Does cannabis availability help prevent opioid overdoses?

There’s been lots of chatter about the cannabis-opioid substitution question.

Newsweek headlines, “Can Legal Marijuana Solve the Opioid Crisis?”  while Dr. Jeff Sessions opines that cannabis is “only slightly less awful” than heroin.

People whose background is medical research tend to distrust anything that’s not a randomized controlled trial. They point to the positive correlation between cannabis use and opioid use at the individual level, and the fact that opioid deaths continue to rise even where cannabis is most freely available. Their position is, “We don’t know anything about this. Let’s due the clinical studies before taking action.”

But “not taking action” now means continuing to criminalize even the possession of cannabis. If cannabis substitutes for opioids, those laws cost lives: lives that can’t be regained ten years from now, after the clinical-trial results are in.

Moreover, the relevant clinical trials can’t actually be done in the U.S. Continue reading “Does cannabis availability help prevent opioid overdoses?”

Hoffman and the Hype about “Killer Heroin”

Phillip-Seymour-HoffmanWithin hours of the death of Philip Seymour Hoffman, rumors spread that this magnificent actor had been taken from us by “killer heroin”. The threat of a batch of impurity-laced, unusually potent heroin is a staple of opioid overdose news coverage and popular debate. But it’s usually hype.

Hoffman’s tragic overdose was absolutely the norm: He died from a combination of drugs, not from impure or unusually strong heroin. The benzodiazepines may have been particularly lethal in that they, like alcohol, seem able to lower acute tolerance for opioids, thereby turning a user’s standard dose into an “overdose”.

Two people who will be totally unsurprised by Hoffman’s toxicological test results are addiction researchers Shane Darke and Michael Farrell:

If there’s one thing we can quite clearly say about heroin deaths, it’s that impurities are rarely, if ever, found or are relevant to the death. Those that are found are typically innocuous substances, such as sucrose.

Data on overdose deaths from legally-manufactured prescription opioids are the other reason to doubt the killer heroin hype that so regularly grips the media. Prescription painkllers are consistently pure and of knowable dose, yet they kill 5 times as many Americans a year as does heroin.

The FDA’s Mixed Signals on Pain Pill Policy

The FDA’s policy on prescription opioids has been internally contradictory this year, and that’s bad for public health

Prescription opioids like hydrocodone are remarkably useful for acute pain relief but are also capable of fomenting addiction and overdose. The most effective public policies regarding these medications keeps both of those realities in mind rather than yielding to an extreme anti- or pro-opioid stance. No federal government agency grapples with this challenge more than the Food and Drug Administration, and the evidence of the last week is that it has yet to come to an internal consensus on how to proceed.

First, the FDA recommended after years of study that hydrocodone combination products like Vicodin would be moved from Schedule III to the more restrictive Schedule II. This is a significant tightening of control over the most widely prescribed drugs in the U.S. (not just for pain, for anything). The impetus was the leading role of hydrocodone combination products in overdose deaths and emergency room admissions.

Yet 24 hours later, the FDA overruled its own expert panel and approved Zohydro, a pure hydrocodone pain medication that is 5 to 10 times more potent than Vicodin. In the process, FDA also overturned a precedent it had set only six months ago to not approve easily abused-opioids. After refusing in April to approve generic oxycontin because it lacked abuse-resistant properties, the FDA approved a drug whose full potency can be instantly released merely by crushing it or dropping it into alcohol (Get ready for a rash of Zohydro-cocktail deaths).

What the country needs on prescription opioids is carefully designed, balanced and consistent policy. What we are getting is policy that contradicts itself month-to-month and even day-to-day.

Painkiller Pill Mills and Corporate Responsibility

Purdue Pharma kept secret it’s knowledge of how doctors were fomenting addiction and overdose by overprescribing painkillers.

Imagine you were a manufacturer of powerful opioid painkillers and your sales representatives discover suspicious activities at the offices of some physicians who prescribed your product. These activities include patients lining up to pay cash for prescription opioids, drug deals going down in the parking lot, people falling asleep from opioid intoxication in the waiting room and physicians being visibly intoxicated themselves. In response would you:

(A) Report these doctors to the authorities?
(B) Insulate yourself by not sending your representatives to these doctors anymore, but continue to pocket the huge profits they generate from writing countless prescriptions for your products?
(C) Keep a secret list of these doctors but publicly promote the idea that painkiller abuse is not driven by wayward doctors but by other sources, such as pharmaceutical robberies?
(D) Reveal the list of doctors to authorities years later only because at that point it could stop a competitor from introducing a new generic medication that might cut into your own sales?
(E) A combination of B, C and D, but certainly not A.

According to Scott Glover and Lisa Girion of the L.A. Times, Purdue Pharma chose option E and thereby preserved its astounding profits from Oxycontin. Continue reading “Painkiller Pill Mills and Corporate Responsibility”

Towards Effective Public Policy Regarding Pain Pills

I gave a plenary address at the American Academy of Pain Medicine about opioid-related public policies that might promote pain relief while minimising addiction and overdoses. I suggested five approaches that seem promising (if I had had time, I would have added a sixth, which is increasing access to naloxone).

What I was most struck by in spending a few days with pain medicine experts is that hardly any of them were at the screaming extremes of the policy debate. Lots of them are worried that their field has over-prescribed opioids. Rarely was this worry based in fear of the DEA; rather as doctors should be, they were worried that patients have been harmed.

Many were struggling with an dysfunctional regulatory environment in which it is almost impossible to get rid of excess opioids. A number told me they engaged regularly in illegal behavior, for example taking back opioids returned by patients who had had a relative die in hospice and who understandably didn’t want all the remaining pills lying around in a house full of teenagers (Yes, it is stupid that it should be illegal for the doctor to take the pain pills back in such a situation, but that’s where we are).

The seriousness and decency of the pain medicine professionals was impressive, which makes some of the more oversimplified media discussions of the issue all the more disappointing. Pain medicine professionals are looking for guidance in handling a tough problem. They are seeking thoughtful, rational advice from each other, from their patients and from those who follow public policy. I hope people who write about and analyze the issue in the media will respond with equal seriousness and balance.