The prescription opioid epidemic in a nutshell

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lobelsteve said:
http://onlinelibrary.wiley.com/doi/10.1111/papr.12176/abstract?campaign=woletoc

Sorry 101.
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I think that it's interesting that "cynicism" is a negative prognostic indicator for treatment outcome in chronic opioid therapy and should not be poo-poo'd. There's something particularly "soul-sucking" about some patients with chronic pain that make them difficult to deal with in the clinic. I hope that other groups follow-up this finding.

I think that elevated cynicism scores could potentially be a more useful stratification tool than the ORT, SOAPPR, etc--especially in Medicaid population. I might consider making one condition of treatment be that the patient feels optimistic about success. It could also be a proxy, biomarker, or psychological "sed rate" for adverse selection, terribly sad-life syndrome, external locus of control, etc. I would suspect that highly cynical chronic pain patients are also more likely to sue in the event of a bad outcome.
 
As a side note, my experience with the Medicaid population is that opioid therapy is the only treatment they are not cynical about...
 
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http://www.bendbulletin.com/localstate/2970971-151/oregon-working-to-lower-heroin-overdose-deaths#

"...Conventional wisdom has largely settled on one narrative to explain the rise in heroin-related deaths: As painkillers containing synthetic opioids rose in prevalence, widespread abuse of prescription drugs followed. When federal law enforcement began cracking down on prescription pill abuse, users craving an opioid high often turned to heroin when painkillers were unavailable. This often resulted in fatal overdoses, particularly when black tar heroin, a particularly strong narcotic imported from Mexico, was involved.

That’s part of the story, said Millet, but there’s not as much crossover between prescription painkillers and heroin as people think. Yes, the medical community in Oregon has reconsidered the appropriate doses and lengths of time for people to take opioid painkillers, but other factors have helped reduce Oregon’s heroin fatalities, she said.

First, Oregon removed methadone as a preferred drug administered during heroin detox for Medicaid patients, and saw a quick drop in fatalities, she said. Particularly when used as a prescription painkiller, methadone can build up in the body and lead to slowed breathing and disrupted heart rhythms, according to the CDC..."

  • Oregon continues to mis-manage its State and Federal Medicaid funds paying for naturopathic medicine, massage, acupuncture, and other useless modalities in lieu of bona fide pain management.
  • Oregon continues to not fund treatment for opioid addiction.
  • Oregon continues to promote dangerous fail-first algorithms and arduous pre-authorization red-tape for safer medication substitution therapies like ADF buprenorphine/naloxone
 
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High risk afternoon:



older patients.JPG
 
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http://www.wsj.com/articles/heroin-laced-with-additive-more-widespread-dea-finds-1426705286

Heroin Laced With Additive More Widespread, DEA Finds
Synthetic opiate fentanyl increases strength of heroin, results in more fatal overdoses
By
ANDREW GROSSMAN
March 18, 2015

WASHINGTON—Drug dealers are increasingly adding a powerful anesthetic to heroin to increase its effect, contributing to deaths throughout the U.S., the Drug Enforcement Administration said Wednesday.

In recent months, the agency has found more heroin laced with fentanyl, which is typically used to treat severe pain in people with chronic illness. Fentanyl and similar compounds can be up to 50 times as potent as heroin. It has become a powerful additive for drug dealers and traffickers looking to increase the strength of their product. It also means it can more easily cause fatal overdoses.

The rise in fentanyl use in some ways represents the latest escalation in a wave of opiate abuse that has swept the U.S. in the past decade. It started with more common prescription painkillers, but government crackdowns made those harder to get. That drove some users to heroin, which in many cases was cheaper and more available. Now fentanyl makes that heroin go further.

The DEA on Wednesday warned law enforcement agencies around the country that they, too, could be in danger from fentanyl when they’re making drug busts, since it can be accidentally inhaled or absorbed through the skin.

Last year, law enforcement found 3,344 samples of drugs containing fentanyl, more than triple the total in 2013.

“Drug incidents and overdoses related to fentanyl are occurring at an alarming rate throughout the United States and represent a significant threat to public health and safety,” said Michele Leonhart, the DEA administrator.

Not all fentanyl use is illicit. There were 6.6 million U.S. prescriptions for the drug in 2014, according to the DEA. Cancer patients suck on fentanyl lozenges to treat spikes in pain. People with chronic pain are sometimes prescribed fentanyl patches.

But legal fentanyl is sometimes diverted or stolen. Some people intentionally abuse fentanyl, cutting up patches and putting them under their tongues. In many other cases, it is added to heroin without the drug user’s knowledge.

At a Senate hearing last week, Ms. Leonhart pointed to fentanyl as a key driver of a doubling in the number of heroin-related deaths in Maryland last year.

“We’re looking at those deaths, and we’re finding that a number of them are actually fentanyl-laced heroin overdoses,” she said.

Hundreds of deaths in Pennsylvania over the past two years have also been linked to fentanyl, with users in some cases injecting pure forms of the drug.

In addition to fentanyl diverted from legitimate uses, the DEA is also worried about labs that make similar compounds on their own. Mexican law enforcement has seized a number of such labs there. U.S. law enforcement has also been making an increasing number of arrests of alleged heroin dealers and finding fentanyl-laced drugs in their possession.

Last year, DEA agents in New York arrested two men linked to three overdose deaths. Their product, which was branded Breaking Bad, in an apparent reference to the popular TV series, turned out to be a mixture of heroin, quinine and fentanyl, according to the DEA.
 
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Ducttape said:
Um... No...
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Maybe got my dates off by a few years...http://www.medscape.com/viewarticle/837417

2006 was the big year with 1000s of deaths from this.

But I recall hearing about this before I became a doctor growing up in the Phila suburbs. And I am correct so.

SO ducttape: Nana booboo, stick your head in dodo, I am better than you dude.

http://www.nytimes.com/1991/02/04/nyregion/toxic-heroin-has-killed-12-officials-say.html

http://articles.baltimoresun.com/1992-03-12/news/1992072009_1_fentanyl-heroin-synthetic-drugs
 
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yes, but use of "Tango and Cash" dropped significantly after 1993, and wasnt reported to reoccur until recently. the reason:

http://articles.courant.com/1993-02...yl-christopher-moscatiello-federal-drug-agent

Stalking A `Serial Killer' Narcotic From Boston To Wichita
Stalking A `Serial Killer' Narcotic
February 23, 1993|By EDMUND MAHONY; Courant Staff Writer
Last December, a drug dealer from Boston named Christopher Moscatiello let slip a comment that would prove invaluable to police in Hartford and every other big city in the Northeast.

It was just small talk, part of the prattle around a drug sale by Moscatiello to a man he didn't know was a federal drug agent. Moscatiello was peddling an incredibly potent form of synthetic heroin called fentanyl. He remarked in passing that his supplier had nearly died the previous summer in Wichita, Kan., by inhaling fentanyl vapors.

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The offhand allusion to Wichita by Moscatiello -- who was found dead this month tied up and shot twice in the skull -- was the piece of information the U.S. Drug Enforcement Administration needed to unravel a deadly mystery that had frustrated narcotics detectives for nearly two years.

At least 126 people from around the Northeast have died from overdoses of fentanyl, a designer drug so powerful that a speck the size of a grain of sand, when ingested, can kill someone instantly by shutting down his respiratory system.

In some cases it has been found to be 400 times more powerful than pure heroin. Junkies who shoot it are routinely found dead with syringes still stuck in their arms. The DEA had no idea where the fentanyl was coming from.

On Feb. 4, nearly two years to the day after fentanyl began pouring into East Coast cities, poisoning addicts and engaging emergency rooms with overdose cases, DEA agents used Moscatiello's tip to descend upon suburban Wichita and shut down the only lab in the country manufacturing what DEA administrator Robert C. Bonner called "the serial killer of the drug world."

The same day, the agents charged a couple of odd Kansas scientists with running the lab and selling the fentanyl. George V. Marquardt, 46, schoolboy science prodigy and self-described genius who in the 1970s devoted himself to creating the perfect hallucinogen, was arrested and accused of manufacturing fentanyl. Phillip S. Houston, 45, a geologist with a homemade astronomical

observatory, was charged with distributing the drug.

In recent weeks, government chemists have compared fentanyl taken from Marquardt's lab with samples bought over the past two years by undercover agents or taken from the bodies of dead addicts. They match. The DEA now believes it can link most, if not all, of 126 deaths over two years to the Wichita lab.

Two of those deaths were in Hartford, which, like other cities between Boston and Washington, staggered under what seemed to be a synchronized assault by fentanyl dealers on Saturday, Feb. 2, 1991.

Sam Theodore Jackson was the first to die. Hartford detectives found him slumped on a sofa in an apartment on Hampton Street. The police mentally marked him as another inexplicable death and watched as the body was carted to the morgue. Back at the police station, however, the detectives realized there was something more to Jackson's death.

"The first one started as an untimely death," said one detective. "Then we started realizing over time that we had all these OD's happening. They had been happening the night before and they continued the next day. It was a wild time."

That Sunday morning, Charles Logan was found dead, sitting in a vacant store on Center Street, a syringe dangling from a vein. By then, police had identified the killer as fentanyl. Officers with bullhorns roamed the city warning drug users that a lethal drug was for sale on the street.

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The warning backfired. Addicts poured into the streets, hoping to buy an unusually potent high. Ambulances charged around the city, taking 28 overdose cases to emergency rooms. By Sunday night, police believed fentanyl was responsible for 11 deaths in Connecticut, New York and New Jersey and hundreds more near-deaths.

Hartford police later arrested a city man they believe provided the fentanyl that killed Logan. They suspect the fentanyl was purchased at an open-air drug market in the Bronx, a kind of regional wholesaler to dealers from cities around the Northeast. The Hartford dealer was sentenced to 10 years in prison. Prosecutors had hoped to charge him with causing Logan's death but were unable to do so because of a defect in state narcotics laws. They would have had to show the victims had no other drugs in their bodies at the time they ingested the fentanyl.

It is unclear why there was such a rash of deaths attributed to fentanyl in early February 1991.

Chances are, DEA agents said, addicts who bought fentanyl from street dealers thought they were getting their usual fixes of regular, organic heroin. Both organic heroin and its synthetic cousin fentanyl are white, powdery substances that act on the central nervous system and gastrointestinal tract, causing a rush of euphoria when injected.

