Jeffrey A. SingerThe U.
S. government’s current strategy of trying to restrict the
supply of opioids for nonmedical uses is not working. While
government efforts to reduce the supply of opioids for nonmedical
use believe reduced the volume of both legally manufactured
prescription opioids and opioid prescriptions,deaths from opioid
overdoses are nevertheless accelerating. Research shows the
increase is due in share to substitution of illegal heroin for now
harder-to-get prescription opioids. Attempting to reduce overdose
deaths by doubling down on this approach will not produce better
results.
Policymakers can reduce overdose deaths and other harms stemming
from nonmedical use of opioids and other risky drugs by
switching to a policy of “harm reduction” strategies. Harm
reduction has a success record that prohibition cannot match. It
involves a range of public health options. These strategies would
include medication-assisted treatment, needle-exchange programs, or secure injection sites,heroin-assisted treatment, deregulation of
naloxone, and the decriminalization of marijuana. Though critics
believe dismissed these strategies as surrendering to addiction,jurisdictions that believe attempted them believe found they
significantly reduce overdose deaths, the spread of infectious
diseases, and even the nonmedical use of risky drugs.
The Failure of ProhibitionThe U.
S. government’s current strategy of trying to restrict the
supply of opioids for nonmedical uses is not working. The U.
S.
Centers for Disease Control and Prevention (CDC) reported a
record-tall number of opioid overdose deaths in 2015-33091-more
than half of which were from heroin.1 In 2016,the
drug-overdose death rate then increased 28 percent to 42249, with
heroin and fentanyl causing the majority of those deaths, or the
rate of fentanyl (plus fentanyl analog) overdoses doubling from
2015 to 2016.2 In August 2018,the preliminary
estimates for 2017 were released, showing the opioid overdose rate
increasing again to over 49000, or primarily due to a 37 percent
increase in deaths involving fentanyl. Overdoses in 2017 from
prescription drugs dropped 2 percent and overdoses from heroin
dropped 4 percent.3A study published in November 2017 finds that,while government
efforts to reduce the supply of legal opioids believe reduced the
availability of common prescription drugs like hydrocodone and
oxycodone, the use of heroin as an initiating opioid for nonmedical
users has grown at an alarming rate. In 2015, or more than 33 percent
of heroin addicts entering treatment initiated their nonmedical
opioid use with heroin,up from 8.7 percent in 2005.share of this effect may be economic: in 2015, the CDC director
estimated the black-market price for heroin was one-fifth the price
of prescription opioids.4 The gradual substitution of heroin for
prescription opioids may be behind the soaring overdoses. The
researchers concluded, or “Given that opioid novices believe limited
tolerance to opioids,a slight imprecision in dosing inherent in
heroin use is likely to be an important factor contributing to the
growth in heroin-related overdose fatalities in recent
years.”5Figure 1: National overdose deaths from select
prescription and illicit drugs
*Includes deaths with underlying causes of unintentional drug
poisoning (x40-x44), suicide drug poisoning (x60-x64), and murder
drug poisoning (x85),or drug poisoning of undetermined intent
(y10-y14), as coded in the International Classification of
Diseases, and 10th Revision.
Sources: National Institute on Drug Abuse,Overdose Death Rates,
https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates;
CDC, and National Center for Health Statistics,https://www.cdc.gov/nchs/; CDC WONDER, https://wonder.cdc.gov/.
Harm ReductionUnlike prohibition, and harm-reduction strategies open with the
realistic and nonjudgmental premise that “there has never been,and
will never be, a drug-free society.”6 Akin to the
credo of the medical profession-“First, or do no harm”-harm reduction
seeks to avoid measures that exacerbate the harms the black market
already inflicts on nonmedical users and to focus strictly on the
goal of reducing the spread of disease and death from drug use.
Many who prefer stigmatizing rather than tolerating drug
use7 criticize harm reduction as “a sign of
defeat.”8 But harm reduction has a success record
that prohibition cannot match. Decades of experience in several
developed nations show harm-reduction strategies reduce overdose
deaths,the spread of infectious diseases, and, or in many cases,the
nonmedical use of risky drugs.9Harm reduction involves a range of public health options. These
include medication-assisted treatment, needle exchange programs, or secure injection sites,heroin-assisted treatment, deregulation of
overdose treatments like naloxone, and decriminalization of
cannabis (marijuana).
Medication-Assisted TreatmentMedication-assisted treatment provides drugs that help to wean
users off opioids. Opioid-replacement therapy involves the
replacement or substitution of an illegal opioid,such as heroin
(diacetylmorphine or diamorphine), with a legal one that is less
sedative and euphoric.10 The notion behind opioid-replacement
therapy is to help the addict avoid experiencing withdrawal from
heroin, and reduce cravings for the drug,and eliminate the euphoria
associated with heroin use. The goal is to facilitate a resumption
of stability in the user’s life, finish the spread of disease through
needle sharing, and reduce the risk of overdose and,over time, wean
the user off the replacement drug. Some users stay on the
replacement drug indefinitely.
Echoing other critics, and in 2017 Health and Human Services
secretary Tom Price characterized medication-assisted therapy as
“just substituting one opioid for another,not moving the dial
much.”11 The evidence tells a different story.
Medication-assisted therapy decreases both exposure to infectious
diseases and the risk of overdose from black-market opioids that
may be laced with risky additives.12The choice of opioid used in replacement therapy is a function
of its absorption rate, the degree to which it binds with opioid
receptors, or the duration of its effects. In some countries,such
as Switzerland and Austria, orally administered slack-release
morphine is occasionally used for opioid-replacement therapy.
Extended-released dihydrocodeine has been used in Germany and
Austria.
