/10.1111/j.1468-2435.1992.tb00776.x">marginalizes an individual</a>.</p>
<p>In terms of addiction and treatment, marginalization means socially separating someone who has nowhere else to go. When someone who has grappled with addiction throughout their entire life makes an effort to break free from its grip, only to encounter rejection, they experience marginalization. They don’t want to go back to addiction, but because of policies on sobriety, they cannot move forward.</p>
<p>Recovery requires <a href="https://www.routledge.com/Addiction-Behavioral-Change-and-Social-Identity-The-path-to-resilience/Buckingham-Best/p/book/9781138934085">re-learning how we see ourselves</a>. It is taking the jump from <a href="https://doi.org/10.3109/16066359.2015.1075980">one life to another</a>. It means getting vulnerable and asking for help. I’ve seen firsthand how important it is for people to feel accepted. It makes sense, considering they are putting themselves out there to start a new life. This feeling of insecurity is something we can all relate to. </p>
<p>We can destigmatize addictions and support people in recovery by creating policies that recognize the <a href="https://doi.org/10.1016/j.drugpo.2022.103609">difference between addictions and recovery</a>. We should not just tell people they are good enough; we should help them see themselves as worthy. </p>
<h2>Find balance in policy</h2>
<p>I’m not saying to completely do away with policies on sobriety requirements that provide structure for government services. There are <a href="https://www.worksafebc.com/en/health-safety/hazards-exposures/substance-use-impairment#:%7E:text=Impairment%20from%20substance%20use%20can,reaction%20time%2C%20and%20sensory%20perception">safety concerns</a> that agencies are not specialized in accommodating. But we need to recognize the impact that these policies have and seek balance. </p>
<p>In my experience, someone with three months of sobriety starting to get back into work or school is just as steadfast in their recovery as someone who has stayed sober for a year. This begs the question of who these policies are actually helping. Is someone who has been sober for months still struggling with addiction? Are we inadvertently marginalizing someone new to recovery by labeling them by their past rather than present? </p>
<p>We should not be afraid to give people in recovery a chance at getting a new life. By reconsidering these policies, we stand a better chance at destigmatizing addiction in a meaningful way. Hopefully, we can even save lives. </p>
<p>If you or someone you know is struggling with substance abuse, <a href="https://www.canada.ca/en/health-canada/services/substance-use/get-help-with-substance-use.html">know that there is help available</a>. Do not be afraid to ask for it.</p><img src="https://counter.theconversation.com/content/223539/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Max Weselowski is affiliated with InnerVisions Recovery Society of BC, a non-profit bed-based treatment provider. He is also affiliated with InnerStart Training & Education, which provides addictions-specific training programs. </span></em></p>Calls to destigmatize language around drug addiction must be combined with action to change policies that stigmatize people in early recovery.Max Weselowski, Doctoral student, College of Interdisciplinary Studies, Royal Roads UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2158702023-10-27T12:18:30Z2023-10-27T12:18:30ZWhite patients are more likely than Black patients to be given opioid medication for pain in US emergency departments<figure><img src="https://images.theconversation.com/files/556165/original/file-20231026-19-8q0th6.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5499%2C3663&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Doctors have struggled to find the balance between effective pain management and the very real addiction risks that come with prescription pain medication.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/macro-of-oxycodone-opioid-tablets-with-prescription-royalty-free-image/1162845770?phrase=pain+treatment&adppopup=true">BackyardProduction/iStock via Getty Images Plus</a></span></figcaption></figure><p>White people who visit hospital emergency departments with pain are 26% more likely than Black people to be given opioid pain medications such as morphine. This was a key finding from <a href="https://doi.org/10.1007/s11606-023-08401-2">our recent study</a>, published in the Journal of General Internal Medicine. We also found that Black patients were 25% more likely than white patients to be given only non-opioid painkillers such as ibuprofen, which are typically available over the counter. </p>
<p>We examined more than 200,000 visit records of patients treated for pain, taken from a representative sample of U.S. emergency departments from 1999 to 2020. Although white patients were far more likely to be prescribed opioid medication for their pain, we found no significant differences across race in either the type or severity of patients’ pain. Furthermore, racial disparities in pain medication remained even after we adjusted for any differences in insurance status, patient age, census region or other potentially important factors.</p>
<p>Our analysis of prescribing trends spanning over two decades’ worth of records found that opioid prescribing rates rose and fell, reflecting changing attitudes in clinical practice toward the use of opioid drugs. Notably, however, there appeared to be little change over time in the prescribing disparity across race.</p>
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<h2>Why it matters</h2>
<p>These findings are important because they suggest that efforts to promote equitable health care in the U.S. over the past two decades, such as <a href="https://www.hhs.gov/healthcare/about-the-aca/index.html">the Affordable Care Act</a>, or “Obamacare,” do not appear to have translated to clinical practice – at least with regards to pain management in hospital emergency departments.</p>
<p>There’s no question that as the <a href="https://www.nytimes.com/2023/02/20/nyregion/sudden-deaths-overdoses-fentanyl-nyc.html">ongoing opioid crisis</a> <a href="https://www.npr.org/2023/08/30/1196343448/fentanyl-deaths-teens-schools-overdose">continues to escalate</a>, a careful balance must be struck between the risks and benefits of prescribing opioids. But their appropriate use is an essential component of pain control in the emergency department, and they typically provide superior relief to non-opioids for short-term moderate to severe pain. </p>
<p>Undertreated pain produces unnecessary suffering and can result in a range of negative outcomes, even including a <a href="https://doi.org/10.1111/j.1526-4637.2010.00983.x">greater likelihood of developing long-term pain</a>. There are over <a href="https://doi.org/10.1007/s11606-023-08401-2">40 million pain-related emergency department visits annually</a>, so it is clear that equitable pain treatment is a fundamental component of a fair health care system. </p>
<h2>What still isn’t known</h2>
<p>We do not know why such marked racial disparities exist. Some researchers <a href="https://doi.org/10.1056%2FNEJMsa2034159">have argued</a> that prescribing fewer opioids may be beneficial for Black patients as it reduces the risk of addiction. But this argument doesn’t square with the data, which show that overdose rates have traditionally been <a href="https://doi.org/10.1111/add.15233">lower in Black populations compared with white people</a>. However, this trend has <a href="https://doi.org/10.1111/add.15233">started to change in recent years</a>. </p>
<p>In addition, some evidence suggests that clinicians <a href="https://doi.org/10.1073/pnas.1516047113">may hold unconscious biases</a>, incorrectly believing Black patients to be less sensitive to pain or that certain racial groups are <a href="https://doi.org/10.1371/journal.pmed.1001411">less willing to accept pain medication</a>. </p>
<p>While there is preliminary evidence that these factors may be important, there is not enough research that examines the degree to which they influence clinical practice. Researchers like us also know very little about whether promising remedial strategies based on these factors – such as educational training during medical school that challenges stereotypical beliefs – are effective, or indeed even implemented, in the real world. </p>
<h2>What’s next?</h2>
<p>The need for tackling racial disparities in health was brought into focus once more in February 2023, when the <a href="https://www.whitehouse.gov/briefing-room/statements-releases/2023/02/16/fact-sheet-president-biden-signs-executive-order-to-strengthen-racial-equity-and-support-for-underserved-communities-across-the-federal-government/">Biden-Harris administration</a> signed an executive order on further advancing racial equity. Given the long history of these issues, it is clear that more research is needed to help develop better strategies for tackling health inequalities.</p>
<p>The most effective strategies for addressing racial disparities in pain treatment are likely to be those that target the underlying causes. We are currently undertaking research to try to better understand these causes, how they contribute to disparities in real-world clinical practice and whether strategies designed to address them are actually effective.</p><img src="https://counter.theconversation.com/content/215870/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>Undertreated pain can result in unnecessary suffering and a greater likelihood of long-term chronic pain.Trevor Thompson, Associate Professor of Clinical Research, University of GreenwichSofia Stathi, Professor of Social Psychology, University of GreenwichLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2076792023-06-27T21:21:32Z2023-06-27T21:21:32ZLet evidence, not opinion, guide harm reduction policy and practice in Canada’s drug poisoning crisis<p>The poisoning of the unregulated drug supply, especially in Canada, is a public health crisis that deserves a high priority for the integration of evidence into policy and practice. </p>
<p>The <a href="https://www.cbc.ca/news/health/drug-poisoning-deaths-language-1.6457834">drug poisoning crisis</a> is often referred to as the opioid crisis, but it is all illicit substances, including stimulants, that are tainted with fentanyl, benzodiazepines and other dangerous ingredients, <a href="https://doi.org/10.1111/add.15844">increasing the risk of harm, especially overdose</a>. </p>
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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>
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<p>It is still an ongoing battle for those in positions of power to submit to the rigorous evidence supporting harm reduction, despite strategies like <a href="https://doi.org/10.1186/s12954-017-0154-1">supervised consumption sites</a> and the distribution of drug equipment <a href="https://www.phs.ca/insite-an-anniversary-of-hope/">being more than two decades old</a>. </p>
<p>For example, North America’s first formal supervised consumption site, <a href="https://www.phs.ca/program/insite/">Insite</a>, has been in operation for 20 years showcasing what its founding organization, PHS Community Services, calls a “<a href="https://www.phs.ca/insite-an-anniversary-of-hope/">pragmatic and humane approach to the risks of drug use</a>.” </p>
<p>Thorough evaluation of harm reduction strategies has shown they can <a href="https://doi.org/10.1186/s12954-017-0154-1">save money, save lives and promote health</a> at an individual and population level. Furthermore, denial of access to supervised consumption is a <a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/7960/index.do">violation of Section 7 of the Canadian Charter of Rights and Freedoms</a>, which protects an individual’s right to life, liberty and security of the person.</p>
<h2>Stigma and ideology</h2>
<p>Recently, Canada’s leader of the Opposition Pierre Poilievre had his motion to defund safer supply voted down in Parliament. His reference to a “<a href="https://www.ourcommons.ca/DocumentViewer/en/44-1/house/sitting-200/hansard">tax-funded drug supply</a>” as fuelling addiction rather than recovery is not supported by evidence and follows the <a href="https://www.cbc.ca/news/politics/conservative-motion-safe-supply-fails-1.6858551">failed prejudicial ideology of the war on drugs era</a>. </p>
<p>Poilievre’s actions mirror the sentiments of former federal health minister Rona Ambrose, whose opinion also superseded evidence while in a position of influence. In 2013 she attempted to deny access to heroin assisted treatment (HAT) — an <a href="https://doi.org/10.1136/bmj.327.7410.310">opioid substitution treatment using diamorphine/diacetylmorphine (medical grade heroin</a>) — for persons with substance use disorder in Vancouver. </p>
<p><a href="https://www.providencehealthcare.org/sites/default/files/Supreme%20Court%20of%20British%20Columbia%20Decision.pdf">Ambrose publicly stated that</a> “Our policy is to take heroin out of the hands of addicts, not to put it into their arms.”</p>
<p>Ambrose made this public declaration <a href="https://doi.org/10.1016/j.jsat.2006.04.007">despite evidence</a> from both <a href="https://doi.org/10.1056/NEJMoa0810635">Canada</a> and <a href="https://doi.org/10.1136/bmj.317.7150.13">Europe</a> that <a href="https://doi.org/10.1192/bjp.bp.106.026112">showcased the efficacy</a> of HAT in six <a href="https://doi.org/10.1016/S0140-6736(10)60349-2">randomized controlled trials</a> with over 1,500 patients.</p>
<h2>What is evidence?</h2>
<p>What is considered evidence, especially regarding public health? From an epistemological (justified belief, as opposed to opinion) perspective, we may think evidence equals truth. However <a href="https://global.oup.com/academic/product/population-health-science-9780190459376?cc=ca&lang=en&">causation cannot be observed, only inferred</a>. While evidence may be viewed as more of a confirmation, truly <a href="https://doi.org/10.1046/j.1365-2753.2000.00244.x">definitive scientific evidence is rare due to its ever-changing and evolving nature</a>. </p>
<p>Evidence comes in many forms, and although it may not constitute absolute “proof,” it is reliable.</p>
<p>In harm reduction, best practices are grounded in evidence that comes from several facets including peer-reviewed literature, unpublished reports or grey literature, and the experiential knowledge of persons who use drugs themselves. </p>
<p>The way <a href="https://doi.org/10.1016/j.drugpo.2020.103015">harm reduction has progressed in Canada</a> tells us that <a href="https://doi.org/10.1186/s13011-021-00406-6">people who use drugs are key informants at the table</a> as they articulate their own experience of what it is like to use substances from an unregulated supply and to navigate the health and social services system. <a href="https://doi.org/10.1111/add.158441196COMMENTARIES">Their voice in the conversation</a> helps to reduce stigma, support client-centred essential services and policies, and prioritize the needs of people who use substances.</p>
<h2>Barriers to progress</h2>
<p>The question still remains as to why government policies across Canada, public stigma, and ignorance towards the use of substances and the people who use them, are still able to create barriers to the promotion of strategies that fight the current drug poisoning crisis. </p>
<p>During the COVID-19 pandemic, <a href="https://www.who.int/emergencies/diseases/novel-coronavirus-2019/interactive-timeline">public health strategies were implemented at a rapid pace</a>, but this same urgency is not translating to our community of people who use unregulated drugs. One would think that <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants">the loss of nearly 40,000 Canadians to opioid overdoses since 2016</a> would be impetus for not just change, but bold action.</p>
<p>Has government not learned its lessons about taking all aspects of evidence into consideration while also considering the urgency of action required in crisis situations? After public health failures during the 2001 SARS crisis, <a href="https://doi.org/10.1098/rsfs.2021.0079">Justice Archie Campbell recommended in his report</a>: </p>
<blockquote>
<p>“Where there is reasonable evidence of an impending threat to public harm, it is inappropriate to require proof of causation beyond a reasonable doubt before taking steps to avert the threat…that reasonable efforts to reduce risk need not await scientific proof.” </p>
</blockquote>
<p>The ultimate question that needs to be asked to those who have the power to move harm reduction forward is: If they want to be a part of ending the drug toxicity crisis, then why and for whom? Is their primary objective more votes? Or is it to value all members of our community, and not just keep people who use drugs alive, but to help them thrive? </p>
<p>If the goal is wanting to be a part of ending this crisis for the betterment of the persons experiencing it, then the approach must include weighing evidence from a variety of sources and triumphing over public and political ideology and stigma. </p>
<p><a href="https://plato.stanford.edu/entries/egalitarianism/#Pri">Prioritarianism</a>, as a principle of justice, puts the focus on the population most in need, whether it be in terms of health, resources, opportunities or access. The moral and ethical values of this approach intend to maximize overall well-being for those who need it the most. </p>
<p>Movement forward requires collaboration that builds on existing strengths and capacities, with the guiding principle being to <a href="https://healthydebate.ca/2021/09/topic/encampments-pandemic-covid/">put the needs of the persons living this experience first</a>. Bioethicist Anita Ho describes epistemic humility — the ability to challenge one’s preconceived and biased assumptions — as “<a href="https://doi.org/10.2979/intjfemappbio.4.2.102">characterized by a commitment to mutual collaboration and trust with those they serve</a>.” </p>
<p>A healthy public includes us all.</p><img src="https://counter.theconversation.com/content/207679/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ross Upshur receives funding from Health Canada, CIHR, Atlas Institute for Veterans and Families</span></em></p><p class="fine-print"><em><span>Karla Ghartey does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Harm reduction is grounded in evidence. But policies, stigma and ignorance about substance use still create barriers in battling Canada’s drug poisoning crisis.Karla Ghartey, Doctor of Public Health (DrPH) student, University of TorontoRoss Upshur, Professor, Dalla Lana School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2004192023-05-28T11:32:23Z2023-05-28T11:32:23ZDeaths of despair: How income inequality puts Canadian youth at risk<figure><img src="https://images.theconversation.com/files/528639/original/file-20230526-19-j4xo.jpg?ixlib=rb-1.1.0&rect=253%2C176%2C4709%2C3096&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Income inequality is the gap between the highest and lowest earners in a given area. It can contribute to people's risk of poor health, and specifically mental health.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Income inequality has been linked to poor physical and mental health in past research, but more recent evidence suggests the issue of income inequality may be much more severe than previously expected. </p>
<p>While completing my PhD in epidemiology at the University of Alberta, I <a href="http://dx.doi.org/10.1136/jech-2022-219630">published a study</a> highlighting an association between experiencing income inequality in youth and deaths of despair among young Canadians.</p>
<p>Deaths of despair are deaths attributable to suicide, drug overdose and alcohol-related liver disease. These deaths are on the rise in Canada, and finding points of intervention is key to reducing the burden of this crisis.</p>
<p>In collaboration with my doctoral supervisor, <a href="https://www.emergeresearchlab.com">Roman Pabayo</a>, I led a study on a representative sample of Canadian youth and followed them up over a 13-year period to calculate average hazard for deaths of despair. The study sample included 1.5 million Canadians between the ages of 0 and 19 from 2006 to 2018. </p>
<h2>Income inequality and health</h2>
<figure class="align-center ">
<img alt="Tiny human figures standing on coins: a few people on a tall stack, and a lot of people on much smaller stacks" src="https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&rect=75%2C0%2C5513%2C3728&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/528636/original/file-20230526-28817-v1vl9k.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Areas where income inequality is higher are less likely to have the type of social programs that are key to improving the health of communities.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
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</figure>
<p>Income inequality is the gap between the highest and lowest earners in a given area. It can contribute to people’s risk of poor health, and specifically mental health, in a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1088996/">few key ways</a>. </p>
<p>First, in areas with higher income inequality, people are less likely to relate to their neighbours, regardless of whether they earn more or less income than they do. This can lead to social comparisons, which are detrimental for mental health and self esteem. </p>
<p>Secondly, this lack of connection with those around you — also called “social cohesion” — can cause mistrust and ill feelings about others. This in turn can lead people to become withdrawn or isolate themselves. Lack of social cohesion and isolation are both risk factors for poor mental health and substance use. </p>
<p>Finally, areas where income inequality is higher are less likely to have the type of social programs that are key to improving the health of communities. For example, divesting in mental health services and supports can lead to worsened mental health, and removal or lack of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5685449/">harm reduction services</a> and <a href="https://doi.org/10.1177%2F070674371405901005">mental health services</a> can put people at a higher risk of deaths of despair. </p>
<h2>Income inequality and deaths of despair</h2>
<p>Deaths of despair are on the rise in Canada. Specifically, drug overdose death events have increased so rapidly that the <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants">drug poisoning crisis</a> has been referred to as an epidemic. This is a major concern, as these deaths have strong <a href="https://doi.org/10.24095%2Fhpcdp.38.6.02">impacts on the well-being of communities, families and friends</a>; but also because this crisis doesn’t appear to be ending anytime soon. </p>
<p>The impact the crisis is having on young Canadians is especially important, considering that unfamiliarity with substances, lower tolerance and risk-taking behaviours may leave them at an increased <a href="https://doi.org/10.1089%2Fcap.2019.0013">risk for drug overdose</a>. Further, suicide is a <a href="https://vizhub.healthdata.org/gbd-compare/">leading cause of death</a> among young people in Canada, indicating a critical need to intervene.</p>
<p>The results of this <a href="http://dx.doi.org/10.1136/jech-2022-219630">new study</a> also showed that higher levels of income inequality in youth are associated with an increased hazard of death from any cause, deaths of despair and drug overdose in young Canadians. </p>
<h2>Urgent need for services</h2>
<p>My colleagues and I are continuing this work by investigating income inequality and deaths of despair in other populations by using other indicators of social equity. We are also investigating more harms we suspect are associated with income inequality, such as hospitalizations owing to despair. </p>
<p>This line of work shows the urgent need for increased access to health services such as counselling and harm reduction, particularly in areas of higher income inequality, to reduce the risk of deaths of despair in these spaces. </p>
<p>The study results should be communicated to policymakers, who inform discussions on reducing income inequality and harms due to drug overdose, suicide and alcohol-related liver disease. Programs to mitigate this problem may include cash transfer programs, increases to minimum wage, or <a href="https://theconversation.com/a-guaranteed-basic-income-could-end-poverty-so-why-isnt-it-happening-182638">universal basic income programs</a> to reduce the gap between the highest and lowest earners.</p><img src="https://counter.theconversation.com/content/200419/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Benny receives funding from the Women and Children's Health Research Institute (WCHRI).</span></em></p>Higher levels of income inequality in youth are associated with increased ‘deaths of despair’ in young Canadians.Claire Benny, PhD Candidate, Epidemiology, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2053782023-05-17T12:40:39Z2023-05-17T12:40:39ZBarbara Kingsolver’s ‘Demon Copperhead’ and the enduring devastation of the opioid crisis<figure><img src="https://images.theconversation.com/files/526588/original/file-20230516-35975-5ps8gu.jpg?ixlib=rb-1.1.0&rect=453%2C590%2C3095%2C2057&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Barbara Kingsolver's protagonist, Demon, is much more than his drug habit.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/child-lying-on-the-waterfall-royalty-free-image/537292087">SergioZacchi/iStock via Getty Images</a></span></figcaption></figure><p><a href="http://barbarakingsolver.net">Barbara Kingsolver’s</a> literary honors range from the National Book Prize of South Africa to the PEN/Faulkner Award. </p>
<p>On May 8, 2023, she added a <a href="https://www.pulitzer.org/winners/barbara-kingsolver">Pulitzer Prize</a> to her accolades. </p>
<p>Her winning novel, “<a href="https://www.harpercollins.com/products/demon-copperhead-barbara-kingsolver?variant=40073146204194">Demon Copperhead</a>,” is more than just a reimagining of Charles Dickens’ “<a href="https://www.gutenberg.org/files/766/766-h/766-h.htm">David Copperfield</a>.” Casting an opioid-addicted Appalachian orphan as her protagonist, Kingsolver sheds new light on one of America’s greatest health crises. </p>
<p>Understandably, the COVID-19 pandemic eclipsed media coverage of and national concern over the opioid epidemic; nevertheless, opioids remain a massive public health problem, and I think the author’s attention to it is both welcome and necessary. </p>
<p>In taking up the topic, she joins artists with ties to Appalachia, such as bluegrass guitar phenom <a href="https://www.billystrings.com/">Billy Strings</a>, the late singer-songwriter <a href="https://www.johnprine.com/">John Prine</a> and photographer <a href="https://www.stacykranitz.com/">Stacy Kranitz</a>, all of whom have used their art to highlight the ravaging effects of these drugs on their region.</p>
<h2>How artists can reclaim a place</h2>
<p><a href="https://www.middlebury.edu/college/people/william-nash">As an American Studies professor</a> who teaches courses on both country music and images of rural America, I see this groundbreaking work through the lens of <a href="https://researchguides.dartmouth.edu/human_geography/cultural">cultural geography</a>, which explores the relationship between culture and place.</p>
<p>A region can inspire unique forms of art, music, literature and architecture, and the work of geographer <a href="https://www.aag.org/memorial/edward-w-soja/">Edward Soja</a> helped show how this work can push back against stereotypes. </p>
<p>In 1996, Soja published “<a href="https://geography.ruhosting.nl/geography/index.php?title=Thirdspace">Thirdspace: Journeys to Los Angeles and Other Real-and-Imagined Places</a>.” </p>
<p>In it, he argued that stereotypes of a region’s people and landscape could lead to damaging politics and policies. For example, outsiders’ views of “the inner city” as hotbeds for poverty, crime and broken families led to the implementation of racist <a href="https://www.blackpast.org/african-american-history/moynihan-report-1965/">public housing policies in the 1960s</a>.</p>
<p>Soja’s book was a call to arms for artists and the marginalized: In what he called “thirdspace” – a place that exists at the intersection of the real and the imagined – they can reclaim and reframe visions of their region, showcasing <a href="https://theconversation.com/how-black-poets-and-writers-gave-a-voice-to-affrilachia-155706">different identities and experiences</a>. </p>
<p>Appalachia is a region that, for generations, has been subjected to <a href="https://qz.com/1167671/the-100-year-capitalist-experiment-that-keeps-appalachia-poor-sick-and-stuck-on-coal">economic oppression</a>, <a href="https://www.npr.org/sections/codeswitch/2014/04/03/298892382/stereotypes-of-appalachia-obscure-a-diverse-picture">classist stereotyping</a> and environmental and medical recklessness. <a href="https://www.justice.gov/opa/speech/assistant-attorney-general-brian-benczkowski-gives-remarks-west-virginia-and-appalachian">The pumping of opioids into rural communities</a> represents just another chapter in this story of exploitation. </p>
<p>Yet artists and writers like Kingsolver are able to show that the people in the region are more than just backward, powerless victims – that they are complicated people with the same goals, longings and fears as the rest of us. </p>
<h2>More than an addict</h2>
<p>Kingsolver, who was raised in rural Kentucky and who currently resides in Virginia, had a keen vision for Copperhead. She weaves the history of the economic fallout from the tobacco industry and coal mining into her protagonist’s backstory.</p>
<p>Her central concern, though, was always the opioid crisis. </p>
<p><a href="https://www.nytimes.com/2022/10/14/books/barbara-kingsolver-demon-copperhead.html?smid=nytcore-ios-share&referringSource=articleShare">As she told The New York Times in October 2022</a>, “I wanted to say, ‘Look, it’s still here, and this got done to us and we didn’t deserve it.’”</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Book cover of 'Demon Copperhead.'" src="https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=774&fit=crop&dpr=1 600w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=774&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=774&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=973&fit=crop&dpr=1 754w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=973&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/526611/original/file-20230516-34052-cr44y0.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=973&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">‘Demon Copperhead’ won the 2023 Pulitzer Prize for fiction.</span>