Both are sold on the street in small bags and are marketed under flashy street names by dealers. The deadly fentanyl that circulated in Hartford was called Tango and Cash after a then-popular movie. In New York, it was called Goodfellas.

The difference between heroin and fentanyl is potency. Fentanyl, a narcotic analgesic, was developed in the 1960s for legitimate use as an intravenous anesthetic. Substances used in the manufacture are legally available, and in the late 1970s underground laboratories began producing it illegally for the heroin market, the DEA said. The drug agency said Marquardt made two kinds of fentanyl: one 80 times more powerful than heroin and

one 400 times more powerful.

What makes illegally produced fentanyl so lethal are flaws in the dilution of chemicals during the manufacturing process, said James Seward, an agent in the DEA's Pittsburgh office. DEA chemist Jack Fasano said in court documents that Marquardt had state-of-the-art manufacturing equipment, including a $10,000, 10-liter rotary evaporator that a distributor bought him to use in the dilution process. But other agents said something nonetheless went wrong.

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"Improper dilution is deadly," Seward said.

Once manufactured, fentanyl is further diluted by using cutting agents such as powdered sugar, much like organic heroin is cut. But if the manufacturing process is flawed, "there is no good way to cut it," Seward said.

There is nothing difficult, however, about making money from fentanyl, Seward said. It costs about $2,000 to make a kilogram. If sold as heroin, the same kilogram can fetch up to $200,000, he said.

After the first spate of deaths and overdoses, the DEA and city police departments struggled to determine the source of the lethal fentanyl. But the work was not paying off. Drug users continued to die up and down the East Coast, in Connecticut, Delaware, Massachusetts, Maryland, New Jersey, New York, Pennsylvania, South Carolina and Virginia. Thirty-five deaths occurred in Philadelphia alone.

Undercover drug agents routinely try to buy narcotics from drug dealers as part of any investigation. But in the fentanyl case, agents also began tracing the purchase of what they call fentanyl precursors -- the chemicals needed to manufacture the synthetic heroin.

Both investigative strategies led to Mascatiello. He was buying fentanyl precursors for reasons that are still unclear, DEA agents said. But more important, he sold agents at least 3 grams of the 37 pounds of fentanyl that the DEA ultimately seized in the Boston area as part of the investigation. It was during a sale in December that Moscatiello described how his supplier nearly died in Wichita the previous summer.

The mention of Wichita was puzzling. There was no fentanyl problem in the Midwest. But Barry Jamison, the agent who runs the DEA office in Wichita, said his office took the information from Boston and checked emergency calls, ambulance runs and hospital admissions, looking for a summertime drug overdose in the Wichita area.

The routine records check led the agents to Joseph Martier, 42, of Pittsburgh. The name rang a bell. Martier had been sentenced to 15 years in prison after being caught in 1979 with 50 pounds of PCP, another illegal synthetic drug. He served five.

Rescue workers told the agents that Martier collapsed from vapors he inhaled at a makeshift laboratory in the Goddard Industrial Park in suburban Wichita. It was registered to a Marquardt-owned company called Prarielabs.

Agents found all the trappings of a large-scale fentanyl manufacturing operation at the industrial park, enough evidence to permit them to raid the Wichita homes of Marquardt and Thompson. They found a smaller-scale lab in Marquardt's home, along with a small amount of fentanyl. They found 3 ounces of fentanyl hidden in a videotape cassette in Thompson's home.

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Marquardt provided information that permitted the DEA to arrest two other men suspected of being major fentanyl distributors: Martier and a New York man named Benito Febre, who operated under the alias Brooklyn Bob. The agents tried to arrest Moscatiello, but found he had been shot to death two days earlier. DEA agents in Boston will not elaborate on the murder, other than to say he was found shot in the head with his hands tied behind his back.

The DEA has described Marquardt as the brains behind the drug manufacturing operation. In an interview with the Tulsa World newspaper in Oklahoma in 1978, Marquardt was not at all bashful about discussing earlier involvement with illegal drugs. He described himself as a genius who won the Wisconsin State Science Fair in 1964 but was expelled from school for unspecified reasons the same day.

At the time of the interview, he had just been arrested by Oklahoma authorities for running another manufacturing operation that he claimed was going to turn out a new drug with "spectacular effects."

Marquardt told the newspaper he started taking and making drugs after reading newspaper accounts of former Harvard Professor Timothy Leary's experiences with the hallucinogen LSD. During the 1978 jailhouse interview, Marquardt said of his then-prospective product:

"It was going to be the hallucinogen of the future. It combined the best features of amphetamines but acted more like LSD. The effects were spectacular, beyond the realm of anything I experienced with LSD."

Marquardt told the newspaper he was so innured to vapors associated with drug manufacture that he didn't even notice the kind of odor that nearly killed Martier.

"I can't smell anything anymore. I could probably breathe atmosphere that would kill normal persons," he said.

Once, Marquardt said, he was working at one of his labs when he looked over and saw a pet dog drop dead from fumes.

The DEA believes that eliminating the lab in Wichita will solve the fentanyl problem at its source, at least for now.

"This is the only known organization manufacturing fentanyl in the United States," said Bonner, the agency's administrator. "These deadly laboratories are shut down and out-of-business.
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the last 2 paragraphs are prophetic. "solve the fentanyl problem... at least for now."
 
Extremely important read:

http://aspe.hhs.gov/sp/reports/2015/OpioidInitiative/ib_OpioidInitiative.pdf

"Underlying prescription opioid-related morbidity and mortality is the large number of people who report nonmedical use of prescription drugs—use without a prescription or use for the feeling or experience the drug caused. Nonmedical use of psychotherapeutic drugs in the past year among people 12 years and older has ranged from 5.7 to 6.7 percent during 2002-2013, according to the National Survey on Drug Use and Health (NSDUH). For prescription pain relievers, the percentage has ranged from 4.2 percent to 5.1 percent during this time period.14 However, these relatively flat rates of nonmedical use mask a sharp increase in nonmedical use of prescription pain relievers by a relatively small number of “heavy users.” Chronic nonmedical use – nonmedical use of 200 days or more in the past year – had increased by roughly 75 percent between 2002-2003 and 2009-2010.15"

..and..

"Although available literature indicates that abuse of prescription opioids is a risk factor for future heroin use, only a small fraction, roughly 4 percent of opioid abusers, transition to heroin use within five years of initiating opioid abuse.21 The assertion that a crackdown on the supply of opioid pain relievers is the driver of the recent increases in heroin use and deaths does not appear to be supported by the currently available data."
 
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You've taken editorial license with your post. Here is what you chose not to include:

While occasional nonmedical users (those who use the drugs nonmedically less than 30 days a year) are most likely to obtain their drugs from a friend or relative for free, the highest-use, highest-risk nonmedical users (i.e. those who reported nonmedical use 200 or more days a year) were more likely to obtain their drugs directly from a doctor’s prescription than from any other source. 17
 
101N said:
You've taken editorial license with your post. Here is what you chose not to include:

While occasional nonmedical users (those who use the drugs nonmedically less than 30 days a year) are most likely to obtain their drugs from a friend or relative for free, the highest-use, highest-risk nonmedical users (i.e. those who reported nonmedical use 200 or more days a year) were more likely to obtain their drugs directly from a doctor’s prescription than from any other source. 17
Click to expand...

One fact doesn't change the other: The epidemiology supports a dis-continuous (buckets) spectrum of risk groups--in other words, the risk data is ordinal, but not necessarily linear...likely synergistic clumping of factors at various intervals...

http://www.jabfm.org/content/27/3/329.long
 
Misuse of Opana linked to HIV Outbreak in Indiana...

http://www.wsj.com/articles/indiana...ergency-over-hiv-outbreak-1427380731?mod=e2fb

Drug-Related HIV Outbreak Sparks Emergency in Indiana
CDC medical team helps with swelling case load in southeastern part of state

Indiana Gov. Mike Pence declares a public health emergency after the state confirms 79 cases of HIV in one county. WSJ’s Matthew Dolan reports. Photo: AP
By
MATTHEW DOLAN
Updated March 26, 2015 5:39 p.m. ET

Indiana Gov. Mike Pence declared a public-health emergency in a rural southern county to counter the spread of HIV linked to intravenous drug use—an outbreak he said has reached epidemic proportions.

In an executive order, Mr. Pence authorized Scott County to institute a “targeted, short-term needle-exchange program” to contain the outbreak, according to the governor’s office.

“I do not support needle exchange as an antidrug policy,” Mr. Pence said in an interview. But at the urging of the federal Centers for Disease Control and Prevention, he said a 30-day exception was warranted in Scott County, near the Kentucky border.

The Indiana State Department of Health identified 79 confirmed cases of HIV since the beginning of the year originating in Scott County. Typically, the county has fewer than five new HIV cases in a year, state officials said.

Most of the cases are linked to abuse of the painkiller Opana, which contains the powerful opioid oxymorphone, officials said.The drug is ground up and injected, and users sometimes share needles, officials said.

“The majority of physicians here don’t even write scripts for it any more because so many people abuse it,” said Brittany Combs, Scott County’s public health nurse.

The number of people contracting HIV due to the outbreak could exceed 100, according to Jennifer Walthall, Indiana deputy health commissioner. “We know that the culture of IV drug abuse is communal use,” she said. “All it really takes is one HIV positive user.”

Scott County has a population of about 25,000, with nearly 20% of county residents below the poverty line, according to the U.S. Census. Residents say the county has experienced economic hardship in recent years, and employment opportunities are relatively scarce.

Federal and state health officials said they are investigating the source of the outbreak and trying to assess how far it may have spread. Mr. Pence said some arrests have been made in connection with the outbreak. Between 75 and 100 people who may have had contact with those recently diagnosed with HIV are being contacted so they can be tested, Ms. Combs said.

After the outbreak was first identified in late January, state officials say they have worked to contain it.A medical team from the CDC arrived in Scott County Monday to help with following up on contacts of HIV-positive individuals.

The emergency order will set up an incident command center to coordinate HIV and substance-abuse treatment. It requires state and local health, law-enforcement and emergency-response agencies to cooperate and assist in disaster response.

HIV transmission from intravenous drug use remains relatively rare. An estimated 7% of diagnosed cases of HIV infections in 2012 in the U.S. were due to IV drug use, according to the most recent CDC data.

