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.
At Burning Man 2006, at the Entheogen Camp on the Esplanade, I watched someone ask Shulgin how many times a year he thought it was safe to take MDMA. He said “do you really want to know?” The guy who asked the question wasn’t so sure, being confronted with the possibility of a real answer. On August 26th, 2017, the Multidisciplinary Association for Psychedelic Studies announced that the FDA had granted MDMA the Breakthrough Therapy Designation for its treatment of post-traumatic stress disorder. After decades of demonization, lies, bad science and straight up villainy by the powers that be, MDMA is being given its time to shine. This victory in a long road that MAPS & MDMA have traveled is a long time coming and absolutely pivotal. “Breakthrough Therapies” are seen as crucial, high-value drugs that the FDA wants to assist through development and review. To receive this designation, a drug must qualify in two ways:
The drug treats a serious or life threatening disease or condition.
This designation is a victory, but if you only know MDMA as something to take at parties, you might not know why. From its use as a legal alternative to alcohol in the club/house music scene in 80’s Chicago/Dallas/NYC to its current iteration as the much maligned “Molly,” MDMA has gotten a pretty bad rap over the years. To understand why this news is being celebrated in harm reduction, drug policy and legalization advocacy circles, we need to look back at how MDMA took hold of America & how it became illegal, because a lot of what you think you may know about its history is wrong. For example, most believe Alexander Shulgin invented the compound for the first time in 1965 for Dow Chemical, while it was actually first synthesized in 1912 by Anton Köllisch, a German chemist working for Merck. The chemist was studying substances to stop bleeding but without bumping into the patent held by Bayer for hydrastinine, so in a bit of 20th century novel psychopharmacology, they developed an analogue, methylhydrastinine. MDMA was actually only synthesized as an intermediate step in the methylhydrastinine synthesis process. One of the most important drugs of the 20th Century was created accidentally, just like Hofmann producing LSD accidentally 36 years later.
This week’s edition of “Why We Can’t Have Nice Things” is a look at a couple of different secondary effects of the opiate overdose epidemic that I don’t think are being given enough scrutiny. With Donald John Trump Jr. declaring a “state of emergency” but not promising any tangible resources, I thought it would be best to do the opposite. Dive into the nitty-gritty of two facets of the opiate epidemic that are so far out into the policy weeds that our president has probably never thought about them.
One of the more complex problems caused by the flood of fentanyl and fentanyl analogs is the difficulty in investigating overdose deaths. This is somehwat related to the explosion in complexity that ER staff are forced to cope with when it comes to determining what someone is overdosing from exactly. I spoke about this a while ago but only touched on the difficulties Emergency Rooms and hospitals are dealing with while working with the patient in vivo. But the work doesn’t stop there.
In what is the biggest “I can’t believe we have to prove this academically” story of the year, three Johns Hopkins researchers showed that 66-92% of people who got a pile of prescription opioids, didn’t use them all. Not only did 67-92% of patients report unused opioids (92!) but up to 71% of opioids obtained even by surgical patients weren’t consumed. This review of 6 different studies drives home the need for much of the mainstream addiction/treatment community to modernize their thinking when it comes to harm reduction and human behavior. Unsurprisingly, 3 out of 4 people didn’t secure their opioids properly (yes, the FDA legitimately believes that people should store pain pills in locked containers). Even more unsurprisingly, no more than 9% of patients in any study “disposed” of their drugs “properly.” What does disposing drugs properly look like? This:
Picture New York City, Christmas Eve night, Bellevue Hospital. 60 people hospitalized over the course of the evening, with another 23 hospitalized from drug poisoning within the next 48 hours. With 8 dead by the time the smoke cleared, it sounds like a news story you’ve heard every week this year coming out of some distraught community in Ohio or Connecticut or Georgia? It’s got to be a bad batch of fentanyl? Maybe some spiked heroin or morphine that no one saw coming. It was actually alcohol and the year was 1926. As the Chicago Tribune editorialized in 1927:
“Normally, no American government would engage in such business. … It is only in the curious fanaticism of Prohibition that any means, however barbarous, are considered justified.” Others, however, accused lawmakers opposed to the poisoning plan of being in cahoots with criminals and argued that bootleggers and their law-breaking alcoholic customers deserved no sympathy. “Must Uncle Sam guarantee safety first for souses?” ~The Chemist’s War (Deborah Blum, 2/19/2010 Slate.com)
Returning to the History of Addiction series this week, I’m going to be exploring one of the lesser known eras of adulterated drugs in world history, Prohibition-era America. While it’s widely known that alcohol was still available during Prohibition, we have a romanticized idea of what this was like, with the speakeasy culture, Al Capone and flappers dominating our vision of it. The reality of bathtub gin and moonshine had some dangerous facets that we don’t talk about, that even continue to this day in places like Russia. This ties directly to the continued prohibition/unaffordable nature of scheduled substances.