<span class="attribution"><a class="source" href="https://cdn.shopify.com/s/files/1/0570/7209/1326/products/33274BCF-6D06-40F3-B603-2C8F57086E36.jpg?v=1669761668">Black Bird Bookstore and Cafe</a></span>
</figcaption>
</figure>
<p>That’s the story of Demon’s life. An orphan who experiences poverty, an abusive foster home and social isolation, he finds freedom and glory on the football field, only to experience a devastating knee injury. </p>
<p>Pressured by his coach and the townspeople to play through his pain, he blindly takes the OxyContin that the local Dr. Feelgood prescribes, only to find himself crippled physically, psychologically and emotionally by his addiction.</p>
<p>And yet, through all of that, Demon is much more than his habit. Kingsolver foregrounds his humanity, his humor and his potential for goodness in a way that makes him more than “just an addict.” </p>
<p>In doing so, Kingsolver uses her connection to the region, her empathy for its residents and her awareness of stereotypes about Appalachians and addicts to avoid what could have easily been a reductive portrayal. Instead, she crafts a realistic and still-not-despairing vision from the inside.</p>
<p>This approach – an example of Soja’s thirdspace – is, in my view, the most powerful tool that artists have at their disposal to counteract the impulse to move on from grappling with this ongoing epidemic.</p>
<h2>Filling the void</h2>
<p>What Kingsolver does in prose, Billy Strings and John Prine do in song. </p>
<p>Strings, whose breakout hit, “<a href="https://outsider.com/entertainment/music/country-music/billy-strings-dust-in-a-baggie-lyrics-story-behind-song/">Dust in a Baggie</a>,” is a portrait of methamphetamine addiction, takes on opioids in “<a href="https://americansongwriter.com/billy-strings-enough-to-leave-video-jason-isbell-tour-announcement/">Enough to Leave</a>,” a track from his album “Home.” </p>
<p>Written to commemorate two friends who overdosed on fentanyl-laced heroin within the same week, <a href="https://lyrics.lol/artist/1431433-billy-strings/lyrics/4694970-enough-to-leave">the song</a> is a <a href="https://jambands.com/news/2020/02/20/billy-strings-shares-in-studio-video-of-enough-to-leave/">haunting evocation of grief</a> for those left behind when addiction takes its toll:</p>
<pre class="highlight plaintext"><code> Enough to kill ya, enough to put you down
Seems like every way you turned was like a hard wind comin' down
Enough to leave me, enough to leave me here
And though the room is empty now I can almost feel you near
</code></pre>
<p>The same is true for Prine’s “Summer’s End,” a track from his last album, 2018’s “The Tree of Forgiveness.”</p>
<p>The video for that song, directed by West Virginia filmmakers Kerrin Sheldon and Elaine McMillan Sheldon, <a href="https://www.rollingstone.com/music/music-news/how-john-prines-summers-end-video-addresses-the-opioid-crisis-776514/">portrays an aging grandfather and his young granddaughter</a> going about the mundanities of daily life in the wake of their daughter and mother’s death. A single frame depicts a news headline about the opioid crisis, illuminating the source of their suffering without overshadowing the regularity of their routines.</p>
<p>The video brings to mind a line from Samuel Beckett’s 1953 novel “<a href="https://www.britannica.com/topic/The-Unnamable">The Unnamable</a>”: “You must go on. I can’t go on. I’ll go on.”</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/nXbEFTv9zr0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">The music video for ‘Summer’s End.’</span></figcaption>
</figure>
<h2>Upending a theory of ‘genetic decline’</h2>
<p>Words, music and pictures – all have become powerful tools in this thirdspace reading of opioid-afflicted Appalachia. </p>
<p>Like the Sheldons, Kentucky-born photographer Stacy Kranitz offers gritty, complex and beautiful photographic portraits of Appalachia.</p>
<p><a href="https://www.readingthepictures.org/2014/02/stacy-kranitz-the-rape-of-appalachia/">She has written</a> about how she wants her work to provide a corrective to the negative portraits of Appalachia penned by Kentuckian <a href="https://en.wikipedia.org/wiki/Night_Comes_to_the_Cumberlands">Harry Caudill</a> and New York Times reporter <a href="https://en.wikipedia.org/wiki/Homer_Bigart">Homer Bigart</a> in the 1960s. </p>
<p>Caudill, who emphasized the economic exploitation of Appalachia, also came to embrace William Shockley’s <a href="https://www.splcenter.org/fighting-hate/extremist-files/individual/william-shockley">theory of dysgenics</a>, arguing that “genetic decline” among the people of Appalachia played a contributing role in the perpetuation of their suffering.</p>
<p>Their work brought Appalachia to the <a href="http://acsc.lib.udel.edu/exhibits/show/legislation/appalachian">Johnson administration’s awareness</a>. But it also amplified the national perception of the region and its people as backward, helpless and ripe for exploitation. </p>
<p>Kranitz’s engagement with Appalachia – particularly her refusal to let Caudill’s stereotypical views of its inhabitants as backward and regressive stand – offers a thirdspace revision of the region and its residents. Her series “<a href="https://www.stacykranitz.com/as-it-was-given-to-me">As It Was Given to Me</a>” juxtaposes a burning cross at a Klan rally with an image of a lovely, innocent girl holding a lit sparkler. Unafraid to illustrate the ugliness of the region, Kranitz is equally insistent on finding its beauty. </p>
<p>Like these artists and musicians, Kingsolver set out in “Demon Copperhead” to wrestle with the region’s complex history and its current social ills. </p>
<p>In that, she succeeded. </p>
<p>Hopefully the Pulitzer committee’s recognition of the novel will lead others to not only educate themselves about Appalachia, but also participate in the work needed to undo the damage that these drugs have done – and continue to do. </p>
<p><div data-react-class="InstagramEmbed" data-react-props="{"url":"https://www.instagram.com/p/CQtOSdzMXDr","accessToken":"127105130696839|b4b75090c9688d81dfd245afe6052f20"}"></div></p><img src="https://counter.theconversation.com/content/205378/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>William Nash does not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The Pulitzer Prize-winning author is just one of many artists from Appalachia who are probing the crisis in their work, while taking pains to ensure that it doesn’t define the region and its people.William Nash, Professor of American Studies and English and American Literatures, MiddleburyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1991642023-02-20T16:14:00Z2023-02-20T16:14:00ZDecriminalizing hard drugs in B.C. will help reduce the stigma of substance abuse<figure><img src="https://images.theconversation.com/files/510135/original/file-20230214-20-10cqun.jpg?ixlib=rb-1.1.0&rect=934%2C862%2C4374%2C3107&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A man runs past shoes hung on the Burrard Bridge in Vancouver in remembrance of victims of illicit drug overdoses on International Overdose Awareness Day in August 2020. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><p><a href="https://www.psychiatry.org/patients-families/addiction-substance-use-disorders/what-is-a-substance-use-disorder">Substance use disorder</a> is a chronic but treatable medical condition. </p>
<p>Unlike other physical and mental health conditions, however, substance use disorder — or addiction — has historically been seen as a moral failing and was for many years <a href="https://commons.allard.ubc.ca/fac_pubs/717/">relegated to the fringes of the medical community</a>. </p>
<p>Instead of receiving treatment in an accessible medical setting, many individuals went untreated or turned to a largely unregulated system of public and private treatment options. Drug use was criminalized and because many still believe that people who use drugs are engaging in deliberately deviant behaviour, we often choose to punish, rather than treat, drug addiction.</p>
<p>That’s why British Columbia’s recent move to eliminate criminal penalties for the possession of small amounts of illicit drugs for personal use is an important step toward the decriminalization of addiction. </p>
<h2>The dangers of stigma</h2>
<p>Policies that label drug users as criminals only enhance the stigma experienced by people attempting to manage a debilitating and sometimes life-threatening health condition, and in many cases hamper or even prevent them from receiving appropriate medical treatment.</p>
<p>Stigma surrounding drug use and addiction has an enormous impact on the social determinants of health and treatment outcomes for individual users. Criminal convictions stemming from drug use can impact someone’s ability to secure housing and employment. And perceptions of stigma and discrimination can prevent or delay people with substance use disorders from seeking treatment. </p>
<p>A <a href="https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Life-in-Recovery-from-Addiction-Report-2017-en.pdf">recent study</a> found that nearly half of respondents reported perceiving stigma because of their addiction from friends and family, from work colleagues and even from medical providers. </p>
<p><a href="https://www.cbc.ca/news/canada/british-columbia/gurdwara-international-student-overdoses-1.6718307">In some cases</a>, fear of negative opinions from people in their social circles is one reason people who know they need help with substance use do not pursue treatment.</p>
<p>Instead of receiving treatment, many individuals with addiction go untreated, and for some of them, their first exposure to treatment can come as a result of involvement with the criminal justice system. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/510129/original/file-20230214-28-i7f2u0.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A grey-haired woman with glasses in a blue suit smiles faintly." src="https://images.theconversation.com/files/510129/original/file-20230214-28-i7f2u0.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/510129/original/file-20230214-28-i7f2u0.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=421&fit=crop&dpr=1 600w, https://images.theconversation.com/files/510129/original/file-20230214-28-i7f2u0.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=421&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/510129/original/file-20230214-28-i7f2u0.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=421&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/510129/original/file-20230214-28-i7f2u0.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=528&fit=crop&dpr=1 754w, https://images.theconversation.com/files/510129/original/file-20230214-28-i7f2u0.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=528&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/510129/original/file-20230214-28-i7f2u0.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=528&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Jennifer Whiteside, B.C.’s minister of mental health and addictions, steps away from the podium after speaking during a news conference in Vancouver about B.C.’s decriminalization policy.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>A <a href="https://www.ccsa.ca/sites/default/files/2019-04/ccsa-011058-2004.pdf">recent report</a> found that three in four people in prison in B.C. have a substance use disorder or other mental health condition, and half of federal prisoners report that their arrest was in some way related to substance use. </p>
<p>And while most incarcerated people do have access to some form of treatment, <a href="https://www.prisonpolicy.org/blog/2021/05/13/mentalhealthimpacts/">much of that treatment is not based on best practices</a> and the experience of incarceration can worsen their addiction and their physical and mental health.</p>
<h2>Improving treatment options</h2>
<p>Decriminalization has an important role to play in recharacterizing addiction as a chronic health condition instead of a criminal activity, reducing the stigma associated with drug use and improving treatment options for this vulnerable population.</p>
<p><a href="https://time.com/longform/portugal-drug-use-decriminalization/">Studies in Portugal</a>, which decriminalized all illicit drugs in 2001 and shifted to a harm-reduction approach to substance use, have shown significant reductions in drug-related illnesses and mortality. </p>
<p>Importantly, resources that were previously devoted to the prosecution and imprisonment of drug users in Portugal are now available for treatment. And because the public has witnessed these improvements, there has been <a href="https://www.tni.org/files/publication-downloads/greenwald_whitepaper.pdf">no substantial push to return to a criminal model</a> of drug use. </p>
<figure class="align-center ">
<img alt="A teenager looks at his phone with shimmering water behind him and people walking along a pier." src="https://images.theconversation.com/files/510167/original/file-20230214-18-knue6u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/510167/original/file-20230214-18-knue6u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/510167/original/file-20230214-18-knue6u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/510167/original/file-20230214-18-knue6u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/510167/original/file-20230214-18-knue6u.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/510167/original/file-20230214-18-knue6u.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/510167/original/file-20230214-18-knue6u.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">A teenager checks his phone by the Tagus River at Lisbon’s Comercio square in January 2023. Portugal decriminalized all hard drugs more than 20 years ago.</span>
<span class="attribution"><span class="source">(AP Photo/Armando Franca)</span></span>
</figcaption>
</figure>
<p>B.C.’s decision to decriminalize the possession of only small amounts of drugs is not without its critics. <a href="https://www.cbc.ca/news/canada/british-columbia/drug-decriminalization-bc-reaction-1.6730656">Many point out</a> that the allowable amount of drugs, 2.5 grams, is less than a daily supply for many, and is especially unhelpful for those who must travel long distances to purchase drugs.</p>
<h2>Harm reduction disappointments</h2>
<p>Other harm reduction strategies that have been implemented since <a href="https://news.gov.bc.ca/10694">B.C. declared drug use a public health emergency in 2016</a> have often come up short. <a href="https://www.theglobeandmail.com/canada/article-bc-coroner-review-opioid-deaths/">Safe supply programs</a> have been limited to a small number of users, and <a href="https://www.cbc.ca/news/canada/british-columbia/toxic-drug-deaths-from-smoking-bc-1.6606503">safe consumption sites</a> have been unavailable to users who smoke, even though inhaled drugs account for many drug-related overdoses in the province. </p>
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Read more:
<a href="https://theconversation.com/supervised-consumption-sites-reduce-drug-overdoses-and-disease-transmission-and-deserve-government-support-197593">Supervised consumption sites reduce drug overdoses and disease transmission — and deserve government support</a>
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<p><a href="https://www.ccsa.ca/sites/default/files/2020-12/CCSA-COVID-19-Impacts-Pandemic-Substance-Use-Treatment-Capacity-Canada-2020-en.pdf">It’s also still difficult</a> for many people who do seek treatment for addiction to find available treatment providers in the community.</p>
<p>Notwithstanding these ongoing challenges, the criminal justice system is not the appropriate place to treat people with addiction — and decriminalization represents a choice to respond with treatment, not punishment. </p>
<p>While B.C. has a long way to go in its approach to the treatment of addiction, decriminalization is an important step toward reducing the stigma associated with drug use. In turn, it will improve individual outcomes and reduce the significant impact that the criminalization of drugs has on public health.</p><img src="https://counter.theconversation.com/content/199164/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sara Gordon 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>Decriminalization helps recharacterize drug addiction as a chronic health condition instead of a criminal activity, reduces the stigma associated with drug use and improves treatment options.Sara Gordon, Associate Professor of Law, University of British ColumbiaLicensed 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>
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<span class="caption">An advocate holds a sign at a demonstration in Victoria in April 2022. Decriminalization alone may have little effect on drug deaths without changes to the addiction treatment system.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Chad Hipolito</span></span>
</figcaption>
</figure>
<p>The provincial and federal governments have <a href="https://www.theglobeandmail.com/canada/british-columbia/article-federal-minister-promises-data-on-impact-of-decriminalization/">committed to a data-driven approach</a> to decriminalization. Ongoing drug supply monitoring will help public health professionals characterize what changes occur to the unregulated drug supply as a result of the policy change. Yet the act of decriminalizing drugs for personal use does not have any direct effect on the cause of the ongoing poisoning crisis. </p>
<p>The <a href="https://news.gov.bc.ca/releases/2023PSSG0008-000109">consensus among experts</a> has consistently pointed to unpredictable drugs from an unregulated supply and the absence of a functioning addiction treatment system. For those who want to seek treatment, the lack of available space leaves people waiting, once again left to rely on the toxic drug supply. </p>
<p>If B.C. is serious about confronting the leading cause of unnatural death in the province, it is going to take far more than decriminalizing simple drug possession. People who use drugs require an alternative to the toxic unregulated supply to not be risking their lives every time they use drugs. </p>
<p>Increasing access to a safer supply of drugs through a <a href="https://theconversation.com/safer-supply-of-opioids-saves-lives-providing-alternatives-to-toxic-street-drugs-177925">variety of formats</a> and providing meaningful funding for accessible treatment options are some examples of ways the province can take immediate steps to make an impact. </p>
<p>In the meantime, <a href="https://bc.ctvnews.ca/illicit-drug-death-toll-surpasses-2-000-in-b-c-for-a-2nd-consecutive-year-1.6253605">six more people will die today</a> from a drug poisoning in B.C. And another six will die tomorrow. How many more days can this go on?</p><img src="https://counter.theconversation.com/content/199239/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Samuel Tobias does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>As British Columbia begins a new era in drug policy, the drug poisoning crisis continues without an end in sight.Samuel Tobias, PhD Student, School of Population and Public Health, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1914062022-10-11T17:02:43Z2022-10-11T17:02:43ZDrug overdoses in public bathrooms are common: new tools could prevent harm and improve response<figure><img src="https://images.theconversation.com/files/488340/original/file-20221005-19-y6wjjn.jpeg?ixlib=rb-1.1.0&rect=38%2C230%2C4272%2C2551&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Bathrooms are common settings for overdose but can be made safer.</span> <span class="attribution"><a class="source" href="https://www.envirotechygieneservices.co.uk/healthcare-waste/">(Envirotec)</a></span></figcaption></figure><p>The drug poisoning crisis in Canada is at its worst in British Columbia, with over <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug.pdf">10,000 lives lost</a> since 2016. A key setting for overdoses in B.C. is bathrooms, though <a href="https://www.straight.com/news/1287391/more-overdoses-are-happening-public-washrooms-and-vancouver-wants-businesses-know-they">this information has not always been readily available</a>. </p>
<p>Every month in B.C., <a href="http://www.saferbathrooms.ca/">more than 50 overdoses happen in bathrooms</a>. This statistic is based on 911 calls where overdose was specifically documented to have occurred in bathrooms. As such, it is likely an undercount of all drug poisonings that take place in bathrooms across the province. </p>
<p>More must be done to prevent and improve how we respond to overdoses in these settings.</p>
<p>There are <a href="https://doi.org/10.1080/08897077.2019.1640834">many reasons for substance use and overdose in bathrooms</a>. </p>
<p>Bathrooms can be private, seemingly safe spaces for people to use substances, especially when they are <a href="https://ohrn.org/resources/safer-washroom-evaluation-healthy-sexuality-harm-reduction-wrha/">unable to access supervised consumption or overdose prevention sites</a>. Even when these services are available, some people will continue to use substances in bathrooms. This is often due to <a href="https://doi.org/10.1186/1477-7517-10-22">stigma as well safety and privacy concerns</a>, including the fear of others knowing about one’s substance use.</p>
<p>There can be <a href="https://doi.org/10.1080/08897077.2019.1640834">serious risks</a> to using substances in bathrooms. Chief among these is the risk of overdosing alone and not receiving lifesaving help in time. Fortunately, there are many ways to make bathrooms safer for people who use substances. </p>
<h2>The Safer Bathroom toolkit</h2>
<p>Our <a href="https://healthresearchbc.ca/award/the-safer-washroom-campaign-disseminating-best-practices-in-the-public-and-private-sectors/">team of substance use and harm reduction researchers</a> has spent the last year identifying best practices and developing a range of tools that people and organizations can use to make bathrooms safer. </p>
<p>Together, we launched a <a href="https://paninbc.ca/2021/11/15/creating-a-safer-washroom-campaign-stakeholder-consultation/">provincewide consultation</a> to ask community members, service providers, city staff and other stakeholders about overdose in bathrooms. </p>
<p>Almost half (44 per cent) of the 237 people surveyed felt their organizations’ bathrooms were not safe for people who use substances, and many others (27 per cent) weren’t sure. They shared common barriers to bathroom safety and highlighted resources they needed to better prevent and respond to overdose in these settings. </p>
<p>We developed the <a href="http://www.saferbathrooms.ca/">Safer Bathroom toolkit</a> based on this consultation. The toolkit provides practical resources related to overdose and bathroom safety, all of which can be adapted to suit individual and organizational needs. </p>
<figure class="align-center ">
<img alt="The architectural blueprints for a single-stall bathroom, overlayed with various design features to promote bathroom safety." src="https://images.theconversation.com/files/487938/original/file-20221004-22-2sr87s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/487938/original/file-20221004-22-2sr87s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=359&fit=crop&dpr=1 600w, https://images.theconversation.com/files/487938/original/file-20221004-22-2sr87s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=359&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/487938/original/file-20221004-22-2sr87s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=359&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/487938/original/file-20221004-22-2sr87s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=452&fit=crop&dpr=1 754w, https://images.theconversation.com/files/487938/original/file-20221004-22-2sr87s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=452&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/487938/original/file-20221004-22-2sr87s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=452&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Safer Bathroom toolkit includes an architectural design fact sheet, which identifies safety and overdose prevention features to consider when building or modifying bathrooms.</span>
<span class="attribution"><span class="source">(Hannah Leyland, Intern Architect)</span></span>
</figcaption>
</figure>
<p>These tools include a checklist for evaluating and improving bathroom safety, a guide to inform policy and protocol development, mock overdose scenarios to help with training and support, and examples of signs that convey non-judgmental information to bathroom users. We also created a bathroom design and remodelling fact sheet, working in close collaboration with architects who specialize in harm reduction. </p>
<p>Some of the best practices we share in the toolkit are for organizations to have policies and protocols in place about when and how often to do bathroom safety checks, for staff to complete a monthly mock overdose response exercise, and for bathrooms to be designed in such a way that people can easily and safely respond to overdoses, if they occur. </p>
<p>Incorporating these practices while raising awareness about overdose is one way that communities can come together to save lives.</p>
<h2>Is bathroom safety really the answer?</h2>
<figure class="align-right ">
<img alt="Public restroom lit with uv blue light" src="https://images.theconversation.com/files/489210/original/file-20221011-20-d3o1p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/489210/original/file-20221011-20-d3o1p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/489210/original/file-20221011-20-d3o1p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/489210/original/file-20221011-20-d3o1p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/489210/original/file-20221011-20-d3o1p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1131&fit=crop&dpr=1 754w, https://images.theconversation.com/files/489210/original/file-20221011-20-d3o1p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1131&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/489210/original/file-20221011-20-d3o1p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1131&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Neon-blue lights in bathrooms are used to deter injection drug use by making it more difficult for people to see their veins.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Existing public health measures are <a href="https://doi.org/10.3389/fcomm.2022.781564">not doing enough</a> to respond to the drug poisoning crisis. What we urgently need is a safer, regulated and accessible <a href="https://doi.org/10.1503%2Fcmaj.201618">drug supply</a>, an <a href="https://www2.gov.bc.ca/gov/content/governments/about-the-bc-government/mental-health-and-addictions-strategy">improved system</a> of voluntary substance use treatment and care and scaled up harm reduction services. As we continue the work of filling gaps in access to these essential supports, making bathrooms safer should be a priority. </p>
<p>This is important because designated, supervised spaces for safer substance use are <a href="https://www.uvic.ca/research/centres/cisur/assets/docs/bulletin-15-every-washroom-overdose-emergency.pdf">scarcely available</a> in many regions in B.C. and across Canada. When these aren’t accessible, public and private bathrooms in our communities can function as <a href="https://www.straight.com/news/1287391/more-overdoses-are-happening-public-washrooms-and-vancouver-wants-businesses-know-they">“de facto” drug consumption sites</a>.</p>
<p>What we must not do is try to prevent or deter access to bathrooms for people who use substances. Some may try measures like installing <a href="https://www.saanichnews.com/news/blue-lit-public-bathrooms-dont-deter-drug-use-says-provincial-authority/">neon-blue lights</a> that make it more difficult to see veins. However, doing so is <a href="https://doi.org/10.1186/1477-7517-10-22">ineffective at preventing substance use in bathrooms</a> and actually <a href="https://doi.org/10.1016/j.healthplace.2010.01.007">increases risks</a>.</p>
<p>From our perspective, making bathrooms safer is part of the solution and one that benefits all bathrooms users. Our hope is that the <a href="http://www.saferbathrooms.ca/">Safer Bathroom toolkit</a> will offer concrete tools to achieve this. </p>
<h2>Access to (safer) bathrooms is a human rights issue</h2>
<figure class="align-center ">
<img alt="A sign, titled 'Crab Park Improvements,' shows an image of and describes a public bathroom that will be piloted in the area." src="https://images.theconversation.com/files/487942/original/file-20221004-467-nuf9ct.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/487942/original/file-20221004-467-nuf9ct.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/487942/original/file-20221004-467-nuf9ct.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/487942/original/file-20221004-467-nuf9ct.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/487942/original/file-20221004-467-nuf9ct.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/487942/original/file-20221004-467-nuf9ct.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/487942/original/file-20221004-467-nuf9ct.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The Vancouver Park Board pilots new public bathrooms in CRAB Park, in the heart of Vancouver’s Downtown Eastside neighbourhood.</span>
<span class="attribution"><span class="source">Shannon Riley</span></span>
</figcaption>
</figure>
<p>The COVID-19 pandemic and safety measures have <a href="https://www.cbc.ca/news/canada/british-columbia/where-to-go-what-happens-when-nature-calls-during-a-pandemic-1.5610802">renewed calls</a> for more public bathrooms, especially as people are spending more time outdoors. This is even more so in B.C. and other areas that are hard hit by <a href="https://www.sfchronicle.com/opinion/editorials/article/Editorial-San-Francisco-is-fighting-over-toilets-16234160.php">housing</a> and <a href="https://public.wmo.int/en/media/news/world-toilet-day-sustainable-sanitation-and-climate-change">climate crises</a>. For many people, especially our communities’ most vulnerable, <a href="https://www.cbc.ca/news/canada/british-columbia/about-here-public-bathrooms-1.6404578">finding a bathroom to use can be a very difficult task</a>. </p>
