Do No Harm: Initial Prescription Details Influence Chance of Opiate Dependence

By Terry Gotham

One of the biggest problems with writing about the War on Drugs is the almost exclusive focus on problems. There’s this myth that drug use is a combination between a ratchet & Russian roulette. It’s going to keep getting worse, and it gets harder and harder to “not be addicted” the longer you do it. This continued narrative is believed widely (just ask your family at Easter dinner), while being only lightly supported with evidence. Harm reduction & physician/client education is surprisingly effective at mitigating a lot of the factors that contribute to this “it’s probably going to kill you” problem, but outside of needle exchange/safe injection sites & drinking water while partying, complex harm reduction ideas rarely make it into non-academic circles. So, I’m going to start talking about constructive, modern ideas and research that have been either theorized, published or put into practice, about how to fight this deluge.

Continue reading

The Elephant In The Emergency Room: Heroin & “Standard” Treatment

By Terry Gotham

I know that sometimes I can seem all doom & gloom about the state of the drug-consuming universe, but once and a while I happen upon something that justifies my concern. This letter by Dr. Leon Gussow, published in the Emergency Medicine News (March 2017) journal is one of those things.

The filtration of fentanyl & fentanyl analogs into the recreational opiate supply has pushed us into a place where the simple “opiate overdose” prognosis in emergency rooms & EMT visits is no longer simple. Previously, treating an opiate overdose involved a single dose of narcan/naloxone, with a few hours of observation before the patient was back on their feet. The patient was then assessed for discharge and removed from the workload of the emergency room if released. This allowed even severe opiate overdoses to be handled in a timely, almost mundane fashion, if the EMTs were timely and the staff was experienced. But as Dr. Gussow explains, this is no longer the case.

Continue reading

Cops Don’t Keep Festivals Clean: Hard Proof From Australia

Via The Village Voice

Via The Village Voice

I was sent this paper by a professor at NYU who I hold in the highest regard. While local authorities all around the world continue to argue about the best way to “secure” festivals, from crime and medical harm, the Aussies have done some real work. Published in this month’s International Journal of Drug Policy, Caitlin Elizabeth Hughes, Vivienne Moxham-Halla, Alison Rittera, Don Weatherburnb, Robert MacCounc of the National Drug & Alcohol Research Centre at the University of New South Wales in Sydney have made a fascinating discovery. One that, while novel, will seem obvious immediately once you understand what they proved. The core assumption they sought to evaluate the validity of seems almost common sense, yet has been at the core of the West’s strategy : Police can deter, discourage or prevent drug offending/consumption. Given that we’ve already spent $1.2 Billion in 2017 already to police and prohibit, you’d hope that the core tenet of “Police presence reduces drug offense” would be bullet-proof.

Over 4000 people took part in a Drug Policing Survey over a 5 month period. This survey asked takers (who had self-identified as regular festival/club attendees who consumed recreational drugs or had friends who did) to evaluate how certain types of police presence at clubs and festivals would cause them to change their drug taking tactics. As opposed to treating party people as some skittish, crack-addicted group that couldn’t be reasoned with, Dr. Hughes & her team depended on the festival/club attendees to evaluate scenarios where evading law enforcement was the goal. This might seem a little subversive to Americans, but even in cybersecurity, probing weaknesses using data from blackhats is worth its weight in gold. And this study was no exception.

Five different experimental vignettes were presented to the surveytakers. They were hypothetical scenarios that included an assortment of policing strategies: High Visibility Policing, Riot Policing, Collaborative Policing & Policing with Drug Detection Dogs, and a control scenario (No police presence). Essentially, how would your drug consumption or purchasing change if one of these police presence schema was used at the club or festival you attended. While any police presence led to a 4.6% reduction in overall illicit drug offending, it led to merely a reduction in people willing to carry drugs into an event or carry them on their person. Which makes sense. Ask any party person you know, they’ll probably regale you with tales of very minor substance use inside the club, maybe a few key bumps or lines in the bathroom. Very few people have the cajones to bring drugs into festivals or clubs that have big time security. They just assume they’ll purchase whatever they need inside the venue. And that’s exactly what the researchers found.