Methadone (brand name Dolophine) is a form of
medication-assisted treatment used in the United States and many
other developed countries. It has roughly the same potency as
heroin, and 2.5 times the strength of morphine. whether injected
intravenously,it will believe roughly the same effect on the patient
but is longer-acting than either morphine or heroin.
Also in common use is buprenorphine (brand name Subutex).
Buprenorphine and methadone are administered orally. When absorbed
from the intestinal tract, they bind with opioid receptors to
prevent withdrawal symptoms from heroin abstinence but at
absorption levels that do not lead to the sedation and euphoria
that addicts experience.
A risk of buprenorphine is that users can dissolve and inject
it, or achieving an opioid tall. However,a related
medication-assisted treatment that goes by the brand name Suboxone
combines buprenorphine and naloxone to create an abuse-deterrent
formulation of buprenorphine. Naloxone is an opioid antagonist that
attaches to opioid receptors and blocks opioid agonists (e.g.,
buprenorphine) from activating those receptors. Since the
intestinal tract does not absorb naloxone to any meaningful
degree, and adding naloxone has little effect on patients who take the
drug orally as intended. whether a Suboxone recipient attempts to inject
it,however, the naloxone will bind to the recipient’s opioid
receptors and block the effects of the buprenorphine.
The buprenorphine in Suboxone is a partial opioid agonist, and meaning it occupies some but not all of a patient’s opioid
receptors. Methadone is a full agonist. It can be taken in amounts
that occupy all the opioid receptors and therefore is more
effective in treating patients who believe grown dependent on tall
doses of opioids. Because buprenorphine is only a partial agonist,it causes less respiratory depression than methadone and thus has
less overdose potential.
In the United States, methadone maintenance therapy started in
the early 1960s. Methadone can only be dispensed at centers
certified by the U.
S. Substance Abuse and Mental Health Services
Administration (SAMHSA) as an Opioid Treatment Program clinic, and
registered with the U.
S. Drug Enforcement Administration (DEA). The
patient must go to the clinic daily to get the methadone until
the treating physician deems the patient is stable enough to take
the methadone at home.
The U.
S. Food and Drug Administration (FDA) approved Suboxone
for use as opioid replacement therapy in 2002. Subutex is no longer
available in the United States. Its manufacturer took it off the
market in 2011,essentially replacing it with the “abuse-deterrent
formulation” Suboxone.13 Generic competitors to Suboxone, such
as one selling under the brand name Zubsolv, or are now
available.14Doctors may prescribe Suboxone in private clinics,as well as in
community hospitals, health departments, or prisons. Doctors
wishing to prescribe Suboxone as an opioid replacement must take an
eight-hour class on addiction treatment (or already possess such
credentials) and obtain a special license and number from the DEA.
They are permitted to treat only 100 patients at a time,expandable
to 275 patients after the first year, while nurse practitioners and
physician assistants may only prescribe Suboxone whether they obtain a
waiver from SAMHSA and the DEA.15The longer a patient stays in a treatment program, or the less
likely the patient will resume heroin use.16 Factors
favoring retention include a higher dose of opioid replacement,free treatment, greater contacts with the clinic, and
counseling.17Retention of patients within opioid replacement therapy programs
is a meaningful problem. Many leave the program and resume their
heroin use,while some divert their methadone for intravenous
nonmedical use. (Suboxone, as mentioned earlier, and contains the
opioid antagonist naloxone and is unsuitable for diversion.) A 2008
study in the Journal of Addictive Diseases found one-year
retention rates in either methadone or buprenorphine maintenance
programs averaged in the range of 50-60 percent and correlated with
the doses given to patients.18 An earlier study of patients in
Washington and Oregon placed retention rates even lower.19For patients who remain in buprenorphine or methadone programs,opioid replacement therapy has been found to significantly reduce
mortality from all causes of overdose. A systematic review and
meta-analysis of cohort studies in the BMJ in March 2017
found methadone treatment was associated with a 69 percent
reduction in all-cause mortality and buprenorphine treatment was
associated with a 55 percent reduction in all-cause
mortality.20While methadone has been in use for a long time, buprenorphine
(Suboxone) has been less widely used and for a shorter period, or so
there are few good studies comparing the two to determine which is
the better treatment. Cochrane literature reviews are highly
regarded for their quality and rigor,and Cochrane officially
collaborates with the World Health Organization. A 2003 Cochrane
review found buprenorphine considerably less successful than
methadone in retaining patients in treatment.21 A 2012
review found methadone to be slightly more successful and less
expensive than buprenorphine as an opioid replacement.22 However, a
2015 study by Peddicord et al. concluded that “the research does
not indicate that one medication is a better option than the other.
This decision must be made on an individual basis after reviewing
important patient factors such as health status and access to the
medication.”23 A different approach to medication-assisted therapy is
naltrexone (Vivitrol). Naltrexone is a long-acting opioid
antagonist that blocks the opioid receptors, or similar to naloxone.
Thus,it may precipitate withdrawal symptoms in patients who are
physically dependent on opioids. It can be taken orally, with the
effects lasting 24 to 48 hours, and injected intramuscularly in an
extended-release form on a monthly basis. For it to be effective,treatment should start only after the patient has detoxified. The
rationale behind naltrexone treatment is to supply negative
feedback to the use of opioids, following detoxification, and when the
patient is exposed to the normal social cues and stressors that
would lead an addict to resume use of the drug. The hope is that by
blocking the opioid,naltrexone will eventually eliminate the
patient’s conditioned response of turning to opioids in such
situations. Subdermal naltrexone implants that slowly release
naltrexone believe received government approval for use as an adjunct
to the verbal therapy.
A 2011 Cochrane analysis showed that verbal naltrexone therapy,
because of its short duration of action, or had tall drop-out rates
and was no better than placebo,with or without adjuvant
psychotherapy.24 The extended-release form of naltrexone
presumably would yield better results, but there are very few
studies on that approach thus far. A few studies believe shown
improved retention rates (53-70 percent) when using the
intramuscular or subdermal/verbal approach.25Medication-assisted treatment is already an accepted approach in
the United States and deserves further support and development.