<p>In our view, the safer bathroom conversation ties into the broader conversation about <a href="https://www.hrw.org/report/2017/04/19/going-toilet-when-you-want/sanitation-human-right">access to bathrooms being a human right</a>. As our communities strive to <a href="https://www.macleans.ca/sponsored/future-of-public-washrooms/">improve bathroom access</a>, we must invest in making these spaces safe and accessible for all, including people who use substances.</p><img src="https://counter.theconversation.com/content/191406/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>This work is funded by a Reach Award from Michael Smith Health Research BC. Trevor Goodyear receives trainee support through the University of British Columbia and the Canadian Institutes of Health Research.</span></em></p><p class="fine-print"><em><span>Marilou Gagnon receives funding from Michael Smith Health Research BC, Canadian Institutes of Health Research, and Social Sciences and Humanities Research Council of Canada. </span></em></p>More than 50 overdoses happen in bathrooms every month in British Columbia. Public bathrooms can be made safer for everyone, including people who use substances.Trevor Goodyear, PhD Candidate, School of Nursing, University of British ColumbiaMarilou Gagnon, Professor, School of Nursing, Faculty of Human and Social Development, University of VictoriaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1787102022-07-26T12:01:00Z2022-07-26T12:01:00ZThe opioid crisis isn’t just the Sacklers’ fault – and making Purdue Pharma pay isn’t enough on its own to fix the pharmaceutical industry’s deeper problems<figure><img src="https://images.theconversation.com/files/474172/original/file-20220714-17678-rvc47r.jpg?ixlib=rb-1.1.0&rect=7%2C0%2C5234%2C3387&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Many companies have sold dangerous prescription drugs.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/large-capsule-of-dangerous-medicine-royalty-free-image/1175215967?adppopup=true">Peter Dazeley/The Image Bank via Getty Images</a></span></figcaption></figure><p>You may have heard of the <a href="https://theconversation.com/how-the-purdue-opioid-settlement-could-help-the-public-understand-the-roots-of-the-drug-crisis-166701">Sackler family</a> and the role that they and their privately held company, <a href="https://www.cbsnews.com/news/purdue-pharma-sackler-family-wealth-where-did-the-sacklers-shift-cash-from-opioid-maker/">Purdue Pharma</a>, played in the opioid crisis. One TV series depicting the family as a villainous clan <a href="https://www.emmys.com/shows/dopesick">earned 14 Emmy nominations</a>, winning two. Another is in the works.</p>
<p>Purdue is infamous for its <a href="https://www.jstor.org/stable/45345199">hard-sell marketing of its powerful, long-acting opioid OxyContin</a>. Among its troubling tactics: co-opting legitimate medical organizations to spread messages overstating the drug’s effectiveness and understating its addiction risks. Sales boomed, <a href="https://www.dirt.com/more-dirt/heirs-heiresses/oxycontin-david-sackler-house-bel-air-11220/">making its owners</a> <a href="https://oversight.house.gov/news/press-releases/committee-releases-documents-showing-sackler-family-wealth-totals-11-billion">fabulously wealthy</a> and building what journalist Patrick Radden Keefe memorably calls an “<a href="https://www.penguinrandomhouse.com/books/612861/empire-of-pain-by-patrick-radden-keefe/">empire of pain</a>.” </p>
<p>Purdue’s profit-seeking became a <a href="https://www.washingtonpost.com/investigations/2022/07/07/american-cartel-book/">model for other drugmakers</a>, <a href="https://ncdoj.gov/attorney-general-josh-stein-announces-26-billion-agreement-with-opioid-distributors-manufacturer/">distributors</a> and <a href="https://doi.org/10.1136/bmj.n2893">pharmacy chains</a>. The ensuing sales frenzy led to skyrocketing rates of opioid addiction and related harms by the early 2000s – <a href="https://www.cdc.gov/opioids/basics/epidemic.html">perhaps the worst pharmaceutical crisis</a> in U.S. history.</p>
<p>So when Purdue Pharma’s bankruptcy settlement was revised in March 2022 to <a href="https://www.npr.org/2022/03/03/1084163626/purdue-sacklers-oxycontin-settlement">make the family pay US$6 billion</a>, mostly to local and state governments, the news was greeted with at least <a href="https://slate.com/news-and-politics/2022/03/sacklers-oxycontin-opioid-crisis-purdue-pharma-bankruptcy-settlement.html">some satisfaction</a>. Although it looks as though no members of that family will go to prison, the people often <a href="https://www.npr.org/2021/11/12/1051811415/dopesick-opioids-purdue-pharma-sacklers">regarded as the saga’s primary villains</a> were at least paying a price for their misdeeds.</p>
<p>But as a <a href="https://scholar.google.com/citations?user=bQa5NtoAAAAJ&hl=en">historian of addictive pharmaceuticals</a>, I see a danger in associating the opioid crisis too closely with the Sackler family. My research has shown that the crisis isn’t an aberration caused by the individual misdeeds of bad actors. Punishing people who broke the law, and making business leaders pay to repair the harms they caused, surely helps. Yet broad reforms are also needed to prevent similar disasters from happening again.</p>
<h2>Who are ‘the Sacklers’?</h2>
<p>Despite the many individuals and companies involved, the Sacklers became the public face of the opioid crisis. In part this acknowledged their status as pioneers: They were the first to hypermarket strong opioids, and they led the pack in <a href="https://www.cbsnews.com/news/purdue-executive-richard-sackler-cast-blame-on-opioid-victims-old-emails-show/">blaming the resulting catastrophe on consumers who became addicted</a> to those prescription painkillers.</p>
<p>But who are they? Their story began with <a href="https://www.theguardian.com/us-news/2018/feb/13/meet-the-sacklers-the-family-feuding-over-blame-for-the-opioid-crisis">Arthur, Mortimer and Raymond Sackler</a>, three brothers who were all doctors and made a collective fortune in medical marketing. They acquired what was then called Purdue Frederick Co. in 1952.</p>
<p>After Arthur died in 1987, <a href="https://www.propublica.org/article/sacklers-who-disavow-oxycontin-may-have-benefited-from-it">Mortimer and Raymond bought their brother’s stake</a> in the company from his family for $22 million. For that reason, <a href="https://apnews.com/article/museums-lawsuits-us-news-business-opioids-f69d14706030450da26dd6b0f5466eb8">Arthur Sackler’s heirs</a> aren’t involved in opioid-related litigation that’s on track to be resolved through Purdue’s bankruptcy settlement.</p>
<p>“The Sacklers” I refer to here – and when you read about them elsewhere – are Mortimer and Raymond and their heirs who benefited from Purdue’s profit machine, <a href="https://www.stamfordadvocate.com/business/article/Sacklers-quit-Purdue-Pharma-board-signaling-13742946.php">many of whom worked there, served on its board</a> – or both.</p>
<p>Richard Sackler ran the company for years and subsequently became a micromanaging board member. His cousin Kathe Sackler, another former Purdue executive, repeatedly claimed that <a href="https://www.theguardian.com/us-news/2021/apr/09/kathe-sackler-oxycontin-empire-of-pain-book">OxyContin was her idea</a>, Patrick Radden Keefe has reported. Pinpointing exactly how much money they collectively extracted from Purdue is impossible, but in 2021 those two branches of the Sackler family were estimated to hold about <a href="https://oversight.house.gov/news/press-releases/committee-releases-documents-showing-sackler-family-wealth-totals-11-billion">$11 billion in assets</a>.</p>
<h2>Pop culture villainy</h2>
<p>The Sacklers used their profits to protect the family’s reputation through <a href="https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain">lavish charitable donations</a> to museums like the Guggenheim and the Louvre, and several universities – <a href="https://www.wgbh.org/news/local-news/2019/12/05/tufts-university-severs-ties-with-sacklers-the-family-behind-oxycontin">including Tufts</a> and <a href="https://yaledailynews.com/blog/2022/03/09/university-quietly-severs-sackler-ties/">Yale</a>.</p>
<p>Their philanthropy produced an aura of respectability but also made them highly visible. Eventually journalists connected the dots, leading to a cottage industry of <a href="https://www.simonandschuster.com/books/Pharma/Gerald-Posner/9781501151897">books</a> and <a href="https://www.esquire.com/news-politics/a12775932/sackler-family-oxycontin/">media</a> <a href="https://www.hbo.com/documentaries/the-crime-of-the-century">coverage</a> of the opioid crisis casting the Sacklers as the bad guys responsible for historic levels of addiction and overdose.</p>
<p>The Sacklers-as-comic-book-villains story is on full display in actor <a href="https://www.emmys.com/events/74th-emmy-nominations-announcement">Michael Stuhlbarg’s</a> <a href="https://www.emmys.com/shows/dopesick">Emmy-nominated performance</a> as a remarkably creepy Richard Sackler in the Hulu series “<a href="https://press.hulu.com/shows/dopesick/">Dopesick</a>,” based on <a href="https://www.littlebrown.com/titles/beth-macy/dopesick/9780316551281/">Beth Macy’s book</a> by the same name. The show won <a href="https://www.emmys.com/shows/dopesick">two Emmys in 2022</a>.</p>
<p>Viewers can probably expect similar fare from <a href="https://www.whats-on-netflix.com/news/painkiller-netflix-limited-series-everything-we-know-so-far/">Michael Broderick</a>, who will play Richard Sackler in “<a href="https://www.netflix.com/title/81095069">Painkiller</a>,” an upcoming Netflix limited series about how the opioid crisis began.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/EzrLrUG2QVk?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">‘Dopesick,’ a Hulu series, dramatizes Purdue’s role in bringing about the opioid epidemic.</span></figcaption>
</figure>
<h2>‘White market drugs’</h2>
<p>As satisfying as it may be, focusing on the Sacklers’ misdeeds can obscure as much as it reveals about the deeper causes of the opioid crisis.</p>
<p>Purdue did not invent the tactics it used to sell OxyContin. Pharmaceutical companies discover and sell genuinely miraculous products, but they also routinely wield troubling influence over every step of the <a href="https://www.matteringpress.org/books/ghost-managed-medicine">production and circulation of knowledge about drugs</a>, which can make it difficult to understand the true value of a medicine. They oversee the research that demonstrates drug effectiveness. They write or help write the publications based on the research.</p>
<p>Drugmakers script or influence the professional guidelines that encourage prescribing. They underwrite professional organizations and pay medical experts to spread the word. They fund and channel patient advocacy organizations into supporting the medicines they manufacture.</p>
<p>And then they lobby for legislation, regulations and anything else that can gin up more demand for their drugs.</p>
<p>Until the <a href="https://www.fda.gov/drugs/information-drug-class/timeline-selected-fda-activities-and-significant-events-addressing-opioid-misuse-and-abuse">Food and Drug Administration approved OxyContin in 1995</a>, these marketing techniques <a href="https://press.uchicago.edu/ucp/books/book/chicago/W/bo58927880.html">were forbidden for opioids</a>, which authorities considered to be too dangerous for them.</p>
<p>As I explain in my book, “<a href="https://press.uchicago.edu/ucp/books/book/chicago/W/bo58927880.html">White Market Drugs</a>,” federal regulators, supported by cautious medical authorities, appointed leading pharmacologists to test the addictiveness of new opioid products. They scrutinized advertisements to make sure the risks were fully and accurately conveyed.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/475888/original/file-20220725-14-z4hx12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Old-fashioned article warns readers to be wary when the 'Prescription says 'DOPE''" src="https://images.theconversation.com/files/475888/original/file-20220725-14-z4hx12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/475888/original/file-20220725-14-z4hx12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=878&fit=crop&dpr=1 600w, https://images.theconversation.com/files/475888/original/file-20220725-14-z4hx12.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=878&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/475888/original/file-20220725-14-z4hx12.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=878&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/475888/original/file-20220725-14-z4hx12.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1103&fit=crop&dpr=1 754w, https://images.theconversation.com/files/475888/original/file-20220725-14-z4hx12.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1103&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/475888/original/file-20220725-14-z4hx12.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1103&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">This 1944 article decried the dangers of prescribed opioids.</span>
<span class="attribution"><span class="source">David Herzberg/National Archives</span></span>
</figcaption>
</figure>
<p>Pharmaceutical companies tried to outfox regulators with a parade of now-forgotten “miracle opioids” long before OxyContin. Indeed, one of these would-be wonder drugs was none other than oxycodone, OxyContin’s main ingredient.</p>
<p>Oxycodone, <a href="https://doi.org/10.1016/j.jpainsymman.2005.01.010">discovered in 1916</a>, had been sold in the U.S. for most of the 20th century. </p>
<p>In 1949, Endo Products claimed that <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1515192/">Percodan, its new oxycodone product</a>, shouldn’t face strict federal controls because it was chemically <a href="https://www.addictioncenter.com/opiates/codeine/">similar to codeine</a>, a relatively weak opioid used in cough syrups. The company insisted it wasn’t addictive when used as prescribed.</p>
<p>Expert pharmacologists working with federal regulators pushed back. Noting that oxycodone produced an “intense” addiction, they pointed out that people did not always follow doctors’ orders – especially with addictive drugs.</p>
<p>Purdue’s real innovation with OxyContin was commercial, not scientific. The company was the first to market a powerful opioid using the most aggressive strategies other drug companies regularly used to get pharmaceutical innovations into bodies with great speed and efficiency – while maximizing profits.</p>
<p>Once Purdue showed it could be done, competitors quickly followed suit. The industry replaced U.S. medicine’s century-old habits of opioid precautions with a reckless boosterism. </p>
<h2>Complicity of many industries</h2>
<p>Purdue, that is, didn’t act alone.</p>
<p>Other drugmakers such as <a href="https://ag.ny.gov/opioidsettlement">Endo</a> and <a href="https://apnews.com/article/business-health-lawsuits-epidemics-west-virginia-8ba921c65638ea7d2260c4111d35ab59">Janssen</a> imitated and even surpassed Purdue’s example once the taboo had been broken. </p>
<p>Generic manufacturers such as <a href="https://www.sfcityattorney.org/2022/07/12/city-attorney-announces-54-million-settlement-with-opioid-defendants-allergan-and-teva">Allergan and Teva</a> then profited by expanding and prolonging the boom, as did <a href="https://ag.ny.gov/opioidsettlement">wholesale drug distributors</a> and <a href="https://www.nytimes.com/2021/11/23/health/walmart-cvs-opioid-lawsuit-verdict.html">retail chain pharmacies</a>. Even the prestigious <a href="https://www.nytimes.com/2021/02/03/business/mckinsey-opioids-settlement.html">McKinsey consulting firm</a> got into the game, advising others how to maximize sales.</p>
<p>The complicity of so many industries makes opioid litigation complex and hard to follow. Cities, states and other plaintiffs didn’t just sue Purdue. They turned to the legal system to make sure that all the other companies pay to repair the harms they caused in building the historic opioid boom that has contributed to more than <a href="https://www.cdc.gov/opioids/data/analysis-resources.html">500,000 overdose deaths</a> since 1996.</p>
<p>To date the largest national opioid settlement is with the three main opioid distributors and Johnson & Johnson, manufacturer of the <a href="https://www.jnj.com/johnson-johnson-reaches-opioid-settlement-agreement-with-new-york-state-consistent-with-terms-of-previously-announced-broader-settlement-agreement-in-principle">Duragesic and Nucynta</a> opioids. It totals <a href="https://www.washingtonpost.com/health/2022/02/25/opioid-settlement-final/">$26 billion</a>, significantly more than what Purdue and the Sacklers are paying.</p>
<p>But financial settlements cannot solve every problem that made this crisis possible. Purdue and its competitors were able to put profits over consumer safety for so long, in part, because their marketing strategies closely approximated how other medicines are sold in the U.S. </p>
<p>The <a href="https://www.ncbi.nlm.nih.gov/books/NBK448203/">opioid crisis</a>, in other words, revealed in an exaggerated fashion problems prevalent in the pharmaceutical industry more generally. Until those broader problems are resolved, the unhappy <a href="https://press.uchicago.edu/ucp/books/book/chicago/W/bo58927880.html">history of addictive prescription drugs</a> will keep repeating itself.</p>
<p><em>This article was updated on Sept. 13, 2022, to include the two Emmys “Dopesick” won in 2022.</em></p><img src="https://counter.theconversation.com/content/178710/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Herzberg has served as a paid consultant and expert witness for plaintiffs in U.S. opioid litigation. He has received funding from the National Institute of Health.</span></em></p>Making them pay is important but it’s not going to stop drugmakers from endangering public health.David Herzberg, Associate Professor of History, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1863612022-07-07T21:01:59Z2022-07-07T21:01:59Z$150M is not enough: Canada’s proposed Purdue Pharma settlement for opioid damages is paltry and won’t prevent future crises<figure><img src="https://images.theconversation.com/files/472872/original/file-20220706-95-jgs9g3.jpg?ixlib=rb-1.1.0&rect=273%2C62%2C2627%2C2070&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">OxyContin, an opioid drug heavily marketed by Purdue Pharma, is associated with billions of dollars of health-care costs in Canada related to the opioid crisis.</span> <span class="attribution"><span class="source">(AP Photo/Toby Talbot)</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/150m-is-not-enough--canada-s-proposed-purdue-pharma-settlement-for-opioid-damages-is-paltry-and-won-t-prevent-future-crises" width="100%" height="400"></iframe>
<p>On June 29, Canadian federal and provincial governments reached a proposed <a href="https://www.theglobeandmail.com/canada/article-purdue-canada-agrees-to-pay-150-million-over-opioid-harms/">$150-million settlement with Purdue Pharma Canada</a>, makers of OxyContin, an opioid-based pain medication. The settlement is intended to recover the health-care costs related to the damaging effects from the sale and marketing of OxyContin.</p>
<p>While this is the largest settlement of a governmental health-care cost claim in Canadian history, it is also a paltry amount compared to the approximately <a href="https://www.reuters.com/business/healthcare-pharmaceuticals/sacklers-will-pay-up-6-bln-resolve-purdue-opioid-lawsuits-mediator-2022-03-03/">US$6 billion</a> that Purdue will pay in the United States. A population-equivalent Canadian settlement would have been closer to CA$900 million. </p>
<p>Until this $150-million fine, there is no record of any drug company ever having been fined for its promotion of one of its prescription drug products in Canada. Despite illegal drug promotion documented in the United States, Health Canada did not investigate whether such practices were also present in Canada. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2622774/pdf/221.pdf">One example</a> was the distribution of 15,000 copies of a video in the U.S. claiming, without any substantiation, that opioids caused addiction in fewer than one in 100 patients.</p>
<p>When asked why, <a href="https://www.thestar.com/news/canada/2014/06/26/dangers_of_offlabel_drug_use_kept_secret.html">agency officials responded</a> that Health Canada “has not been made aware of any specific similar issue in Canada and has not received complaints.” </p>
<p>Equally concerning, however, is the intense focus on financial settlements at the expense of regulatory changes.</p>
<h2>Regulatory loopholes</h2>
<p>Since the opioid crisis emerged, researchers and journalists have identified a range of strategies and policy loopholes that companies took advantage of to push their products. These included: </p>
<ul>
<li><p><a href="https://doi.org/10.2105%2FAJPH.2007.131714">industry influence over clinical practice guidelines</a>, which are <a href="https://www.ncbi.nlm.nih.gov/books/NBK390308/">recommendations for patient care</a>, </p></li>
<li><p><a href="http://dx.doi.org/10.1136/medethics-2013-101343">funding that can bias medical education</a>, </p></li>
<li><p>providing health-care professionals with <a href="https://doi.org/10.1016/j.amjmed.2017.12.045">free trips to exotic locations in order to listen to “expert opinions,”</a></p></li>
<li><p>insufficient transparency around <a href="https://www.motherjones.com/crime-justice/2019/08/unsealed-documents-show-how-purdue-pharma-created-a-pain-movement/">funding of non-profit organizations</a> and </p></li>
<li><p>a government-sanctioned culture of <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999539/">self-regulation, enabling the pharmaceutical industry to regulate its own promotion practices</a>. </p></li>
</ul>
<p>Despite this knowledge, virtually all of these strategies remain entirely legal.</p>
<h2>Funding transparency</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Protesters with signs and a skeleton made of pill bottles outside a building" src="https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=426&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=426&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=426&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=535&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=535&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472876/original/file-20220706-26-il0pw1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=535&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Protesters outside a Boston, Mass. courthouse in 2019, during a lawsuit against Purdue Pharma over its role in the national drug epidemic. The company’s U.S. settlements for OxyContin lawsuits total about US$6 billion.</span>
<span class="attribution"><span class="source">(AP Photo/Charles Krupa)</span></span>
</figcaption>
</figure>
<p>Transparency around pharmaceutical funding of health-care professionals and non-profit organizations remains virtually non-existent in Canada. The United States passed the <a href="https://www.healthaffairs.org/do/10.1377/hpb20141002.272302/full/">Physician Payments Sunshine Act</a> in 2010 requiring transparency of financial relationships between physicians and the health-care industry. Yet no such system of transparency exists in Canada. </p>
<p>In fact, the federal government has <a href="https://www.cbc.ca/news/health/pharmaceutical-drug-company-doctor-physician-payment-disclosure-transparency-1.4169888">explicitly rejected setting up a similar mechanism</a>. The one attempt to do so in Ontario was <a href="https://doi.org/10.1503/cmaj.109-5718">terminated in 2018</a> when Doug Ford’s Progressive Conservatives took office. Such a system would have significantly increased transparency around the types of physician payments that directly influenced opioid prescription patterns. </p>
<h2>Funding medical education</h2>
<p>Pharmaceutical companies are <a href="https://www.thestar.com/news/investigations/2019/02/11/family-doctors-can-no-longer-claim-ritzy-drug-dinners-as-professional-training.html"><em>still</em> permitted</a> to fund groups putting on accredited medical education events for Canadian doctors. This is despite <a href="https://doi.org/10.1371/journal.pmed.1000352">significant evidence</a> that industry funding leads to a bias in prescriptions and few improvements in prescribing. </p>
<p><a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">This type of funded “medical education”</a> was one of the main avenues through which Purdue Pharma and other companies managed to convince health-care professionals of the benefits of their products, while minimizing the products’ overall risk of addiction. </p>
<p>There is little evidence that removing industry funding would create an information gap, and it is <a href="https://doi.org/10.1371/journal.pmed.1000352">likely to drastically reduce overall industry influence over the profession</a>. Yet the federal government has often done little to use such practices to ensure appropriate drug prescribing and use, putting it at odds with governments in many other <a href="https://www.nps.org.au">wealthy industrialized countries</a>.</p>
<h2>Product monographs</h2>
<figure class="align-center ">
<img alt="White pills scattered on a black background" src="https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/472878/original/file-20220706-9520-6h9cs9.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">
<figcaption>
<span class="caption">Since the opioid crisis emerged, researchers and journalists have identified a range of strategies and policy loopholes that companies took advantage of to push their products.</span>
<span class="attribution"><span class="source">(AP Photo/Keith Srakocic)</span></span>
</figcaption>
</figure>
<p>Canadian regulators have revealed little about how they plan to reduce industry influence over product monographs, which provide detailed information for doctors about specific drugs. </p>
<p><a href="https://www.canada.ca/en/health-canada/services/drugs-health-products/drug-products/applications-submissions/guidance-documents/product-monograph/frequently-asked-questions-product-monographs-posted-health-canada-website.html">Health Canada states</a> that a product monograph should be a “factual, scientific document on a drug product … devoid of promotional material.” </p>
<p>Despite this, Oxycontin’s original Canadian product monograph in 1996 recommended increased use of the product in cases of “<a href="https://www.gov.nl.ca/hcs/files/publications-oxycontin-final-report.pdf">breakthrough pain</a>,” a term that had previously appeared in Oxycontin advertisements. Moreover, the product monograph <a href="https://doi.org/10.1111/add.14929">provided no recommended maximum dose</a>, meaning there was no upper dose threshold for OxyContin when it was marketed. </p>
<p>Despite this, there has been no formal inquiry into how this scientific document could be so significantly affected by industry interests, or how to prevent similar influence from recurring.</p>
<h2>Gifts to health-care professionals</h2>
<p>The pharmaceutical industry continues to provide non-research-related transfers to health-care professionals. These transfers include gifts of food and drink, all-expenses paid travel to conferences and marketing-related consultancies. Again, <a href="https://nationalpost.com/news/canada/the-selling-of-oxycontin">this form of funding was repeatedly used by opioid manufacturers</a> to influence health-care professionals, with companies even flying them out to exotic locations to listen to “key opinion leaders” speak on the benefits of Oxycontin and other opioids.</p>
<p>Despite virtually no rationale for the “educational” value of these events, such financial transfers continue today. In 2020, 10 of the 47 drug company members of Innovative Medicines Canada, the organization that represents the pharmaceutical industry, <a href="https://www.doi.org/10.12927/hcpol.2022.26729">spent over $28 million on fees and travel for health-care providers</a>.</p>
<p>The settlement with Purdue Pharma Canada is <a href="https://www.cbc.ca/news/canada/british-columbia/purdue-bankruptcy-filings-provinces-68b-us-opioid-crisis-oxycontin-1.5799580">frustratingly small in comparison to the billions in health-care costs of the opioid crisis</a>. But it also shouldn’t distract from the bigger issue: despite the many lessons learned from the crisis, there have been very few regulatory changes made in Canada since. </p>
<p>Unless something radically changes in how the pharmaceutical industry is regulated, there is little reason to assume a similar crisis won’t occur again.</p><img src="https://counter.theconversation.com/content/186361/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Daniel Eisenkraft Klein receives funding from a Social Sciences and Research Council Doctoral Fellowship and through internal grants from Johns Hopkins University's Opioid Industry Documents Archive. He is presently a part-time Policy Analyst in the Tobacco Control Directorate at Health Canada. </span></em></p><p class="fine-print"><em><span>In 2019-2021, Joel Lexchin received payments for writing a brief on the role of promotion in generating prescriptions for Goodmans LLP and from the Canadian Institutes of Health Research for presenting at a workshop on conflict-of-interest in clinical practice guidelines. He is a member of the Foundation Board of Health Action International and the Board of Canadian Doctors for Medicare. He receives royalties from University of Toronto Press and James Lorimer & Co. Ltd. for books he has written. </span></em></p>The Purdue Pharma settlement is paltry compared to costs of the opioid crisis. Without major changes to pharma industry regulation, there is little reason to think a similar crisis won’t occur again.Daniel Eisenkraft Klein, PhD Candidate, Dalla Lana School of Public Health, University of TorontoJoel Lexchin, Professor Emeritus of Health Policy and Management, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1849262022-06-19T12:50:48Z2022-06-19T12:50:48ZDecriminalizing hard drugs in B.C. follows decades of public health advocacy<figure><img src="https://images.theconversation.com/files/469560/original/file-20220617-14205-7slb7v.JPG?ixlib=rb-1.1.0&rect=0%2C467%2C5439%2C3853&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">B.C. Minister of Mental Health and Addictions Sheila Malcolmson holds a copy of exemption documents that enable British Columbia to decriminalize possession of small amounts of 'hard' drugs for personal use. B.C.’s bold experiment will be closely watched as a comparator with other progressive jurisdictions.