Via The Village Voice

Via The Village Voice

Given police presence, purchasing of drugs increased significantly within festival grounds. High Visibility Policing reduced overall drug offending, while Drug Detection dogs reduced drug possession the most, which makes sense. If you can see cops everywhere, you’re less likely to engage in risky shit. However, if you see drug dogs, you’re more likely to not carry, especially into the festival. And here’s the kicker. While you’re less likely to carry, you’re much more likely to buy and consume at the event.

This leads to all sorts of terrible shit, as people don’t test drugs they buy to consume immediately. Moreover, when you buy drugs from a dealer you’re likely to never have contact with again, because you’re not a regular customer, it’s that much more likely they’re going to sell you some bunk. If you’re a regular reader, you can probably guess why this concerns me. The idea that policing is not only ineffective, but also increasing the chance that drug consumers are going to take untested, is a significant departure from the “police just send drug use underground” talking point that we’ve been dealing with for years.

The truth is way more complicated of course. People do drugs in the safest way they’re able, exposing themselves to as little liability as they can while still achieving their ends. If that means buying LSD and taking it while they’re standing in line, they do that. If they prefer a drug that’s got a shorter duration, like MDMA or cocaine, some might be down to bring drugs in, but most are not willing to take that risk. That leads to the massive market opportunity that drug dealers at festivals & clubs exploit. This is simple market economics that most prohibitionists are unwilling to admit. Dealers, like life in Jurassic Park, find a way. Neatly tethered to the events of BPM, criminals will always find a way to ensure they profit from market demand. And in this case, our insatiable demand for drugs can’t even be stopped by the “North Korea with neon lighting” levels of policing that events like Electric Zoo have put forth. High definition cameras to capture buys, drug dogs and high visibility severe response policing can put a damper on drug possession or even perhaps trafficking into the event, but these types of enforcement mechanisms can’t stop consumption.

If anyone believes these findings don’t apply to the USA, I’d love to hear your reasoning. This is the type of bipartisan, public-health focused research that I think we should be relying on. As we’ve seen over the last month, attempting to appeal to morality, ethics, or some form of value system will fail and fail hard during the reign of Orange Xerxes. The only chance we have at winning is to force the conversation entirely into data and effects of current policies on the ground. A study like this is something that police, “family first” organizations and even straight up anti-drug advocates have a hard time responding to. It allows us to move the conversation from “What should America be like?” to “What actually works?” By doing so, you neatly remove the “People shouldn’t be doing drugs!” talking point from the repertoire of the advocate you’re debating with. Even if you believe people shouldn’t be doing drugs, you can’t ignore the fact that the policing schemes that are discussed in the study simply don’t work to achieve those ends.

There will always be people whose cognitive dissonance is so large that this will fall on deaf ears. But, for those who are willing to listen, discussing this study might just be a step in the door with your cop uncle or Catholic cousin. We need all the help we can get, so tread softly, avoid people who steal your bandwidth, and find consensus wherever you can. 2017 demands it.

 

BPM & Ending The War on Drugs: Don’t You Dare Look Away Now

Narco-sign in Playa Del Carmen after BPM shooting

Photo By Trevor Dunn

Editorial/Analysis by Terry Gotham

I’ve spent the last week interviewing people and collecting information about the worst thing to happen in live events since Orlando. Last week, the BPM Festival suffered a terrible attack, leaving 5 dead and more than a dozen wounded. Long considered one of the crown jewels of the festival circuit, this heinous attack has resulted in the local government showing BPM and all other music festivals the door. As usual, most commentary on the causes or effects either totally misses the mark or descends into slap fighting.