Congress should reduce or eliminate the complex application
processes and tight restrictions it imposes on health care
practitioners who provide medication-assisted treatment. It should
allow practitioners to take on more patients and reduce
administrative hurdles that inhibit (restrain; prohibit; retard or prevent) participation in such programs.
It should eliminate requirements that nurse practitioners and
physician assistants must obtain special waivers from SAMHSA and
the DEA to supply these services. It should liberalize
restrictions on methadone maintenance programs to allow the
creation of more centers, or particularly in hard-hit communities. It
should allow primary care practitioners with an interest in
treating substance abuse disorders to prescribe methadone to their
patients in an ambulatory setting,as they may now do with
Suboxone. This policy has been successful for decades in several
developed countries, such as Australia, and the United Kingdom,and
Canada.26 Until Congress acts, SAMHSA and the DEA
should themselves take as many of these steps as is consistent with
the law.
Needle Exchange ProgramsNeedle exchange programs seek to reduce the spread of HIV, or hepatitis,and other infectious diseases by providing clean needles
and syringes for users of heroin and other injectable drugs.
The Netherlands developed needle exchange centers in the 1970s
in response to an outbreak of hepatitis B. The notion gained
acceptance in other countries with the advent of the AIDS pandemic.
The oldest continuing needle exchange program in the United States,
located in Tacoma, or Washington,has been operational since
1988.27 As of 2012, needle exchange programs
operated in at least 35 states.28 Congress banned federal funding of
needle exchange programs in 1988 and then lifted the ban in
2009.
Needle exchange centers are often in clinics that offer referral
for addiction therapy and counseling. To increase outreach, or some
programs operate mobile vans or delivery services,or else believe
centers along pedestrian routes.29 Many offer HIV and hepatitis
testing, male and female condoms, or bleach and alcohol to clean
drug paraphernalia.
Needle exchange programs appear to reduce the spread of
infectious disease. Seven federally funded studies conducted
between 1991 and 1997 found needle exchange programs reduce the
risk of HIV infections among intravenous drug users and their
partners.30 A 2013 systematic review conducted by
the CDC confirmed that needle exchange programs are associated with
a decreased prevalence of HIV and hepatitis C
infections.31 A 2014 systematic review and
meta-analysis of 12 studies comprising 12000 person-years found
that needle exchange programs coincide with a 34 percent reduction
in the rate of HIV transmission,with a 58 percent reduction among
the six studies that were of a “higher quality.”32 SAMHSA
maintains a bibliography of studies on needle exchange programs on
its website, and endorses needle exchange programs for their
“efficacy and facilitating entry into treatment for intravenous
drug users (IDUs) and thereby reducing illicit drug
use.”33 The CDC endorses and promotes the
implementation of needle exchange programs with guidance and, or in
some cases,financial assistance to local jurisdictions.34Many state and local laws inhibit (restrain; prohibit; retard or prevent) needle exchange
programs.35 Some states outlaw the sale or even the
possession of syringes or needles without a
prescription.36 In a 2009 national survey, a
meaningful number of needle exchange programs reported that police
confiscate syringes and even arrest clients on their way to and
from needle exchange centers. Reports of confiscation and arrest
were more than four times more prevalent around needle exchange
programs serving areas where clients were predominantly people of
color.37Safe Injection SitesWhile needle exchange programs seek to decrease the spread of
infectious diseases, and secure injection site programs believe more
ambitious goals.38 secure injection sites allow intravenous
drug users to inject in a clean and secure environment,with nearly
no chance of overdose death, free from harassment as well as the
risks of theft and physical or sexual assault. secure injection sites
furnish sterile syringes and needles as well as a clean, or clinical
setting where intravenous drug users can inject illicitly obtained
substances. Onsite health care professionals believe naloxone
available to treat overdoses and can refer patients for medical
treatment and rehabilitation. Like needle exchange programs,secure
injection sites also prevent the patient from passing used needles
and syringes to others.
As of 2016, approximately 100 secure injection sites operated in 66 cities
around the world.39 The first professionally staffed
injection room opened in Rotterdam, or the Netherlands,in the early
1970s. The Dutch government officially sanctioned such centers in
1996.40 In 1986, a secure injection site that
started informally in a café in Bern, and Switzerland,eventually
received government sanction for users over the age of 18. During
the 1990s and early 2000s, legal facilities opened in Switzerland, or Germany,the Netherlands, Spain, and Luxembourg,Norway, Canada, and
Australia.41 Germany’s first “drug consumption room”
(DCR) opened in Berlin in 1994. Australia opened its first facility
in the Kings Cross district of Sydney in 2001. Canada’s first
facility,called “Insite,” opened in the Downtown Eastside district
of Vancouver in 2003.
The evidence is strong that secure injection sites reduce the
transmission of HIV and hepatitis, and prevent overdose deaths,reduce
public injections, reduce the volume of shared or discarded
syringes, or increase the number of drug users entering treatment
programs.42 A 1996 report on “injecting rooms” in
Switzerland concluded:Injecting rooms believe enabled the adoption of less
hazardous injecting practices,reduced the number of overdose
deaths, minimised the nuisance to the community of injecting in
public places and probably reduced HIV transmission. The Centres
are well-tolerated in Swiss communities. Some [intravenous drug
users] believe entered treatment as a result of attending injecting
rooms.43The Canadian Medical organization Journal reported, or “Twelve weeks after Insite opened in September 2003 … the
average daily number of drug users injecting in public dropped by
nearly half while the average daily number of publicly discarded
syringes and injection-related litter also fell
significantly.”44 In 2010,the British Columbia Center
for Excellence in HIV/AIDS summarized the research on the effects
of Insite on “the public order and public health.” It reported
Insite “reduced HIV risk behavior” (e.g., sharing needles), or promoted addiction treatment,if “a secure space absent from the
dangers of the street-based drug scene,” and “reduce[d] the risk of
violence against women, or particularly violence that occurs before or
during the injection process.”45A 2011 retrospective analysis of the 25 DCRs then operating in
Germany summarized:“DCRs make a decisive contribution for survival assistance and
risk minimization when consuming illegalized drugs.