</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</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/decriminalizing-hard-drugs-in-b-c--follows-decades-of-public-health-advocacy" width="100%" height="400"></iframe>
<p><a href="https://globalnews.ca/news/8882290/bc-overdose-crisis-decriminalize-possession/?utm_source=NewsletterNational&utm_medium=Email&utm_campaign=2022">British Columbia has become</a> the first province to be granted an exemption under the <a href="https://laws-lois.justice.gc.ca/eng/acts/c-38.8/">Controlled Drugs and Substances Act</a> to remove criminal penalties for possession of opioids, cocaine, methamphetamine and MDMA for personal use. </p>
<p>This means that police will no longer arrest, charge or seize drugs from adults found with 2.5 grams or less of these substances. Instead, people with drugs will be offered information on available health and social services and assistance with referrals to access treatment if they choose.</p>
<p>B.C.’s bold experiment to decriminalize “hard” drugs will be closely watched as a comparator with other progressive jurisdictions, such as <a href="https://www.pbs.org/newshour/politics/oregon-1st-state-to-decriminalize-possession-of-hard-drugs">Oregon</a> and <a href="https://www.theguardian.com/news/2017/dec/05/portugals-radical-drugs-policy-is-working-why-hasnt-the-world-copied-it">Portugal</a>. Decriminalization in these places has been implemented differently, reflecting the distinctive circumstances and priorities that influence drug policy in different global contexts.</p>
<p>As a sociologist who has been studying drug policy development in Canada for nearly 30 years, it is plainly evident to me that decision-making is a political process that does not rest on facts alone. <a href="https://doi.org/10.1017/S0829320100006566">Drug policy</a> reflects <a href="https://doi.org/10.1080/0959523021000023270">ideological commitments</a> that are influenced by, and in turn influence, prevailing public understandings and opinions about drugs. <a href="https://doi.org/10.1080/09595230500404145">Exposure to the facts</a> — which are also contested — and <a href="https://doi.org/10.1016/S0955-3959(01)00085-8">constructive dialogue about social norms and values</a> is needed to facilitate more meaningful debate. </p>
<figure class="align-center ">
<img alt="Cropped image of a group of people, one of whom is holding a hand-lettered sign reading 'Every death is a drug policy failure'" src="https://images.theconversation.com/files/469561/original/file-20220617-20-ftu74x.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469561/original/file-20220617-20-ftu74x.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469561/original/file-20220617-20-ftu74x.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469561/original/file-20220617-20-ftu74x.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469561/original/file-20220617-20-ftu74x.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469561/original/file-20220617-20-ftu74x.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469561/original/file-20220617-20-ftu74x.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Advocates gather in Victoria to mark the anniversary of the declaration of a public health emergency in opioid-related overdoses in British Columbia on April 14.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Chad Hipolito</span></span>
</figcaption>
</figure>
<p>Decriminalizing drug use is the <a href="https://www.oupcanada.com/catalog/9780199007882.html">realization of 50 years of policy discussions</a> advocating for removal of all penalties for small amounts of drugs. The called-for public health perspective is just beginning to materialize, despite extensive evidence that <a href="https://cannabiscoalition.ca/info/HarmReductionHeadway_Resistance_IJDPX2008.pdf">the war on drugs has failed</a>. The research evidence instead supports the view that prohibition of substance use has been ineffective, costly, inhumane and harmful to the user and society.</p>
<h2>Why so little progress for so long?</h2>
<p>Canada has long pursued half-measures by adopting a hybrid model recognizing public health considerations within a legal framework that enforces prohibition. The <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1947221/pdf/canmedaj01573-0103.pdf">LeDain Commission of Inquiry</a> in 1972 proposed a gradual withdrawal from criminal penalties for illicit drug possession, phasing out incarceration in favour of medical treatment. </p>
<p>The LeDain report foreshadowed the emergence of drug policy with the goal of <a href="https://ontario.cmha.ca/harm-reduction/">harm reduction</a> and the need for more attention to the principles that underlie drug policy debates. What is meant by “harm” has been contentious when determining the proper role of law when the police and politicians define harm in ways that justify continued prohibition.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/469565/original/file-20220617-23-jl5q1d.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman at a podium in front of a row of flags, and two other women at opposite sides of stage, in front of background with the words 'A pathway to hope'" src="https://images.theconversation.com/files/469565/original/file-20220617-23-jl5q1d.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469565/original/file-20220617-23-jl5q1d.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469565/original/file-20220617-23-jl5q1d.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469565/original/file-20220617-23-jl5q1d.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469565/original/file-20220617-23-jl5q1d.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469565/original/file-20220617-23-jl5q1d.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469565/original/file-20220617-23-jl5q1d.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">Minister of Mental Health and Addictions Sheila Malcolmson discusses details about the province’s application for decriminalization at the provincial legislature in Victoria on Nov. 1, 2021, as provincial health officer Dr. Bonnie Henry and chief coroner Lisa Lapointe look on.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Chad Hipolito</span></span>
</figcaption>
</figure>
<p>Ten years after the LeDain report, the enactment of the <a href="https://www.justice.gc.ca/eng/csj-sjc/rfc-dlc/ccrf-ccdl/">Charter of Rights and Freedoms</a> provided legal tools that complement more scientific evidence-based arguments for drug policy reform. The success of <a href="https://doi.org/10.1017/S0829320100006566">legal challenges on Charter grounds</a>, however, has been largely limited to striking down the most egregious policing practices and penalties for drug crimes.</p>
<p>Sweeping changes in the law might well have been expected with the launch of <a href="https://www.csc-scc.gc.ca/research/forum/e133/133a_e.pdf">Canada’s Drug Strategy</a> in 1987. The language change was monumental: it covered the full spectrum of non-medical drug use, including legal drugs like alcohol, prescription drugs and even solvents; and it signalled an intent to set out in a new direction that dramatically departed from the war-on-drugs approach. </p>
<p>The implementation of the strategy, however, was much less so. Police continued to command the lion’s share of funding, despite the promise of pursuing a “more balanced” and coherent public health approach to substance use. </p>
<p>Thirty-five years later, the situation has changed little. In 2018, after decades of debate, but little action indicating actual commitment to reform, <a href="https://www.justice.gc.ca/eng/cj-jp/cannabis/">cannabis was legalized in Canada</a>, transforming its users from pariahs to responsible consumers. Users of more dangerous drugs continue to be treated differently, primarily because such use elicits more concern for crime control than protecting health. </p>
<h2>Lessons from other jurisdictions</h2>
<p>In Oregon, the lack of full commitment to a public health approach explains the <a href="https://abcnews.go.com/Health/wireStory/oregon-decriminalized-drugs-2020-hows-83846382">“mixed results.”</a> U.S.-style decriminalization there has been adopted as a social justice remedy to mitigate the impact of policing on marginalized communities.</p>
<p>In 2020, Oregon voters approved a <a href="https://www.oregonlegislature.gov/lpro/Publications/Background-Brief-Measure-110-(2020).pdf">ballot measure to decriminalize hard drugs</a> as a way to keep addicts out of prison and get them into treatment. Possession of controlled substances is now a “violation” carrying a maximum US$100 fine. The fine is waived if the offender calls a hotline for assessment, which may lead to them receiving treatment. </p>
<p>However, after the first year, just one per cent had used the hotline, and nearly half did not show up to court, prompting criticism that the system is too lenient.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/469563/original/file-20220617-19-1btqrg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A black wall with colourful handprints and names on it" src="https://images.theconversation.com/files/469563/original/file-20220617-19-1btqrg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/469563/original/file-20220617-19-1btqrg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/469563/original/file-20220617-19-1btqrg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/469563/original/file-20220617-19-1btqrg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/469563/original/file-20220617-19-1btqrg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/469563/original/file-20220617-19-1btqrg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/469563/original/file-20220617-19-1btqrg.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 of the handprints of people recovering from drug addiction are seen on a wall in the parking lot of an addiction recovery centre in McMinnville, Ore., on Dec. 9, 2021.</span>
<span class="attribution"><span class="source">(AP Photo/Andrew Selsky)</span></span>
</figcaption>
</figure>
<p>Portugal’s adoption of decriminalization measures has been <a href="https://transformdrugs.org/blog/drug-decriminalisation-in-portugal-setting-the-record-straight">implemented more successfully</a>, in part because its social safety net is far more comprehensive and better integrated with the criminal justice system. </p>
<p>Portugal’s approach is both more vigorous and nuanced, recognizing that most drug use is “low risk” and requires no intervention. The vast majority of cases referred by the police are deemed non-problematic and the charges are suspended. Those who have a pattern of repeated violations may be issued fines or offered counselling appointments. Substance use dependence and abuse in high-risk cases more often triggers a referral for non-mandatory treatment. </p>
<p>Portugal’s adoption of a graduated system of intervention demonstrates a view that is consistent with coherent harm reduction policy development. Drug use is treated as a health issue. And the proof is in the pudding. Since these measures were enacted in 2001, drug-related deaths and rates of drug use have remained below the European Union average. The rates of HIV infection from injection drug use, and incarceration for committing drug offences, have also been dramatically reduced. </p>
<p>Canada’s adoption of a public health perspective on substance use is hampered by its failure to address the inconsistencies inherent in its hybridized approach. Enacting harm reduction within a prohibition framework perversely criminalizes people recognized as needing help.</p>
<p>B.C.’s bold experiment provides an opportunity to implement more balance in Canadian drug policy, and a more principled withdrawal from the war on drugs. Much can be learned from other places in deciding the path forward, and the world is waiting for new lessons to be learned.</p><img src="https://counter.theconversation.com/content/184926/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Hathaway 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>British Columbia’s bold experiment provides an opportunity to implement more balance in Canadian drug policy, and a more principled withdrawal from the war on drugs.Andrew Hathaway, Professor, Department of Sociology and Anthropology, University of GuelphLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1818202022-06-10T15:10:50Z2022-06-10T15:10:50ZWhy opting out of opioids can be dangerous in the operating room<figure><img src="https://images.theconversation.com/files/467588/original/file-20220607-14-psmm5p.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C2119%2C1414&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Opioids can help reduce the amount of medication needed to achieve anesthesia.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/female-anesthesiologist-during-hard-operation-royalty-free-image/1139854034">gpointstudio/iStock via Getty Images Plus</a></span></figcaption></figure><p>Currently, patients in <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2793282">seven states</a> can tell their physicians they don’t want to be treated with opioids in any health care setting, even during surgery. While unnecessary opioid exposure is a big reason behind the opioid epidemic in the U.S., we believe that <a href="https://www.michigan.gov/mdhhs/inside-mdhhs/newsroom/2019/03/28/nonopioid-directive-form-helps-fight-opioid-epidemic-by-allowing-patients-to-notify-health-professi">non-opioid directives</a> that allow patients to opt out of opioids in the operating room may lead to unexpected harms.</p>
<p>Non-opioid directives share some common features with <a href="https://medlineplus.gov/advancedirectives.html">advance directives</a>, legally recognized documents that allow patients to list their preferences for what happens at the end of life. Both documents guide care based on the desires of the patient. Non-opioid directives are mandates that a patient must not receive opioids under any circumstances. Exceptions are rare.</p>
<p>Congress is currently considering legislation allowing access to these directives across the nation. While only one of the seven states with non-opioid directives excludes <a href="http://legislature.mi.gov/doc.aspx?2021-HB-5261">care during surgical procedures</a>, both proposed bills in the <a href="https://www.congress.gov/bill/117th-congress/house-bill/4098">House</a> and <a href="https://www.congress.gov/bill/117th-congress/senate-bill/1292/">Senate</a> contain an exclusion specific to care in the operating room.</p>
<p>We are a <a href="https://scholar.google.com/citations?user=mQswfH4AAAAJ&hl=en">team</a> <a href="https://www.uofmhealth.org/profile/1322/paul-edward-hilliard-md">of</a> <a href="https://scholar.google.com/citations?user=FyPUG8cAAAAJ&hl=en">physicians</a> who work with and study the use of opioids in surgical settings. Two of us co-direct the <a href="https://michigan-open.org">Opioid Prescribing Engagement Network</a>, which develops best practices for opioid prescriptions after surgery. We have seen medical practice shift from embracing opioids to eliminating them altogether. We believe that opioids serve an essential tool in the operating room for many patients, and avoiding them for certain cases can make it <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2793282">difficult if not impossible</a> to avoid harming patients.</p>
<h2>The role of opioids in anesthesia</h2>
<p>Anesthesia is tailored for each patient depending on the surgical procedure, with the appropriate <a href="https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia">degree of sedation</a> varying for each case. At one end of the scale is minimal sedation, which usually allows patients to respond to verbal commands. At the other end is general anesthesia, which keeps patients unconscious even during pain. Different medications make this range of sedation possible. </p>
<p>A concept called <a href="https://doi.org/10.1016/j.jclinane.2003.07.005">balanced anesthesia</a> has guided clinicians in how they care for patients in the operating room for more than a century. The goal is to give a patient different types of medications to obtain loss of pain, memory, movement and consciousness while preserving other essential functions of the body.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/ZSsYjQeK0qg?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Scientists are still learning about the biomechanisms behind how anesthesia works.</span></figcaption>
</figure>
<p>Relying on only one or two types of medication usually requires higher doses to achieve anesthesia, which can result in bothersome or concerning side effects. Using a <a href="https://doi.org/10.1213%2FANE.0000000000003668">combination of drugs</a>, on the other hand, lowers the amount of drug needed to achieve sedation. Because each drug works on a different set of receptors in the body, the desired effects can be attained with smaller doses of each drug than with one drug given alone. This reduces the risk of side effects and leads to more stable vital signs during surgery.</p>
<p>Opioids stand out among the typical sedatives and anesthetics used in the operating room by <a href="https://doi.org/10.1016/s0952-8180(97)00122-0">significantly reducing</a> the amount of other drugs needed to achieve pain relief, sedation and loss of consciousness. Even small doses of opioids are sufficient to <a href="https://doi.org/10.1097/ALN.0b013e318238bba6">activate areas</a> in the brain that decrease the input of pain signals from other areas of the body.</p>
<h2>Why the operating room is different</h2>
<p>As broader calls to reduce unnecessary opioid use rise, anesthesiology and surgery researchers have asked whether avoiding all opioids in the operating room would lead to better patient outcomes. The first set of published studies on this question suggests that completely eliminating opioids from the operating room may do more harm than good.</p>
<p>In <a href="https://doi.org/10.1097/aln.0000000000003725">one study</a>, researchers randomly assigned patients who needed general anesthesia for surgery to either a group that received an ultrafast-acting opioid or a non-opioid sedative commonly used in intensive care units. After a surprising number of patients in the non-opioid group experienced serious adverse events during surgery, such as dangerously reduced heart rates and low oxygen blood concentration, the researchers stopped the study early because of safety concerns.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Close-up of IV drip in operating room." src="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467594/original/file-20220607-15494-i4e91v.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">Eliminating opioids in the OR may not have many benefits over reducing dosages.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/close-up-of-iv-drip-bag-royalty-free-image/1347166189">Porta/E+ via Getty Images</a></span>
</figcaption>
</figure>
<p>Similarly, a <a href="https://doi.org/10.1097/ALN.0000000000003572">review of studies</a> found that eliminating opioids during surgery did not decrease either patient use of prescription opioids after discharge or provider overprescription of opioids beyond just reducing opioid dosage during the procedure.</p>
<h2>Non-opioid directives and the OR</h2>
<p>Drug overdoses in the United States continue to reach record numbers, with estimates of more than <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">107,000 deaths</a> in 2021. How best to use pharmaceutical company lawsuit settlement payouts given to <a href="https://www.wsj.com/articles/j-j-settles-with-west-virginia-in-opioid-suit-for-99-million-11650302927">West Virginia</a> and <a href="https://apnews.com/article/health-business-washington-lawsuits-opioids-9de7c4bdf0f3c4360d355bb8da8c740f">other states</a> has been hotly <a href="http://doi.org/10.1001/jamahealthforum.2021.1765">debated</a>. But we believe that approaches that allow patient to opt out of opioids in the operating room may lead to unsafe care. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="White pills spilling out of orange bottle" src="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/467600/original/file-20220607-24-lxap8v.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">Non-opioid directives can help reduce unintended opioid exposure but may not be safe when applied to the OR.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pills-pour-out-of-prescription-medication-bottle-royalty-free-image/828608164">DNY59/iStock via Getty Images Plus</a></span>
</figcaption>
</figure>
<p>Opioids are useful beyond pain reduction and play a role in helping patients safely emerge from general anesthesia. Avoiding opioids may be a safe option when general anesthesia is not needed, such as procedures on the hand, leg or feet that use only <a href="http://doi.org/10.1097/EJA.0b013e3283349d68">nerve blocks</a> to reduce pain. Prescription opioids may also not be needed when patients recover at home <a href="https://michigan-open.org/prescribing-recommendations/">after many types of surgery</a>.</p>
<p>Opioids are a tool that can complement a thoughtful anesthetic and surgical plan. Whether or not patients receive opioids during surgery doesn’t affect how likely they are to continue using opioids or receive an opioid prescription afterward. We believe that wholesale elimination of opioids without considering the unique setting of the operating room may lead to unintended safety risks for patients. A more nuanced care plan that relies on reduced amounts of opioids could set patients up for a faster recovery with fewer side effects and better outcomes after surgery.</p><img src="https://counter.theconversation.com/content/181820/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark C. Bicket receives funding from the National Institutes of Health, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the US Centers for Disease Control and Prevention, and the Patient-Centered Outcomes Research Institute. He received past funding from the Arnold Foundation. He served as a consultant in the past for Axial Healthcare and Alosa Health.</span></em></p><p class="fine-print"><em><span>Jennifer Waljee receives funding from the National Institutes of Health, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, the US Centers for Disease Control and Prevention, and the Patient-Centered Outcomes Research Institute. </span></em></p><p class="fine-print"><em><span>Paul Edward Hilliard 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>Non-opioid directives allow patients to refuse opioids in all health care settings. For surgical procedures that require anesthesia, however, this may do more harm than good.Mark C. Bicket, Co-Director, Opioid Prescribing Engagement Network and Assistant Professor, University of MichiganJennifer Waljee, Associate Professor of Plastic and Reconstructive Surgery, University of MichiganPaul Edward Hilliard, Clinical Associate Professor of Anesthesiology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1826422022-06-07T14:01:43Z2022-06-07T14:01:43ZMaking video games can help support addiction recovery<figure><img src="https://images.theconversation.com/files/465156/original/file-20220524-24-dgq66e.jpg?ixlib=rb-1.1.0&rect=0%2C418%2C3880%2C2786&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Game jams are powerful spaces for galvanizing creativity in disenfranchised communities.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>The opioid epidemic is driven by more than the sale of <a href="https://www.cbc.ca/news/canada/canada-illicit-drug-supply-explainer-1.6361623">illicit drugs</a>, <a href="https://www.hqontario.ca/System-Performance/Specialized-Reports/Opioid-Prescribing">increased opioid prescribing</a> and the <a href="https://www.canada.ca/en/services/health/campaigns/drug-prevention.html">pandemic</a>. </p>
<p>Stigma fills the lives of many people living with opioid addiction, exacerbating hopelessness, <a href="https://newsinteractives.cbc.ca/longform/crystal-meth-addiction-canada">loss of dignity</a> and shame. There is a broad misconception that opioid dependence is a <a href="https://doi.org/10.1001/amajethics.2020.702">personal moral failing</a>, but many people misuse opioids to <a href="https://www.doi.org/10.25318/82-003-x202101200002-eng">manage pain</a>. </p>
<p>Individual failure is not the driver of opioid addiction. It is a complex and intertwined set of root causes <a href="https://doi.org/10.2105%2FAJPH.2017.304187">including poverty, social isolation, disability and physical and psychological trauma</a>.</p>
<p>I am the lead researcher of an <a href="https://www.canada.ca/en/health-canada/services/science-research/science-advice-decision-making/research-ethics-board.html">ethics-approved</a> study investigating the practice of making video games to support addiction recovery. We hope that our work will help fight the stigma of opioid addiction and give support to those struggling.</p>
<h2>Aspects of the study</h2>
<p>The study will give adults living with, or who have a history of opioid addiction, the tools and resources to tell their story, learn about themselves, build community and raise awareness about addiction-related stigma, while also acquiring valuable computer skills. </p>
<p>We will do this by bringing people together to connect in a physical space and make video games informed <a href="https://www.jstor.org/stable/540572">by their stories</a>. We will mentor and teach them about how to make their first game prototype. This includes learning how to tell their story through a video game, create the <a href="https://www.gamedeveloper.com/blogs/12-principles-for-game-animation">art and animation</a>, programming the game and <a href="https://www.techopedia.com/definition/27197/playtesting">playtesting</a> it. </p>
<p>Telling a life story is a profound self-learning exercise because it requires the storyteller to explain and clarify their decision-making processes in life. Rendering a life story through a digital game requires the game maker to tell it computationally, through digital code, which also compels them to think creatively and logically.</p>
<figure class="align-center ">
<img alt="Children play video games at Romics fair in Rome, an international festival of comics, animation, cinema and games." src="https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/465157/original/file-20220524-26-ez17zm.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The practice of making video games could support addiction recovery.</span>
<span class="attribution"><span class="source">(AP Photo/Alessandra Tarantino)</span></span>
</figcaption>
</figure>
<p>We plan on conducting a series of <a href="https://www.gamedeveloper.com/design/a-brief-history-of-game-jams">game jams</a> in Ontario cities affected by the opioid crisis including Brantford, Hamilton and Toronto. </p>
<p>A game jam is a game making workshop where a group of people come together to make games over a short time period, usually between 24 and 72 hours. Game jams are like musical jamming sessions, inviting a kind of furious improvisation that most creators love. But they are also community-building events energized by the spirit of collaboration, which often outweighs the act of making games. </p>
<h2>Autobiographical digital games</h2>
<p>It might seem counter-intuitive to use video games for storytelling, given that many assume gamers are all <a href="https://doi.org/10.1016/j.entcom.2021.100439">violent and antisocial</a> — a <a href="https://www.wired.com/2020/06/geeks-guide-videogame-researchers/">moral panic not supported by evidence</a>. </p>
<p>In the past 10 years, video games have come a long way. The emergence of autobiographical digital games about illness and health, such as Zoe Quinn’s interactive narrative, <a href="http://www.depressionquest.com/#info-section"><em>Depression Quest</em></a>; Green, Green and Larson’s <a href="http://www.thatdragoncancer.com/"><em>That Dragon, Cancer</em></a> and Anna Anthropy’s <a href="https://freegames.org/ca/dys4ia/"><em>Dys4ia</em></a> have shaken up games culture. </p>
<p>Non-traditional game makers — like women and LGBTQ+ designers that don’t fit the typical profile of a developer — have <a href="https://www.nytimes.com/2014/11/23/magazine/twine-the-video-game-technology-for-all.html">reimagined video games as a powerful art for exploring personal trauma</a>. </p>
<p>Free and easy to use software like <a href="http://twinery.org/"><em>Twine</em> </a> have accelerated a cultural awakening of computer games as <a href="https://daily.jstor.org/venn-diagram-of-lgbtq-and-gaming-communities-goes-here/">an expressive vehicle for marginalized creators</a>. Collectives have also sprung up to organize game jams and throw support behind marginalized creators with no design or programming experience — like <a href="https://dmg.to/">DMG</a> in Toronto and <a href="https://pixelles.ca/">Pixelles</a> in Montréal. </p>
<p>Game jams have become powerful spaces for galvanizing creativity in disenfranchised communities and giving them creative agency and voice.</p>
<figure class="align-center ">
<img alt="A girl sits behind a computer screen playing a video game" src="https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/465158/original/file-20220524-24-mlyts5.jpg?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">
<figcaption>
<span class="caption">A game jam is a game making workshop where people come together to make games over a short period of time.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<h2>Rebuilding identity and healing wounds</h2>
<p>I have been researching the topic of making games for mental health for eight years. In 2014, I organized my first game jam study for game designers living with depression, anxiety, bipolar disorder, post-traumatic stress disorder and other mental health conditions. The outcome of that study was my <a href="https://hdl.handle.net/1807/89836">doctoral dissertation</a>, which looked at making games about illness and disability as a rich healing and communal practice. </p>
<p>My research showed that digital game design enables new forms of self-awareness for young people struggling with their mental health. For example, <a href="https://ised-isde.canada.ca/site/choose-science/en/government-canada-and-stem">STEM-rich</a> practices, such as coding, engage a mode of thought called computational thinking. <a href="https://cacm.acm.org/magazines/2017/6/217742-remaining-trouble-spots-with-computational-thinking/fulltext">Although controversial in the computer science community</a>, computational thinking allows game makers to cultivate mindfulness, especially when telling a story about themselves. </p>
<p>When game makers model their characters after themselves and fashion a new self, they have to <a href="https://dulwichcentre.com.au/articles-about-narrative-therapy/illness-narratives/">find coherence</a> in their life story, which can help them rebuild their identity and <a href="https://press.uchicago.edu/ucp/books/book/chicago/W/bo14674212.html">heal wounds</a>. When creators render a story as a playable game, it also compels them to act out their characters and embody their newly fashioned self. </p>
<p>Game making is an art form that many aren’t intimately familiar with. Unlike other creative practices, game makers must create the rules and laws that govern and shape player behaviours. This is a powerful practice that has the potential to contribute to recovery for opioid addiction. </p>
<p>I hope that this approach encourages policymakers to take up creative methods to empower hard-to-reach communities and uproot the stigma that is a significant barrier to solving the opioid crisis.</p><img src="https://counter.theconversation.com/content/182642/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Sandra Danilovic receives research funding from the Social Sciences and Humanities Research Council (SSHRC) and Wilfrid Laurier University. She is also a member of the not-for-profit videogame arts association DMG.to. </span></em></p>Game making is an art form that many aren’t intimately familiar with. Unlike other creative practices, game makers must create the rules and laws that govern and shape player behaviours.Sandra Danilovic, Assistant Professor of Game Design and Development in the Faculty of Human and Social Sciences, Wilfrid Laurier UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1826782022-05-12T04:22:01Z2022-05-12T04:22:01ZOne in three people with chronic pain have difficulty accessing ongoing prescriptions for opioids<figure><img src="https://images.theconversation.com/files/462365/original/file-20220511-17639-wu5i5a.jpg?ixlib=rb-1.1.0&rect=50%2C40%2C6659%2C4426&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/upset-mature-woman-suffering-backache-after-1504807832">Shutterstock</a></span></figcaption></figure><p><a href="https://pubmed.ncbi.nlm.nih.gov/11166468/">One in five</a> Australians live with chronic pain lasting three months or more. <a href="https://www.painaustralia.org.au/static/uploads/files/the-cost-of-pain-in-australia-final-report-12mar-wfxbrfyboams.pdf">Common causes include</a> back and neck pain, headache, and joint pain. </p>
<p>Opioid medicines – such as oxycodone, morphine, fentanyl and codeine – are essential medicines and <a href="https://pubmed.ncbi.nlm.nih.gov/32100394/">provide relief</a> to many people with this type of pain. </p>
<p>However, opioids can also cause <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012509.pub2/full">side effects</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/25581257/">harms</a> including dependence and <a href="https://pubmed.ncbi.nlm.nih.gov/29498021/">overdose</a>, which <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6324425/">may be</a> <a href="https://pubmed.ncbi.nlm.nih.gov/28826104/">fatal</a>.</p>
<p>Over the past decade, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6698322/">measures have been introduced in Australia</a> to curb growing rates of opioid use and harms. But this has come at the expense of access for some people who genuinely need them. </p>
<p>In our <a href="https://www.sciencedirect.com/science/article/abs/pii/S095539592200127X">new study</a>, one-third of participants prescribed opioids long-term for chronic, non-cancer pain had difficulties getting ongoing prescriptions. </p>
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Read more:
<a href="https://theconversation.com/1-in-5-aussies-over-45-live-with-chronic-pain-but-there-are-ways-to-ease-the-suffering-137891">1 in 5 Aussies over 45 live with chronic pain, but there are ways to ease the suffering</a>
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<h2>Tightening access</h2>
<p>In 2018, <a href="https://www.nps.org.au/australian-prescriber/articles/changes-for-codeine">codeine</a> was made a “<a href="https://www.tga.gov.au/codeine-info-hub">prescription-only</a>” medicine. In the same year, Australia’s Chief Medical Officer <a href="https://www1.racgp.org.au/newsgp/professional/government-to-warn-almost-5000-gps-over-high-rates">wrote to doctors</a> prescribing a lot of opioids to encourage them to consider reducing their prescribing. </p>
<p>States have also <a href="https://pubmed.ncbi.nlm.nih.gov/26937665/">introduced</a> <a href="https://www.nps.org.au/assets/p164-Dobbin-Liew-v2.pdf">prescription monitoring programs</a>, allowing providers to see whether their patients are getting opioids from other doctors or pharmacies.</p>
<figure class="align-center ">
<img alt="Patient talks to a pharmacist at the counter." src="https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462367/original/file-20220511-26-sf16el.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">In some states, doctors and pharmacists can check if patients are getting scripts elsewhere.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/pharmacist-medical-face-mask-talking-customer-1696625050">Shutterstock</a></span>
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</figure>
<p>We’re underaking a <a href="https://ndarc.med.unsw.edu.au/project/point-study-pain-and-opioids-treatment">long-term study</a> of just over 1,500 Australians prescribed opioids for chronic non-cancer pain. We started asking questions about accessing opioid prescriptions in our 2018 interviews with participants. </p>
<p>These weren’t prescriptions for new pain conditions, but ongoing prescriptions for people who had been <a href="https://pubmed.ncbi.nlm.nih.gov/25599444/">using these medicines for four years</a>, on average, and living with pain for ten years, before the study.</p>
<h2>Opioids can cause significant harm</h2>
<p>Over the past 30 years, the amount of opioids (doses per Australian per day) dispensed on the Pharmaceutical Benefits Scheme (PBS) <a href="https://pubmed.ncbi.nlm.nih.gov/26991673/">has increased four-fold</a>. </p>
<p>There has also been a <a href="https://www.publish.csiro.au/ah/AH18245">15-fold increase</a> in opioid prescriptions dispensed on the PBS between 1995 and 2015. Australia <a href="https://link.springer.com/article/10.1007/s40429-018-0227-6">currently ranks eighth</a> among <a href="https://www.incb.org/documents/Narcotic-Drugs/Technical-Publications/2015/NAR-tech_pub_2015.pdf">countries using the most opioids</a>. </p>
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<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>As opioid use has risen, <a href="https://www.mja.com.au/journal/2011/195/5/prescription-opioid-analgesics-and-related-harms-australia">so have harms</a>. Opioids are the <a href="https://ndarc.med.unsw.edu.au/resource-analytics/trends-drug-induced-deaths-australia-1997-2019">main drug involved</a> in drug-induced deaths.</p>
<p>Pharmaceutical opioids are now involved in <a href="https://www.aihw.gov.au/reports/illicit-use-of-drugs/opioid-harm-in-australia/summary">more deaths than heroin</a>. Pharmaceutical opioids also contribute more to <a href="https://ndarc.med.unsw.edu.au/resource-analytics/trends-drug-related-hospitalisations-australia-1999-2019">poisoning-related hospital visits</a> than heroin, with hospitalisations doubling since 1999. </p>
<h2>So what did our research find?</h2>
<p>In <a href="https://www.sciencedirect.com/science/article/abs/pii/S095539592200127X">our study</a>, one in five people reported problems relating to accessing doctors. </p>
<p>As opioids become more restricted, people may need to visit their doctor more frequently because they’re given smaller pack sizes and fewer repeats. They may be put in a position where they’re unable to get prescriptions if doctors aren’t available. </p>
<p>Opioids can cause <a href="https://pubmed.ncbi.nlm.nih.gov/14640337/">dependence</a> and <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2628209/">tolerance</a> with continuous and long-term use. However, sudden interruptions to opioid medicine supply may place people at risk of experiencing <a href="https://pubmed.ncbi.nlm.nih.gov/31986228/">unpleasant withdrawal symptoms</a> such as nausea and vomiting, flu symptoms, and muscle cramping.</p>
<p>One in ten people in our study reported their doctor wanted to reduce or stop opioid medicines against their wishes. </p>
<figure class="align-center ">
<img alt="Older man holding a glass of water takes tablets in his hands." src="https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462370/original/file-20220511-20-psgfpj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Ceasing opioids needs to be undertaken carefully.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/older-man-young-girl-home-granddaughter-2128075508">Shutterstock</a></span>
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</figure>
<h2>Patients and doctors need to work together</h2>
<p>More doctors are <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6902834/">practising</a> “opioid tapering” (reducing opioid doses over time), especially in the United States, <a href="https://pubmed.ncbi.nlm.nih.gov/33515197/">following</a> the release in 2016 of Centers for Disease Control and Prevention (CDC) <a href="https://jamanetwork.com/journals/jama/fullarticle/2503508">guidelines</a> for chronic pain. </p>
<p>However, there were soon reports of opioids being ceased <a href="https://pubmed.ncbi.nlm.nih.gov/32844498/">without</a> <a href="https://pubmed.ncbi.nlm.nih.gov/31079950/">reducing the dose first</a>, which risks withdrawal. This <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1904190">prompted the CDC to warn</a> that applying guidelines without adequate care could harm patients.</p>
<p>Worryingly, studies have linked stopping or reducing opioids with death by <a href="https://pubmed.ncbi.nlm.nih.gov/33863865/">suicide</a> <a href="https://pubmed.ncbi.nlm.nih.gov/31468341/">and</a> <a href="https://pubmed.ncbi.nlm.nih.gov/34342618/">overdose</a>, even for <a href="https://www.annfammed.org/content/20/Supplement_1/2871.abstract">people prescribed opioids at low doses</a> to begin with. </p>
<p>These studies also found people who stopped opioids were more likely to visit the emergency department or be admitted to hospital for <a href="https://pubmed.ncbi.nlm.nih.gov/34342618/">mental health crises</a>, <a href="https://pubmed.ncbi.nlm.nih.gov/33863865">illicit drug use</a> and <a href="https://pubmed.ncbi.nlm.nih.gov/31079950/">overdoses</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/opioid-script-changes-mean-well-but-have-left-some-people-in-chronic-pain-156753">Opioid script changes mean well, but have left some people in chronic pain</a>
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<p>For some people, reducing or stopping opioids will be the right thing for them, clinically. Some studies suggest <a href="https://link.springer.com/article/10.1007/s11606-020-06253-8">stopping opioids can be done</a> without <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6993952/">increasing pain</a>. </p>
<p>Some studies suggest <a href="https://www.mja.com.au/journal/2021/214/9/opioid-cessation-associated-reduced-pain-and-improved-function-people-attending">pain may even improve</a> when <a href="https://pubmed.ncbi.nlm.nih.gov/31764391/">opioids are stopped</a>. However, participants in these studies are usually enrolled in special pain programs. These programs are notoriously difficult to access in Australia and it is <a href="https://pubmed.ncbi.nlm.nih.gov/33106875/">common to wait months to years</a> for services.
