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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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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Fentanyl, Toxicology, Healthcare Costs & Estate Planning: Strange Bedfellows in 2017

Report by Terry Gotham

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.

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Shockingly, People Don’t Actually Throw Out Drugs.

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:

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Prohibition, Jake Leg, Methanol & Jamaican Ginger: Adulterants 100 Years Ago

Report by Terry Gotham

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.

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