Photo by Semanario Playa News Aqui y Ahora

Photo by Semanario Playa News Aqui y Ahora

Before I dig into this story any deeper, I need to make a strong caveat. This commentary is in no way blaming anyone who was shot at, injured or killed for the violence that was done to them. I cannot stress this enough. While macroeconomic forces, drug cartels and America’s ineffectual responses to the growing demands for legalization are to blame for this attack, blaming BPM or BPM ticketholders for narco-terrorism is tone-deaf to the point of brutality. While I assume people will believe that was my aim to engage in some classist/leftist/racist point that serves only to divide, I believe this can be a wake up call for everyone who parties, not just those who take drugs or care about legalization, but for all Americans who believe in Constitutional rights.

According to Miguel Angel Pech Sen (district attorney of Quintana Roo, a Mexican state) at 2:30 AM, Monday morning, the security at Elrow’s closing party at the Blue Parrot was overwhelmed and the club was entered by an as-yet undetermined number of assailants. BPM declared that there was a lone gunman on the FB post about the shooting, but this has been called into question by a number of witnesses who spoke to Billboard and claimed they saw multiple shooters. The Attorney General later said it appeared there were “a lot of people carrying arms” in the club, and that many of those wounded were hit when security personnel were attempting to shoot the attacker. The attacker escaped, he said, and may have been assisted by a taxi in getting away. Three members of security died, a 4th, who seemed to be the target, and a fifth person died in the stampede to escape the club.

After the shooting at the Blue Parrot, the violence raged across Playa Del Carmen for the rest of the week. On Tuesday, a “Code Red” was activated in Cancun when the Control Center for Command, Computing & Communications was attacked by 10 armed men who arrived by motorcycle. Their goal was to extract a local drug cartel leader from holding, not kidding. Avenues in Cancun were attacked with fucking grenades, while shots were reported inside of the Plaza Las Americas Shopping Center. Narco-signs (messages from the cartels) sprang up, with the Zetas claiming responsibility and announcing that more violence was to come. Again, Playa Del Carmen banned not just BPM, but electronic music festivals, in case you had tickets to the Arena Festival, slated to go on in the beginning of February.

At this point, I hope it’s clear that this is a situation that the police and military do not have under control. While plenty of American and Canadian party people live blissfully unaware of the spiral of drug-fueled violence that Mexico is enduring, we need to stop pretending “this is fine.”

mexican-safety-map

Whether it’s the Fast & Furious gun program, Hillary’s refusal to support legalization, or the psychedelic libertarianism I’ve written about before, the indifference to legalization as a priority has put billions into the hands of cartels that have much of Latin America by the balls. MS13, the Zetas, the Sinaloa Cartel, and dozens of others we’ve probably never even heard of have rained suffering and death across so much of our hemisphere. Our continued inability to care about the problems that come with drugs, namely opiate abuse by the poor and swelling the coffers of organized crime, has all but ensured that tragedies like the one that befell the Blue Parrot will keep happening anywhere the drug war has touched.

I don’t want to hear that legalizing drugs will just cause the cartels to make money somewhere else. The revenue is non-trivial. Even before legalization hit, the RAND Corporation and the Mexican Institute of Competitiveness estimated that almost 30% of cartel revenue (not profit) came from cannabis. With legalization, we’re already seeing cannabis seizures drop:

In the Border Patrol’s San Diego sector, marijuana seizures fell to 8,158 pounds in fiscal 2015, an 88 percent drop compared to a decade-high of 68,825 pounds seized in fiscal 2011…As marijuana seizures have declined, other drugs including heroin, cocaine and methamphetamine are skyrocketing at the border. Traffickers are capitalizing on the growing opiate epidemic, as well as their ability to cheaply produce enormous amounts of pure meth from Chinese precursor chemicals in Mexican “superlabs.”
~San Diego Tribune