<a href="https://www.painaustralia.org.au/federal-budget-more-mbs-items-needed-for-people-with-chronic-pain">Increased investment</a> in pain services and programs is needed. </p>
<p>There is also a need for opioid tapering to be undertaken in a <a href="https://pubmed.ncbi.nlm.nih.gov/33012347/">collaborative way</a>, with patients and doctors working as a team to achieve <a href="https://pubmed.ncbi.nlm.nih.gov/34382602/">agreed upon goals</a>. </p>
<h2>Balancing benefits and harms</h2>
<p>Since we conducted our study, new <a href="https://www.nps.org.au/radar/articles/opioids-new-and-amended-pbs-listings">restrictions introduced</a> in 2020 reduced the quantities of opioids that can be prescribed on the PBS. For most opioids, doctors can only supply quantities and repeats for up to three months at a time. </p>
<p>So it’s likely to have become harder for people with pain to access pain medicines. In a survey released last month by Painaustralia, half of the respondents said <a href="https://www.painaustralia.org.au/static/uploads/files/painaustralia-impact-of-opioid-regulatory-reforms-on-people-living-with-chronic-pai-wfopkycfkmnq.pdf">their pain management was worse</a>, and their pain was more severe, because of the changes. </p>
<figure class="align-center ">
<img alt="Woman talks to doctor via a smartphone" src="https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/462371/original/file-20220511-22-bm3npg.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Opioid harms need to be recognised and addressed, as does pain.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/young-woman-patient-conversation-specialist-over-1943749642">Shutterstock</a></span>
</figcaption>
</figure>
<p>When it comes to using opioids for chronic non-cancer pain, it’s important to balance both benefits and harms. Potential opioid-related harms need to be recognised and addressed. At the same time, adequate treatment of pain is essential, and we need to make sure people don’t suffer harms due to changes to opioid access. </p>
<p>The needs of people who live with pain and the impact of restrictions on them need to remain at the centre of all decisions and discussions about opioids.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/patients-leaving-hospital-sometimes-need-opioids-doctors-can-reduce-risks-of-long-term-use-and-dependence-181941">Patients leaving hospital sometimes need opioids. Doctors can reduce risks of long-term use and dependence</a>
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</p>
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<img src="https://counter.theconversation.com/content/182678/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Ria Hopkins receives funding from the Australian National Health and Medical Research Council (NHMRC).
</span></em></p><p class="fine-print"><em><span>Natasa Gisev 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>Measures to curb growing rates of opioid use are also making it difficult for people with long-term, chronic pain to get ongoing prescriptions.Ria Hopkins, PhD Candidate, National Drug and Alcohol Research Centre, UNSW SydneyNatasa Gisev, Clinical pharmacist and Scientia Senior Lecturer at the National Drug and Alcohol Research Centre, UNSW SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1779252022-03-11T16:31:22Z2022-03-11T16:31:22ZSafer supply of opioids saves lives: Providing alternatives to toxic street drugs<figure><img src="https://images.theconversation.com/files/450317/original/file-20220307-109224-rux7pe.jpg?ixlib=rb-1.1.0&rect=710%2C486%2C5059%2C3288&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Methamphetamine, heroin and cocaine distributed by the Drug User Liberation Front, a grassroots organization proving a safe supply of illicit drugs, in Vancouver, in April 2021.
</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><p>Over 25,000 Canadians have died from opioid overdose since 2016 — with <a href="https://health-infobase.canada.ca/substance-related-harms/opioids-stimulants/">6,306 people dying in 2020</a> alone. </p>
<p>The overdose crisis is driven by an unregulated drug supply made up mostly of fentanyl, increasingly potent fentanyl analogues such as carfentanil, and more recently, <a href="https://theconversation.com/benzo-dope-may-be-replacing-fentanyl-dangerous-substance-turning-up-in-unregulated-opioids-164286">unregulated benzodiazepines</a>. Early in the COVID-19 pandemic, fentanyl directly contributed to <a href="https://odprn.ca/research/publications/opioid-related-deaths-and-healthcare-use/">89 per cent of all overdose deaths</a> in Ontario. </p>
<p>The volatility and toxicity in the unregulated drug supply continues to lead to more deaths. The British Columbia coroner’s report shows that <a href="https://news.gov.bc.ca/releases/2022PSSG0010-000188">more people died in 2021</a> from suspected illicit toxic drugs than ever before. In 2021, there was a 26 per cent increase in overdose deaths compared to 2020. </p>
<p>The Public Health Agency of Canada recently estimated that without new interventions, <a href="https://www.canada.ca/en/health-canada/services/opioids/data-surveillance-research/modelling-opioid-overdose-deaths-covid-19.html">another 8,000 overdose deaths will occur in 2022</a>. Addressing this devastating crisis requires bold action that includes expanding current evidence-based harm reduction and treatment services, alongside new interventions to prevent overdose deaths.</p>
<h2>Safer supply</h2>
<p><a href="https://www.canada.ca/en/health-canada/services/opioids/responding-canada-opioid-crisis/safer-supply.html">Safer supply</a>, the practice of providing a medical prescription for pharmaceutical drugs of known quality, is one of those new interventions. In Ontario, safer supply programs are run mostly by community health centres that specialize in providing care to our most marginalized community members. These small pilot programs are a low-barrier first step alternative to the toxic drug supply.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Orange signs with black block lettering instructions on how to pick up safe supply of illicit drugs." src="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451089/original/file-20220309-13-14opv3.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Safe supply programs are run mostly by community health centres.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>There are several <a href="https://www.canada.ca/en/health-canada/services/substance-use/canadian-drugs-substances-strategy/funding/substance-use-addictions-program.html">research studies funded across Canada</a> to evaluate different parts of these pilot safer supply programs. We are public health researchers involved in some of these studies, and initial results are promising.</p>
<p>At London’s Intercommunity Health Centre, close to 250 clients are prescribed pharmaceutical opioids as a daily-dispensed prescription that they take home and use at their discretion. <a href="https://lihc.on.ca/wp-content/uploads/2022/01/2021-SOS-Evaluation-Full.pdf">A recent evaluation of this program</a> reported decreased use of fentanyl and other street-acquired drugs, reduced hospitalizations and a dramatic decrease in overdoses among clients.</p>
<p>Importantly, clients reported that the program was saving their life and helped them to take steps to improve their health. </p>
<h2>Addiction treatment models</h2>
<p>Unfortunately, there has been <a href="https://www.theglobeandmail.com/opinion/article-as-a-doctor-i-was-taught-first-do-no-harm-thats-why-i-have-a-problem/">opposition to safer supply programs</a> from some in the addiction treatment community. Such opposition has the potential to undermine public support for people who use drugs and the expansion of lifesaving interventions that are urgently needed. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A hand holding a small box labelled 'Ingredients: Cocaine. Please see insert. NOT FOR SALE. Keep away from children and pets.'" src="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451093/original/file-20220309-4153-5ecz10.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A client of the Drug User Liberation Front in Vancouver holds safe supply cocaine.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
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</figure>
<p>Current interventions to respond to opioid use don’t work for everyone. Opioid agonist treatments (OAT) like methadone and buprenorphine, are intended to reduce cravings for opioids and manage withdrawal symptoms, but they do not produce euphoria or the high associated with other opioids. </p>
<p>There are issues with both access and retention in OAT. Fewer than <a href="https://doi.org/10.1111/add.14947">70 per cent</a> of people who are diagnosed with an opioid use disorder ever start OAT. And although retention rates vary, an Ontario study found that after one year, <a href="https://doi.org/10.1097/adm.0000000000000156">less than half</a> of people who do start are still using OAT. Although there isn’t a set rule for how long someone should stay on OAT, generally <a href="https://www.camh.ca/-/media/files/professionals/canadian-opioid-use-disorder-guideline2021-pdf.pdf">longer treatment is associated with better outcomes</a>.</p>
<p>Despite low retention rates, addiction medicine has been reluctant to address the barriers to care that people who use drugs have been <a href="https://doi.org/10.1016/j.drugpo.2021.103364">attempting to call attention to for years</a>. </p>
<p>People who use drugs have highlighted for a long time how restrictions around take-home doses reduce people’s ability to stay in methadone programs. And they are right — when restrictions on taking home doses of methadone were loosened during the COVID-19 pandemic to facilitate physical distancing, <a href="https://doi.org/10.1001/jama.2022.1271">retention to methadone improved</a> without increased negative outcomes like overdose. </p>
<h2>Listening to drug users</h2>
<p>To address the toxic drug poisonings that are killing Canadians at such an alarming rate, we need to start listening to people who use drugs when they tell us what’s not working with the current system. </p>
<p>The war on drugs has so demonized people who use drugs that they are mostly dismissed by addiction medicine experts when they have tried to say <a href="https://sway.office.com/UjvQx4ZNnXAYxhe7?ref=Link&loc=play">what will help their communities</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="People holding signs in support of safer drug supply marching in a street" src="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/451091/original/file-20220309-25-mrb6e2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">People march in the Downtown Eastside to call on the government to provide a safe supply of illicit drugs in April 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<p>Groundbreaking grassroots work being done by organizations such as the <a href="https://www.dulf.ca/">Drug User Liberation Front</a> (DULF) in Vancouver has highlighted the demand for <a href="https://filtermag.org/compassion-clubs-vancouver/">a non-medicalized model for a safer supply</a> of drugs. </p>
<p>DULF has organized in its community to distribute tested drugs to keep people alive during a crisis; contrast this to prominent members of the addiction medicine community attempting to use their social power to <a href="https://filtermag.org/people-who-use-drugs-safer-supply/">deliberately undermine</a> their efforts. </p>
<p>Opposition to safer supply often misrepresents both the aim and benefits of safer supply. Safer supply is intended to keep people alive — and it works. </p>
<h2>Building new models</h2>
<p>We need new options. Both for people for whom current addiction treatment models have not worked and for those who simply don’t need or want treatment. </p>
<p>People are dying from using a toxic drug supply. Building models of care that listen to the voices of people who use drugs and centre their needs is critical and should not be dismissed based on the fears of doctors who act as gatekeepers of the status quo. The status quo did not prevent, and it will not address, the overdose crisis. </p>
<p>Urgent actions — like decriminalization and access to a regulated drug supply — are part of the policy changes needed to address the toxic drug crisis in Canada. But for the people at risk of drug poisoning today, and for their friends, families and loved ones, safer supply represents a real chance at preventing more tragedy.</p><img src="https://counter.theconversation.com/content/177925/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Rose A Schmidt is employed as a research coordinator at the University of Toronto on a project that receives funding from The Ontario HIV Treatment Network about Safer Supply programs in Ontario.</span></em></p><p class="fine-print"><em><span>Gillian Kolla receives funding from a Canadian Institutes of Health Research Banting Postdoctoral Researcher Award and a Canadian Network on Hepatitis C (CanHepC) Postdoctoral Fellowship. She has consulted for Parkdale Queen West Community Health Centre, London Intercommunity Health Centre, The Neighbourhood Group, Street Health, and The Working Centre. </span></em></p><p class="fine-print"><em><span>Nat Kaminski is part of the University of Toronto research project on Safe Supply in Ontario, and is president of The Peel Drug Users Network & Ontario Network of People who use drugs and secretary of the Canadian Association of People who use drugs. They reviewed the guidelines for safe supply in Ontario and advocate for the expansion of services medically prescribed safe supply.</span></em></p>People are dying from using a toxic drug supply. Safer supply and other approaches that listen to the needs of people who use drugs are critical to saving lives and addressing the opioid crisis.Rose A Schmidt, PhD candidate, Dalla Lana School of Public Health, University of TorontoGillian Kolla, Postdoctoral research fellow, Canadian Institute for Substance Use Research, University of VictoriaNat Kaminski, Research assistant, School of Public Health, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1738452022-02-11T13:34:32Z2022-02-11T13:34:32ZIn research studies and in real life, placebos have a powerful healing effect on the body and mind<figure><img src="https://images.theconversation.com/files/445014/original/file-20220208-19-1dce055.jpg?ixlib=rb-1.1.0&rect=38%2C76%2C5078%2C3322&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The concept of placebos – which are sometimes called "sugar pills" – has been around since the 1800s.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/pharmaceutical-research-conceptual-image-royalty-free-image/185760489?adppopup=true">Wladimir Bulgar/Science Photo Library via Getty Images</a></span></figcaption></figure><p>Did you ever feel your own shoulders relax when you saw a friend receive a shoulder massage? For those of you who said “yes,” congratulations, your brain is using its power to create a “placebo effect.” For those who said “no,” you’re not alone, but thankfully, the brain is trainable. </p>
<p>Since the 1800s, <a href="https://doi.org/10.1001/jama.1955.02960340022006">the word placebo</a> has been used to refer to a fake treatment, meaning one that does not contain any active, physical substance. You may have heard of placebos referred to as “sugar pills.” </p>
<p>Today, placebos play a crucial role in medical studies in which some participants are given the treatment containing the active ingredients of the medicine, and others are given a placebo. These types of studies help tell researchers which medicines are effective, and how effective they are. Surprisingly, however, in some areas of medicine, placebos themselves provide patients with <a href="https://doi.org/10.1016/S0140-6736(09)61706-2">clinical improvement</a>. </p>
<p>As two psychologists interested in how <a href="https://scholar.google.com/citations?hl=en&user=LFOKsvwAAAAJ&view_op=list_works&gmla=AJsN-F7HTmfem-T2-tGORhXc3ZwClbf_3X8_ap-HWeyTOTMcJPTzWkutZ6ZL85CJwi2v87spWvAQmnmkjzKIh4ULAdFAV8KVFSBRBC6VQ8ky36RvnyreDoY">psychological factors affect physical conditions</a> and <a href="https://ihpi.umich.edu/our-experts/schrodeh">beliefs about mental health</a>, we help our patients heal from various <a href="https://ihpi.umich.edu/our-experts/ehpatter">threats to well-being</a>. Could the placebo effect tell us something new about the power of our minds and how our bodies heal?</p>
<h2>Real-life placebo effects</h2>
<p>Today, scientists define these <a href="http://programinplacebostudies.org/">so-called placebo effects</a> as the positive outcomes that cannot be scientifically explained by the physical effects of the treatment. Research suggests that the placebo effect is caused by <a href="https://doi.org/10.1038/nrn3976">positive expectations</a>, the provider-patient relationship and the <a href="https://doi.org/10.1016/S0140-6736(09)61706-2">rituals around receiving medical care</a>.</p>
<p>Depression, pain, fatigue, allergies, <a href="https://doi.org/10.1186/s13063-017-1964-x">irritable bowel syndrome</a>, Parkinson’s disease and even <a href="https://doi.org/10.1056/nejmoa013259">osteoarthritis of the knee</a> are just <a href="https://doi.org/10.1159/000490354">a few of the conditions</a> that <a href="https://www.npr.org/2020/05/11/853753307/all-the-worlds-a-stage-including-the-doctor-s-office">respond positively to placebos</a>. </p>
<p>Despite their effectiveness, there is stigma and debate about <a href="https://doi.org/10.1159/000514435">using placebos in U.S. medicine</a>. And in routine medical practice, they are rarely used on purpose. But based on new understanding of how non-pharmacological aspects of care work, safety and patient preferences, some experts have begun recommending <a href="https://doi.org/10.1159/000490354">increasing the use of placebos in medicine</a>.</p>
<p>The U.S. Food and Drug Administration, the organization that regulates which medicines are allowed to go to the consumer market, requires that all new medicines be tested in randomized controlled trials that show they are <a href="https://www.regdesk.co/fdas-guidance-on-placebos/#">better than placebo treatments</a>. This is an important part of ensuring the public has access to high-quality medications. </p>
<p>But studies have shown that the placebo effect is so strong that many drugs don’t provide more relief <a href="https://doi.org/10.1017/S2045796018000240">than placebo treatments</a>. In those instances, drug developers and researchers sometimes see placebo effects as a nuisance that masks the treatment benefits of the manufactured drug. That sets up an incentive for drug manufacturers to try to do away with placebos so that drugs pass the FDA tests.</p>
<p>Placebos are such a problem for the enterprise of drug development that a company has developed a <a href="https://verasci.com/the-placebo-control-reminder-script-now-available-on-pathway/">coaching script to discourage patients</a> who received placebos from <a href="https://doi.org/10.1038/s41386-020-00911-5">reporting benefits</a>.</p>
<h2>Treating depression</h2>
<p>Prior to the COVID-19 pandemic, about 1 in 12 U.S. adults had a <a href="https://www.cdc.gov/nchs/products/databriefs/db303.htm">diagnosis of depression</a>. During the pandemic, those numbers rose to <a href="https://www.bu.edu/articles/2021/depression-rates-tripled-when-pandemic-first-hit/">1 in 3 adults</a>. That sharp rise helps explain why <a href="https://www.businesswire.com/news/home/20210426005303/en/Global-Antidepressants-Market-Report-2021-COVID-19-Causes-a-Surge-in-Demand-for-Antidepressant-Drugs-as-Mental-Health-Problems-Rise---ResearchAndMarkets.com">US$26.25 billion worth of antidepressant medications</a> were used across the globe in 2020.</p>
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<figcaption><span class="caption">Brain-imaging studies show that the brain has an identifiable response to the expectations and context that come with placebos.</span></figcaption>
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<p>But according to psychologist and placebo expert Irving Kirsch, who has studied placebo effects for decades, a large part of <a href="https://doi.org/10.3389/fpsyt.2019.00407">what makes antidepressants helpful</a> in alleviating depression is the placebo effect – in other words, the belief that the medication will be beneficial. </p>
<p>Depression is not the only condition for which medical treatments are actually functioning at the level of placebo. Many well-meaning clinicians offer treatments that appear to work based on the fact that patients get better. But a recent study reported that <a href="https://www.sciencealert.com/around-90-percent-of-your-medical-treatments-isn-t-backed-by-high-quality-evidence">only 1 in 10</a> <a href="https://doi.org/10.1016/j.jclinepi.2020.08.005">medical treatments sampled</a> met the standards of what is considered by some to be the gold standard of high quality evidence, according to <a href="https://www.cochrane.org/evidence">a grading system</a> by an international nonprofit organization. This means that many patients improve even though the treatments they receive have not actually been proved to be better than the placebo. </p>
<h2>How does a placebo work?</h2>
<p>The power of the placebo comes down to the power of the mind and a person’s skill at harnessing it. If a patient gets a <a href="https://www.hopkinsmedicine.org/health/conditions-and-diseases/headache/tension-headaches">tension headache</a> and their trusted doctor gives them a medicine that they feel confident will treat it, the relief they expect is likely to decrease their stress. And since <a href="https://www.mayoclinic.org/diseases-conditions/tension-headache/in-depth/headaches/art-20046707">stress is a trigger for tension headaches</a>, the magic of the placebo response is not so mysterious anymore.</p>
<p>Now let’s say that the doctor gives the patient an expensive brand-name pill to take multiple times per day. Studies have shown that it is even more likely to make them feel better because all of those elements subtly convey the message that they <a href="https://doi.org/10.1016/bs.irn.2018.07.014">must be good treatments</a>.</p>
<p>Part of the beauty of placebos is that <a href="https://www.nytimes.com/2016/01/25/books/review-in-cure-accepting-the-minds-role-in-a-bodys-health.html">they activate existing systems</a> of <a href="https://www.aapb.org/i4a/pages/index.cfm?pageID=3386">healing within the mind and body</a>. Elements of the body once thought to be outside of an individual’s control are now known to be modifiable. A legendary example of this is Tibetan monks who <a href="https://doi.org/10.1371/journal.pone.0058244">meditate to generate enough body heat</a> to dry wet sheets in 40-degree Fahrenheit temperatures.</p>
<p>A field called <a href="https://bensonhenryinstitute.org/mission-history/">Mind Body Medicine</a> developed from the work of cardiologist Herbert Benson, who observed those monks and other experts mastering control over automatic processes of the body. It’s well understood in the medical field that <a href="https://us.macmillan.com/books/9780805073690#">many diseases are made worse</a> by the automatic changes that <a href="https://www.hsph.harvard.edu/nutritionsource/stress-and-health/">occur in the body under stress</a>. If a placebo interaction reduces stress, it can <a href="https://www.apa.org/topics/stress/body#">reduce certain symptoms</a> in a scientifically explainable way. </p>
<p>Placebos also work by creating expectations and conditioned responses. Most people are familiar with <a href="https://pubmed.ncbi.nlm.nih.gov/29262194/">Pavlovian conditioning</a>. A bell is rung before giving dogs meat that makes them salivate. Eventually, the sound of the bell causes them to salivate even when they do not receive any meat. A recent study from Harvard Medical School successfully used the same conditioning principle to help patients <a href="https://doi.org/10.1097/j.pain.0000000000002185">use less opioid medication for pain following spine surgery</a>. </p>
<p>Furthermore, multiple brain imaging studies demonstrate changes in the brain in response to successful placebo treatments for pain. This is excellent news, given the <a href="https://theconversation.com/oxycontin-created-the-opioid-crisis-but-stigma-and-prohibition-have-fueled-it-167100">ongoing opioid epidemic</a> and the need for effective pain management tools. There is even evidence that individuals who respond positively to placebos <a href="https://doi.org/10.1126/science.1093065">show increased activity in areas of the brain</a> that release naturally occurring opioids. </p>
<p>And emerging research suggests that even when people know they are receiving a placebo, the inactive treatment still has <a href="https://doi.org/10.1038/s41467-020-17654-y">effects on the brain and reported levels of improvement</a>. </p>
<h2>Placebos are nontoxic and universally applicable</h2>
<p>In addition to the ever-increasing body of evidence surrounding their effectiveness, placebos offer multiple benefits. They have no side effects. They are cheap. They are not addictive. They provide hope when there might not be a specific chemically active treatment available. They mobilize a person’s own ability to heal through multiple pathways, including those studied in the <a href="https://www.pnirs.org/">field of psychoneuroimmunology</a>. This is the study of relationships between the immune system, hormones and the nervous system. </p>
<p>By defining a placebo as the act of setting positive expectations and providing hope through psychosocial interactions, it becomes clear that placebos can enhance traditional medical treatments.</p>
<h2>Using placebos to help people in an ethical way</h2>
<p>The placebo effect is recognized as being powerful enough that the American Medical Association considers it <a href="https://www.ama-assn.org/delivering-care/ethics/use-placebo-clinical-practice#">ethical to use placebos</a> to enhance healing on their own or with standard medical treatments if the patient agrees to it.</p>
<p>Clinically, doctors use the principles of placebo in a more subtle way than it is used in research studies. A 2013 study from the U.K. found that <a href="https://doi.org/10.1371/journal.pone.0058247">97% of physicians</a> acknowledged in a survey having used some form of placebo during their career. This might be as simple as expressing a strong belief in the likelihood that a patient will feel better from whatever treatment the doctor prescribes, even if the treatment itself is not chemically powerful. </p>
<p>There is now even an international <a href="https://placebosociety.org/home">Society for Interdisciplinary Placebo Studies</a>. They have written <a href="https://doi.org/10.1159/000490354">a consensus statement</a> about the use of placebos in medicine and recommendations for <a href="https://doi.org/10.1159/000510738">how to talk with patients about it</a>. In the past, patients who improved from a placebo effect might have felt embarrassed, as if their ailment were not real. </p>
<p>But with the medical field’s growing acceptance and promotion of placebo effects, we can envision a time when patients and clinicians take pride in their skill at harnessing the placebo response.</p>
<p>[<em>Get fascinating science, health and technology news.</em> <a href="https://memberservices.theconversation.com/newsletters/?nl=science&source=inline-science-fascinating">Sign up for The Conversation’s weekly science newsletter</a>.]</p><img src="https://counter.theconversation.com/content/173845/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>Drug manufacturers often shun the use of placebos in clinical trials. But research suggests that placebos could play an important role in the treatment of depression, pain and other maladies.Elissa H. Patterson, Clinical Assistant Professor of Psychiatry and Neurology, University of MichiganHans Schroder, Clinical Assistant Professor of Psychiatry, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1722122021-11-22T13:31:04Z2021-11-22T13:31:04ZHow the pandemic helped spread fentanyl across the US and drive opioid overdose deaths to a grim new high<figure><img src="https://images.theconversation.com/files/432742/original/file-20211118-23-14aslbz.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C3997%2C2656&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Emblems of America's epidemics.</span> <span class="attribution"><span class="source">David Gannon/AFP via Getty Images</span></span></figcaption></figure><p>For the past 20 years, I have been engaged in efforts to end the opioid epidemic, as a <a href="https://heller.brandeis.edu/facguide/person.html?emplid=fed1af017db070b94ce59c13714f1e7970a787ad">public health official, researcher and clinician</a>. And for every one of those years I have looked on as the number of deaths from drug overdoses has set a new record high. </p>
<p>Yet even knowing that trend I was surprised by the <a href="https://www.cnn.com/2021/11/17/health/drug-overdose-deaths-record-high/index.html">latest tally from the CDC</a> showing that for the first time ever, the number of Americans who fatally overdosed over the course of a year surpassed 100,000. In a 12-month period ending at the end of April 2021, <a href="https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2021/20211117.htm">some 100,306 died in the U.S.</a>, up 28.5% over the same period a year earlier. </p>
<p>The soaring death toll has been fueled by a much more dangerous black market opioid supply. Illicitly synthesized fentanyl – a potent and inexpensive opioid that has driven the rise in overdoses since it emerged in 2014 – is increasingly replacing heroin. Fentanyl and fentanyl analogs were <a href="https://www.cnn.com/2021/11/17/health/drug-overdose-deaths-record-high/index.html">responsible for almost two-thirds</a> of the overdose deaths recorded in the 12 months period ending in April 2021.</p>
<p>It is especially tragic that these deaths are mainly occurring in people with a disease – opioid addiction – that is both preventable and treatable. Most heroin users want to avoid fentanyl. But increasingly, the heroin they seek is mixed with fentanyl or what they purchase is just fentanyl without any heroin in the mix.</p>
<p>While the spread of fentanyl is the primary cause of the spike in overdose deaths, the coronavirus pandemic also made the crisis worse.</p>
<p>The <a href="https://www.economist.com/graphic-detail/2021/03/30/opioid-deaths-in-america-reached-new-highs-in-the-pandemic">geographical distribution of opioid deaths</a> makes it clear that there has been a change during the pandemic months.</p>
<p>Before the COVID-19 health crisis, the skyrocketing increase in fentanyl-related overdose deaths in America was <a href="https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2725487">mainly affecting the eastern half of the U.S.</a>, and hit especially hard in urban areas like Washington, D.C., Baltimore, Philadelphia and New York City. A possible reason behind this was that in the eastern half of the U.S., heroin has mainly been available in powder form rather than the black tar heroin more common in the West. It is easier to mix fentanyl with powdered heroin.</p>
<p>COVID-19 resulted in less cross-national traffic, which made it harder to <a href="https://www.unodc.org/documents/data-and-analysis/covid/Covid-19-and-drug-supply-chain-Mai2020.pdf">smuggle illegal drugs across borders</a>. Border restrictions make <a href="https://www.latimes.com/world-nation/story/2020-04-20/cartels-are-scrambling-virus-snarls-global-drug-trade">it harder to move bulkier drugs</a>, resulting in smugglers’ increased reliance on fentanyl – which is more potent and easier to transport in small quantities and as pills, making it easier to traffic by mail. This may have helped fentanyl spread to areas that escaped the earlier surge in fentanyl deaths.</p>
<p>Opioid-addicted individuals seeking prescription opioids instead of heroin have also been affected, because counterfeit pills made with fentanyl <a href="https://www.dea.gov/alert/sharp-increase-fake-prescription-pills-containing-fentanyl-and-meth">have become more common</a>. This may explain why public health officials in <a href="https://www.economist.com/graphic-detail/2021/03/30/opioid-deaths-in-america-reached-new-highs-in-the-pandemic">Seattle and elsewhere</a> are reporting many fatalities resulting from use of counterfeit pills.</p>
<p>Another factor that may have contributed to the soaring death toll is that the pandemic made it <a href="https://www.nytimes.com/2021/01/04/nyregion/addiction-treatment-coronavirus-new-york-new-jersey.html">harder for those dependent on opioids to get in-person treatment</a>.</p>
<p>More than anything else, what drives opioid-addicted individuals to continue using is that without opioids they will experience severe symptoms of withdrawal. Treatment, especially with buprenorphine and methadone, has to be easy to access or addicted individuals will continue using heroin, prescription opioids or illict fentanyl to stave off withdrawal. Some treatment centers innovated in the face of lockdowns, for example, by allowing more patients to <a href="https://apnews.com/article/science-health-pandemics-coronavirus-pandemic-c36442b3fe8f2074e2fe3907d11ca579">take methadone unsupervised at home</a>, but this may not have been enough to offset the disruption to treatment services.</p>
<p>And maintaining access to treatment is crucial to avoid relapse, especially during the pandemic. Research has shown that social isolation and stress – which <a href="https://www.healthaffairs.org/do/10.1377/hblog20200609.53823">became more common</a> <a href="https://www.apa.org/news/press/releases/stress/2020/report-october">during the pandemic</a> – increase the chances of a <a href="https://khn.org/news/addiction-is-a-disease-of-isolation-so-pandemic-puts-recovery-at-risk/">relapse in someone in recovery</a>.</p>
<p>In the past, one slip might not be the end of the world for someone in recovery. But given the extraordinarily dangerous black market opioid supply, any slip can result in death.</p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://memberservices.theconversation.com/newsletters/?source=inline-youresmart">You can read us daily by subscribing to our newsletter</a>.]</p><img src="https://counter.theconversation.com/content/172212/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Kolodny receives federal funding for research on opioid addiction treatment and serves as an expert witness on behalf of states and counties in litigation against the opioid industry. He is also a co-founder of Physicians for Responsible Opioid Prescribing.</span></em></p>The number of fatal drug overdoses in the US over a 12-month period has surpassed 100,000 for the first time. Fentanyl is the main driver of the spike in deaths.Andrew Kolodny, Co-Director of Opioid Policy Research, Brandeis UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1671002021-09-16T12:11:03Z2021-09-16T12:11:03ZOxyContin created the opioid crisis, but stigma and prohibition have fueled it<figure><img src="https://images.theconversation.com/files/421389/original/file-20210915-17-1lvjamv.jpg?ixlib=rb-1.1.0&rect=6%2C12%2C997%2C597&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People around the world mourned loved ones on International Overdose Awareness Day on Aug. 31, 2021.