The cluster of HIV cases in Indiana is the first in the U.S. associated with injection of a prescription painkiller, said Daniel Raymond, policy director for the Harm Reduction Coalition, an advocacy organization that addresses health problems connected to drug use.

“I worry this isn’t going to be the last one,” he added.

It can be traced to a rise in the injection of heroin and other drugs, he said, “what I call the second phase of America’s opioid epidemic.”

There were 421 new HIV cases reported in Indiana in 2014. Only one HIV case stemmed from intravenous drug-use transmission, health-department data show.

—Betsy McKay contributed to this article.
 
This is around 30 miles from me. In my state we have pain docs that extoll the virtues of their pain clinics purity by claiming they write for few opioids but collaborate with independent nurse practitioners that have set up their own pill mill. As a quid pro quo, the NP gets to treat all the druggies while referring procedures to the pain doc. Amazing....
 
on one hand the feds/state want to quash the rx and heroin epidemic, on the other hand they are ramping up payment structures that will guarantee more and more NPs and CRNAs will practice 'pain' and those providers dont have the proper training to RX properly. ultimately they will get what they pay for
 
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Recent NPR piece on addiction and isolation is evocative of Sean Mackey's studies on love and chronic pain....

http://www.npr.org/blogs/13.7/2015/...ign=npr&utm_term=nprnews&utm_content=20150327

"Now, Hari is convinced that Alexander has unlocked the true essence of addiction. Addiction is caused by isolation. And the cure for addiction, it follows, is love. We need to give the addict back his or her feeling of connection to others."

http://med.stanford.edu/news/all-ne...-where-pain-leaves-off-brain-study-shows.html

“When people are in this passionate, all-consuming phase of love, there are significant alterations in their mood that are impacting their experience of pain,” said Sean Mackey, MD, PhD, chief of the Division of Pain Management, associate professor of anesthesia and senior author of the study, published online Oct. 13 in PLoS ONE. “We’re beginning to tease apart some of these reward systems in the brain and how they influence pain. These are very deep, old systems in our brain that involve dopamine — a primary neurotransmitter that influences mood, reward and motivation.”
 
drusso said:
Recent NPR piece on addiction and isolation is evocative of Sean Mackey's studies on love and chronic pain....

http://www.npr.org/blogs/13.7/2015/...ign=npr&utm_term=nprnews&utm_content=20150327

"Now, Hari is convinced that Alexander has unlocked the true essence of addiction. Addiction is caused by isolation. And the cure for addiction, it follows, is love. We need to give the addict back his or her feeling of connection to others."

http://med.stanford.edu/news/all-ne...-where-pain-leaves-off-brain-study-shows.html

“When people are in this passionate, all-consuming phase of love, there are significant alterations in their mood that are impacting their experience of pain,” said Sean Mackey, MD, PhD, chief of the Division of Pain Management, associate professor of anesthesia and senior author of the study, published online Oct. 13 in PLoS ONE. “We’re beginning to tease apart some of these reward systems in the brain and how they influence pain. These are very deep, old systems in our brain that involve dopamine — a primary neurotransmitter that influences mood, reward and motivation.”[/QUOTE
Click to expand...

http://media.mnn.com/sites/default/files/user/131413/puppychair.jpg

Cured.
 
The ASAM definition of addiction is big and ambiguous by intent. There is a lot of politics and money involved in viewing addiction as a primary brain disease. Just as there is with the IASP's definition of pain, or the IOMs 100M.

IMO many advocates in the addiction treatment world are taking the 'destigmatization' narrative - the associated behavior is just a part of the disease, it's no one's fault, it's never a matter of responsibility any more than cancer or bad luck, it's a disease deal with it or your just a troglodyte and bigot - too far.

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Addiction affects neurotransmission and interactions within reward structures of the brain, including the nucleus accumbens, anterior cingulate cortex, basal forebrain and amygdala, such that motivational hierarchies are altered and addictive behaviors, which may or may not include alcohol and other drug use, supplant healthy, self-care related behaviors. Addiction also affects neurotransmission and interactions between cortical and hippocampal circuits and brain reward structures, such that the memory of previous exposures to rewards (such as food, sex, alcohol and other drugs) leads to a biological and behavioral response to external cues, in turn triggering craving and/or engagement in addictive behaviors.
 
101N said:
The ASAM definition of addiction is big and ambiguous by intent. There is a lot of politics and money involved in viewing addiction as a primary brain disease. Just as there is with the IASP's definition of pain, or the IOMs 100M.
Click to expand...

That's why we need science-informed public policy--not politically-driven science...
 
Is dopamine the answer?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3184588/

Four Cases of Chronic Pain That Improved Dramatically Following Low-Dose Aripiprazole Administration

To the Editor: The role played by the brain's dopamine system in pain control has garnered attention in recent years.1 Herein, we report 4 cases of long-term chronic pain (pain disorder [DSM-IV-TR]) that improved dramatically following administration of a low dose of aripiprazole, a partial dopamine agonist. None of these 4 patients satisfied the DSM-IV-TR diagnostic criteria for schizophrenia.

Case 1. Mr A, a 42-year-old man, had a chief complaint of chronic head and neck pain that had persisted for 10 years and was refractory to administration of morphine 70 mg/d. He visited our department in December 2008 and was diagnosed with pain disorder and pervasive developmental disorder. Although fluvoxamine treatment was started, with the dosage gradually increased to 200 mg/d, it was ineffective and the pain exacerbated. Upon switching to aripiprazole 3 mg/d, the pain improved dramatically, and the patient was able to discontinue morphine. After increasing the dose to 6 mg/d, the patient became able to go fishing for the first time in a few years, and his motivation increased.

Case 2. Mr B, a 35-year-old man, had chronic back and leg pain that had persisted for 15 years and particularly worsened following sexual intercourse. He had visited over 20 medical institutions in the past and had not responded to antidepressants. He visited our department in March 2009 and was diagnosed with pain disorder. Pain disappeared after initiation of aripiprazole 2 mg/d, and the patient's passion for his work in computer software development improved.

As aripiprazole was effective in the treatment of pain disorder in Cases 1 and 2, we subsequently also used it for Cases 3 and 4, and it was effective. Below are concise descriptions of Cases 3 and 4.

Case 3. Ms C, an 83-year-old woman, had developed Parkinson's disease and back and leg pain (pain disorder) 4 years before. She visited our department in August 2009. Pain improved following administration of aripiprazole 3 mg/d, and the patient began going out rather than staying home as she had been, and her level of activity improved.

Case 4. Ms D, a 68-year-old woman, had developed pain at the top of the head (pain disorder) a year before she visited our department in October 2009. Pain disappeared after we added aripiprazole 2 mg/d to sertraline 100 mg/d, and the patient's motivation toward housework improved.

These 4 patients were characterized by reduction of pain and improved motivation following low-dose aripiprazole administration. Dopamine plays a role in pain processing via μ opioids.1 Dopamine-related diseases often exhibit pain-related symptoms. For example, pain is a common complaint among patients with Parkinson's disease,2 and those with schizophrenia are known to have a reduced pain sensitivity.3 In other words, the degree of dopamine system activation is inversely proportional to the degree of pain. These 4 cases suggest that aripiprazole, a dopamine system stabilizer, may be a therapeutic option for chronic pain.
 
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http://journals.lww.com/pain/Fullte...opioid_misuse,_abuse,_and_addiction_in.3.aspx
Pain:April 2015 - Volume 156 - Issue 4 - p 569–576

doi: 10.1097/01.j.pain.0000460357.01998.f1
Comprehensive Review
Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis
Vowles, Kevin E.a,*; McEntee, Mindy L.a; Julnes, Peter Siyahhana; Frohe, Tessaa; Ney, John P.b; van der Goes, David N.c

Abstract

Abstract: Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.


 
http://www.bendbulletin.com/lifestyle/3005513-151/joining-forces-to-fight-drug-addiction

Oregon’s highest overdose death rate? Ages 45 - 54


"The solution:
The report’s authors included a series of recommendations the state could follow to reduce the number of people who die from an overdose each year.
They included removing methadone for pain management from the Oregon Health Plan’s drug formulary (this drug alone was responsible for 27 deaths among 45- to 54-year-olds each year,) teaching patients and the general public more about the risks associated with using and abusing prescription drugs, and increasing access to pain management clinics that provide people a way they can manage their symptoms without prescription drugs."

Adverse tiering is just one way the insurance industry can cherry-pick its customers. By making safer alternative like abuse-deterrent buprenoprhine/naloxone a less preferred choice over more dangerous methadone, insurance companies create a unsafe choice architecture for patients and prescribers. Similarly, by squandering public money on non-evidence based pain treatments such as acupuncture, massage, naturopathic medicine, etc instead of proven modalities including interventional pain treatments.
 
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101N said:
http://journals.lww.com/pain/Fullte...opioid_misuse,_abuse,_and_addiction_in.3.aspx
Pain:April 2015 - Volume 156 - Issue 4 - p 569–576

doi: 10.1097/01.j.pain.0000460357.01998.f1
Comprehensive Review
Rates of opioid misuse, abuse, and addiction in chronic pain: a systematic review and data synthesis
Vowles, Kevin E.a,*; McEntee, Mindy L.a; Julnes, Peter Siyahhana; Frohe, Tessaa; Ney, John P.b; van der Goes, David N.c

Abstract

Abstract: Opioid use in chronic pain treatment is complex, as patients may derive both benefit and harm. Identification of individuals currently using opioids in a problematic way is important given the substantial recent increases in prescription rates and consequent increases in morbidity and mortality. The present review provides updated and expanded information regarding rates of problematic opioid use in chronic pain. Because previous reviews have indicated substantial variability in this literature, several steps were taken to enhance precision and utility. First, problematic use was coded using explicitly defined terms, referring to different patterns of use (ie, misuse, abuse, and addiction). Second, average prevalence rates were calculated and weighted by sample size and study quality. Third, the influence of differences in study methodology was examined. In total, data from 38 studies were included. Rates of problematic use were quite broad, ranging from <1% to 81% across studies. Across most calculations, rates of misuse averaged between 21% and 29% (range, 95% confidence interval [CI]: 13%-38%). Rates of addiction averaged between 8% and 12% (range, 95% CI: 3%-17%). Abuse was reported in only a single study. Only 1 difference emerged when study methods were examined, where rates of addiction were lower in studies that identified prevalence assessment as a primary, rather than secondary, objective. Although significant variability remains in this literature, this review provides guidance regarding possible average rates of opioid misuse and addiction and also highlights areas in need of further clarification.
Click to expand...

http://www.forbes.com/sites/cjarlot...c-pain-patients-is-around-25-new-study-shows/

Opioid Misuse In Chronic Pain Patients Is Around 25%, New Study Shows

Various studies on problematic opioid use in chronic pain patients have been conducted over the years, but many of them have failed to clearly define misuse, abuse and addiction. One group of researchers believe they’ve uncovered an updated review of this topic with definitions of their own.

