Let’s Not Keep Meds From Chronic Pain Patients Because Dr. Nick Keeps Killing Celebrities.

Via wikimedia.

Opinion by Terry Gotham

This article goes out directly to the party people & Burners who think they can party like rockstar gods. While the measure of any varsity party person is the ability to handle multiple types of substances concurrently, that game has become intensely more dangerous in the last 5 years. In case you missed it, the coroner’s reports on Tom Petty & Dolores O’Riordan’s deaths came back. The lead singer of The Cranberries & one of the most distinctive voices of a generation is suspected of killing herself via fentanyl poisoning. And Tom Petty’s toxicology is so startling, I’ll just quote TMZ  (yes, it’s been corroborated elsewhere put the pitchforks down) directly:

Tom’s autopsy report shows the singer was on several pain meds, including Fentanyl patches, oxycodone (Oxycontin), temazepam (Restoril), alprazolam (Xanax), citalopram (Celexa), acetyl fentanyl and despropionyl fentanyl. The reason doctors prescribed the meds was because of a number of medical problems, including emphysema, knee problems and a fractured hip.
~Tom Petty Died From Massive Accidental Drug OD. TMZ.com 1.19.18

In the immortal words of Alex Shulgin, that is a “heroic” cocktail. For all my psychonauts and chem nerds out there, Kevin Shanks has an exceptional review of the chemicals here. For people out there that might not be too familiar with pharmacology, I’d like to explain why this combination of drugs is terrifying and a perfect example of the crisis currently afflicting all 50 states. While many have seen that pile of substances and flagged it as an “opiate overdose,” in a lot of toxicology reports, autopsies revealing multiple drugs are categorized in similarly incorrect ways. Some counties would flag it as a synthetic opiate overdose, while others only bucket many different types of opiates under the umbrella term “drug overdose.” Still others might even classify it as a benzo or Xanax overdose. While New York City differentiates between fentanyl and heroin in its reporting, this is not the norm. And that is a huge problem. Especially now that it’s easier than ever to be on half a dozen different drugs.

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10 Questions With Terry Gotham: Brad Burge (MAPS)

(When meeting Brad Burge several years ago, I was immediately struck by his masterful ability to communicate to all comers at an academic conference we were speaking at. He connected immediately, and never lost the purpose, message, or empathy that we all strive to have when speaking to people we care about, even when addressing someone he’d never met before. He’s become one of MAPS’ most effective ambassadors, overseeing a period of rapid visibility expansion, to the point where MDMA & PTSD is coming up at the watercooler and at the holiday dinner table. I wanted an update on the MDMA/PTSD clinical trial after my previous article on it, so I was overjoyed when he obliged! Enjoy the chat, and feel free to refer to it while talking about MDMA & PTSD with your family over the holidays!)

Photo courtesy of MAPS.

Interview by Terry Gotham

1. Even with the recent Breakthrough Therapy designation, how do you keep going in the Age of Trump?
We have been able to make a lot of progress since the election, including getting the FDA’s stamp of approval for Phase 3 trials and the Breakthrough Therapy Designation, which came in August. Trump has taken a fairly hands-off policy when it has come to the FDA so far and has given every indication that his administration supports facilitating accelerated development of pharmaceuticals and new medical treatments. Plus, and more importantly, we see psychedelic science and psychedelic therapy research as bipartisan issues, since they are not about being countercultural or revolutionary or being oppositional in the traditional sense, but rather about being careful scientists and treating serious mental health conditions. Of course we think that this research has tremendous transformational value, and that the approval of MDMA-assisted psychotherapy for PTSD is likely to change how our culture understands and treats mental illness, but we are working with the system to make those changes happen, not outside it. We have had equally positive media reports, for example, from The New York Times and Scientific American as from Fox News and Breitbart.

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Ketamine & Mental Health: What We Know Already

A very good friend sent me a landmark study surrounding Ketamine a little while ago.  In drug research, big effects and powerful findings are usually accompanied by tiny sample sizes and weird statistics magic to rig the findings. So when I read the meta-analysis and systematic review published in The American Journal of Psychiatry, I was heartened. This is serious science and serious stats, with 167 patients evaluated across multiple studies. Also, the reporting scales (MADRS, HAM-D, QIDS-SR & the BDI) are well understood, robust and respected in the field. All of this adds up to this results abstract being very, VERY important:

Ketamine rapidly (within 1 day) reduced suicidal ideation significantly on both the clinician-administered and self-report outcome measures. Effect sizes were moderate to large (Cohen’s d=0.48–0.85) at all time points after dosing. A sensitivity analysis demonstrated that compared with control treatments, ketamine had significant benefits on the individual suicide items of the MADRS, the HAM-D, and the QIDS-SR but not the BDI. Ketamine’s effect on suicidal ideation remained significant after adjusting for concurrent changes in severity of depressive symptoms.
~The Effect of a Single Dose of Intravenous Ketamine on Suicidal Ideation: A Systematic Review & Individual Participant Data Meta-Analysis (Wilkinson et al)

That’s a dense couple of sentences, so let me explain why it’s so earth shattering. Suicidal thoughts, (known as suicidal ideation in clinical psychology) and depressed feelings are very difficult to get rid of, especially for depressed people. Treatment-resistant depression is a term associated with someone who has attempted multiple types of treatment for their Axis I disorder, but it hasn’t gotten better. After trying multiple types of interventions with no success, people slide quickly into hopelessness and thoughts of self harm. Up until now, depression treatments like SSRI drugs and Cognitive Behavioral therapy take time to work, sometimes more than a month. If you’re not in a good place right now, these things can’t help you. Ketamine infusions help immediately, and the change is apparent both to the patient and to the interviewing physician afterwards. This bit is huge, as most drug research relies heavily on self-report, which leads to bias and distorted findings. But, people are already talking to the press swearing by it, and it’s getting quite a lot of press, so here’s what they’re talking about.

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Cannabis, Decommodification & Brake Lights: Gifting in 2017

Column by Terry Gotham

While the Best Coast has just about legalized the growth & sale of cannabis from the Mexican to Canadian borders, us poor unfortunate souls stuck in New England, the Mid-Atlantic, and what’s traditionally thought of as the Deep South, remain mired in drug reform purgatory. In New York state, medical cannabis laws allow for purchase of concentrates, edibles and, non-plant matter containing products that have THC/CBD, but dispensaries are few & far between, and there is a steep fee to obtain an MMJ license. In Massachusetts, cannabis became legal a full year before dispensaries are allowed to open, providing legal cover to people who can already access the stuff, while propagating the same patterns of arrest and harassment of gray/black market channels as before the law was passed. We’ve seen similar patterns of arrest for dealers who don’t play by the “tax stamp” rules in Colorado, but Washington DC takes the cake when it comes to cannabis market dysfunction.

“Thank you and here’s a gift for you to have as a souvenir.”
~Legal loophole in DC creates bizarre pot bazaar, Ashraf Khalil – Associated Press 9.28.17

In Washington DC, cannabis was legalized, but a congressional committee gets to review all laws the District of Columbia passes. Some asshole named Andy Harris, an anesthesiologist member of the “Freedom Caucus” who opposes the cannabis legalization, got a rider passed that prohibited DC from spending cash on figuring out how to tax or regulate pot. So, it remains legal to possess, but illegal to buy or sell. While this is one of the dumbest things you’ll hear all month, that hasn’t stopped DC. Businesses all over the city have started selling mugs, t-shirts, calendars, and tons of other swag with “a little something.” With DC police in no hurry to stamp out anything but the most in your face abuse of this system, we’re starting to see what happens when something that starts as Mutual Aid or gifting, turns into a market economy.

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There Are No More Heroin Overdoses

Report by Terry Gotham

Enough people sent me the NY Times article about Fentanyl overtaking Heroin that I had to say something about it. If you’ve not seen it and the plurality of think pieces surrounding it, the only piece you need to read on it is by the person who runs The Dose Makes The Poison, Kevin Shanks. He’s been one of my go to sources on novel psychoactive substances for years now, and he, along with a handful of others have been yelling as loud as they possibly can. The point he raised almost a month ago is one I’ve not seen a single mainstream medical journal begin to grapple with in any kind of meaningful way.

As I’ve said for a while now, this ain’t your father’s heroin. At what point do we stop calling it heroin and refer to the standard “heroin” product on the street as fentanyl?
~Kevin Shanks (9/2/17)

While drug overdose deaths are up 22% from 2015 alone, fentanyl deaths doubled. That’s not including the fact that cases are severely under counted, given the volume of fentanyl analogs in circulation right now. I previously reported on the report coming out of Ohio with 24 analogs & active metabolites being identified. That, combined with the increased cost in testing for analog substances, we’ve arrived at a place where medical staff have no idea how many chemicals they’re not testing for. How many rural communities are testing for acrylfentanyl or butyrylfentanyl? How many rural communities are seeing analogs that we don’t even know about yet? Communities along the migratory arc that fentanyl takes from China into Western Canada or Mexico into border communities, that see these substances first, are they still getting the same analogs, or is there already something new? At this point, it’s likely the unknown unknowns are already on the ground and slowly being consumed for the first time.

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