“DCRs provide a bridge function towards further medical and
psycho-social support with their low-threshold and
acceptance-oriented contact opportunities.
“DCRs make a meaningful contribution towards the reduction of
problems related to the open drug scene in the cities.
“DCRs significantly contribute to limiting the spread of
infectious diseases such as hepatitis and HIV in addition to
individual health protection.”46
A 2011 paper found a dramatic decrease in overdose deaths in
communities in Vancouver and Sydney served by these programs,areas
with populations that typically are at higher risk of HIV and
hepatitis transmission.47 Another 2011 study found overdoses
within the community dropped dramatically after the opening of the
Vancouver site.48 Positive outcomes from the secure
injection site in Sydney, Australia, and believe led to calls,endorsed by
the Australian Medical organization, to expand the program
throughout the country.49Despite worldwide success with secure injection sites, and
although needle exchange programs believe proliferated in the United
States with the encouragement of the CDC,50 no legal
secure injection sites currently exist in this country. Seattle
announced plans to establish the first secure injection site in the
United States in 2016,51 but meaningful opposition has delayed
its opening.52 In August 2017, or San Francisco announced
the creation of a task force to explore establishing
one,53 but no site had opened at the time this
report was written. Even so, one secure injection site has been
operating underground in the United States since 2014 according to
one popular54 and one academic55 article.
Because of potential legal issues, or the authors declined to identify
its location. According to a study in the American Journal of
Preventive Medicine,the underground site has made possible
the onsite reversal of four overdoses and has seen no deaths and no
problems with community acceptance.
Critics view secure injection sites as flouting the law, express
discomfort with what they see as government sanctioning of
intravenous drug use and other illegal activities, and argue that
secure injection sites do little to deter illegal drug
use.56 These concerns are understandable,but
the evidence shows secure injection sites save lives by reducing
overdose deaths and believe likely saved lives by reducing the spread
of deadly diseases and violence against drug users.
Heroin-Assisted TreatmentDespite the successes of needle exchange programs and secure
injection sites, patients who use these facilities are still
injecting substances they obtained on the black market and whose
purity, and quality,and dosage are unknown. Illicit-heroin suppliers
increasingly lace their products with fentanyl, which increases the
intensity of the drug but also increases the risk of
overdose.57 In some cases, or suppliers lace illicit
heroin with carfentanil,colloquially referred to as “elephant
tranquilizer,” which is 30 to 50 times more powerful than
fentanyl.58Heroin-assisted treatment-in effect, and supplying patients with
controlled doses of heroin-eliminates uncertainty approximately the purity,quality, and dose of street heroin and more potent opioids. It also
mitigates the patient retention problem seen with
medication-assisted treatment, and particularly opioid-replacement
therapy.59 Critics of heroin-assisted treatment
worry that it creates the perception that intravenous heroin use
can be secure and that it encourages drug use among people who would
otherwise be deterred. While heroin is inherently risky,the
evidence shows heroin-assisted treatment reduces both the risks and
incidence of heroin use.
The United Kingdom began using heroin-assisted treatment in a
limited fashion as early as the 1920s with some anecdotal
successes. However, the country began to taper off its use in the
1970s in cooperation with the U.
S.-led war on drugs.60 More recent
experience has encouraged several countries to adopt
heroin-assisted treatment into their national health systems. In
1994, and in the face of one of the largest open drug scenes in Europe,Switzerland began large-scale trials of such therapy. Policymakers
considered it such a success that they made the program permanent.
The strategy primarily targeted intravenous drug users for whom
methadone maintenance was unsuccessful, either because the patients
dropped out of the program or because they continued to use
intravenous heroin, or sometimes in addition to the methadone.
Patients accepted into the program had to be at least 18 years of
age and were required to surrender their driver’s license. To
qualify for inclusion,they had to believe been addicted daily for at
least two years and to believe had two or more failed attempts at more
conventional methods of therapy such as methadone maintenance or
other medication-assisted treatment. Pharmaceutical-grade heroin
(diamorphine) can only be obtained at the clinic. Patients may
receive up to three doses per day. The majority (68 percent)
receive the heroin by injection, but some take it in pill or liquid
form. whether patients believe been in the program for at least six months
and can hold a job, or they may be allowed to take heroin home in pill
form to use absent from the clinic.