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/edmontonians-pose-wooden-crosses-with-roses-on-news-photo/1234986137?adppopup=true"> NurPhoto/Getty Images</a></span></figcaption></figure><p>The <a href="https://theconversation.com/how-the-purdue-opioid-settlement-could-help-the-public-understand-the-roots-of-the-drug-crisis-166701">highly contentious</a> <a href="https://www.npr.org/2021/09/01/1031053251/sackler-family-immunity-purdue-pharma-oxcyontin-opioid-epidemic">Purdue Pharma settlement</a> announced Sept. 1, 2021, comes at a pivotal time for the U.S. overdose crisis: 2020 was the worst year on record, with over <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">93,000 Americans</a> losing their lives to fatal drug overdose. The drug overdose epidemic, now more than two decades long, has claimed the lives of <a href="https://www.cdc.gov/opioids/data/index.html">more than 840,000</a> people since 1999. Current estimates suggest that some <a href="https://www.rand.org/content/dam/rand/pubs/research_reports/RR3100/RR3140/RAND_RR3140.pdf">2.3 million people</a> in the U.S. use heroin and <a href="https://www.drugabuse.gov/drug-topics/opioids/opioid-overdose-crisis">1.7 million people</a> use pharmaceutical opioids without a prescription. </p>
<p>Since 2016, I’ve <a href="https://gc-cuny.academia.edu/EmilyCampbell?from_navbar=true">studied the overdose crisis</a> with an eye to understanding its roots as well as its ramifications. As a <a href="https://www.holycross.edu/academics/programs/sociology-and-anthropology/faculty/emily_b_campbell">sociologist</a>, I came to this area of research in my own quest for meaning, as each year brought more funerals of former classmates and friends. What I found was an increasingly dangerous drug environment for people who use drugs, often exacerbated by policies not founded in research and by attitudes that harm those affected.</p>
<h2>How prohibition fuels dangerous markets</h2>
<p>Research shows that <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">the illicit drug market adapts</a> to both demand and drug enforcement efforts. </p>
<p>The first consequence of increased demand is that drugs become <a href="https://doi.org/10.1016/j.drugpo.2007.11.016">cheaper over time</a>. For example, the price of heroin and cocaine have been falling for decades. Political economists explain that demand, coupled with globalization, increases efficiency and competition. The result is that there are more drugs on the illicit market, which in turn lowers prices. </p>
<p>Second, as a response to drug prohibition, <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">drugs become more potent</a>. A stronger product in a smaller package is easier to transport and harder to detect. The American overdose crisis has become <a href="https://doi.org/10.1016/j.drugpo.2017.05.050">a case study</a> in the devastating interplay of demand and prohibition. </p>
<p>OxyContin was released in 1996 and <a href="https://doi.org/10.2105/AJPH.2007.131714">mass-marketed as a revolutionary intervention</a> in the medical treatment of pain. Purdue Pharma, its maker, <a href="https://www.nytimes.com/2007/05/10/business/11drug-web.html?smid=url-share">knowingly downplayed</a> its addictive potential. As an opioid and central nervous depressant, <a href="https://doi.org/10.1300/J069v23n04_01">OxyContin has effects</a> similar to those of morphine or heroin. Not surprisingly, studies show that prescription patterns of opioids from 1999 to 2008 were <a href="https://pubmed.ncbi.nlm.nih.gov/22048730/">directly linked to a surge in overdose deaths</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Pill bottle and pills of OxyContin prescription-only pain medication" src="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420692/original/file-20210913-27-4nizsn.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Oxycontin prescription-only pills were aggressively promoted to primary care physicians as a safe and effective pain control method for patients.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/oxycontin-pills-oxycodone-hydrochloride-prescription-only-news-photo/563590877?adppopup=true">Lawrence K. Ho/Los Angeles Times via Getty Images</a></span>
</figcaption>
</figure>
<p>As concern over opioid overdose grew, doctors’ prescribing practices <a href="https://doi.org/10.1007/s11013-016-9496-5">came under scrutiny</a>. In 2010, Purdue Pharma replaced the original OxyContin with an <a href="https://doi.org/10.1001/jamapsychiatry.2014.3043">“abuse deterrent” formulation</a> that was more difficult to crush and inhale. As a result, many people who were addicted to OxyContin turned to heroin, which was <a href="https://doi.org/10.1162/rest_a_00755">cheaper and easier to get</a>. This spurred a surge in heroin-related fatal overdoses, which is often termed the <a href="https://doi.org/10.1016/j.drugpo.2019.01.010">second wave of the overdose crisis</a>.</p>
<p>The growing market for heroin paved the way for the <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">introduction of fentanyl</a> into the illicit U.S. drug market. Fentanyl, a drug used in medical settings for severe pain, is <a href="https://www.drugabuse.gov/publications/drugfacts/fentanyl">50 times more potent than heroin</a>. From the standpoint of efficiency for shipping and trafficking, fentanyl is easier to transport and sell than heroin. Fentanyl’s entry into the illicit drug market, in particular in combination with heroin, <a href="https://doi.org/10.1016/j.drugpo.2017.06.010">led to a doubling and tripling </a>of overdose deaths around 2012 to 2013. </p>
<p><a href="https://journals.lww.com/co-psychiatry/fulltext/2021/07000/the_rise_of_illicit_fentanyls,_stimulants_and_the.4.aspx">Since then, fentanyl</a> <a href="https://doi.org/10.1016/j.drugpo.2021.103353">has contaminated</a> the U.S. illicit drug supply: It is often found in not just heroin but cocaine, MDMA – commonly known as Ecstasy – methamphetamine and counterfeit prescription pills. The result is that most people <a href="https://doi.org/10.1016/j.drugpo.2019.07.008">do not know the potency or contents</a> of what they are using. </p>
<p>As the overdose crisis evolves, <a href="https://doi.org/10.1007/s40615-021-01007-6">communities of color</a> in particular have experienced a surge in fatal overdoses – deaths that are often preventable. And most recently, COVID-19 supply chain disruptions led people to use whatever was available, causing <a href="https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2021.306256">a surge in overdoses</a> from drug mixing. </p>
<h2>Barriers to treatment</h2>
<p>Too often, people who use drugs are bombarded with messages that are not supported by research and that deepen the harm. </p>
<p>Public health officials and community leaders urge people to seek treatment and highlight that recovery is within reach. Yet, roughly 70% of people who seek treatment are <a href="https://www.rcorp-ta.org/sites/default/files/2020-06/Improving-Access-to-Evidence-Based-Medical-Treatment-for-OUD_FINAL.pdf">unable to access it</a>. <a href="https://doi.org/10.1080/10826084.2017.1363238">Barriers to treatment</a> include health care costs, lack of available treatment options and social stigma. Research also demonstrates that some people are not ready for treatment or <a href="https://doi.org/10.1080/10826084.2017.1310247">do not want to be sober</a>.</p>
<p>Sobriety is touted as the ultimate goal for people who use drugs. Yet research shows that addiction is a <a href="https://doi.org/10.1038/s41386-020-00950-y">recurring brain disease</a>, and relapse is highly likely. Most people who use drugs do so in a <a href="https://www.ucpress.edu/book/9780520293472/hurt">sporadic way</a> that features bouts of controlled and uncontrolled use as well as sobriety. It is also well documented that fear of arrest and shame encourages people to hide their drug use in ways that <a href="https://doi.org/10.1080/10826084.2020.1790008">increase their risk</a> of a fatal overdose. This is because when people use alone, there is no one there to call 911 or perform CPR should an overdose occur. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Woman holding up phone with image of brother and son who died after taking fentanyl-laced drugs" src="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=431&fit=crop&dpr=1 600w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=431&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=431&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=541&fit=crop&dpr=1 754w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=541&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/420698/original/file-20210913-23-1llv382.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=541&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Laurie Restivo’s brother, David Restivo, 47 (left on phone image), died from fentanyl-laced heroin, and her son, Jason Fisher Jr., 25 (right), died from fentanyl-laced cocaine.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/fentanyl-overdose-restivo-johnson-laurie-restivo-displays-a-news-photo/1315873058?adppopup=true">Reading Eagle/MediaNews Group via Getty Images</a></span>
</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>
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<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/1667012021-09-01T22:00:43Z2021-09-01T22:00:43ZHow the Purdue opioid settlement could help the public understand the roots of the drug crisis<figure><img src="https://images.theconversation.com/files/418136/original/file-20210826-13-v1fcqw.jpg?ixlib=rb-1.1.0&rect=114%2C73%2C5349%2C3186&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Esther Nesbitt lost two of her children to drug overdoses.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/esther-nesbitt-who-has-lost-two-of-her-children-to-drug-news-photo/1335688676">Andrew Lichtenstein/Corbis via Getty Images</a></span></figcaption></figure><p>There’s a long history of U.S. courts being called upon to fix large-scale public health crises.</p>
<p>Lawyers and judges, for instance, were key in settling claims related to <a href="https://www.asbestos.com/mesothelioma-lawyer/settlements/">asbestos</a>, <a href="https://www.pbs.org/newshour/nation/lead-paint-suppliers-to-pay-305-million-to-settle-california-lawsuit">lead paint</a>, <a href="https://www.benefits.va.gov/COMPENSATION/claims-postservice-agent_orange-settlement-settlementFund.asp">Agent Orange</a> and <a href="https://www.publichealthlawcenter.org/topics/commercial-tobacco-control/commercial-tobacco-control-litigation/master-settlement-agreement">tobacco</a>. More recently, they have dealt with the fallout of the <a href="https://theconversation.com/opioid-overdoses-spiked-during-the-covid-19-pandemic-data-from-pennsylvania-show-161635">U.S. opioid epidemic</a>, which is linked to the deaths of some <a href="https://wkow.com/2021/08/27/judge-urges-talks-between-purdue-pharma-and-holdout-states/">500,000 Americans</a> over the past two decades. </p>
<p>This litigation can serve several important goals. It can identify wrongdoers and hold them accountable. It can repair damage by compensating the victims. And it can protect the public by producing evidence regarding dangerous products and practices.</p>
<p>When cases are settled, however, the litigation rarely accomplishes all three goals together. <a href="https://www.reuters.com/investigates/special-report/usa-courts-secrecy-lobbyist/">Settlements deny plaintiffs their day in court</a> and can bypass admissions of guilt or allow companies to evade public scrutiny. They frustrate and disappoint almost by design.</p>
<p><a href="https://www.youtube.com/watch?v=uaCaIhfETsM">Frustration and disappointment</a> have been evident in the <a href="https://www.npr.org/2021/09/01/1031053251/sackler-family-immunity-purdue-pharma-oxcyontin-opioid-epidemic">settlement reached on Sept. 1, 2021</a>, that ended thousands of the lawsuits filed by states, cities, counties and native tribes against Purdue Pharma. Even as <a href="https://twitter.com/BrianMannADK/status/1433131417664466948">Robert Drain</a>, a federal bankruptcy judge in White Plains, New York, approved the deal he observed that it would fail to fully hold Purdue’s owners, the <a href="https://www.newyorker.com/magazine/2017/10/30/the-family-that-built-an-empire-of-pain">Sackler family</a>, accountable for their role in the opioid crisis.</p>
<p>Still, the deal is about more than a single family’s fate. As a <a href="https://history.ucr.edu/people/antoine-lentacker">historian of drugs and the pharmaceutical industry</a>, I see promise in it.</p>
<h2>Settling with the Sacklers</h2>
<p>If the deal holds up, it will cap 20 years of litigation against Purdue Pharma, a privately held drugmaker. The company <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">pleaded guilty twice</a> to <a href="https://www.addictioncenter.com/news/2020/11/purdue-pharma-plead-guilty-opioid-criminal-charges/">federal criminal charges</a> in connection with its marketing of OxyContin. No lawsuit against Purdue ever advanced to trial. Cases were settled out of court and records were sealed. The company continued to <a href="https://www.npr.org/sections/health-shots/2018/02/13/585402385/doctors-in-maine-say-halt-in-oxycontin-marketing-comes-20-years-late">promote OxyContin to doctors through 2018</a>.</p>
<p>By that time, the Sacklers had reaped an estimated <a href="https://www.businessinsider.com/who-are-the-sacklers-wealth-philanthropy-oxycontin-photos-2019-1">US$10.7 billion from sales of Purdue’s signature product</a>. But the <a href="https://apnews.com/article/8c84158a0cab4bd4b58be2315b4558fb">family</a> <a href="https://www.propublica.org/article/we-are-releasing-the-full-video-of-richard-sacklers-testimony-about-purdue-pharma-and-the-opioid-crisis">denies that it</a> <a href="https://www.nytimes.com/2021/08/18/health/richard-sackler-purdue-testimony.html">bears any responsibility for the devastation</a> wrought by the opioid crisis and has sought protection from lawsuits.</p>
<p>Under the terms of the <a href="https://apnews.com/article/purdue-pharma-opioid-settlement-6fd3e10dcd6b0eeffd2f0b885efd4693">settlement</a>, the Sacklers will hand over a total of $4.5 billion over nine years provided they can be released of any liability for their role in the opioid crisis. This immunity would extend to members of the family as well as to <a href="https://www.npr.org/2021/08/20/1028761427/sacklers-immunity-opioid-bankruptcy-trial">hundreds of foundations, trusts</a>, business associates, attorneys, lobbyists, Purdue subsidiaries and <a href="https://www.npr.org/2021/06/02/1002085031/sackler-family-empire-poised-to-win-immunity-from-opioid-lawsuits">other entities</a>.</p>
<p>The prospect of extensive immunity has attracted <a href="https://www.npr.org/2021/08/31/1032778376/purdue-pharma-bankruptcy-doj-justice-department-sackler-oxycontin-opioid">fierce criticism</a> and <a href="https://www.reuters.com/legal/transactional/states-seek-direct-appeal-purdue-pharma-plan-2nd-circuit-2021-09-30/">legal challenges</a> from eight states and the <a href="https://www.npr.org/2021/09/16/1037806819/opioids-purdue-pharma-sackler-settlement-bankruptcy-deal">Justice Department</a>.</p>
<p>On Dec. 16, 2021, a federal judge <a href="https://apnews.com/article/business-health-lawsuits-opioids-colleen-mcmahon-1e96ea41f783d8f5db0a024fbb304c1f">ruled against the plan</a>, but the company has vowed to appeal her decision.</p>
<p>If the deal holds up, however, the Sacklers will still retain most of the <a href="https://oversight.house.gov/news/press-releases/committee-releases-documents-showing-sackler-family-wealth-totals-11-billion">fortune</a> they amassed from the sales of OxyContin fully insulated against future lawsuits brought in connection with Purdue’s opioids.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A sign hanging in the Metropolitan Museum of Art's Sackler Wing names all three brothers, Arthur, Mortimer and Raymond." src="https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418492/original/file-20210830-19-jjhb1s.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Metropolitan Museum of Art’s Sackler wing is named for the three brothers who built Purdue Pharma into a massive privately held drugmaker.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/sign-welcomes-visitors-to-the-sackler-wing-at-the-news-photo/1138930605">Spencer Platt/Getty Images</a></span>
</figcaption>
</figure>
<h2>Compensating the plaintiffs</h2>
<p>The abuse of prescription opioids <a href="https://www.cdc.gov/media/releases/2017/a0315-Business-Pulse-opioids.html">costs the U.S. economy $78.5 billion every year</a>, according to a Centers for Disease Control and Prevention estimate. The funds pledged by the Sacklers fall far short of paying this tab. However, the deal offers a creative way to help resolve the crisis.</p>
<p>The centerpiece of the deal is a plan to <a href="https://theconversation.com/oxycontin-maker-purdue-pharma-may-settle-legal-claims-with-a-new-public-trust-that-would-still-be-dedicated-to-profit-148604">dissolve Purdue</a> and reestablish it as a <a href="https://www.law.cornell.edu/wex/public_benefit_corporation">public benefit corporation</a>. The new entity will continue to sell some of Purdue’s signature products – including opioid painkillers, opioid substitution therapies like <a href="https://www.samhsa.gov/medication-assisted-treatment/medications-counseling-related-conditions/buprenorphine">buprenorphine</a> and anti-overdose medications like <a href="https://theconversation.com/explainer-naloxone-the-antidote-to-opioid-overdose-32481">naloxone</a> – and use the profits of these sales to fund addiction treatment and prevention programs.</p>
<p>Members of the Sackler family will have no stake in the new entity. Resuscitated as a public trust, the new Purdue will be bound to refrain from the kind of <a href="https://www.washingtonpost.com/graphics/2019/investigations/opioid-marketing/">pill-pushing methods</a> that made its fortune. </p>
<p>If successful, this new arrangement would show that a different way of producing and distributing drugs is possible.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/uaCaIhfETsM?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">John Oliver has repeatedly skewered the Sacklers in his “Last Week Tonight” show.</span></figcaption>
</figure>
<h2>Informing the public</h2>
<p>Lawsuits against the industry have produced millions of internal company documents that shed light on the origins of the opioid catastrophe. Together with other historians, I drafted an <a href="https://www.statnews.com/2019/09/12/historians-push-for-opioid-documents-archive/">amicus brief</a> in 2019 that made the case for the full disclosure of all the evidence unearthed in the course of the litigation.</p>
<p>When 46 U.S. states reached another sweeping <a href="https://www.publichealthlawcenter.org/topics/commercial-tobacco-control/commercial-tobacco-control-litigation/master-settlement-agreement">settlement with the tobacco industry in 1998</a>, we explained, the companies were asked to turn over their internal documents and pay for their collection and preservation.</p>
<p><a href="https://www.industrydocuments.ucsf.edu/tobacco/">Posted to the internet, these documents exposed</a> how the tobacco industry misled the public about the consequences of smoking and the nature of nicotine addiction for decades after these risks were discovered.</p>
<p>Overall, more than 1,000 books, research papers and articles about the impact of corporate behavior on public health were written based on this trove of evidence. The same approach, we argued, needs to be taken with the <a href="http://www.doi.org/10.1086/713409">opioid industry documents</a>.</p>
<p>We filed our brief just as Purdue made its opening settlement bid. The <a href="https://www.reuters.com/investigates/special-report/usa-courts-secrecy-judges/">Sacklers fought long</a> and <a href="https://www.statnews.com/2019/08/26/kentucky-supreme-court-allows-release-of-purdue-oxycontin-records/">hard to guard their secrets</a>, concealing some of the most incriminating evidence behind claims of attorney-client privilege. They were forced to relent to get <a href="https://www.mass.gov/news/ag-healey-announces-resolution-with-purdue-pharma-and-the-sackler-family-for-their-role-in-the-opioid-crisis">more states</a> on board.</p>
<p>As a result, 30 million documents – business plans, memos, emails, meeting minutes, legal records and even deposition videos – will be turned over to archivists and made available in text-searchable form through a user-friendly portal. Purdue’s inner workings will be exposed like those of few U.S. corporations before. This will help researchers, journalists and the public better understand the causes of the opioid epidemic.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Men in suits move large boxes of documents around outside a courthouse." src="https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=425&fit=crop&dpr=1 754w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=425&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/418519/original/file-20210830-19-1n2e6et.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=425&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Boxes of opioid-related evidence are transported in Central Islip, N.Y., in 2021 amid litigation against opioid manufacturers, distributors and drugstore chains.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/boxes-are-wheeled-out-in-a-landmark-case-before-a-jury-news-photo/1326472902">Raychel Brightman/Newsday RM via Getty Images</a></span>
</figcaption>
</figure>
<h2>Looking ahead</h2>
<p>By a striking quirk of timing, the court order compelling the release of the tobacco industry documents <a href="https://twitter.com/industrydocs/status/1430576443810062340">expired on Sept. 1, 2021</a>. The yearslong effort to collect the documents obtained from the tobacco industry will wind down just as the work to bring Purdue’s documents to the public begins.</p>
<p>Public access to industry documents altered the course of the <a href="https://www.washingtonpost.com/outlook/minnesota-tobacco-document-depository/2021/08/25/cdc1ecfc-050c-11ec-a654-900a78538242_story.html">litigation against Big Tobacco</a>. For decades, cigarette makers beat back lawsuits with claims that the science about the risks of smoking remained unsettled and that the companies were sincerely trying to mitigate known harms. They also held that smokers were making a choice and denied knowing anything about nicotine’s addictive potential. These defenses crumbled when the documents came to light and <a href="https://truthinitiative.org/who-we-are/our-history/master-settlement-agreement">more plaintiffs prevailed</a> in court. </p>
<p>Given the broad immunity granted to the Sacklers, the disclosure of Purdue’s opioid litigation documents may not lead to new lawsuits against them. But it might strengthen future litigation against other defendants in opioid cases. </p>
<p><a href="https://www.reuters.com/world/us/six-us-states-will-not-join-26-bln-opioid-settlements-with-distributors-jj-2021-08-23/">Drug distributors</a>, <a href="https://www.legalexaminer.com/health/first-pharmacy-settlements-in-nationwide-opioid-crisis/">pharmacies</a>, other <a href="https://www.nejm.org/doi/full/10.1056/NEJMp1710756">drugmakers</a> and even <a href="https://www.justice.gov/opa/pr/justice-department-files-lawsuit-against-tampa-area-physician-pharmacy-and-clinic-owners">some doctors are embroiled in their own lawsuits</a> and negotiating their own settlements.</p>
<p>Historians like me, public health experts, journalists, lawyers, survivors and the public need access to the evidence underpinning all of that litigation too. If only Purdue’s opioid-related documents are made public, the world would be left with a distorted picture of what caused this catastrophe.</p>
<p>The Sacklers, I fear, would continue to play their role as useful villains, diverting attention from the <a href="https://www.doi.org/10.1001/amajethics.2020.743">broader</a> <a href="https://www.washingtonpost.com/national/congressional-report-drug-companies-dea-failed-to-stop-flow-of-millions-of-opioid-pills/2018/12/18/5bc750ee-0300-11e9-b6a9-0aa5c2fcc9e4_story.html">systemic</a> <a href="https://www.nytimes.com/2020/05/27/health/opioids-pharmacy-cvs-litigation.html">failures</a> that allowed one <a href="https://www.justice.gov/opa/pr/justice-department-announces-global-resolution-criminal-and-civil-investigations-opioid">company</a> to cause so much damage.</p>
<p><em>Editor’s note: The descendants of <a href="https://www.theguardian.com/us-news/2018/feb/13/meet-the-sacklers-the-family-feuding-over-blame-for-the-opioid-crisis">Arthur Sackler</a>, the brother of Mortimer and Raymond Sackler, sold their stake in Purdue before the launch of OxyContin. They aren’t involved in opioid-related litigation against the company or Purdue’s related settlements. This article was updated on Dec. 17, 2021, with the latest details regarding the settlement’s status.</em></p>
<p>[<em>Over 110,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p><img src="https://counter.theconversation.com/content/166701/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Antoine Lentacker is a member of the National Advisory Committee for the Opioid Industry Documents Archive, a partnership of the University of California, San Francisco, and Johns Hopkins University. </span></em></p>The multibillion-dollar settlement will trigger the release of troves of documents that may shine new light on what caused the opioid crisis.Antoine Lentacker, Assistant Professor of History, University of California, RiversideLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1657322021-08-20T15:16:24Z2021-08-20T15:16:24ZOpioid lawsuit payout plans overlook a vital need: Pain management care and research focused on smarter use of addictive drugs<figure><img src="https://images.theconversation.com/files/417080/original/file-20210819-25-qghrw5.jpg?ixlib=rb-1.1.0&rect=14%2C0%2C4927%2C3823&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The improper prescription of opioids for pain treatment is one of the central drivers of the opioid epidemic.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/illustration/men-and-women-suffering-with-pain-trapped-royalty-free-illustration/901762524">ah_designs/iStock via Getty Images Plus</a></span></figcaption></figure><p>The opioid crisis has resulted in <a href="https://wonder.cdc.gov/controller/saved/D77/D205F251">more than 500,000 overdose deaths</a> over the past two decades. The federal government, states and other entities have <a href="https://doi.org/10.1056/NEJMp1710756">filed litigation</a> against drug manufacturers, suppliers and pharmacies as one approach to address the harm and suffering caused by inappropriate opioid prescribing practices. <a href="https://www.wsj.com/articles/states-announce-26-billion-settlement-to-resolve-opioid-lawsuits-11626890613">Billions</a> of <a href="https://www.cnn.com/2021/07/20/investing/opioid-settlement-new-york-1-1-billion/index.html">dollars</a> of <a href="https://www.wsj.com/articles/purdue-pharma-reaches-8-34-billion-settlement-over-opioid-probes-11603292613">funds</a> have since been awarded, and more is likely to come. </p>
<p>To ensure these funds are used in areas relevant to opioids, policy and public health groups led by experts at <a href="https://opioidprinciples.jhsph.edu/">Johns Hopkins University</a>, <a href="https://fxb.harvard.edu/warondrugstoharmreduction/">Harvard University</a> and other organizations have <a href="https://www.lac.org/resource/opioid-settlement-recommendations-from-the-addiction-solutions-campaign">proposed</a> <a href="https://www.lac.org/resource/evidence-based-strategies-for-abatement-of-harms-from-the-o">frameworks</a> detailing priorities on what to do with the money. But none of them address the needs of one critical group: patients who suffer from acute and chronic pain.</p>
<p>Gaps in pain care and treatment, one of the key factors that enabled inappropriate opioid prescribing in the first place, persist. I am a <a href="https://scholar.google.com/citations?user=mQswfH4AAAAJ&hl=en">physician scientist specializing in pain medicine</a>. My colleagues, law professor <a href="https://michigan.law.umich.edu/faculty-and-scholarship/our-faculty/barbara-l-mcquade">Barbara McQuade</a> and anesthesiologist <a href="https://scholar.google.com/citations?user=FQIBJYEAAAAJ&hl=en">Chad Brummett</a>, and I believe there are <a href="https://jamanetwork.com/journals/jama-health-forum/fullarticle/2783468">three key ways</a> these funds could be used to improve pain treatment and address resource gaps for patients with acute and chronic pain.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care provider holding a person's bent leg below the knee." src="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=361&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=361&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=361&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=453&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=453&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417082/original/file-20210819-17-cm4f6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=453&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Expanding pain treatment beyond medication could help curb the opioid epidemic.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/senior-man-having-medical-exam-royalty-free-image/846421676">gilaxia/E+ via Getty Images</a></span>
</figcaption>
</figure>
<h2>1. Comprehensive pain management</h2>
<p>There are two common types of pain. <a href="https://doi.org/10.1016/S0140-6736(99)03313-9">Acute pain</a> is usually sharp and sudden. It’s the pain typically felt after a cut or an injury, and helps warn the body about tissue damage. Acute pain is very common, and generally goes away once the body heals. </p>
<p><a href="https://medlineplus.gov/chronicpain.html">Chronic pain</a>, on the other hand, persists even after tissue has healed and the injury has resolved. When this happens, pain can transform from a symptom into a chronic disease. Many conditions can cause chronic pain, ranging from <a href="https://medlineplus.gov/arthritis.html">arthritis</a> and <a href="https://medlineplus.gov/migraine.html">migraines</a> to <a href="https://medlineplus.gov/fibromyalgia.html">fibromyalgia</a> and nerve pains like <a href="https://medlineplus.gov/sciatica.html">sciatica</a> and <a href="https://www.cdc.gov/shingles/about/complications.html">postherpetic neuralgia from shingles</a>, among others. Why acute pain transforms into chronic pain is not always clear. </p>
<p>Due to a <a href="https://dx.doi.org/10.1016%2Fj.drugalcdep.2016.12.002">combination of factors</a>, recent approaches to pain treatment, such as the concept of the <a href="https://dx.doi.org/10.1016%2Fj.pmn.2017.10.010">fifth vital sign</a> which reduced pain to a number on a scale between 0 and 10, led to an over-reliance on medications and limited approaches to treatment, all of which persist to this day.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/I7wfDenj6CQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">People have different responses to different levels of pain. What may be an effective treatment for one person might not be for someone else.</span></figcaption>
</figure>
<p>The most effective care for chronic pain, however, typically includes therapy beyond pills. <a href="https://www.ncbi.nlm.nih.gov/books/NBK82511/">Comprehensive pain management</a> involves care from a <a href="https://doi.org/10.1016/0304-3959(92)90145-2">diverse team of clinicians</a>, such as physical therapists and pain psychologists, to name a few. It also involves a suite of treatment approaches and care methodologies, including <a href="https://doi.org/10.1136/bmj.h444">behavioral therapy</a> which focuses on the psychological and social aspects of pain. <a href="https://www.nccih.nih.gov/health/complementary-alternative-or-integrative-health-whats-in-a-name">Complementary and integrative approaches</a>, such as acupuncture, biofeedback and yoga, can also be combined with <a href="https://doi.org/10.1016/j.cger.2016.06.003">interventional approaches</a> like injections, dry needling and electrical stimulation.</p>
<p>While the right combination of therapies depends on the individual patient, the goal is to alleviate their pain, help them regain their ability to perform everyday activities and improve their quality of life.</p>
<p>This multidisciplinary and multimodal approach to pain management became less common due to <a href="https://dx.doi.org/10.1016%2Fj.drugalcdep.2016.12.002">financial pressures after the rise of managed care</a> in the late 1980s and early 1990s. Limited access to comprehensive pain management can lead to worse outcomes for patients. One study found that insurance policies that <a href="https://www.healthychildren.org/English/family-life/health-management/health-insurance/Pages/What-Is-an-Insurance-Carve-Out.aspx">carve out</a> physical therapy from pain management programs led to <a href="https://doi.org/10.1213/01.ane.0000058886.87431.32">worse physical and psychosocial function</a> up to one year after treatment in patients with chronic pain compared to patients whose insurance policies directly covered physical therapy.</p>
<p>Funding to bolster team-based and multidisciplinary approaches to treatment could not only improve care for patients in pain, but also increase their <a href="https://doi.org/10.1037/a0035514">accessibility outside of academic medical centers</a>.</p>
<h2>2. Evidence-based care models</h2>
<p><a href="https://doi.org/10.1136/bmj.a1714">Translating research into evidence-based care models</a> will help bring the best treatment approaches to patients in pain. These models of care <a href="https://www.ahrq.gov/opioids/evidence.html">review the evidence provided by clinical studies</a> and implement their findings to improve patient care. </p>
<p>For example, there is <a href="https://www.doi.org/10.23970/AHRQEPCCER240">evidence to support the use</a> of heat therapy and acupuncture for acute lower back pain, and non-opioid pills for kidney stone pain. Yet patients may not be offered these treatments due in part to <a href="https://doi.org/10.1001/jamanetworkopen.2018.0235">wide variation</a> <a href="https://doi.org/10.1001/jamanetworkopen.2018.3044">in coverage</a> of these treatments.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care provider performing acupuncture on a person's back." src="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=358&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=358&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=358&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=450&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=450&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417086/original/file-20210819-15-8lqo30.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=450&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Complementary therapies can be integrated with traditional interventional approaches to treat pain.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/physio-performing-acupuncture-on-a-patient-royalty-free-image/1290749382">Catherine Falls Commercial/Moment via Getty Images</a></span>
</figcaption>
</figure>
<p>Opioid prescribing represents another area where several gaps in evidence exist for their effectiveness in treating both <a href="https://doi.org/10.17226/25555">acute</a> and <a href="https://stacks.cdc.gov/view/cdc/38026">chronic</a> pain. Until a few years ago, there was no data-driven answer as to what dose of opioids should be prescribed <a href="https://michigan-open.org/prescribing-recommendations/">after common types of surgery</a>. This was partly based on an assumption that patients needed prescription opioids after certain surgeries, which is <a href="https://doi.org/10.1097/sla.0000000000004965">not always the case</a>. Building evidence-based pain management recommendations to prevent unnecessary exposure to prescription opioids remain a focus of organizations like the <a href="https://michigan-open.org/">Michigan Opioid Prescribing Engagement Network</a>. </p>
<h2>3. Research on acute and chronic pain</h2>