Source: Washington Post

It’s not just along the California border. According to the US Border Patrol, cannabis is just not showing up at numbers it used to be anywhere they’re seizing it:

But the amount of one drug — marijuana — seems to have finally fallen. U.S. Border Patrol has been seizing steadily smaller quantities of the drug, from 2.5 million pounds in 2011 to 1.9 million pounds in 2014. Mexico’s army has noted an even steeper decline, confiscating 664 tons of cannabis in 2014, a drop of 32% compared to year before.
~Time

The Zetas aren’t super-villains from the 50’s. They know how much money they can make getting certain substances over the border and into the hands of eager consumers. This connects back to parties almost depressingly well. How many people do we all know that expect there to be drugs for them to buy at parties? How many of them honestly give a fuck about whether they’re legal or not? Just think of the thousands of party people who demand farm to table, vegan/vegetarian or some other form of “I don’t consume things made unethically” cuisine, but then proceed to put $200 worth of possibly Peruvian Cocaine up their noses. I really think we should be more concerned about the lives of indigenous people living under cartels than whether our almond milk was sprayed with pesticide before it landed in my smoothie. As a dear friend put it, we couldn’t stop the Orlando mass shooting, but decriminalization/legalization probably would have stopped this shooting.

stratfor-map-2014

You need to ask yourself, if this shooting happened at a club on the beach that only Mexicans went to, and had nothing to do with BPM, would you have cared? Would you have even seen it on your news feeds? I’ve spoken to dozens of Clinton supporters over the last 18 months who strongly supported her not legalizing. If the Zetas weren’t able to wholesale pot into every city in America outside of a handful of states, would they be able to buy weapons and commit crime? Of course. But certainly not to the levels that they’ve been able to in the last several years.

Not a lot of people remember this, but over a decade ago, we deported a bunch of MS13 members, trying to break the back of the gang. This backfired so spectacularly that MS-13 chapters cropped up all across Latin America, accelerating its growth from a few thousand members in LA to an international cartel, possessing a massive supply chain and a network that rivals most intelligence services. We trained & funded the 34 commandos that eventually flipped the script & became Los Zetas. Remember them from earlier in the article? Yup, the very same. Our efforts to stop people from doing drugs are directly responsible for this shit. The blood of party people is on American hands.

But don’t think this is anything new. Whether it was Al Capone and the bootleggers profiting from prohibition, the evolution of disco and cocaine, house dealers in the superclubs of the 1990s & 2000s or the flood of adulterated psychoactive substances that find their way into the hundreds of music festivals occurring in North America every year, Americans have partied for decades without agitating for legalization. While the mob did move on to other illegal activities once Prohibition ended, you bet your ass they jumped right back into trafficking once drug prohibition returned in the 20th Century. Until we (whether we do drugs or not) demand decriminalization/legalization and an end to the DEA/ATF/FBI/CIA’s fuckery south of our border, we should expect things like this to keep happening. Some people are fine with throwing up our hands, giving up and only partying/consuming illegal drugs made within our national  borders, but that still resigns millions of our fellow citizens to a fate of incarceration, underemployment and a life controlled by the scarlet letter of conviction. People demand the ability to modulate the contents of our minds. We should allow them to, and join them in ensuring they can, legally…if only to ensure a horrific attack like this one never happens again.

Morphine, Myth & The Civil War: Before Cause and Effect

Editorial by Terry Gotham

Last week, we spoke about the gendering of drug use in America and how that may have led to the original wave of drug prohibition laws. This was one example of the  many times where drug use was distorted as a justification for it to be outlawed. One of the biggest myths associated with heroin usage was that the Civil War “created 500,000 addicts.” This is of course not the case, so let’s unpack the various reasons brought up to justify this erroneous attribution. An exceptional paper published in War In History by Jonathan Lewy of Harvard University helps to round up the main reasons this assumption is wrong, which I’ll be quoting from liberally.