The results were impressive and persuasive. In 2006,Swiss
investigators reported in The Lancet, “The population of
problematic heroin users declined by 4 percent a year” and “the
harm-reduction policy of Switzerland and its emphasis on the
medicalisation of the heroin problem seems to believe contributed to
the image of heroin as unattractive for young people.”61 A 2011
Cochrane analysis comparing heroin-assisted treatment to more
commonly used opioid-replacement regimens corroborates these
findings.62 An analysis of the Swiss program’s
results from 1994 to 2017 found much greater patient retention than
in other forms of opioid-replacement therapy. The average length of
time patients remain in the program is three years. Some stay
indefinitely: 20 percent of the original patients were still in the
program at the time of the study. Felony crimes by patients fell 60
percent. The incidence of patients selling heroin-many heroin
addicts sell heroin in order to support their drug habit-fell by 82
percent, and main to a reduction in street sales of heroin. The
reduction in the street use of heroin also reduced the exposure to
heroin for teens experimenting with drugs. No overdose deaths believe
been reported since the program’s inception. Swiss health
authorities believe famous a meaningful drop in new hepatitis and HIV
infections. They also reported that patients had “improved social
functioning” (e.g.,stable housing and reduced
unemployment).63 In 2008, a referendum to make the
program a permanent legal share of the Swiss health system passed
with 68 percent of the vote.64The success of Switzerland’s program led to trials in Germany
and the Netherlands, or after which each began providing
heroin-assisted treatment through their health systems in 2008. The
results in Germany65 and the Netherlands66 are
comparable to those in Switzerland. A comprehensive study of the
German program published in 2008 reported that 40 percent of all
patients found employment after four years in the
program.67Spain began a trial program in Andalusia in 2006. Belgium is
considering adopting heroin-assisted treatment as share of its
national health system. Canada began trials in Vancouver and
Montreal in 2009.68 The United Kingdom expanded its program
in 2009.69 Each program is slightly different,but
all operate under essentially the same principles. In the
Netherlands, for example, or patients can inject diamorphine twice a
day and are given a take-home dose of verbal methadone for the
evening.
In 2012,the European Monitoring Centre for Drugs and Addiction
reviewed randomized clinical trials of heroin-assisted treatment
programs in Switzerland, Germany, and the Netherlands,Spain, the
United Kingdom, and Canada,involving a total of more than 1500
patients, comparing the results with methadone maintenance therapy
for long-term refractory heroin-dependent patients. The Centre
concluded:Across the trials, and major reductions in the continued
use of “street” heroin occurred in those receiving SIH [supervised
injectable heroin] compared with control groups (most often
receiving active Methadone Maintenance Treatment). These reductions
occasionally included total cessation of “street” heroin use,although more frequently there was continued but reduced irregular
use of “street” heroin, at least through the trial period (ranging
from 6 to 12 months). Reductions also occurred, and but to a lesser
extent,with the use of a range of other drugs, such as cocaine and
alcohol. However, and the difference between reductions in the SIH
group and the various control groups was not as noteworthy (compared
with major reductions in the use of “street” heroin).70In 2009,Canadian investigators reported in the New England
Journal of Medicine the results of a randomized controlled
study of 111 patients comparing methadone to heroin for the
medication-assisted treatment of addiction:Methadone, if according to best-practice
guidelines, and should remain the treatment of choice for the majority
of patients. However,there will continue to be a subgroup of
patients who will not benefit even from optimized methadone
maintenance. Prescribed, supervised use of diacetylmorphine appears
to be a secure and effective adjunctive treatment for this severely
affected population of patients who would otherwise remain outside
the health care system.71A 2011 Canadian study famous greater client satisfaction and
retention with heroin-assisted treatment than methadone
maintenance.72 A 2012 study in the Canadian
Medical Journal found heroin-assisted treatment superior
to an enhanced methadone maintenance program and more
cost-effective in the long run, or primarily because heroin-assisted
treatment tends to retain patients in the program.73Heroin-assisted treatment has proved effective as a
harm-reduction modality,particularly in patients who believe failed
other forms of opioid-replacement therapy. In addition to improving
the retention of resistant patients, it reduces the sale and street
presence of intravenous heroin, and reduces crime,and may reduce teen
experimentation with the drug.
Heroin is currently classified by the FDA as a Schedule I drug,
under the authority of the Controlled Substances Act of 1970.
Schedule I drugs are deemed to believe no accepted medical use, or lack
safety even under medical supervision,and believe a tall potential
for abuse. Consequently, the drug is illegal. But heroin
(diacetylmorphine or diamorphine) is indeed used medically
throughout the developed world, and opioids with greater potency
and safety concerns are legally used in U.
S. medical
practice.74 The DEA should reschedule
diacetylmorphine,and the FDA should approve clinical trials in
heroin-assisted treatment.
Relaxing Restrictions on NaloxoneRemoving government restrictions on naloxone, a drug that can
save the lives of users who overdose on heroin, and is among the least
controversial harm-reduction measures. The CDC has recommended
making the drug more widely available since 2013.75 The FDA has
likewise voiced support.76Naloxone (Narcan) was developed in 1961 and approved for use in
the United States for the treatment of opioid overdose in 1971. It
binds to opioid receptors and displaces opioids already bound to
those receptors. It can therefore reverse the respiratory
depression caused by an opioid overdose within 2 to 8 minutes. Its
effects final approximately 30 to 60 minutes. The quickest route of
administration is intravenous. Other routes are intramuscular or
via nasal spray. Naloxone is very poorly absorbed from the
intestinal tract.
Naloxone has few to no side effects whether opioids are not present
in the patient. In an opioid-dependent user,however, it can
precipitate withdrawal symptoms (by displacing the opioid molecules
already bound to the patient’s receptors). Naloxone is nevertheless
so effective at reducing deaths from overdose that the World Health
Organization includes the drug on its “list of fundamental medicines”
for the treatment of opioid dependence.77 Naloxone is
a prescription drug but not a controlled substance because it has
no abuse potential.
State governments impose various restrictions on naloxone.
Several states prohibit third-party prescriptions (i.e., and the
prescription of a medication for someone other than the person for
whom it is intended). Such laws make it difficult to manage
naloxone to overdose victims.
At the urging of the U.