<p>Additional research is needed to advance therapies to treat acute and chronic pain. A recent summary of acute pain treatments noted a <a href="https://www.doi.org/10.23970/AHRQEPCCER240">lack of evidence to support current therapies</a> for patients with sickle cell, acute nerve and neck pain, among others.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Group of five health care providers sitting around a table in discussion." src="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=391&fit=crop&dpr=1 600w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=391&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=391&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=491&fit=crop&dpr=1 754w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=491&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/417087/original/file-20210819-21-gjtzne.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=491&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Multidisciplinary care teams offer a more holistic way to manage pain.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/multidisciplinary-meetings-make-for-a-more-thorough-royalty-free-image/1248714799">shapecharge/E+ via Getty Images</a></span>
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</figure>
<p>The National Institutes of Health has boosted funding for research on pain and opioids in recent years via the <a href="https://heal.nih.gov/">HEAL Initiative</a>, a program focusing on opioid addiction and pain management. In 2019, the NIH <a href="https://www.nih.gov/news-events/news-releases/nih-funds-945-million-research-tackle-national-opioid-crisis-through-nih-heal-initiative">awarded US$945 million to projects</a> on improving chronic pain treatment, reducing opioid misuse and overdose and facilitating recovery from opioid addiction. Despite this effort, however, significant gaps still exist in both <a href="https://www.nap.edu/read/24781/chapter/6#120">lab-based</a> and <a href="https://doi.org/10.23970/AHRQEPCTB33">clinical</a> pain research. </p>
<h2>Giving patients with pain a seat at the table</h2>
<p>The economic impact of pain has been estimated to have a <a href="https://www.ncbi.nlm.nih.gov/books/NBK92521/">more than $700 billion dollar price tag</a> in the U.S. when adjusted for inflation. A little more than half of that amount comes from care costs, while the other half comes from reduced productivity or the inability to work. </p>
<p>[<em>Over 100,000 readers rely on The Conversation’s newsletter to understand the world.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=100Ksignup">Sign up today</a>.]</p>
<p>Addressing gaps in <a href="https://www.samhsa.gov/data/sites/default/files/reports/rpt29393/2019NSDUHFFRPDFWHTML/2019NSDUHFFR090120.htm#fig64">addiction treatment</a> and <a href="https://www.cdc.gov/nchs/nvss/vsrr/drug-overdose-data.htm">overdose prevention</a> is vital to turning the tide on the opioid epidemic. But implementing even some of these three ways to improve pain care could also put a dent in how much the U.S. spends on pain. Giving patients with pain a say in how funds from the opioid lawsuits are distributed can help make sure they’re not forgotten.</p><img src="https://counter.theconversation.com/content/165732/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mark Bicket receives grant funding from the National Institutes of Health (R01DA042859, R01DA044987, R01DA049789), the Arnold Foundation, Michigan Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, and the US Centers for Disease Control and Prevention. He served as a consultant in the past for Axial Healthcare and Alosa Health. </span></em></p>Ending the opioid epidemic requires addressing not only treatment gaps in addiction and overdose, but also inadequate pain management.Mark C. Bicket, Assistant Professor of Anesthesiology, University of MichiganLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1642862021-08-11T19:29:30Z2021-08-11T19:29:30Z‘Benzo-dope’ may be replacing fentanyl: Dangerous substance turning up in unregulated opioids<figure><img src="https://images.theconversation.com/files/415383/original/file-20210810-13-9vnesq.jpg?ixlib=rb-1.1.0&rect=92%2C29%2C3140%2C2004&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Naloxone can prevent deaths from opioid overdose, but there is no way to reverse the effects of benzodiazepine overdose without risk.</span> <span class="attribution"><span class="source">(THE CANADIAN PRESS/Jonathan Hayward)</span></span></figcaption></figure><p>Canada has seen a drastic shift in the unregulated drug supply with the emergence of benzodiazepine-adulterated opioids (also known as “benzo-dope”). Benzodiazepines have been detected in as many as <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">60 per cent of overdose deaths in British Columbia</a>.</p>
<p>Recent data from B.C. has observed a steady rise in opioids testing positive for benzodiazepines between August 2020 and April 2021, <a href="https://drugcheckingbc.ca/monthly-reports/">from a low of five per cent to a high of 25 per cent</a>.</p>
<p>British Columbia is not alone in seeing this trend: data from Toronto has shown that this issue is even more prominent. During the same time period, there was an increase from <a href="https://drugchecking.cdpe.org/">45 per cent to 57 per cent</a> in samples containing etizolam, a specific benzodiazepine-like compound.</p>
<p>Commonly prescribed benzodiazepines include drugs like Xanax and Valium. These medications treat a variety of conditions such as anxiety and insomnia and have been used since the 1960s. </p>
<p>However, what is being detected in opioids in Canada are not pharmaceutical drugs. They are drugs from the benzodiazepine class that are neither prescribed nor used in medicine in Canada, meaning they may possess unknown strengths or side-effects. Since benzodiazepines are sedatives, combining them with another type of depressant, like opioids, significantly increases the risk of overdose.</p>
<p>As researchers in substance use, we questioned whether the increasing supply of benzo-dope in the unregulated drug market would saturate the opioid supply in a similar way fentanyl did to heroin years ago. The data seem to suggest we should be prepared for the unregulated drug supply to adjust to a new normal.</p>
<p>In this context, there are significant public health issues that need to be considered. </p>
<h2>Emergence of ‘benzo-dope’</h2>
<p>The increasing availability of benzo-dope is cause for concern given that when taken together, the combined effects of benzodiazepines and opioids can result in overdose and death. According to the B.C. Coroner’s Service, there has been a substantial increase in benzodiazepines detected in illicit drug toxicity deaths, <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicit-drug-type.pdf">from 15 per cent in July 2020 to 60 per cent in May 2021</a>. </p>
<p>Most people do not intend to consume benzodiazepines with their opioids. As a consequence, people wanting to use opioids may unknowingly increase their risk of overdose from benzodiazepine adulteration. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A test strip in a paper cup" src="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=416&fit=crop&dpr=1 600w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=416&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=416&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=523&fit=crop&dpr=1 754w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=523&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/415386/original/file-20210810-13-18w6emp.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=523&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Drug checking services can provide people with timely information about the contents of their unregulated drugs using things like the fentanyl test strip shown here. However, benzodiazepine test strips may miss detecting the drug.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Jonathan Hayward</span></span>
</figcaption>
</figure>
<p>Benzodiazepines are also slower to take effect compared to opioids, meaning someone can experience delayed overdose symptoms. Thefts and sexual assaults have also been reported after people were given benzodiazepine-adulterated opioids without their knowledge and consequently knocked into an unresponsive state.</p>
<p>The reason behind the adulteration of benzodiazepines in opioids is unclear. Some suggest they may be added to opioids to produce similar effects at a lower total cost to drug suppliers, or intentionally used to prolong or enhance the desirable effects of opioids. Regardless, there is growing evidence that co-use and dependence on opioids and benzodiazepines is occurring in parallel to the rising supply of these drugs. </p>
<p>Deaths from opioid overdose can be prevented with <a href="https://towardtheheart.com/naloxone">naloxone, which counteracts the effects of opioids</a>. However, there is no evidence-based antidote to reverse the effects of benzodiazepines without potential consequences such as withdrawal or seizures.</p>
<p>Additionally, due to the complications of benzodiazepine withdrawal, many addiction treatment providers will not admit individuals who test positive for benzodiazepines. As a result, people may not be able to access substance use treatment because of an imposed adulterant to their drugs.</p>
<h2>Challenges detecting benzo-dope</h2>
<p><a href="https://drugcheckingbc.ca/">Drug checking services</a> have been implemented across Canada to monitor the unregulated drug supply and provide people with timely information about the contents of their drugs. In many settings in B.C., benzodiazepine test strips are used alongside a technology called <a href="https://drugcheckingbc.ca/what-is-drug-checking/overview-of-technologies/">Fourier-transform infrared</a> spectroscopy to detect the presence of benzodiazepines. However, limitations of these technologies sometimes cause benzodiazepines to be missed when present in small concentrations. </p>
<p>Etizolam, the most common benzodiazepine-like compound found in opioids, is particularly difficult to detect using point-of-care drug-checking technologies because of its chemical structure. Thus, there may be an under-reporting of how pervasive this issue really is in B.C. and elsewhere in Canada. </p>
<h2>A new wave of the overdose epidemic?</h2>
<p>There have been a number of crucial life-saving responses to address the fentanyl-driven overdose epidemic, such as <a href="http://www.bccdc.ca/our-services/programs/harm-reduction">supervised consumption sites and expanded distribution of naloxone</a>. However, less attention has been paid to the growing issue of benzo-dope and its associated health harms. As this public health emergency worsens, it is important that we incorporate a broader understanding of overdose risk that goes beyond opioids in our efforts to prevent, treat and respond.</p>
<p>It’s too soon to know whether benzo-dope will saturate the unregulated opioid market. As long as there remains a lack of any legal framework to promote a safer supply of drugs (safe supply and <a href="https://theconversation.com/decriminalizing-drug-use-as-we-contain-the-coronavirus-is-the-humane-thing-to-do-136165">decriminalization</a>), there will always be a level of unpredictability in the unregulated opioid supply that can harm people’s health.</p><img src="https://counter.theconversation.com/content/164286/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lianping Ti receives funding for her research from the Michael Smith Foundation for Health Research and Health Canada.</span></em></p><p class="fine-print"><em><span>Samuel Tobias does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Fentanyl adulteration led to the replacement of heroin in the unregulated drug supply of British Columbia. Now that benzodiazepines are present in many opioids, are we headed towards a ‘new normal?’Lianping Ti, Assistant Professor, Department of Medicine, University of British ColumbiaSamuel Tobias, Research Data Coordinator, British Columbia Centre on Substance Use, University of British ColumbiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1624972021-06-28T19:24:38Z2021-06-28T19:24:38ZDecriminalizing drug use is a necessary step, but it won’t end the opioid overdose crisis<figure><img src="https://images.theconversation.com/files/408451/original/file-20210625-26-1kcq5n5.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4673%2C3113&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Advocating for decriminalization carries many benefits, including reducing the need for police involvement.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Media, policy-makers, advocates and the public claim that decriminalization will make <a href="https://thetyee.ca/News/2021/05/12/Vancouver-Drug-Decriminalization-Plan-Disaster/">drug use safer</a> and <a href="https://vancouversun.com/opinion/donald-macpherson-federal-government-must-decriminalize-drugs-to-save-lives-and-protect-communities">save lives</a>. But can it?</p>
<p>Decriminalization has been somewhat of a policy buzzword in recent years, with <a href="https://www.theglobeandmail.com/topics/decriminalization/">ample media coverage</a>. It comes with both <a href="https://angusreid.org/opioid-crisis-covid/">public</a> and <a href="https://news.gov.bc.ca/releases/2021MMHA0017-000706">government</a> support.</p>
<p>A 2020 survey of more than 5,000 Canadians showed that <a href="https://angusreid.org/opioid-crisis-covid/">the majority (59 per cent) favour the decriminalization of drugs</a>. The <a href="https://www.cacp.ca/index.html?asst_id=2189">Canadian Association of Chiefs of Police</a> has also publicly supported decriminalization, along with British Columbia’s <a href="https://www2.gov.bc.ca/assets/gov/health/about-bc-s-health-care-system/office-of-the-provincial-health-officer/reports-publications/special-reports/stopping-the-harm-report.pdf">chief public health officer</a>. </p>
<p>Such support has also come with action. This year, the City of Vancouver submitted an application to Health Canada for an exemption from Canada’s Controlled Drugs and Substances Act — a policy reform referred to as <a href="https://vancouver.ca/people-programs/decriminalizing-simple-possession-of-illicit-drugs-in-vancouver.aspx">the Vancouver Model of decriminalization</a>.</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/cKwh_Db8SQE?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Vancouver activists work toward decriminalization.</span></figcaption>
</figure>
<h2>An alternative response</h2>
<p>In the simplest terms, decriminalization is an alternative response to criminal penalties for simple possession. The most recent data shows there were over <a href="https://www150.statcan.gc.ca/n1/pub/85-002-x/2020001/article/00010/tbl/tbl03-eng.htm">48,000 drug-related offences</a> in Canada in 2019, most of which were for possession for personal use. </p>
<p>The criminalization of drugs results in significant <a href="https://www.toronto.ca/wp-content/uploads/2018/05/9888-Harms-Associated-with-Drug-Laws.pdf">health, social and economic harms</a>, particularly to those who are homeless, experiencing mental health issues, racialized or Indigenous. By eliminating a criminalized response to drug possession, drug policy reform efforts can minimize the contact between people who use drugs and the criminal justice system, and may increase their <a href="https://doi.org/10.1177/1477370819887514">connection to health and social systems</a>.</p>
<p>However, alongside recognition of the ineffectiveness of criminalization and support for an alternative model, we need to be realistic with our expectations of what decriminalization can do. </p>
<h2>Decriminalization versus regulation</h2>
<p>Decriminalization does not mean that people can buy cocaine and heroin at the store as they would alcohol and tobacco. Only legal regulation can do that. Legal regulation, which <a href="https://gettingtotomorrow.ca/2020/03/10/considering-alternative-drug-policies-decriminalization-legal-regulation/">drug policy advocates endorse </a>, includes rules to control who can access what drug and when, as opposed to a free market or full legalization. </p>
<p>An example of legalization is Canada’s <em><a href="https://laws-lois.justice.gc.ca/eng/acts/C-24.5/">Cannabis Act</a></em>, which provides a legal framework to control the production, sale and possession of cannabis. </p>
<p>Unlike legal frameworks applied to the supply of drugs, decriminalization does not promote a “safer supply” of drugs. The overdose crisis is driven by an unpredictable, illegal drug supply that is <a href="https://ccsa.ca/sites/default/files/2020-05/CCSA-CCENDU-Adulterants-Contaminants-Co-occurring-Substances-in-Drugs-Canada-Bulletin-2020-en_0.pdf">marked with adulterants, contaminants and other substances</a>. Decriminalization won’t directly impact this supply of drugs, they will continue to be made in unregulated ways and places. </p>
<p>The illegal drug market will continue to be criminalized, unpredictable and precarious, and people will continue to be unsure of what’s in their drugs (in lieu of better <a href="https://doi.org/10.1016/j.drugpo.2018.10.001">drug checking services</a> or how potent they are. Under a decriminalized model, the overdose risk will inevitably remain high.</p>
<p>That said, decriminalization is still a necessary step in addressing the crisis.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/408429/original/file-20210625-23-1srr56v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A woman holds a sign during a protest reading FOR DECRIM TO WORK WE NEED A SAFE SUPPLY" src="https://images.theconversation.com/files/408429/original/file-20210625-23-1srr56v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/408429/original/file-20210625-23-1srr56v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=405&fit=crop&dpr=1 600w, https://images.theconversation.com/files/408429/original/file-20210625-23-1srr56v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=405&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/408429/original/file-20210625-23-1srr56v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=405&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/408429/original/file-20210625-23-1srr56v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=509&fit=crop&dpr=1 754w, https://images.theconversation.com/files/408429/original/file-20210625-23-1srr56v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=509&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/408429/original/file-20210625-23-1srr56v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=509&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Advocates are calling on the federal government and the City of Vancouver to halt the march toward possible drug decriminalization in the city, saying that addressing the drug supply is also crucial.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span>
</figcaption>
</figure>
<h2>The benefits of decriminalization</h2>
<p><strong>Decriminalization changes the way we think about drugs.</strong>
Drug use will no longer be treated as a criminal issue, but instead a <a href="https://doi.org/10.1016/j.amepre.2019.08.012">health and social one</a>. This means that instead of addressing drugs through handcuffs, the focus will be on the root causes of drug use, including inequities rooted in housing and health care.</p>
<p><strong>Decriminalization saves governments money.</strong>
A large proportion of the justice system — police, courts, prisons — are occupied with <a href="https://www150.statcan.gc.ca/n1/pub/85-002-x/2020001/article/00010-eng.htm">drug-related crimes</a>. As seen in <a href="https://transformdrugs.org/blog/drug-decriminalisation-in-portugal-setting-the-record-straight">other decriminalized jurisdictions such as Portugal</a>, it can reduce the demands and costs to this system. </p>
<p>Considering the demonstrated need for addiction and mental health resources, the money saved could be well spent elsewhere, such as community-led responses, health care, housing and social programs.</p>
<p><strong>Decriminalization positively impacts people’s lives.</strong>
Especially for those targeted by drug law enforcement, namely poor, homeless and racialized people who use drugs, decriminalization can have a <a href="https://www.tni.org/files/publication-downloads/a_quiet_revolution_march_31_2016.pdf">positive impact</a>. </p>
<p>For example, eliminating <a href="https://scholar.harvard.edu/pager/publications/mark-criminal-record">criminal records</a> related to drug possession offences promotes opportunities for people to access employment and housing. Interactions between people who use drugs and police can also be reduced or, better yet, won’t happen at all.</p>
<p><strong>Decriminalization reduces stigma.</strong>
Negative views towards drugs and people who use them is a <a href="https://journalofethics.ama-assn.org/article/how-structural-violence-prohibition-and-stigma-have-paralyzed-north-american-responses-opioid/2020-08">major factor in the overdose crisis</a>. By reshaping the way our family, friends and the medical profession think about drugs, drug use can be talked about more openly and honestly. </p>
<p>Reducing stigma can also encourage people who use drugs to talk to their doctors about prescription-based therapies. At the very least, it will help bring drug use out from isolation, <a href="https://www2.gov.bc.ca/assets/gov/birth-adoption-death-marriage-and-divorce/deaths/coroners-service/statistical/illicitdrugoverdosedeathsinbc-findingsofcoronersinvestigations-final.pdf">where fatal overdoses tend to be the highest</a>.</p>
<p><strong>Decriminalization encourages people to call 911 at the scene of an overdose.</strong>
Fear of police is currently a barrier to this. Although people cannot be charged with simple possession at the scene of a drug overdose under <a href="https://www.canada.ca/en/health-canada/services/opioids/about-good-samaritan-drug-overdose-act.html">drug-related Good Samaritan laws</a>, fear of the police is still a <a href="https://doi.org/10.1016/j.drugpo.2020.103039">deterrent</a>. Legislation that decriminalizes drug possession can reassure people that they will not face criminal penalties. And police will no longer need to respond to calls about overdoses.</p>
<p><strong>Decriminalization is harm reduction.</strong>
Although some people fear that decriminalization may increase or encourage drug use, this concern is simply not supported by evidence. We know from dozens of countries, states and cities that have decriminalized drugs that <a href="https://doi.org/10.1093/bjc/azq038">use does not significantly increase</a>. In some places, <a href="https://www.tni.org/files/publication-downloads/a_quiet_revolution_march_31_2016.pdf">it has actually decreased</a>. </p>
<p>Decriminalization also lowers overdose and disease rates, while increasing people’s access to social services and health care. In this way, a decriminalization model is a basic <a href="https://journals.mcmaster.ca/ghar/article/view/2319">harm reduction</a> approach, mitigating the harms experienced by people who use drugs by eliminating or minimizing the source of those harms: criminalization. </p>
<h2>A critical step</h2>
<p>Overall, the notion of decriminalization is not a panacea or a standalone solution to the harms of drug prohibition — but it is a critical step in the right direction. It will have a positive impact on the lives of so many people who are harmed daily from criminalization.</p>
<p>However, in recognizing the <a href="https://doi.org/10.1177/07067437211019656">limitations of decriminalization models</a>, governments and other stakeholders can refocus efforts on what does directly impact the overdose crisis: a safer supply. Decriminalization must be paired with greater access to safer pharmaceutical alternatives to the toxic and illegal drug market. </p>
<p>That’s what will save lives.</p>
<p><em>Caitlin Shane, staff lawyer at Pivot Legal Society, co-authored this article.</em></p><img src="https://counter.theconversation.com/content/162497/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alissa Greer receives funding from Simon Fraser University and the Social Sciences and Humanities Research Council. Dr. Greer is an assistant professor in the School of Criminology at Simon Fraser University, a research affiliate at the Canadian Institute for Substance Use Research, and a senior associate at Bunyaad Public Affairs.</span></em></p>Decriminalization is an important step in addressing the overdose crisis, but it is crucial that other approaches — like regulation — are also in place.Alissa Greer, Assistant Professor in the School of Criminology, Simon Fraser UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1616352021-06-14T12:24:36Z2021-06-14T12:24:36ZOpioid overdoses spiked during the COVID-19 pandemic, data from Pennsylvania show<p>Since the <a href="https://doi.org/10.1056/nejmoa2001191">first diagnosed case of COVID-19 in the United States</a> on Jan. 20, 2020, news about infection rates, deaths and pandemic-driven economic hardships has been part of our daily lives. </p>
<p>But there is a knowledge gap in how COVID-19 has affected a public health crisis that existed before the pandemic: the opioid epidemic. Prior to 2020, an average of <a href="https://www.cdc.gov/drugoverdose/epidemic/index.html">128 Americans died</a> every day from an opioid overdose. That trend <a href="https://www.cdc.gov/media/releases/2020/p1218-overdose-deaths-covid-19.html">accelerated during the COVID-19 pandemic</a>, according to the Centers for Disease Control and Prevention.</p>
<p>We are a team of <a href="https://sites.psu.edu/helixlab/">health and environment geography researchers</a>. When social distancing began in March 2020, addiction treatment experts were concerned that shutdowns might result in a spike in opioid overdose and deaths. In <a href="https://doi.org/10.1177/00220426211006362">our latest research</a> in the Journal of Drug Issues, we take a closer look at these trends by examining opioid overdoses in Pennsylvania prior to and following the statewide stay-at-home order.</p>
<p>Our findings suggest that this public health response to COVID-19 has had unintended consequences for opioid use and misuse.</p>
<h2>History of the opioid epidemic</h2>
<p>Opioid misuse has been a major U.S. health threat for <a href="https://doi.org/10.2105/AJPH.2017.304187">over two decades</a>, largely affecting rural areas and white populations. However, a recent shift in the drugs involved, from prescription opioids to illegally manufactured drugs such as fentanyl, has resulted in an expansion of the epidemic in <a href="https://www.cdc.gov/nchs/data/databriefs/db403-H.pdf">urban areas</a> and among other <a href="https://doi.org/10.1016/j.drugalcdep.2020.108059">racial and ethnic groups</a>. </p>
<p>From 1999 to 2013, increasing death rates from drug abuse, primarily for those from 45 to 54 years of age, contributed to the <a href="https://www.pnas.org/content/pnas/112/49/15078.full.pdf">first decline in life expectancy</a> for white non-Hispanic Americans in decades.</p>
<p>There was a modest national <a href="https://www.drugabuse.gov/drug-topics/trends-statistics/overdose-death-rates">decline in overdose mortality from prescription opioids from 2017 to 2019</a>, but the COVID-19 pandemic has upended many of these advances. As one of our public health partners explained to us, “We were making progress until COVID-19 hit.” </p>
<p>We believe this presents an urgent need for research on the relationships between COVID-19 policy responses and patterns of opioid use and misuse.</p>
<h2>Opioid use increases during the pandemic</h2>
<p>Pennsylvania has been among the states hardest hit by the opioid epidemic. It had one of the <a href="https://www.cdc.gov/drugoverdose/data/statedeaths/drug-overdose-death-2018.html">highest rates of death due to drug overdose in 2018</a>, with 65%, <a href="https://www.drugabuse.gov/drug-topics/opioids/opioid-summaries-by-state/pennsylvania-opioid-involved-deaths-related-harms">a total of 2,866 fatalities</a>, involving opioids.</p>
<p>The state’s stay-at-home order, implemented on April 1, 2020, mandated that residents stay within their homes whenever possible, practice social distancing and wear masks when outside the home. All schools shifted to remote learning, and most businesses were required to operate remotely or close. Only essential services were allowed to continue operating in person.</p>
<p>In the following months, the public’s overall cooperation with these mandates contributed to <a href="https://www.health.pa.gov/topics/disease/coronavirus/Pages/Cases.aspx">measurable declines</a> in coronavirus infection rates. To learn how these mandates also affected people’s use of opioids, we assessed data from the <a href="https://data.pa.gov/Opioid-Related/Overdose-Information-Network-Data-CY-January-2018-/hbkk-dwy3">Pennsylvania Overdose Information Network</a> for changes in monthly incidents of opioid-related overdose before and after April 1, 2020. We also examined the change by gender, age, race, drug class and doses of naloxone administered. (Naloxone is a drug <a href="https://www.drugabuse.gov/publications/drugfacts/naloxone">widely used to reverse the effects of overdose</a>.)</p>
<p>Our analysis of both fatal and nonfatal cases of opioid-related overdose from January 2019 through July 2020 revealed statistically significant increases in overdose incidents for both men and women, among whites and Blacks, and across several age groups, most notably the 30-39 and 40-49 groups, following April 1. This means there was an acceleration of overdoses within some of the populations most affected by opioids prior to the COVID-19 pandemic. But there were also uneven increases among other groups, such as Black people.</p>
<p>We found statistically significant increases in overdoses involving heroin, fentanyl, fentanyl analogs or other synthetic opioids, pharmaceutical opioids and carfentanil. This is consistent with <a href="http://dx.doi.org/10.15585/mmwr.mm655051e1">previous research</a> on the main opioid classes contributing to increases in drug overdose and death. The results also affirm that heroin and synthetic opioids such as fentanyl are now the major threats in the epidemic. </p>
<h2>When a pandemic and an epidemic collide</h2>
<p>While we found significant change in opioid overdoses during the COVID-19 pandemic, the findings say less about some of the driving factors. To better understand these, we have been interviewing public health providers since December 2020. </p>
<p>Among the important factors they highlight as contributing to increased opioid use are pandemic-driven economic hardship, social isolation and the disruption of in-person treatment and support services.</p>
<p>From March to April 2020, unemployment rates in Pennsylvania shot up from <a href="https://www.bls.gov/lau/">5% to approximately 16%</a>, resulting in a peak of more than <a href="https://www.uc.pa.gov/COVID-19/Statistics/Pages/default.aspx">725,000 unemployment claims</a> filed in April. As workplace shutdowns made it harder to pay for housing, food and other needs, and the opportunities for in-person support disappeared, some people turned to drugs, including opioids.</p>
<p>People in the early stages of treatment or recovery from opioid addiction may be particularly vulnerable to relapse, suggested one of our public health partners. “They might be working in industries that are closed down, so they have financial problems … [and] they have their addiction issues on top of that, and now they can’t like go to meetings, and they can’t make those connections.” (Under our clearance with Penn State for doing research with human subjects, our public health informants are kept anonymous.)</p>
<p>[<em>Like what you’ve read? Want more?</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=likethis">Sign up for The Conversation’s daily newsletter</a>.]</p>
<p>An addiction treatment counselor told us that especially for those with past or present opioid use problems, or histories of mental health issues, “It’s not a good thing to be alone in your own thoughts. And so, once everybody was kind of locked down … the depression and anxiety hit.”</p>
<p>Another counselor also pointed to depression, anxiety and isolation as driving increased opioid misuse. The pandemic “just spun everything out of control,” they said. “Overdoses up, everything up, everything.”</p>
<p>One question is whether states like Pennsylvania will continue to support telehealth in the future. While the transition from in-person to telehealth services <a href="https://doi.org/10.1177/2374373520948436">has increased access to treatment</a> for some, it has raised challenges for populations like the rural and elderly. As one provider explained, “it’s really hard for that [rural] population out there” to utilize telehealth services due to limited internet and broadband connection. In other words, flexible modes of addiction treatment might work for some but not others.</p>
<p>The goal of our research is not to criticize efforts to mitigate the spread of COVID-19. Without the mandatory stay-at-home order in Pennsylvania, both infection and death rates would have been worse. However, our research shows that such measures have had unintended consequences for those struggling with addiction and emphasizes the importance of taking a <a href="https://theconversation.com/addiction-treatment-shrinks-during-the-pandemic-leaving-people-with-nowhere-to-turn-143731">holistic approach to public health</a> as policymakers work to confront both COVID-19 and the addiction crisis in America.</p><img src="https://counter.theconversation.com/content/161635/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Brian King has received funding from the National Science Foundation. </span></em></p><p class="fine-print"><em><span>Andrea Rishworth and Ruchi Patel do not work for, consult, own shares in or receive funding from any company or organization that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The start of one new public health crisis didn’t mean the end of another.Brian King, Professor, Department of Geography, Penn StateAndrea Rishworth, Postdoctoral Fellow in Geography, McMaster UniversityRuchi Patel, Ph.D. Student in Geography, Penn StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1537612021-03-15T12:53:31Z2021-03-15T12:53:31ZHip-hop professor looks to open doors with world’s first peer-reviewed rap album<figure><img src="https://images.theconversation.com/files/388885/original/file-20210310-15-189tilm.jpg?ixlib=rb-1.1.0&rect=0%2C41%2C1997%2C1227&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Hip-hop professor A.D. Carson</span> <span class="attribution"><span class="source">Dan Addison</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>As a rap artist who is also a professor of hip-hop, I always make it a point to have my songs reviewed by other artists I admire.</p>
<p>So when I released “<a href="https://doi.org/10.3998/mpub.11738372">i used to love to dream</a>” – my latest album – in 2020, I turned to Phonte Coleman, one half of the <a href="https://www.vulture.com/2019/11/little-brother-interview-phonte-big-pooh-drake-influence-reunion.html">trailblazing</a> rap group Little Brother.</p>
<p>“Just listened to the album. S— is dope!” Phonte texted me after he checked it out. “Salute!”</p>
<p>I responded with sincere appreciation for his encouraging words. I told him they meant a lot to me, especially coming from him. </p>
<p>“Nah, bro. The bars are on point,” he replied. “Much love and respect.”</p>
<p>This informal conversation with a <a href="https://www.xxlmag.com/whos-drakes-favorite-rapper-like-for-real/">highly esteemed rapper</a> – one whose work I’ve studied and hold in high regard – is perhaps the most resounding affirmation I can ask for as an artist.</p>
<p>The situation is similar in academia. That is, in order to establish oneself as a serious scholar, an academic must get their work – typically some sort of written product – published in a peer-reviewed journal, which is a journal in which works are evaluated by others in a given field to ensure their relevance and quality.</p>
<p>As a rap artist and academic, I wondered if I could do the same thing with my new album. Could I get my album “published” through an academic press?</p>
<p>Thankfully, I have discovered that the answer was “yes.”