A new report — which was published in the April issue of PAIN, the official journal of the International Association for the Study of Pain (IASP) — found that 20-30% of opioids prescribed for chronic pain are being misused. It also concluded that the rate of addiction is approximately 10%. The journal is published by Wolters Kluwer.

“We find that although opioid misuse (the usage of opioids contrary to medical instructions) and addiction occur in a minority of opiate users, prescribers should closely monitor their patients for signs of these aberrant behaviors,” said study co-author David N. van der Goes, assistant professor in the Department of Economics at the University of New Mexico. “Prescribers can also compare their outcomes to the baseline presented in the paper.”

Researchers used consensus statements published by several medical outlets to define misuse as “opioid use contrary to the directed or prescribed pattern of use, regardless of the presence or absence of harm or adverse effects”; abuse as “intentional use of the opioid for non-medical purpose, such as euphoria or altering one’s state of consciousness; and addiction as “pattern of continued use with experience of, or demonstrated potential for harm.”

Researchers reviewed 38 articles on the topic of problematic opioid use in chronic pain patients. According to the report’s authors, 76% of the articles contributed information on opioid misuse and 32% of them provided additional insight on opioid addiction. Only one of the studies used for the research reported on opioid abuse.

“Some people who become addicted develop the disease from misuse, but people can just as easily become addicted taking pills exactly prescribed,” said Dr. Andrew Kolodny, who is the chief medical officer at Phoenix House, a drug treatment provider, in an interview. “Once addicted, misuse (i.e. taking more pills than prescribed or crushing and snorting pills) becomes more common, but again, keep in mind that patients can still be addicted without misuse.”

According to a Centers for Disease Control (CDC) report from earlier in the year, there were 16,235 deaths involving prescription opioids in 2013, an increase of 1% from 2012. Total drug overdose deaths in 2013 hit 43,982, up 6% from 2012.

The opioid epidemic in the United States puts chronic pain front and center. With more than 100 million Americans suffering from chronic pain, physicians are routinely looking for ways to minimize the risk of patients becoming dependent on prescription painkillers.

For example, an independent panel — convened by the National Institutes of Health (NIH), which is part of the U.S. Department of Health and Human Services — concluded that “individualized, patient-centric care” — even with its challenges — is one way to control opioid tolerance development in chronic pain patients.

State governments have also tried to do their part to curb opioid abuse in the country. Despite only 53% of primary care physicians using prescription monitoring programs (PMPs), state governments have continued to invest in them. In fact, almost every state in the country has implemented its own program to assist physicians with tracking prescriptions for controlled substances. Missouri is the only state without one, but its legislators are making significant progress.

Some experts believe tightening prescription drug abuse regulations and monitoring programs will hurt those patients who have legitimate pain. Bob Twillman, executive director of the American Academy of Pain Management (AAPM), in an interview earlier in the year with PBS, said the most effective way to combat controlled substance abuse is by focusing more on the growing number of Americans suffering from chronic pain.

According to a recent survey by the AAPM, a large number of chronic pain patients feel they’re being singled out, especially after being prescribed the same medication for many years. Approximately 67% of survey respondents reported an inability to access hydrocodone-combination prescriptions. 52% have expressed an increased sense of stigma about being a pain patient, mainly due to strengthened regulations.

Dr. Jane C. Ballantyne, a retired professor of Anesthesiology and Pain Medicine at the University of Washington, questioned the results of the PAIN study in her own response to the report, noting that it’s fairly difficult to define what addiction is when it arises during chronic pain treatment with opioids. “But, could rates of addiction have been underestimated because there cannot be clear distinctions between misuse and addiction, despite the apparent clarify of the definitions?” she asked.

“In fact, do we really know when the dependence that arises in opioid-treated pain patients becomes addiction? Does the absence of defining characteristics of impaired control over drug use, compulsive use, continued use despite harm and craving mean as much in a person essential maintained on opioids, as it does a person needing to procure a drug,” she queried. “And where in the large gray zone between clearly addicted and clearly not addicted, can a line be drawn that not only clearly defines addiction but would also define who is suitable for addiction treatment, or at least addiction-type treatment?”

The study did not look at opioid tolerance — which can be considered to be the “greatest obstacle to the development of effective opioid treatment for intractable pain” — in chronic pain patients. ”Opioid tolerance, while a real issue for both providers and patients, was outside of the scope of this study,” said Dr. John Ney, co-author of the report.

“Our study highlights the need for a common language in defining aberrant behaviors related to prescription opioid usage and more studies that specifically measure aberrant behaviors as endpoints,” said Ney, who is an affiliated assistant professor of Neurology at the University of Washington. “Prescribers, insurers, pharmaceutical firms, and policymakers should adhere to well-defined terms in constructing and evaluating the goals and outcomes of programs, new products, and policies designed to curb opioid misuse and addiction.”
 
http://washex.am/obamacareatfive
POLITICS: HEALTH CARE
Senators introduce bill to slam FDA on painkiller approvals
BY ROBERT KING | APRIL 15, 2015 | 3:19 PM




"The FDA has proven time and time again that it is willing to ignore its own experts and approve...
A new Senate bill would hold the Food and Drug Administration accountable if it ignores its experts when it approves painkillers.

Sens. Joe Manchin, D-W.Va., Shelley Moore Capito, R-W.Va., and David Vitter, R-La., introduced legislation Wednesday that would revamp the agency's drug approval process.

Under the bill, the agency must justify its approval if it ignores advisers' objections when green-lighting a new painkiller. That approval can be overruled by the FDA commissioner, which would be a completely new power.

If the FDA continues to approve the painkiller and ignore adviser objections, the commissioner can be called before Congress to explain why.

The FDA calls for advisory committees of experts to review new brand-name drugs that treat all types of diseases. A committee reviews evidence about the drug, listens to the public and the company sponsoring the product, and makes a recommendation on whether it should be approved.
However, the recommendation is only that. The FDA usually sides with its advisers but it doesn't have to.

In fact, ignoring its advisers is what prompted the bill.

In late 2013 the agency approved a controversial painkiller called Zohydro over the objections of its advisers, who were worried about its potential for abuse.

The drug, a long-acting version of other painkillers such as Vicodin, did not contain technology to help deter abusers. More drug makers are now including technology that prevents an abuser from crushing a pill so that it can be snorted and get high much easier or from chewing a pill to get the same effect.

The approval ignited a public firestorm. Lawmakers from both sides of the aisle were furious that the agency approved the long-acting painkiller even though prescription drug abuse is a chronic problem in the United States.

While the controversy over Zohydro has died down, Manchin has showed no signs of cooling off.

"The FDA has proven time and time again that it is willing to ignore its own experts and approve medications that harm consumers," said Manchin, whose state of West Virginia has been hit hard by painkiller abuse.
 
Serving All Your Heroin Needs
By SAM QUINONESAPRIL 17, 2015

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  • FATAL heroin overdoses in America have almost tripled in three years. More than 8,250 people a year now die from heroin. At the same time, roughly double that number are dying from prescription opioid painkillers, which are molecularly similar. Heroin has become the fallback dope when an addict can’t afford, or find, pills. Total overdose deaths, most often from pills and heroin, now surpass traffic fatalities.

    If these deaths are the measure, we are arguably in the middle of our worst drug plague ever, apart from cigarettes and alcohol.

    And yet this is also our quietest drug plague. Strikingly little public violence accompanies it. This has muted public outrage. Meanwhile, the victims — mostly white, well-off and often young — are mourned in silence, because their parents are loath to talk publicly about how a cheerleader daughter hooked for dope, or their once-star athlete son overdosed in a fast-food restaurant bathroom.

    The problem “is worse than it’s ever been, and young people are dying,” an addiction doctor in Columbus, Ohio — one of our many new heroin hot spots — wrote me last month. “This past Friday I saw 23 patients, all heroin addicts recently diagnosed.”

    So we are at a strange new place. We enjoy blissfully low crime rates, yet every year the drug-overdose toll grows. People from the most privileged groups in one of the wealthiest countries in the world have been getting hooked and dying in almost epidemic numbers from substances meant to numb pain. Street crime is no longer the clearest barometer of our drug problem; corpses are.

    Most of our heroin now comes not from Asia, but from Latin America, particularly Mexico, where poppies grow well in the mountains along the Pacific Coast. Mexican traffickers have focused on a rudimentary, less-processed form of heroin that can be smoked or injected. It is called black tar, which accurately describes its appearance. Cheaper to produce and ship than the stuff of decades past from Asia, heroin has fallen in price, and so more people have become addicted.

    The most important traffickers in this story hail from Xalisco, a county of 49,000 people near the Pacific Coast. They have devised a system for selling heroin across the United States that resembles pizza delivery.

    Dealers circulate a number around town. An addict calls, and an operator directs him to an intersection or a parking lot. The operator dispatches a driver, who tools around town, his mouth full of tiny balloons of heroin, with a bottle of water nearby to swig them down with if cops stop him. (“It’s amazing how many balloons you can learn to carry in your mouth,” said one dealer, who told me he could fit more than 30.)

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    CreditJesse Draxler
    The driver meets the addict, spits out the required balloons, takes the money and that’s that. It happens every day — from 7 a.m. to 7 p.m., because these guys keep business hours.

    The Xalisco Boys, as one cop I know has nicknamed them, are far from our only heroin traffickers. But they may be our most prolific. As relentless as Amway salesmen, they embody our new drug-plague paradigm.