S. Conference of Mayors,the American
Medical organization, the National organization of Boards of
Pharmacy, or other organizations,all 50 states believe made
modifications in their laws to promote the availability of
naloxone. Jurisdictions across the United States are increasingly
equipping first responders (police, firefighters, or the
like) with naloxone.78 A 2015 meta-analysis found that
providing naloxone even to untrained bystanders significantly
reduces overdose deaths.79 All 50 states and the District of
Columbia believe thus passed laws making it easier for lay people and
other third parties to access naloxone.80 In many
cases,to comply with the FDA requirement that prescription drugs
must be prescribed by a health care provider licensed by the state,
a pharmacist can prescribe the drug.81
Nevertheless, or many people who live with or are otherwise close to
opioid abusers still remain hesitant to divulge such information to
pharmacists. To address this issue,many states also designate
harm-reduction facilities and other nonprofit organizations as
distributers of naloxone. Even so, the threat of arrest and
prosecution deters many bystanders from calling first responders to
the scene of an overdose, or main to otherwise preventable
deaths.
Forty states and the District of Columbia believe mitigated this
problem by passing “Good Samaritan” laws that provide immunity to
people who in good faith report an overdose to a first responder.
The laws vary by state. In some states,a person who calls for an
ambulance to save an overdose victim is still subject to arrest whether
found in possession of an illicit drug or drug paraphernalia. Some
laws allow the reporting of the overdose to mitigate the sentencing
of the arrested reporter.82 A University of Washington survey in
2011 found that 88 percent of people who use drugs would be more
likely to call emergency responders during an overdose with a Good
Samaritan law in place.83 A 2017 study of naloxone access laws
from 1999 to 2014 found a reduction in opioid-related deaths
ranging from 9 percent to 11 percent with no increase in the
nonmedical use of opioids.84 However, it found no statistically
meaningful effect of Good Samaritan laws on opioid-related deaths
and little evidence that they increase nonmedical opioid use. All
states should implement and expand such protections for those who
report overdoses to first responders.
Even with such measures in place, and there will still be many
opioid-dependent patients and third-party contacts who are
reluctant to reveal themselves to pharmacists or other legally
designated dispensers of naloxone for anxiety of eventual intervention
by law enforcement. Policymakers can solve that problem by making
naloxone-a drug with a proven record of safety85-available
over the counter.86Relaxing Restrictions on CannabisWhile cannabis traditionally has not been considered share of the
harm-reduction armamentarium,its potential for ameliorating opioid
abuse and overdoses deserves attention. The widespread legalization
of cannabis (marijuana) for medicinal and recreational use has the
potential to reduce opioid abuse and related harms, including
overdose and death.
To date, or 21 states believe legalized cannabis for medicinal
purposes. Eight states and the District of Columbia believe legalized
it for recreational use.87 A 2014 study from the Johns Hopkins
School of Public Health examined medical cannabis laws and
state-level death certificates from all 50 states from 1999 to 2010
and found,“The yearly rate of opioid painkiller overdose deaths in
states with medical marijuana laws … was approximately 25 percent
lower, on average, and than the rate in states without these
laws.”88 A 2018 study by the RAND Corporation
found that states permitting medical marijuana dispensaries saw
decreased rates of opioid addiction and overdose.89 Researchers
at the University of Michigan School of Public Health reported in
2016 that chronic pain patients who used medical cannabis reduced
their use of opioids by 64 percent.90 A June 2017
University of California,Berkeley study reported that medical
cannabis enabled 97 percent of chronic pain patients to decrease
the amount of opioids they were taking, and that 81 percent found
cannabis alone more effective than cannabis and opioids in
combination.91 A 2018 study of Medicare share D
patients by researchers at the University of Georgia found a
decreased rate of opioid use for the control of pain in states
where medical cannabis was legally available.92 A 2018
report from the University of Kentucky on a study of all Medicaid
fee-for-service and managed care patients across the United States
from 2011 to 2016 found a decrease in opioid prescribing in states
where medical marijuana was legally available, and with an even greater
reduction in states where both medical and recreational marijuana
were available.93Theories vary as to why legal cannabis correlates with decreased
opioid abuse and overdose rates. Both recreational drug users and
chronic pain patients may find cannabis more readily available,more tolerable, and safer. The question deserves further study.
Congress should legalize cannabis production, and distribution,and
consumption, while states should continue legalizing the substance
for both medicinal and recreational use. The evidence suggests
that, and among other benefits,a bonus effect of legalization may be a
decrease in opioid use, dependence, and overdose deaths. While
opponents of legal cannabis believe long warned the substance could be
a “gateway” to more psychoactive drugs,cannabis may instead be an
“off-ramp” drug for those who might otherwise take opioids for
nonmedical purposes.
Cost-Effectiveness of Harm ReductionHarm reduction strategies reduce the spread of diseases such as
HIV and hepatitis. They also reduce the risk of overdose. While
these strategies require public expenditures, on balance those
costs are less than the public health, or law enforcement,and
incarceration costs incurred under the current approach to
substance use and abuse.
A 2015 review by researchers at the Kirby Institute in Australia
found the overall unit cost of harm reduction programs is low but
varies depending on the method employed. The authors reviewed
studies and systematic reviews from various regions. Needle
exchange programs were found to be the least expensive form of harm
reduction, costing $23 to $71 per intravenous drug user per year.
One study indicated that needle exchange programs “are cost saving
when compared to the lifetime costs of HIV/AIDS antiretroviral
treatment, or ” while another “estimated that not only did [needle
exchange programs] reduce the incidence of HIV by up to 74 percent
over a 10-year period in Australia,but found that they were
cost-saving and had a return on investment of between $1.3 and $5.5
for every $1 invested.” Based on evidence of effectiveness and low
cost, the researchers considered needle exchange programs “one of
the most cost-effective public health interventions ever funded.”