One of the easiest ways people explain the deluge of opiate & whiskey addicts during the last quarter of the 19th century & the first 2 decades of the 20th was the invention of the hypodermic syringe. The Civil War doctor did use opium for much more than just killing pain. Opium was used for diarrhea, dysentery, stomachache, gallstones, hemorrhoids, tetanus, typhus, syphilus & “neuralgia” (an anachronistic diagnosis that loosely translates to peripheral neuropathy today). But, remember, it’s 1860. Opium powder was usually sprinkled on top of the wounds suffered by soldiers in the field. By the end of the Civil War, a little over 2,000 hypodermic syringes had been fabricated & distributed to the 11,000 surgeons employed by the Union Army, which is one of the pieces of evidence used to support the claim that the modern heroin addict was created by the Civil War.

There’s one crucial difference between a modern syringe & those that were used, especially at the beginning of the Civil War. The first syringes were dull. That’s right, doctors had to puncture your skin first using a lancet (yes, that’s where the journal name comes from), before using the dull and large gauge syringe to deliver the medicine. So, the most hyperbolic claim, that soldiers were shooting up because they were taught to do so at field hospitals and by doctors, can immediately be dismissed. If any of you had nightmares that involved Requiem For A Dream and civil war uniforms, you can put that aside.

Not only was injection drug use essentially impossible, Confederate surgeons had little to no access to spare opium. The Confederacy attempted to grow poppy fields to supply their armies with opium. This sounds like a good idea in theory, but resulted in exceptionally poor quality poppy crops and an inferior supply of pain killers for the Confederate Army. Resulted in the Confederacy relying on smugglers & blockade runners to bring it down from the North, as one of the first examples of drug running in the USA.  The North was buying opium on the world market, as their Navy gave them access to trade with Europe. And boy did they take advantage of that. The Federal Army consumed 10 million opium pills and 80 tons of opium powder & laudanum tinctures before the surrender at Appomattox was signed.

People weren’t converting pills into inject-ready substance in the field, and the Confederacy couldn’t even get its hands on syringes and medical staff/training using them. When you’re taking a small pile of opium and spreading it over a wound with a knife, the person receiving care doesn’t know they’re “doing heroin.” It’s hard to develop a drug habit when you don’t know what drug you’re craving.

There were anecdotal cases of physicians becoming addicted to the morphine, but as a record, this was always classified as misuse, not addiction. General Benjamin Butler discovered one such doctor, and relieved him of his duty. However, no note of addiction, health problems, or vice was mentioned, merely a note of dereliction of duty. This is corroborated by The Medical & Surgical History of the War of the Rebellion, a six-volume epic tome documenting the case histories of the various field surgeons across the US Army. 13 years of records were submitted, accounting for all of the ailments, diseases and afflictions that these doctors, surgeons and field hospital directors encountered. Zero cases of addiction, or anything resembling the modern, conventional definitions of substance abuse/addiction appear.

This isn’t to say that the maladies associated with excess substance use weren’t known. But the idea that the substance use, if continued, would cause dependence or other negative consequences, hadn’t entered the greater medical world, and wouldn’t for years. The Manual of Military Surgery, introduced in 1861, noted that morphine & laudanum (tincture of 10% opium in alcohol) should be used in managing pain and amputation-related hardship. Interestingly, and without further definition, the reader is warned to not abuse the drugs “lest they induce fatal oppression of the brain.” For serious, no other context is given, you can see for yourself on page 50:

“Reaction must be promoted by the cautious use of stimulants ;while pain is allayed by morphia orlaudanum given with more than ordinary circumspection, lest it induce fatal oppression of the brain.” ~Samuel Gross