    Xalisco dealers are low profile — the anti-Scarface. Back home they are bakers, butchers and farm workers, part of a vast labor pool in Xalisco and surrounding towns, who hire on as heroin drivers for $300 to $500 a week. The drug trade offers them a shot at their own business, or simply a chance to make some money to show off back home — kings until the cash goes. Meanwhile, in the United States, they drive old cars with their cheeks packed like chipmunks’, and dress like the day workers in front of your Home Depot.

    The heroin delivery system appeals to them mainly because there is no cartel kingpin, no jefe máximo. It is meritocratic — so unlike Mexico. They are “people acting as individuals who are doing it on their own: micro-entrepreneurs,” said one phone operator for a crew who I interviewed while he was in prison. They are “looking for places where there’s no people, no competition,” he said. “Anyone can be boss of a network.” Thus the system distills what appeals to immigrants generally about America: It is a way to translate wits and hard work into real economic gain.

    The money, meanwhile, helps paper over the Mexican small-town animus against drugs, and the guilt many feel at watching their product reduce kids just like them to quivering slaves.

    They are decidedly nonviolent — terrified, in fact, of battles for street corners with armed gangs. They don’t carry guns. They also have rules against selling to African-Americans because, as one dealer put it, “they’ll steal from you, and beat you.”

    The Boys started out on the fringes of the drug world in West Coast cities. In the late 1990s, they moved east in search of virgin territory. They avoided New York City, the country’s traditional center of heroin, because the market was already run by entrenched gangs. The city still has enormous supplies of dope coming through it, mostly imported now by traffickers from the Mexican state of Sinaloa, and by Dominicans who buy it from Colombians. But New York is no longer the country’s sole heroin hub. They also skipped cities like Philadelphia and Baltimore, where black gangs control distribution.

    The Xalisco Boys migrated instead to prosperous midsize cities. These cities were predominantly white, but had large Mexican populations where the Boys could blend in. They were the first to open these markets to cheap, potent black-tar heroin in a sustained way. The map of their outposts amounts to a tour through our new heroin hubs: Nashville, Columbus and Charlotte, as well as Salt Lake City, Portland and Denver.

    THEY arrived in the Midwest just as a revolution in American medicine was underway, and an epidemic of pain-pill abuse was spreading over that region.

    In the ’90s, some doctors came to believe that opioid painkillers were virtually nonaddictive when used for pain, and they prescribed them freely — not just for terminal cancer patients, but for chronic pain sufferers, too. Many patients were in pain. But instead of pursuing more complicated pain solutions, which might include eating better, exercising more and, thus, feeling better, too many saw doctors as car mechanics endowed with powers to fix everything quickly.

    Continue reading the main story
    Too often, opioid painkillers were prescribed to excess; after I had my appendix removed a few years back, I received 60 Vicodin, when four might have been enough.

    A result has been a rising sea level of prescription painkillers that continues today, of opioids such as Percocet, Vicodin and OxyContin. Sales of these drugs quadrupled between 1999 and 2010. Addiction followed. And this has given new life to heroin, which had been declining in popularity since the early 1980s.

    In places like Columbus, the Xalisco Boys stumbled onto multitudes of new addicts, many of whom were already hooked on opioid pills that doctors had prescribed. Their heroin was cheaper than the pills, yet provided a similar high. And their delivery system made heroin conveniently available to suburban white kids who possessed the trinity of American prosperity, essential to the Xalisco system: their own cellphones (to call the dealer), cars (in which to meet the dealer) and private bedrooms (in which to shoot up and hide the dope).


    Prescription pain pills have created a new home for heroin in rural and suburban Middle America. Thanks to them, the Xalisco Boys built what the justice department called the first coast-to-coast distribution networks, which also included Hawaii and, for a time, Alaska.

    They have kept their edge by betting not on guns but on marketing. Just as pharmaceutical companies promoted prescription pills to doctors as the solution to demanding chronic-pain patients, the Xalisco Boys promoted their system as the safe and reliable delivery of balloons containing heroin of standardized weight and potency. The everyday solution for white suburban addicts afraid of rummaging around Skid Row for dope. Only a phone call away; operators standing by.

    Today, they are our quietest traffickers. And our most aggressive. Other heroin dealers wait for customers to come to them. The Xalisco Boys drive after new ones. They hang out at methadone clinics offering patients free samples. They offer price breaks and occasionally make customer survey calls: Was the dope good? Was the driver polite? Any customers showing signs of quitting get a visit from a driver plying them with free hits.

    They are the only network of Mexican traffickers I know of that manufactures its own product, exports it wholesale into the United States and then retails it on the street in tenth-of-a-gram doses, thus controlling product quality, price and customer service.

    The police try to combat them, but they are like the Internet of dope — a crew can shut down as quickly as a website. One strategy is to arrest drivers, confiscate their cars and apartments. That raises the business costs of the crew owners back in Xalisco, who continue to oversee drug production and recruit new drivers from Mexico. Arresting these owners would be more effective, but we’d have to depend on Mexican law enforcement — which is hobbled by corruption, and stretched thin by far more violent drug networks — for that.

    What we can do is improve our rehabilitation options for those trapped in addiction. Some argue that we should also legalize heroin. But we already have a legal opioid for addiction maintenance. Methadone, when administered properly, is cheap, safe, crime- and needle-free and, unlike heroin, requires one daily dose, thus allowing addicts to live relatively normal lives. Of course, methadone can also keep an addict tethered to dependence. Besides, both of these responses address only the symptoms of the epidemic.

    The tale of the Xalisco Boys, indeed the spread of heroin across America, really gets back to prescriptions for pills to kill our pain.

    Traveling the country to write a book chronicling this story, I was struck by how much agony we create in pursuit of numbed pain. It also occurred to me how un-American this is. America’s greatest idea is self-reliance. That we can take charge of our lives and not have them determined for us. This idea inspires immigrants who come here. It is, in essence, what the Xalisco Boys are about, despite their diabolical behavior. But opiate addiction is the opposite of that American idea. Opiate addicts relinquish free will, enslaved to the pursuit of painlessness.

    Some places have gained ground on the epidemic. Portsmouth, Ohio, was among the first to see a generation addicted, and pill mills — pain clinics where doctors prescribed pills for cash and without a proper diagnosis — were virtually invented there. Portsmouth, like a junkie who has hit rock bottom, has found within it a spirit of self-reliance that has helped kindle a culture of recovery. The town shuttered the pill mills. Narcotics Anonymous meetings are now everywhere; recovering addicts are studying to be counselors. And after years of watching jobs go abroad, in 2009 townspeople stepped in to save one of Portsmouth’s last factories — a shoelace manufacturer, which now exports shoelaces to China, Mexico and Taiwan.

    Like Portsmouth, we need to take accountability for our own wellness. There is a time and a place for pain pills, of course. But we need to question the drugs marketed to us, depend less on pills as solutions and stop demanding that doctors magically fix us.

    It will then matter less what new product a drug company — or the drug underworld — devises.

    The author of “Dreamland: The True Tale of America’s Opiate Epidemic.”
 
http://www.wweek.com/portland/article-24593-fierce_little_scratches.html

Fierce Little Scratches
How Mexican heroin dealers and Russian addicts collided in Portland: An excerpt from Sam Quinones’ new heroin saga, Dreamland.
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ILLUSTRATION: simplykumquat.com


Tags: heroin, Portland, Sam Quinones


The two worlds couldn’t be more different.

The young men of Xalisco toil in the sugarcane fields outside of town, nestled in the hills of southwestern Mexico. They dream of making enough money to pay a band to play all night in the town square, and buy new pairs of dark blue Levi’s 501 jeans.


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Russia’s devout Pentecostal Christians believe in the ecstatic language called “speaking in tongues,” while outlawing dancing, makeup and television. They fled their homeland after decades of hiding their churches from Soviet crackdowns.


Both groups came to Portland—and their worlds collided in an epidemic of black tar heroin, addiction and death.

Over the past 15 years, law-enforcement and public-health officials nationwide have watched a catastrophic surge of Americans—many of them affluent, white teenagers—become hooked on opiates.

The rate of people dying from heroin overdoses in the United States nearly quadrupled from 2000 to 2013—becoming the nation’s top cause of accidental death.

Those deaths have followed the spike in doctors doling out prescriptions to the painkiller OxyContin. That drug has the same psychoactive chemical as heroin: the morphine molecule, which produces rapturous highs and is highly addictive. Addicts often turn to heroin—cheaper and easy to find.

The deadly intersection of prescription painkillers and heroin in Oregon has been reported before. WW has charted the epidemic, and The Oregonian investigated Mexican drug cartels in a 2013 series.


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Sam Quinones worked as reporter at the Los Angeles Times for 10 years. For a decade before that, he lived in Mexico and wrote two nonfiction books: True Tales From Another Mexico: The Lynch Mob, the Popsicle Kings, Chalino and the Bronx and Antonio’s Gun and Delfino’s Dream: True Tales of Mexican Migration.
Photo courtesy of the author.
But for the first time, a writer has woven these stories together. Sam Quinones began tracking the rise in heroin deaths as a reporter for theLos Angeles Times. He traces the source to the town of Xalisco in his new book, Dreamland: The True Tale of America’s Opiate Epidemic(Bloomsbury Press, 384 pages, $28, our review here).


Dealers known as the “Xalisco Boys,” all hailing from the same county in the Mexican state of Nayarit, didn’t operate as a cartel. Their innovation was a system to retail heroin, setting up low-profile franchises in 25 U.S.states with drivers delivering heroin directly to their junkie customers.

The Xalisco Boys found vulnerable customers among the 25,000 Russian-speaking immigrants and their families living in the bedroom communities of East Portland.

The result? Heroin deaths in Oregon, already higher than the national average, tripled over the past decade (see chart below).

Quinones reads from Dreamland at 7:30 pm Tuesday, April 28, at Powell’s City of Books.

The following excerpt is just a glimpse of what he reveals about Portland. —Aaron Mesh


Russian Pentecostals leaned on the severe God of the Old Testament to shepherd them through Soviet oppression.


By the time the Soviet experiment ended, seven hundred thousand people, most of them in the Ukraine and Belarus, were fervent Pentecostals. Then, a dream come true. The United States opened to them. Tens of thousands emigrated, settling mostly in Sacramento, Seattle and Portland.