In August 2020, my album became what Michigan Publishing described as the “<a href="https://www.publishing.umich.edu/stories-of-impact/rethinking-peer-review">first ever peer-reviewed rap album published by a university press</a>.” This is a development that I believe could open doors for scholars from all kinds of different backgrounds – including but not limited to hip-hop scholars – to contribute new forms of knowledge.</p>
<h2>New methods</h2>
<p>“With this new form of scholarship comes a new approach to the peer review and production process,” the University of Michigan Press <a href="https://www.publishing.umich.edu/stories-of-impact/rethinking-peer-review">stated</a> in an article about my work.</p>
<p>But in order to get a peer-reviewed rap album, it’s not like I just went into the studio, rapped over some beats and hoped for the best. I presented liner notes and created a documentary about how I made the album, which I refer to as a “mixtap/e/ssay” – an amalgamation of the words “<a href="https://artists.spotify.com/blog/the-significance-of-the-mixtape-in-the-streaming-era">mixtape</a>,” which is a sampling of an array of select songs, and “essay.” I also submitted articles that help explain how the music relates to certain academic conversations, events in society and my own life.</p>
<figure class="align-left ">
<img alt="A man records an album next to a microphone." src="https://images.theconversation.com/files/388887/original/file-20210310-23-1fd83rx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/388887/original/file-20210310-23-1fd83rx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=305&fit=crop&dpr=1 600w, https://images.theconversation.com/files/388887/original/file-20210310-23-1fd83rx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=305&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/388887/original/file-20210310-23-1fd83rx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=305&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/388887/original/file-20210310-23-1fd83rx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=383&fit=crop&dpr=1 754w, https://images.theconversation.com/files/388887/original/file-20210310-23-1fd83rx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=383&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/388887/original/file-20210310-23-1fd83rx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=383&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">‘i used to love to dream’ is a semi-autobiographic take on Carson’s life growing up.</span>
<span class="attribution"><span class="source">Amy Jackson</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>For instance, since the album is semi-autobiographical and I am from Decatur, Illinois, I note how in May 2020, my hometown was listed as America’s <a href="https://www.census.gov/newsroom/press-releases/2020/south-west-fastest-growing.html">third-fastest shrinking city</a>. Since my album deals with Black life, I note how USA Today ranked Decatur as one of “<a href="https://www.usatoday.com/story/money/2018/11/16/racial-disparity-cities-worst-metro-areas-black-americans/38460961/">the 15 worst cities in America for Black people</a>” in terms of various metrics, such as household income, educational attainment, homeownership, incarceration and life spans.</p>
<p>My album – which is free and open source – deals with topics that range from race and justice to identity and citizenship.</p>
<iframe style="border: 0; width: 500px; height: 406px;" src="https://bandcamp.com/EmbeddedPlayer/album=734046536/size=large/bgcol=333333/linkcol=0f91ff/artwork=small/transparent=true/" seamless="" width="100%" height="400"><a href="https://aydeethegreat.bandcamp.com/album/i-used-to-love-to-dream">‘i used to love to dream’ by A.D. Carson.</a></iframe>
<h2>Confronting societal ills</h2>
<p>In the lyrics, I reflect from where I am now – in my career as an assistant professor of hip-hop at the University of Virginia in Charlottesville – on my memories growing up and living in the central Illinois town. </p>
<p>The content of the album demonstrates this, covering issues like the war on drugs and its legacy in the 1980s and 1990s and contrasting it with the current opioid crisis on the song “<a href="https://doi.org/10.3998/mpub.11738372.cmp.7">crack, usa</a>”; the seeming inevitability of police killings of Black people and how we might prepare ourselves and our loved ones on “<a href="https://doi.org/10.3998/mpub.11738372.cmp.8">just in case</a>”; and the trap of incarceration and institutionalization presented on “<a href="https://doi.org/10.3998/mpub.11738372.cmp.10">nword gem</a>.” It also provides space for processing mental health matters like trauma, alienation, alcoholism and depression with tracks like “<a href="https://doi.org/10.3998/mpub.11738372.cmp.6">ampersand</a>,” “<a href="https://doi.org/10.3998/mpub.11738372.cmp.9">stage fright</a>” and “<a href="https://doi.org/10.3998/mpub.11738372.cmp.12">asterisk</a>.”</p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/2HBw0Wpka5o?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>I published my album with University of Michigan Press because I believe it’s important that hip-hop – and hip-hop scholarship – occupies a space that’s not an “exotic other” and, instead, functions as a way of knowing, similar to, but distinct from, other resources such as a peer-reviewed paper or book.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/380300/original/file-20210123-17-1blrlbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A group of students sit on desks while using their laptops in a classroom." src="https://images.theconversation.com/files/380300/original/file-20210123-17-1blrlbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/380300/original/file-20210123-17-1blrlbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/380300/original/file-20210123-17-1blrlbw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/380300/original/file-20210123-17-1blrlbw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/380300/original/file-20210123-17-1blrlbw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/380300/original/file-20210123-17-1blrlbw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/380300/original/file-20210123-17-1blrlbw.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">Professor A.D. Carson and students in the Rap Lab at the University of Virginia.</span>
<span class="attribution"><span class="source">Miguel 'MiG' Martinez</span>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>In order to review my album as an academic work, the academic publisher had to “come up with appropriate questions for the evaluation of a sonic, rather than written, work.”</p>
<p>“The press’s standard peer review questions consider purpose, organization, and audience,” the University of Michigan Press has <a href="https://www.publishing.umich.edu/stories-of-impact/rethinking-peer-review">stated</a>. “While many of those general themes were captured in the questions developed for ‘i used to love to dream,’ the process for coming up with new questions was much more collaborative.”</p>
<h2>Is higher ed ready?</h2>
<p>I must admit – both before and during my doctoral studies – I was skeptical of the formal peer-review process. My thought was, what is the university to ask hip-hop to prove itself?</p>
<p>But my skepticism faded once I saw the responses from the anonymous scholars who reviewed my album. Based on their insightful feedback, I got the sense that they truly understood Black music and Black rhetoric. They encouraged me to consider how to present the album online in a way that would help audiences better understand the content, which is part of the reason I included the <a href="https://doi.org/10.3998/mpub.11738372.cmp.4">short documentary</a> about the making of the album.</p>
<p>[<em>Get the best of The Conversation, every weekend.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklybest">Sign up for our weekly newsletter</a>.]</p>
<p>This is not my first academic foray using rap. I actually <a href="https://www.npr.org/2017/07/15/537274235/after-rapping-his-dissertation-a-d-carson-is-uvas-new-hip-hop-professor">earned my Ph.D.</a> for writing a <a href="http://phd.aydeethegreat.com">rap album</a>.</p>
<p>I appreciate that hip-hop is sometimes celebrated in the academic world, but it seems to me that a lot of the excitement focuses on hip-hop as a particular kind of content rather than what it teaches people about other things in the world, many of which aren’t hip-hop.</p>
<p>For me, hip-hop is like a telescope, and the topics I discuss are like celestial bodies and galaxies. Taking that astronomical analogy a step farther, I would ask: Does it make sense to spend more time talking about the telescope that brought those faraway objects into focus and a sharper view? Or should more time be devoted to discussing the actual phenomena that the telescope enables people to see?</p>
<p>I can fully understand and appreciate how hip-hop – being not just a telescope but a powerful telescope – would generate a fair amount of discussion as a magnifier. At the same time, at some point society should be able to both focus on the potency of the lens of hip-hop and also concentrate on what hip-hop brings into view.</p><img src="https://counter.theconversation.com/content/153761/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>A.D. Carson 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>Can college professors rap their way into academic publishing? One professor makes an album to prove they can.A.D. Carson, Assistant Professor of Hip-Hop, University of VirginiaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1486042020-10-21T23:24:02Z2020-10-21T23:24:02ZOxyContin maker Purdue Pharma may settle legal claims with a new ‘public trust’ that would still be dedicated to profit<figure><img src="https://images.theconversation.com/files/364832/original/file-20201021-23-1j1jhkj.jpg?ixlib=rb-1.1.0&rect=496%2C229%2C5636%2C3723&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Deputy Attorney General Jeffrey A. Rosen announced a settlement between the Justice Department and opioid maker Purdue on Oct. 21.</span> <span class="attribution"><a class="source" href="https://newsroom.ap.org/detail/USOpioidCrisisPurduePharma/d69562dc33ef441d83f32833f91c4d57/photo?boardId=37be9465fcce45d283d5431cccb20a6a&st=boards&mediaType=audio,photo,video,graphic&sortBy=&dateRange=Anytime&totalCount=36&currentItemNo=2">Yuri Gripas/Pool via AP</a></span></figcaption></figure><p>Purdue Pharma, the company that makes OxyContin and other potentially addictive prescription opioids, has agreed to plead guilty to three felony counts and reached a settlement potentially worth at least <a href="https://apnews.com/article/virus-outbreak-business-criminal-investigations-opioids-epidemics-5f0679ffee14577b1696a94b64abc9c2">US$8.3 billion</a> with the Justice Department.</p>
<p>The deal could clear the way for Purdue to transform from a profit-seeking privately held company into a <a href="https://www.npr.org/2020/10/21/926126877/purdue-pharma-reaches-8b-opioid-deal-with-justice-department-over-oxycontin-sale">public trust</a> that serves the public good, as the company <a href="https://www.npr.org/2019/08/28/755177086/purdue-pharma-considers-converting-to-a-public-trust-amid-lawsuits-over-opioid-c">has proposed</a>.</p>
<p>But the settlement is <a href="https://www.npr.org/2020/10/21/926126877/purdue-pharma-reaches-8b-opioid-deal-with-justice-department-over-oxycontin-sale">subject to the approval of the federal judge</a> overseeing <a href="https://www.vox.com/policy-and-politics/2019/9/16/20868487/purdue-pharma-oxycontin-bankruptcy-opioid-epidemic">Purdue’s bankruptcy case</a>. And it may not resolve the <a href="https://theconversation.com/why-companies-file-for-bankruptcy-and-how-it-protects-both-debtors-and-creditors-113101">thousands of lawsuits</a> Purdue faces for its role in creating the <a href="https://theconversation.com/us/topics/opioid-crisis-41093">opioid crisis</a>. Notably, the <a href="https://www.reuters.com/article/uk-purdue-pharma-opioids-investigations/u-s-states-oppose-settlement-being-negotiated-by-oxycontin-maker-purdue-and-justice-department-letter-idUSKBN26Z2WL">attorneys general from 25 states</a> called on the government a week before the Justice Department announced the deal to simply force the sale of the drugmaker to a new owner instead. </p>
<p>I study the <a href="https://www.davidherzberg.com/">history of prescription drugs</a> (and I have served as a paid consultant and expert witness in opioid litigation). Although there are some recent efforts to <a href="https://theconversation.com/nonprofit-drugmaker-civica-rx-aims-to-cure-a-health-care-system-ailment-104744">establish nonprofit drugmakers</a> to help make <a href="https://theconversation.com/theres-a-way-for-modern-medicine-to-cure-diseases-even-when-the-treatments-arent-profitable-122294">certain pharmaceuticals</a> more readily available, I know of no historical precedent for a big drugmaker like Purdue becoming a nonprofit public health provider.</p>
<p>But two similarly ambitious efforts to build alternatives to the profit-driven pharmaceutical model during and immediately after World War II suggest the potential limits of how well this arrangement might work.</p>
<h2>Antibiotics</h2>
<p>Penicillin was <a href="https://www.sciencehistory.org/historical-profile/alexander-fleming">discovered in 1928</a> but <a href="https://www.pbs.org/newshour/health/the-real-story-behind-the-worlds-first-antibiotic">did not come into use until World War II</a>. It was the first antibiotic: a genuinely revolutionary class of drugs that vanquished previously incurable infectious illnesses.</p>
<p>Because of penicillin’s importance for the war effort, the federal government played an active role in its development. <a href="https://www-jstor-org.gate.lib.buffalo.edu/stable/24623264?seq=24#metadata_info_tab_contents">Federal scientists</a> developed ways to mass-produce it, federal agencies persuaded reluctant pharmaceutical companies to manufacture it and the government’s “<a href="https://doi.org/10.1080/08998280.1988.11929660">penicillin czar</a>” decided which patients would receive the precious drug. </p>
<p>Despite the high stakes and the faith in centralized planning, no one at that time appears to have even considered the possibility of noncommercial or nonprofit development of antibiotics.</p>
<p>As was the case with wartime goods such as rubber and tanks, <a href="http://www.pbs.org/thewar/at_home_war_production.htm">private companies with federal contracts</a> made penicillin. As was also the case with other wartime goods, the arrangement was an unqualified success. It dramatically increased production, and allocated the antibiotic so as to best serve the war effort.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=371&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=371&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=371&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=466&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=466&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303853/original/file-20191126-112539-1kqd8cd.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=466&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A capsule of original penicillin mold from which Alexander Fleming made the drug in 1928.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Britain-Penicillin-Mold/ed84ae41f06145cba41990abd847e6ec/9/0">AP Photo/Alastair Grant</a></span>
</figcaption>
</figure>
<p>For penicillin, as with other goods, federal economic controls quickly faded after the war. As the medical historian <a href="https://ghsm.hms.harvard.edu/faculty-staff/scott-harris-podolsky">Scott Podolsky</a> has observed, drugmakers, freed from government restraints, unleashed an avalanche of brand-name antibiotics whose high-powered marketing campaigns encouraged the <a href="https://jhupbooks.press.jhu.edu/title/antibiotic-era">overuse and misuse of the new medicines</a>.</p>
<p>Interestingly, the Sackler brothers got their start by <a href="https://www.politico.com/magazine/story/2017/12/28/raymond-sackler-obituary-216185">selling antibiotics</a>. The Sacklers, future owners of Purdue Pharma, were pioneers of medical advertising who abandoned earlier restraints and advised their sales representatives to see physicians as “<a href="http://www.doi.org/10.1056/NEJMp1902811">prey</a>.”</p>
<p>The Veterans Administration and the Public Health Service sought to keep their hands on the steering wheel by undertaking massive studies of the new, even mightier <a href="https://www.cambridge.org/us/academic/subjects/history/history-medicine/progress-experiment-science-and-therapeutic-reform-united-states-19001990">antibiotic streptomycin</a> to determine how best to use the drug against one of humanity’s deadliest microbial foes, tuberculosis. But their calls for precision and restraint stood little chance against drug marketers who skillfully exploited Americans’ desire for miracles. </p>
<h2>Metopon</h2>
<p>The second precedent involved the <a href="https://history.nih.gov/exhibits/opiates/docs/3_newDrugs.htm">semi-synthetic opioid Metopon</a>, discovered during World War II by <a href="https://www.jstor.org/stable/236321?seq=1#metadata_info_tab_contents">pharmacologists working for the U.S. National Research Council</a>.</p>
<p>Since the 1920s, opioids had been much more strongly regulated than other pharmaceuticals to <a href="https://theconversation.com/purdue-pharma-taps-a-gilded-age-history-of-pharmaceutical-fraud-112363">protect consumers</a>. As I explain in my new book “<a href="https://press.uchicago.edu/ucp/books/book/chicago/W/bo58927880.html">White Market Drugs</a>,” they could be sold only by a licensed pharmacist on a physician’s prescription. For decades, the Federal Bureau of Narcotics, working with <a href="https://tethys.pnnl.gov/institution/national-research-council-national-academies-nrc">National Research Council</a> pharmacologists, imposed tight restrictions on the development and marketing of new opioids.</p>
<p>It was a daily battle for these government agencies to identify and then counteract what they considered to be dangerous marketing hype by drug companies pushing the latest miracle opioid.</p>
<p>So, daringly, in 1946, the two agencies hatched a radical idea: They would take out a patent on Metopon and market it themselves. Instead of trying to achieve maximum profit, they would only serve public health. They would not advertise Metopon at all. Instead physicians would learn about it through sober, informative pronouncements from experts in medical journals. Moreover, sales would initially be restricted to patients suffering from end-stage cancer. </p>
<p>The government believed Metopon would win out over competitors not because of marketing hype but because it was actually superior. But it didn’t work out that way.</p>
<p>Sales were sluggish after Metopon’s launch in 1947, and remained low even after the authorities allowed sales for more types of pain. Even <a href="https://theconversation.com/re-criminalizing-cannabis-is-worse-than-1930s-reefer-madness-89821">Harry Anslinger</a>, head of the Federal Bureau of Narcotics and an otherwise ferocious critic of pharmaceutical opioid advertising, complained about lackluster marketing. While it remained technically available, Metopon never earned more than a minute fraction of the U.S. opioid market.</p>
<h2>New ownership</h2>
<p>The proposed transformation of Purdue differs from these earlier attempts to find alternatives to the profit-driven model of drug distribution.</p>
<p>Rather than attempting to get profit-making companies to do the right thing, or hoping that a single ethically marketed drug could win out, the Purdue settlement would legally require a major pharmaceutical manufacturer to make public health a higher priority than shareholder profits.</p>
<p>This would, at least in theory, serve two important goals.</p>
<p>First, by legally defining the company’s obligations to public health rather than to shareholders, it would eliminate the kinds of abuses that can result from the pursuit of profit such as marketing that encourages unnecessary or improper use.</p>
<p>Second, by providing addiction treatment at no cost, it would increase access to health care to the sorts of patients – addicted, poor and lacking adequate health insurance – typically ill served or even ignored in today’s system.</p>
<p>In other ways, however, the Purdue settlement seems less of a departure from standard operating procedures than 1940s-era attempts to reduce or eliminate the influence of profit in pharmaceuticals.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/303849/original/file-20191126-112489-11u0je1.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">Emergency responders use this drug to treat narcotic overdoses.</span>
<span class="attribution"><a class="source" href="http://www.apimages.com/metadata/Index/Opioid-Crisis-Purdue/2fd3d7f1b2ef4266b26dfd57af939e3e/5/0">AP Photo/Keith Srakocic</a></span>
</figcaption>
</figure>
<p>By all accounts, the new trust would be a for-profit entity. Indeed, profits from continued sales of pain medicines like OxyContin and addiction treatment medications like <a href="https://www.drugs.com/mtm/buprenorphine-and-naloxone-oral-sublingual.html">buprenorphine and naloxone</a> – <a href="https://www.washingtonpost.com/business/economy/sackler-legacy-is-at-stake-in-familys-bid-to-reinvent-purdue-pharma-as-a-public-trust/2019/11/05/479ea040-ee91-11e9-b648-76bcf86eb67e_story.html">estimated by Purdue to be up to $8 billion</a> per year – are crucial as the “payment” Purdue is offering to compensate the public for the company’s share of the costs of the opioid crisis.</p>
<p>In other words, to achieve its mission, the new Purdue would have to pursue profits just like the old Purdue. And since all pharmaceutical companies officially declare themselves to be dedicated to serving the public good, how different would it really be?</p>
<p>Then, too, the new trust would still be Purdue Pharma, a company with a well-entrenched culture of <a href="https://khn.org/news/purdue-and-the-oxycontin-files/">maximizing sales and profits</a> even as the opioid crisis has grown. One could make a <a href="https://jhupbooks.press.jhu.edu/title/drug-dealer-md">credible case</a> that Purdue’s innovation – the “value” it brought to the table – was not related to any special therapeutic breakthrough in the drugs it developed but instead lay in its genius with marketing these products.</p>
<p>[<em>Deep knowledge, daily.</em> <a href="https://theconversation.com/us/newsletters/the-daily-3?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=deepknowledge">Sign up for The Conversation’s newsletter</a>.]</p>
<p>I can see why it is tempting to be excited about the prospect of a new public trust devoted to addressing addiction.</p>
<p>But for this proposed arrangement to make sense, Purdue would need the tools and expertise required to pursue a radically different mission than it was designed to serve. And history does not offer much assurance that isolated public-sector and nonprofit drugmakers can make a big difference in a pharmaceutical system designed for and powered by profit.</p>
<p><em>This is an updated version of an article originally published on <a href="https://theconversation.com/the-company-that-makes-oxycontin-could-become-a-public-trust-what-would-that-mean-126981">December 4, 2019</a>.</em></p><img src="https://counter.theconversation.com/content/148604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>David Herzberg was retained as a paid expert witness for the plaintiffs in opioid litigation.</span></em></p>The government has tried to harness profit-driven drugmaking to serve public health before. The results were underwhelming.David Herzberg, Associate Professor of History, University at BuffaloLicensed as Creative Commons – attribution, no derivatives.