Could “fatal oppression” be like our modern definition of “brain death?” You betcha. Will we ever know if it was, definitively, and not the fog, memory loss or other neurological side effects of opiate use described at the time? No, which is a huge problem. It’s really easy to assume, but we need confirming evidence and there simply isn’t any. And, to put this lack of information in context, in the late 19th Century, the closest thing to “addiction” most people were aware of was the “habit” (Source Bias warning: Vaguely pearl clutchy, but still relevant historical portrayal of the time).  Alcohol had been seen to be habit forming as early as 1819, but morphine wasn’t seen in the same light. Using opium was seen as roughly equivalent to swearing, paying for sex, gambling and gossiping. If you couldn’t resist the temptation of drink or poon or dope, you were a sinner, or morally weak, not sick. But in 1877, 12 years after the end of the Civil War, that changed. Die Morphiumsucht was published by Eduard Levinstein, connecting drug use with a craving for more drugs, for the first time in the wider, respected medical literature. And I do really mean for the first time. Between 1864 & 1875, when Levinstein lectured publicly on the topic for the first time, only 24 articles discussed pathology stemming from drug use. In the decade after? Over 230. It’s kind of hard to have a mass of people “addicted to drugs” when they couldn’t access the drugs, and “addiction” wasn’t a word at the time. Oh, and the people weren’t there either.

The USA documented approximately 10,000 habitual opium uses (referred to as habitues) in 1842, with that number peaking at 313,000 in 1896, according to some. However that number gets turned on its head when it’s documented in the same source that there were more women habitues than men. Grief caused by becoming a widow explains why all the women are getting high, but, if all of the soldiers are dead, where is the epidemic of strung out veterans? They weren’t in the Sanatoriums, as a casual review of the Second Annual Report to the Citizens in the Delaware County American shows. Even back in 1868, right at the end of the war, when soldiers were most vulnerable to opiates, 2 out of 26 under his care, were there for opium. The rest? Booze. Additionally, they were in there because of social use or physician prescription, not because they even fought in the war. In the “National Homes” in and around Milwaukee,  only one veteran was admitted to the entire system for non-alcoholic drug use between 1867 & 1872. To put that in perspective, 36 people have died from Fentanyl overdoses alone in Milwaukee this year

Were there people who developed habits? Absolutely. The Confederate vet Doc Pemberton was wounded at the battle of Athens, Georgia and became addicted to cocaine after being given it on the battlefield. After the war, as an unemployed chemist, he created a brew of cocaine and kola nut extract, as an attempt to keep up with the hooch being slung at the saloon across the street. Were there a giant pile of strung out drug addicts walking around after the war? No. What were there? A bunch of wounded veterans.

Lewy really does sum it up quite nicely in his conclusion, so I won’t try to out do his words:

Some contemporaries claimed their experience in the war prompted their addiction. A few decades later, Crothers and other physicians supported the notion that the war caused addiction, but not based on fact, at least statistical fact, but was due to the understanding that wars caused trauma. One can only assume that, with the amount of drugs consumed by the armies of the Civil War, a few soldiers and perhaps even a General or two became addicted to drugs, but it would be next to impossible to determine how many (were), and whether this was, indeed, a historical trend. Especially since addiction was only recognized as a full fledged disease several decades after the war.
~
Johnathan Lewy, The Army Disease: Drug Addiction and The Civil War (2013)

Finally, it’s important to note that this fear of drug zombie veterans have been used as a justification for drug laws ever since. A heroin resurgence coincided with the end of World War II, the Korean war sparked rumors that Communists were attempting to dope American youth to beguile them, Vietnam managed to vilify drafted soldiers, decrying their drug habits before they even returned, and the war in Afghanistan is already being blamed for heroin use among soldiers. There will always be people attempting to justify drug prohibition using the trope that veterans would be the most vulnerable of American citizens. Yet, this continues not to be the case, even to this day. Don’t believe the hype. Drug use is an ineffective, yet popular way to cope with trauma, whether you were part of a unit that saw incoming fire at the Battle of Gettysburg or if you’re just growing up in rural America after Bain Capital sent all of the jobs in your town away.