Among them was a young couple, Anatoly and Nina Sinyayev, who arrived from the city of Baksan around 1992. Anatoly was a welder. Nina’s father was an evangelist, touring Germany and Israel to preach the gospel. When the Soviet walls tumbled, the Sinyayevs took their two toddler daughters and fled to Portland.

Nina’s first baby in America was also their first son, Toviy, born in 1994. From then on, she was always pregnant. The couple had ten more children.

Anatoly was always working. They moved eight times, mostly in the Portland suburbs of Gresham and Milwaukie where Russian Pentecostals concentrated. They attended a conservative Russian Pentecostal church, and raised their children in their faith.

But their American dreamland contained hazards they hadn’t imagined. Remaining Christian in America, where everything was permitted, was harder than maintaining the faith in the Soviet Union where nothing was allowed. Churches were everywhere. But so were distractions and sin: television, sexualized and permissive pop culture, and wealth.

Leaders turned to the prohibitions that had sustained the faith during the dark decades back home. Girls couldn’t dye their hair, pierce their ears, or wear makeup. Young men and women could not talk, or date. If a man wanted to marry, he went to his pastor, who asked the young woman if the suitor interested her.

Russian Pentecostals didn’t associate much with American society, which they viewed as a threat. Families with televisions were deemed less holy, and they hid the machines from visitors. Pastors called TV the devil with one eye.

The Sinyayevs’ daughters were not allowed to wear nail polish or mingle with Americans. But Anatoly kept a television in the basement and turned it on when he thought his children weren’t listening. They watched it when he wasn’t home. The Sinyayevs’ second child, Elina, was their most stubborn. A pretty girl with an aquiline nose, Elina raised her siblings while her mother was pregnant and railed at the church teachings that ruled her home.

“All they preached was that women should wear long skirts, head coverings, no makeup,” she said. “They never teach you about love. They didn’t want us to know God forgives.”

As they moved into adolescence, the Sinyayevs’ oldest children hid their lives from their parents. Elina applied makeup on the school bus each morning, and exchanged her long skirts for pants. After school, she donned Pentecostal clothes, removed her makeup, and arrived home looking as plain as she had when she left.

Meanwhile, the U.S. economy frothed. Russian Pentecostals opened auto shops and trucking and welding businesses. After years of Soviet penury, they were suddenly doing quite well, and some grew rich. Pentecostal kids were steeped in consumerist America at school and old-world Russia at home. They endured church but valued wealth. They eschewed college, worked to buy what they wanted, and quietly rebelled against their parents’ old ways.

Then OxyContin appeared.


In 1999, Multnomah County medical director Dr. Gary Oxman recognized a heroin epidemic no one had spotted. His investigation revealed dozens of heroin overdoses had been overlooked, and the mortality rate of drug deaths was higher than anyone had imagined, climbing 1,000 percent over eight years. He led a marketing campaign telling junkies to call 911 if a friend overdosed—and the deaths fell.

But five years later, in 2004, Oxman saw the numbers start to rise again.



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DR. GARY OXMAN
IMAGE: Anna Jaye Goellner
Oxman watched OxyContin arrive from his offices at the Multnomah County Health Department in downtown Portland, and saw overdose deaths again begin to rise. Portland never had many pill mills. Instead, thousands of legitimate doctors began prescribing opiates like OxyContin for chronic pain.



“What we had here is a medical community that’s gone along with the idea that pain is the fifth vital sign,” Oxman said when we met one day years later at a cafe in Northeast Portland. “It’s not this wild abuse. It’s that we have a whole medical community prescribing moderately too much.”

Gary Oxman had seen this story a decade before, of course.

Unstinting supplies of Xalisco black tar heroin lashed Portland addiction and death rates ever higher through the 1990s. Oxman, the group of recovering addicts known as RAP, and others toiled to bring down those numbers, and the numbers did drop. But by 2004, OxyContin was undermining that work. “People are getting recruited into opiate addiction through pills,” he said. “Then, because of the cost of the pills, they transfer to heroin.”

Oxman plotted the data on a graph, as he had for a heroin overdose study in December 1999. The same steady rise in opiate overdose deaths began again in 2004.

Mostly, opiates consumed young people in Portland who had never used them, virtually all of them white. As a group, it appears none fell to it harder than the children of Russian Pentecostals who came fleeing persecution and found U.S. pop culture a greater challenge than anything a Soviet apparatchik could invent.



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TOVIY SINYAYEV
Image courtesy KATU
Elina Sinyayev tried heroin the first time with a friend from work, who told her it would relax her. Her sister started with OxyContin. So did Toviy, her brother. Elina lost her job and, desperate for her dope, began dating a Russian Pentecostal heroin dealer, who also got his tar from the Mexicans delivering it like pizza.


Elina believed she was the only one in her family using heroin. But one night at home she looked at her sister and brother and watched them nod off and knew the truth. Two decades after Anatoly and Nina left the Soviet Union for the freedoms of America, each of their three oldest children was quietly addicted to black tar heroin from Xalisco, Nayarit.

Police arrested Elina’s sister for petty theft and Toviy for shoplifting. Anatoly and Nina frantically began checking their children’s arms. Elina, meanwhile, shot up in other parts of her body.

One afternoon in March 2011, Toviy told his mother he had the flu. He went out with Elina and they returned hours later. He seemed different but Nina had too many kids to pay close attention. The next morning, she found her eldest boy in bed, unconscious and gasping for breath. Paramedics couldn’t revive him. He lasted for three days on life support.

The Portland suburb of Milwaukie is so small and quiet that its police department has only two detectives. That morning, one of the two, Tom Garrett, was on call. He found balloons of heroin and a syringe in Toviy’s bedroom.

Over the next eighteen months, the death of Toviy Sinyayev became a test case for Clackamas County.

Meanwhile, at home, Nina checked the arms of her daughter, Elina, which were always under the long-sleeved blouses of Pentecostal piety. There she found bruises and fierce little scratches.



Dealers from Xalisco, Mexico, started selling drugs in Portland around 1991. But few police realized the dealers came from the same part of Mexico or understood how they operated. Toviy Sinyayev’s overdose in 2011 helped Oregon cops discover how Xalisco heroin cells worked, and taught them a new strategy to fight back.


Adozen harried days had passed since Toviy’s mother found him comatose in his bedroom. Under pressure, his sister Elina told police that their dealer was a Russian Pentecostal heroin addict named Aleksey Dzyuba.

They put a wire on Elina. She called Dzyuba. Going through withdrawals and with her brother on life support, Elina met the dealer in a Safeway parking lot, surveilled by a dozen undercover officers. She bought heroin from him, and passed him some marked cash. As he drove from the parking lot, officers descended and arrested him.

With that, a strategy that Portland had adopted to combat the Xalisco Boys was set in motion, named for a college basketball player who died in 1986 after using cocaine a friend had given him.

A so-called Len Bias case is based in federal law. Under that law, a person who supplies drugs that cause a fatal overdose may be charged with a conspiracy that results in death—a charge that carries a twenty-year prison sentence. Cops have to prove the person died from the suspect’s drugs; a chain of custody has to be established.

But if they can do that, they have a powerful prosecutorial tool and one that was getting a closer look in many parts of the country as the opiate epidemic and fatal drug overdoses spread across the nation. One place that refined the strategy was Portland.

The benefit prosecutors see in Len Bias is that it allows investigators to work up a chain of drug distribution. To save himself from a Len Bias prosecution, a dealer needs to flip, and quickly, burning the dealer one link above him in the chain, hoping for leniency at sentencing time. The last man detectives can trace the drugs to faces the twenty years if convicted—a fateful game of musical chairs.

Thus, a heart-to-heart takes place in an interrogation room. Investigators can’t threaten a suspect, but they do tell him what he faces under federal law. “The tone in the room definitely changes,” Garrett said. “You’re not joking with them. It’s a very powerful conversation.”

Speaking through a Russian interpreter, Dzyuba bridled at this idea. People die every day for their addictions, he told his interrogators. He wasn’t to blame for their choices. Finally, though, a defense attorney explained the situation. Dzyuba gave up the name of the junkie dealer he bought from. With that, Garrett and his colleagues began working up the chain.

Dzyuba’s dealer gave them the name of his supplier, who in turn gave them his dealer. This dealer, three levels up from Toviy, said he bought daily from a Mexican he knew only as Doriro.

This is how, on April 12, 2011, Garrett and his colleagues began calling the number of a man from Nayarit they would later learn went by the name Joaquin Segura-Cordero.

They received no answer. They called through the afternoon. Nothing.


seguracordero.jpg

JOAQUIN SEGURA-CORDERO
IMAGE: Multnomah County
Unbeknownst to them, Segura-Cordero was at that moment being arrested by another department. Portland police had their own Len Bias death case against him. This one originated three hours away, in Bend, Oregon, where a kid named Jedediah Elliott had overdosed and died a couple months before.
Both heroin chains led to Segura-Cordero, who, as it turned out, was a kind of regional sales manager for a Xalisco heroin cell. Normally, as a Xalisco regional manager, Segura-Cordero would have been insulated from the kind of day-to-day heroin sales that would expose him to arrest. But Segura-Cordero had faced a classic small-business problem: a labor shortage.

“He had several runners arrested, so he’d run out of runners,” said Steve Mygrant, one of the prosecutors in the case. “He was having to expose himself. He was taking calls and making deliveries himself.”

Mygrant is a Clackamas County prosecutor deputized to try federal cases. Segura-Cordero was his first Xalisco Boys case. By the time I spoke with him, a couple years after Toviy’s death, Mygrant sounded both harried and amazed by the Xalisco system.

“It used to be you go into the ghettos to buy heroin from street corners,” he said. “Now these organizations are coming to the neighborhoods, to suburbia. They come to you. That’s unique to this organizational model. They’re all coming out of Nayarit and all operating off of this dispatch style. Like the fishermen in Alaska; they work seven days a week and go back home and play.”

The Segura-Cordero case showed that Xalisco heroin spread for 150 miles around Portland. It went out to the quietest rural counties, where kids, addicted to pills, learned to drive to Portland, buy cheap black tar, and triple their money back home while feeding their own habit. In classic Xalisco style, every junkie became a salesman.

I thought back to the conversation with that fellow in prison from whom I first heard the name of the town of Xalisco so long ago now. He had lived in Portland, working legally as a mechanic as he watched the Xalisco system expand.