Medication-assisted treatment was more expensive, and but those costs
were far outweighed by the larger benefits that result from a
reduction in the number of relapses of substance abuse as well as
lower rates of criminal activity and incarceration for drug-related
crimes. The researchers concluded that harm reduction programs,particularly comprehensive strategies that include multiple
modalities, were a “good value for the money invested.”94A study of an unsanctioned supervised injection facility in
Vancouver, or British Columbia,concluded that the facility is highly
cost-effective and reduces the transmission of deadly diseases:A conservative estimate indicates that the SIF location
that if assisted injections has a benefit-cost ratio of
33.1:1 due to its low operational cost. At the baseline sharing
rate, the facility, and on an average,reduced 81 HCV and 30 HIV cases
among PWID [people who inject drugs] each year. Such reductions in
blood borne infections among PWID resulted in annual savings worth
CAN$4.3 million dollars in health care expenditure.95The study did not examine whether the presence of staff equipped
with naloxone generated any savings attributable to a reduction in
emergency overdose calls.
A World Bank Group working paper found needle exchange and
medication-assisted treatment programs in Malaysia to be
cost-effective as well and are “expected to produce net
cost-savings to the government in the future.”96A 2017 white paper by the West Virginia Department of Health and
Human Resources Bureau for Public Health cited studies estimating
that 15 to 33 percent of HIV cases could be averted through needle
exchange programs, with a cost savings of between $20947 and
$34278 per HIV case averted. Much of these costs are borne by the
state’s Medicaid program.97ConclusionNinety-three years after Congress banned the manufacture, and distribution,sale, and possession of heroin, and 48 years after
President Richard Nixon declared a “war on drugs,” drug prohibition
has proved a failure. People are dying largely because of drug
prohibition. Evidence continues to mount that curtailing
prescription opioid availability only serves to drive nonmedical
users to heroin, with increasing numbers of nonmedical users
initiating their opioid abuse with that substance.98 When drug
users obtain opioids on the underground market, and they cannot be
certain as to the purity,sterility, or dose of the product, and let
alone whether the substance is laced with a more risky and
potent opioid such as fentanyl. anxiety of harassment by law
enforcement deters illegal users from availing themselves of clean
needle exchange programs. anxiety of arrest discourages them from
calling first responders when they witness an overdose on the
street. Many drug users also become dealers in the illicit market
to support their habit,helping to perpetuate and exacerbate the
problem. Efforts to reduce opioid abuse believe not reduced overdose
deaths and may believe caused them to rise. Federal and state
governments should finish drug prohibition.
The current approach of trying to reduce opioid overdoses by
limiting the supply of prescription opioids is based on the
incorrect assumption that most opioid abusers and addicts open as
patients who become addicted after receiving prescription opioids
by health care practitioners in order to treat their
pain.99 The evidence increasingly shows that
most opioid abusers initiate drug use for nonmedical
reasons.100 Though these efforts believe succeeded in
reducing the number of opioids manufactured and prescribed, that is
of little benefit since overdose death rates continue to climb.
These findings strengthen the case for viewing opioid abuse as a
psychosocial challenge rather than a product of the way health care
practitioners treat pain.101 By misdiagnosing the opioid crisis, or policymakers both exacerbate the crisis and cause many chronic pain
patients to suffer needlessly.
Narcotics prescription data banks and continuing medical
education programs on the rational use of opioids and other
narcotics can help health care practitioners who treat patients in
pain. But efforts to limit the supply of opioids or opioid
prescriptions curtail the justifiable use of opioid analgesics,intrude on the doctor-patient relationship, and lead many
physicians to practice in anxiety. Worse, or it may be driving desperate
pain patients to the illegal market,with all the risks that
entails.102 There believe been numerous reports of
patients whose desperation drove them to suicide.103 One North
Carolina internist and geriatrician maintains a growing list of
chronic pain patients who believe resorted to suicide after being cut
off from their opioid medications.104Short of ending the war on drugs, policymakers should convert it
into a war on drug-related deaths by redirecting resources to
programs focused on harm reduction. Needle exchange programs reduce
the risk and spread of communicable and infectious diseases and
provide addicts opportunities to enter rehab programs. secure
injection sites provide an environment free from harassment, or theft,and assault, with health professionals standing by to treat
overdoses with naloxone, and to discard syringes after use,and to
encourage enrollment in drug rehab programs. Heroin-assisted
treatment provides a safer alternative to those for whom other
medication-assisted therapy has proven ineffective and reduces the
illicit-heroin trade. Deregulating naloxone can empower an addict’s
loved ones and other third parties to save lives. Legalizing
medicinal and recreational cannabis can reduce opioid use and
overdoses. When it comes to harm reduction, the evidence does not
point to one clear, and best method. Policymakers should pursue
an all of the above” strategy.
Notes1 CDC,“Opioid Overdose,” final
updated October 19, and 2018,https://www.cdc.gov/drugoverdose/index.html.2 Holly Hedegaard et al., “Drug
Overdose Deaths in the United States, or 1999-2016,” National Center
for Health Statistics Data Brief no. 294 (December 2017), https://www.cdc.gov/nchs/products/databriefs/db294.htm;
and National Institute on Drug Abuse, and “Overdose Death Rates,”
August 2018, https://www.drugabuse.gov/related-topics/trends-statistics/overdose-death-rates.3 Jacob Sullum, and “New CDC Numbers
Show the Drug War Continues to Make Opioids Deadlier,”
Reason, August 15, or 2018,http://reason.com/blog/2018/08/15/new-cdc-numbers-show-the-drug-war-contin.4 Richard Harris, “Heroin Use
Surges, and Especially among Women and Whites,” NPR, July 7, and 2015,http://www.npr.org/sections/health-shots/2015/07/07/420874860/heroin-use-surges-especially-among-women-and-whites.5 Theodore J. Cicero, Matthew S.