“In Portland,” he said, “I’d see [the police] grab people with twenty or thirty balloons and they’d let them go. That’s why people began to come to Portland, because they weren’t afraid. They saw there were no consequences. ‘We get caught with this and they let us go.’”

Word spread back in Xalisco that cells did well in Portland, and, furthermore, arrested drivers were only deported. More cells crowded into town, he said.

This reminded me so much of small-town Mexican business culture. I once visited a village in central Mexico—Tzintzuntzan, Michoacán. Tzintzuntzan had at least two-dozen vendors all selling the same kind of pottery on its main street. Once one person did well selling pottery, everyone started doing it. No one thought to vary the offering.

The stores stretched for five or six blocks—with each selling identical pots and bowls, eager to undercut the others. Mexican small-business culture, born of crisis and peso devaluations, was risk averse and imitative.

That described the Xalisco cells. They came and imitated those who’d come before. In so doing, they dropped prices and raised their potency and the natural result, particularly as OxyContin tenderized the market terrain, was more addiction and overdoses.

None of this was on a kingpin’s order. It was something far more powerful than that. It was the free market.


heroin_infographic2.jpg

SOURCE: Oregon Health Authority, Injury and Violence Prevention program


Portland’s catch-and-deport policy was an important reason why. The policy was designed for the small-time street addict/dealer who city officials didn’t want taking jail space from more serious felons. The Xalisco Boys’ drivers worked hard to look small-time. In reality, they were the only visible strands of large webs that sold hundreds of kilos of black tar a year across America, by the tenth of a gram.

So for many years, when they were caught they were deported and faced little jail time, and no prison time. As farm boys on the make, they drew a very different message from leniency than what these Portland officials intended. To them, catch and release looked more like an invitation.

By the time OxyContin came to Portland in the mid-2000s, the city was famous back in Xalisco, Nayarit. The Boys crowded into the Rose City. What’s more, the arrival of OxyContin meant they no longer had to rely on the old street clients. There were now many hundreds more to help jump-start a heroin cell. The addicts were younger and wealthier. Seizures of a few ounces of heroin were big news a decade ago. Now cops routinely found pounds of the stuff.

Len Bias became Portland’s new strategy to combat the Xalisco Boys. In Portland, and for presumably the first time in the history of heroin in America, police began responding energetically—two or three detectives at a time—to a dead junkie in a gas station bathroom. The deceased’s cellphone was mined for contacts that could lead them up the Xalisco ladder. Runners were no longer automatically deported. They were told they faced twenty years in federal prison.

For Len Bias to work, federal, state and local government agencies had to cooperate completely. The state medical examiner had to be willing to quickly perform an autopsy; the local DA had to give up the case if it appeared the feds had more leverage.

Joaquin Segura-Cordero was one example. He was sentenced to fourteen years in prison for selling dope that killed Toviy Sinyayev in a suburb of Portland and Jedediah Elliott out in the Oregon countryside 150 miles away.

I walked a few Portland blocks to the office of a public defender to speak to an attorney who had agreed to talk to me as long as I left his name out of it. He had convinced many Xalisco Boys that their cooperation was the only way to avoid twenty years in prison under Len Bias.

The attorney had a standing order to detectives to call him immediately when a Len Bias case began. He supported quick cooperation with investigators—a controversial idea among defense attorneys.

“The value of your information is at its maximum the closer you are to the time of your arrest,” he said. “If you’re in really quick you can derive great benefit for your client.”

Still, he didn’t see much effect from prosecutors’ new strategy. The pills were so widespread; new kids were getting addicted every day. They were switching to heroin all the time.

Against that backdrop, he figured, prosecutors were only temporarily disrupting the market.

“My dental hygienist came to talk to me,” he said. “Her son was involved with heroin to the point where he was stealing stuff out of stores. This is a middle-class person you’d think would never be touched by something like this. But it’s so prevalent. It’s almost like you were trying to stop drinking coffee [with] a Starbucks on every corner.”


Excerpt from Dreamland by Sam Quinones. Copyright © 2015 by Sam Quinones. Reprinted by permission of Bloomsbury Press. All rights reserved.
 
Marysville police: Girl drugged, raped, sold for sex

Posted: Thursday, April 23, 2015 12:15 am

By Monica Vaughan [email protected]

A 16-year-old girl was drugged, raped and sold for sex for four weeks while under the control of a registered sex offender living in a tent in the Marysville river bottoms, police said Wednesday.

Keith Eugene Crouch, 42, and his girlfriend, Esther Rose Campbell, 36, were arrested at their camp east of the E Street Bridge on Tuesday and booked into Yuba County Jail.

Crouch was booked with no bail on suspicion of human trafficking, along with furnishing a controlled substance to a minor, forcible rape, molesting a child, assault with a deadly weapon, false imprisonment, and attempted lewd acts with a minor.

Campbell was arrested on suspicion of forcible acts of sexual penetration of a minor. Campbell's bail is set at $630,000.

The Yuba County District Attorneys Office said they plan to file charges Thursday. Sex crimes are handled by Deputy District Attorney Shiloh Sorbello, who is currently involved in a trial for a forcible rape case that allegedly occurred near the same area in the river bottoms.

Crouch, who was ordered to register as a sex offender because of a child molestation conviction in 1988, allegedly had sex with the girl several times a day.

Crouch allegedly solicited other men for money and drugs in exchange for sex with the girl. He provided her with methamphetamine and heroin and threatened her with violence two times when she tried to escape from his tent and his car, according to a statement released from the Marysville Police Department.

The victim reported that Crouch claimed to be a tattoo artist, and drew on her genitals with ink pens for personal pleasure, police said.

Police first came into contact with the girl Feb.19 when a patrol officer stopped a sedan driven by a 60-year-old man leaving the Budget Inn on E Street and found it suspicious that the two claimed they didn't know each other. The girl was released to Child Protective Services.

A month later Marysville police received a call from a detective in Idaho who said the same girl was reporting numerous crimes that occurred in Marysville between January and February, including rape, sex trafficking, and the furnishing of drugs to a minor.

Detective Sgt. Chris Miller and a Yuba County Victim Witness advocate boarded a plane and flew to Boise, Idaho, to interview the victim, where they learned she had come to the Marysville area after she'd fled from a life skills facility in Denver.

She lived with her uncle in Olivehurst for a week, then with her aunt at the Budget Inn until she saw Crouch and Campbell at a Marysville restaurant. She knew Campbell as a friend of her dead father and had lived with her before, according to police.

She went with them to their camp, where she was provided with an injection of methamphetamine. Several hours later, Crouch allegedly injected the girl with Dilaudid, an opioid pain medication. When she became sedated, the couple raped her, police said.

On Tuesday, officers were called to the river bottoms for a report of gunshots being heard in the area. They discovered Campbell and later found Crouch hiding in his tent. Both were arrested without incident.

Crouch has a significant criminal record both in and out of state.

In Yuba County, he was convicted of assault with a deadly weapon in 1994, failure to register as a sex offender in 2007, burglary in 2011, and violation of community supervision in 2012. He was convicted of being a felon in possession of a firearm in Oregon in 2014.

The details of his 1988 child molestation case were not immediately available.

CONTACT reporter Monica Vaughan at 749-4783 and on Twitter @ADCrimeBeat.
 
DSM-IV and 5. ASAM and others would be welcome as well.
Here's another. This man has been taking morphine for over a year. Is this appropriate?

 
On a tangent, I wonder how many of the "accidental" addicts I hear about in the press (iatrogenic addiction) have more in common with David Rokisky than they care to admit? Without getting them into a court of law on a witness stand under oath, how can we lend their narrative about bad drug companies and bad doctors any credence?
Here's David Rokisky's sad story. Doris Bloodsworth no longer works as a reporter.

"Rokisky said he had a high-paying job as a computer-company executive, a condo at the beach and a happy marriage until he became hooked on OxyContin. Then, he said, his life was nearly destroyed.

The former Albuquerque, N.M., policeman was used by the Sentinel as an example of an "accidental addict" in daily stories that ran as companion pieces to the main articles.

But the complaints, initially from his mother-in-law and later from Purdue Pharma, about the way Rokisky was portrayed prompted the Sentinel to take a deeper look into his background. Extensive checks of police and court records in Florida and New Mexico, plus interviews with numerous acquaintances show that the newspaper could have discovered earlier that Rokisky:

Pleaded guilty to conspiracy to distribute cocaine in Albuquerque in December 1999. He was sentenced to six months of house arrest and three years' federal probation in April 2000. After the hearing, his now-deceased attorney told the Albuquerque Journal Rokisky "had problems" with cocaine and steroids. Faces sentencing after pleading guilty in April 2001 to forgery in Albuquerque. A date still has to be set.

Was terminated by the Albuquerque Police Department in December 1997 for unspecified reasons. Personnel files are not public in New Mexico.
. . . .
Purdue Pharma said Rokisky's background should have disqualified him from any mention in the Sentinel series.

"If he is not the innocent patient described, then he stands for a very different proposition than the one asserted by the Sentinel. He stands for the proposition that those who abuse medications can be harmed by them," said Howard R. Udell, Purdue executive vice president, in a Feb. 2 letter to the newspaper.

Managing Editor Elaine Kramer said Friday that Rokisky would not have been profiled in the same manner if the newspaper had uncovered his past before publication.

Rokisky, who ultimately refused to answer questions for this story, previously told the newspaper that his background had nothing to do with his addiction to OxyContin.

He repeatedly has denied being a drug abuser. But Rokisky failed a drug test ordered by an Albuquerque judge Nov. 26. According to an audio transcript of the hearing, the test found methamphetamines, opiates, cocaine and "oxycodeine," an apparent reference to oxycodone, in his system. Rokisky said in a Dec. 23 hearing in Albuquerque that he had passed two subsequent tests and the November test was flawed."

http://articles.orlandosentinel.com...prescribed-oxycontin-sentinel-pain-medication
http://www.forbes.com/forbes/2004/0906/048.html
 
TravelerNC said:
Is this woman addicted to morphine?
Click to expand...

yes.
watch this instead:
http://www.jsonline.com/watchdog/wa...-children-of-oxycontin-r65r0lo-169056206.html

the remainder of the videos you posted seem to deal with the lack of availability of opioids in other countries, for cancer related pain. we in the US do not have this problem, since we consume 95% of the world's hydrocodone, and 81% of the world's oxycodone.

They are irrelevant posts for the US, and irrelevant for us pain physicians, as none of us would deny opioid therapy for palliative/cancer pain patients.
 
I have seen that video at jsonline.com I'm just curious. Do you believe that any of the 6-7 patients there are being treated appropriately? The last 3, at least, seem to be benefitting. The first guy? There'
 
I have seen that video at jsonline.com I'm just curious. Do you believe that any of the 6-7 patients there are (or were) being treated appropriately? The last 3, at least, seem to be benefiting. The first guy? There's got to be more to that story that his family is not sharing. How could they watch him fall asleep with his face in his dinner plate, and not do anything to intervene? Maybe they're looking for "secondary gain" (a lawsuit). As a juror, I would think something is fishy about their narrative.

And why, by the way, do you think the woman is addicted in the video above with Dr. Foley?

As for us using 95% of the world's hydrocodone? I don't find that statistic to be compelling proof of gross and epidemic overprescribing for two reasons. One, we also play 100% of the world's football. Everyone else plays soccer (though they call it football). In the Knited Kingdom, for instance, diacetylmorphine (heroin) is legally used to treat both acute and chronic/palliative pain. Two, the videos of the man in the Ukraine are pertinent in this regard. Why? Because the International Narcotics Control Board is telling us that 5.5 billion people in the world have little or no access to morphine for pain relief (much less hydrocodone, Oxycontin, or fentanyl). Here's what concerns them, I would imagine.
 
drusso: I'm not particularly swayed by PET scans either. Here's what Dr. Carl Hart has to say about brain scans (starting at 8:00).



At any rate, why not just legalize drugs the same way we've legalized the sale of ethanol? It would free all the good doctors and other clinicians from having to deal with liability, legal issues (DEA, etc), and prejudice (different people get more or less effective pan management from the same clinician - Why is that?)

We should just legalize drugs. William F. Buckley, Jr. thought so (as do George Schultz, Paul Volcker, and Kofi Annan), so I'm in pretty good company.
 
TravelerNC said:
drusso: I'm not particularly swayed by PET scans either. Here's what Dr. Carl Hart has to say about brain scans (starting at 8:00).



At any rate, why not just legalize drugs the same way we've legalized the sale of ethanol? It would free all the good doctors and other clinicians from having to deal with liability, legal issues (DEA, etc), and prejudice (different people get more or less effective pan management from the same clinician - Why is that?)

We should just legalize drugs. William F. Buckley, Jr. thought so (as do George Schultz, Paul Volcker, and Kofi Annan), so I'm in pretty good company.
Click to expand...

We've had de facto legalization the past 20 years with the easy availability of opiates and ODs have gone up. So I'd say it's a bad idea, unless your intent is encourage more ODs.

Ultimately though, far as legalizing drugs, you're barking up the wrong tree. Talk to the DEA and your congressmen. That's their ballgame.
 
im beginning to feel that you are a troll.

this is what is happening in the US in the last 15 years, in case you were asleep:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic
Weekly
January 13, 2012 / 61(01);10-13

This is another in a series of occasional MMWR reports titled CDC Grand Rounds. These reports are based on grand rounds presentations at CDC on high-profile issues in public health science, practice, and policy. Information about CDC Grand Rounds is available at http://www.cdc.gov/about/grand-rounds.


In 2007, approximately 27,000 unintentional drug overdose deaths occurred in the United States, one death every 19 minutes. Prescription drug abuse is the fastest growing drug problem in the United States. The increase in unintentional drug overdose death rates in recent years (Figure 1) has been driven by increased use of a class of prescription drugs called opioid analgesics (1). Since 2003, more overdose deaths have involved opioid analgesics than heroin and cocaine combined (Figure 2) (1). In addition, for every unintentional overdose death related to an opioid analgesic, nine persons are admitted for substance abuse treatment (2), 35 visit emergency departments (3), 161 report drug abuse or dependence, and 461 report nonmedical uses of opioid analgesics (4). Implementing strategies that target those persons at greatest risk will require strong coordination and collaboration at the federal, state, local, and tribal levels, as well as engagement of parents, youth influencers, health-care professionals, and policy-makers.

Overall, rates of opioid analgesic misuse and overdose death are highest among men, persons aged 20–64 years, non-Hispanic whites, and poor and rural populations. Persons who have mental illness are overrepresented among both those who are prescribed opioids and those who overdose on them. Further defining populations at greater risk is critical for development and implementation of effective interventions. The two main populations in the United States at risk for prescription drug overdose are the approximately 9 million persons who report long-term medical use of opioids (5), and the roughly 5 million persons who report nonmedical use (i.e., use without a prescription or medical need), in the past month (4). In an attempt to treat patient pain better, practitioners have greatly increased their rate of opioid prescribing over the past decade. Drug distribution through the pharmaceutical supply chain was the equivalent of 96 mg of morphine per person in 1997 and approximately 700 mg per person in 2007, an increase of >600% (6). That 700 mg of morphine per person is enough for everyone in the United States to take a typical 5 mg dose of Vicodin (hydrocodone and acetaminophen) every 4 hours for 3 weeks. Persons who abuse opioids have learned to exploit this new practitioner sensitivity to patient pain, and clinicians struggle to treat patients without overprescribing these drugs.

Among patients who are prescribed opioids, an estimated 80% are prescribed low doses (<100 mg morphine equivalent dose per day) by a single practitioner (7,8), and these patients account for an estimated 20% of all prescription drug overdoses (Figure 3). Another 10% of patients are prescribed high doses (≥100 mg morphine equivalent dose per day) of opioids by single prescribers and account for an estimated 40% of prescription opioid overdoses (9,10). The remaining 10% of patients are of greatest concern. These are patients who seek care from multiple doctors and are prescribed high daily doses, and account for another 40% of opioid overdoses (11). Persons in this third group not only are at high risk for overdose themselves but are likely diverting or providing drugs to others who are using them without prescriptions. In fact, 76% of nonmedical users report getting drugs that had been prescribed to someone else, and only 20% report that they acquired the drug from their own doctor (4). Furthermore, among persons who died of opioid overdoses, a significant proportion did not have a prescription in their records for the opioid that killed them; in West Virginia, Utah, and Ohio, 25%–66% of those who died of pharmaceutical overdoses used opioids originally prescribed to someone else (11–13). These data suggest that prevention of opioid overdose deaths should focus onstrategies that target 1) high-dosage medical users and 2) persons who seek care from multiple doctors, receive high doses, and likely are involved in drug diversion.
Click to expand...
 
epidural man said:
A DEA agent recently told me that 80% of heroine users now-a-days started with prescription use. That is in start contrast to 20 years ago.
Click to expand...

That's a scary quote, but I don't trust the intellectual integrity of D.E.A. agents. They have severe conflicts of interest. Here's where that 80% number comes from: http://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm

Now, read this quote from the abstract: "Four out of five recent heroin initiates (79.5 percent) previously used NMPR whereas only 1.0 percent of recent NMPR initiates had prior use of heroin. However, the vast majority of NMPR users have not progressed to heroin use. Only 3.6 percent of NMPR initiates had initiated heroin use within the 5-year period following first NMPR use."

Here's another: "heroin incidence rate was 19 times higher [scary!] among those who reported prior nonmedical pain reliever (NMPR) use than among those who did not (0.39 vs. 0.02 percent) [not as scary any more]"

Moreover, not everyone who reports NMPR (nonmedical pain reliever) use in the SAMSHA National Survey on Drug Use and Health is abusing (much less getting high on) the medicine they used nonmedically. It is a computerized survey - I'll see if I can find my .pdf copy of it if you are interested. But, just to be clear, those numbers Tom Frieden (with all due respect), the DEA, Senator Manchin (no due respect), Andrew Kolodny (same as Manchin), and others like to quote to the press? The people behind those numbers were clicking a mouse on a computer, not being evaluated by a clinician. If we're that confident in NSDUH numbers, perhaps it is time to just let computers provide medical care to pain patients and addiction patients. It would be much cheaper than paying a properly trained clinician, would it not? Barring that, why not just let the D.E.A. take over the provision of medical care to our citizens? They do know so much more about drugs and proper medical practice than anyone else (especially doctors), do they not? (Forgive my sarcasm if I got carried away with it.)
 
TravelerNC said:
That's a scary quote, but I don't trust the intellectual integrity of D.E.A. agents. They have severe conflicts of interest. Here's where that 80% number comes from: http://www.samhsa.gov/data/sites/default/files/DR006/DR006/nonmedical-pain-reliever-use-2013.htm

Now, read this quote from the abstract: "Four out of five recent heroin initiates (79.5 percent) previously used NMPR whereas only 1.0 percent of recent NMPR initiates had prior use of heroin. However, the vast majority of NMPR users have not progressed to heroin use. Only 3.6 percent of NMPR initiates had initiated heroin use within the 5-year period following first NMPR use."

Here's another: "heroin incidence rate was 19 times higher [scary!] among those who reported prior nonmedical pain reliever (NMPR) use than among those who did not (0.39 vs. 0.02 percent) [not as scary any more]"

Moreover, not everyone who reports NMPR (nonmedical pain reliever) use in the SAMSHA National Survey on Drug Use and Health is abusing (much less getting high on) the medicine they used nonmedically. It is a computerized survey - I'll see if I can find my .pdf copy of it if you are interested. But, just to be clear, those numbers Tom Frieden (with all due respect), the DEA, Senator Manchin (no due respect), Andrew Kolodny (same as Manchin), and others like to quote to the press? The people behind those numbers were clicking a mouse on a computer, not being evaluated by a clinician. If we're that confident in NSDUH numbers, perhaps it is time to just let computers provide medical care to pain patients and addiction patients. It would be much cheaper than paying a properly trained clinician, would it not? Barring that, why not just let the D.E.A. take over the provision of medical care to our citizens? They do know so much more about drugs and proper medical practice than anyone else (especially doctors), do they not? (Forgive my sarcasm if I got carried away with it.)
Click to expand...
Our licenses are given to us by the DEA. We have no choice but to follow their rules. If we break their rules, we risk joblessness and bankruptcy or worse, such as jail. We have no choice, whether we agree with you or not. Go troll their forums or your congressman. Seriously, stop trolling us as its a waste of your time. You're barking up the wrong tree.
 
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