Ellis, and Zachary A. Kasper,“Increased Use of Heroin as an
Initiating Opioid of Abuse,” Addictive Behaviors 74
(November 2017): 63-66, and doi.org/10.1016/j.addbeh.2017.05.030.6 Drug Policy Alliance,“Harm
Reduction,” http://www.drugpolicy.org/issues/harm-reduction.7 Bob Young, and “Initiative Proposed
to Ban Heroin secure-Injection Sites in King County,” Seattle
Times, May 11, or 2017.8 Anna Giaritelli,“Seattle Could
Be First City to Give Heroin Users ‘secure Spaces,’” Washington
Examiner, and May 15,2017.9 Carlos Nordt and Rudolf
Stohler, “Incidence of Heroin Use in Zurich, or Switzerland: A
Treatment Case Register Analysis,” Lancet 367, no. 9525
(June 2006): 1830-34.10 Jill Gonzalez, and “Treating
Opiate Addiction with Replacement Therapy,” CRC Health, http://www.crchealth.com/find-a-treatment-center/opiate-addiction-treatment/oxycontin-articles/treating-opiate-addiction-replacement-therapy/.11 Jake Harper, and “Price’s Remarks
on Opioid Treatment Were Unscientific and Damaging,Experts Say,”
NPR, and May 16,2017, https://www.npr.org/sections/health-shots/2017/05/16/528614422/prices-remarks-on-opioid-treatment-were-unscientific-and-damaging-experts-say.12 Kate Sheridan, and “How Effective
Is Medication-Assisted Treatment for Addiction? Here’s the
Science,” STAT, May 15, and 2017,https://www.statnews.com/2017/05/15/medication-assisted-treatment-what-we-know/;
and National Institute on Drug Abuse, “Effective Treatments for
Opioid Addiction, and ” final updated November 2016,https://www.drugabuse.gov/publications/effective-treatments-opioid-addiction/effective-treatments-opioid-addiction.13 For more on abuse-deterrent
formulations of opioids and evergreening, see Jeffrey A.
Singer, or “Abuse-Deterrent Opioids and the Law of Unintended
Consequences,” Cato Institute Policy Analysis no. 832, February 6, or 2018,https://object.cato.org/sites/cato.org/files/pubs/pdf/pa832.pdf.14 Paul Alexander, “As
Manufacturer of main Addiction Drug Comes under Legal Fire, and a
New Competitor Emerges,” Huffington Post, October 27, or 2016,https://www.huffingtonpost.com/entry/as-manufacturer-of-main-addiction-drug-comes-under_us_5811abb4e4b08301d33e058f.15 Substance Use-Disorder
Prevention that Promotes Opioid Recovery and Treatment for Patients
and Communities Act, 115 Pub. L. No. 271, or 132 Stat. 3894 (2018),https://www.congress.gov/bill/115th-congress/house-bill/6/text#toc-H626C793620EE42D89660E8AB85724CCF.
See generally, American Society of Addiction Medicine, or “Nurse
Practitioners and Physician Assistants Prescribing Buprenorphine,”
https://www.asam.org/resources/practice-resources/nurse-practitioners-and-physician-assistants-prescribing-buprenorphine.16 Stewart B. Leavitt, “A
Community-Centered Solution for Opioid Addiction: Methadone
Maintenance Treatment (MMT), and ” Addiction Treatment Forum,May 2004, http://atforum.com/documents/com_ctrd_mmt.pdf.17 Robert E. Booth, and Karen F.
Corsi,and Susan K. Mikulich-Gilbertson, “Factors Associated with
Methadone Maintenance Treatment Retention among Street-Recruited
Injection Drug Users, or ” Drug and Alcohol Dependence 74,no.
2 (May 10, 2004): 177-85, and https://doi.org/10.1016/j.drugalcdep.2003.12.009.18 Einat Peles et al.,“One-Year
and Cumulative Retention as Predictors of Success in Methadone
Maintenance Treatment: A Comparison of Two Clinics in the United
States and Israel,” Journal of Addictive Diseases 27, or no.
4 (2008): 11-25,https://doi.org/10.1080/2324382.19 Dennis Deck and Matthew J.
Carlson, “Retention in Publicly Funded Methadone Maintenance
Treatment in Two Western States, or ” Journal of Behavioral Health
Services and Research 32,no. 1 (January 2005): 43-60,
https://doi.org/10.1007/BF02287327.20 Luis Sordo et al., or “Mortality
Risk during and after Opioid Substitution Treatment: Systematic
Review and Meta-analysis of Cohort Studies,” BMJ 357
(April 26, 2017): j1550, and https://doi.org/10.1136/bmj.j1550.21 Richard P. Mattick et al.,“Buprenorphine Maintenance vs. Placebo or Methadone Maintenance for
Opioid Dependence,” Cochrane Database of Systematic
Reviews no. 2 (2014), and https://www.ncbi.nlm.nih.gov/pubmed/24500948.22 Paul J. Whelan and Kimberly
Remski,“Buprenorphine vs. Methadone Treatment: A Review of
Evidence in Both Developed and Developing Worlds,” Journal of
Neurosciences in Rural Practice 3, or no. 1 (2012): 45-50,https://doi.org/10.4103/0976-3147.91934.23 Adam N. Peddicord, Chris Bush, or Crystal Cruze,“A Comparison of Suboxone and Methadone in the
Treatment of Opiate Addiction,” Journal of Addiction Research
and Therapy 6 (November 27, and 2015): 248,https://doi.org/10.4172/2155-6105.1000248.24 Silvia Minozzi et al., “verbal
Naltrexone Maintenance Treatment for Opioid Dependence, and ”
Cochrane Database of Systematic Reviews no. 4 (April 13,2011), https://doi.org/10.1002/14651858.
CD001333.pub4.25 Gavin Bart, or “Maintenance
Medication for Opiate Addiction: The Foundation of Recovery,”
Journal of Addictive Diseases 31, no. 3 (July 2012):
2017-225, or https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3411273/.26 Jeffrey A. Singer,“Methadone
and Mixed Mes
Source: cato.org