What to do about heroin

Heroin overdoses are the tip of the prescription-opiate iceberg.

In the wake of Philip Seymour Hoffman’s overdose death, Bloomberg sought an op-ed from Lowry Heussler and me, and one from Sally Satel. Short version of both pieces: the heroin problem is the tip of the prescription-opiate iceberg, and that’s where to focus. There’s stuff worth doing – SBIRT to catch developing opiate problems early, overcoming the prejudice against substitution therapy, making naloxone spray available – but no solution around the corner.

Footnote Oddly, there was no similar request for anyone’s wisdom in the wake of the 22 overdose deaths among ordinary folks in Pittsburgh.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

11 thoughts on “What to do about heroin”

  1. Thanks for link. I've been hoping you'd weigh in ever since I saw Carl Hart say on All In with Chris Hayes that the problem is alcohol and we need to educate people not to drink while doing heroin. Ugh.

  2. Hart has a point. In all drug-policy discussions, alcohol is the elephant in the room. I don't know the statistics, but I wouldn't be surprised if alcohol had a big role in what get classified as opiate ODs.

  3. I agree alcohol is a major problem, and maybe he didn't thoroughly articulate his point in the brief segment, but it came off as if he were saying if addicts are educated to not drink *and* do heroin at the same time, it would solve a lot of the problem. My question is: do you think an addict of any drug is going to stop and think "don't drink," when using?

    1. I think it is feasible you could get many who are addicted to heroin or alcohol but not both to avoid mixing the two.

    2. Doesn’t Hart’s own research show that drug addicts can rationally respond to incentives and information in many instances?

  4. We need more information about the effect of social media (such as Yelp) in which disgruntled addicts can give bad ratings to doctors who refuse to prescribe opiates for them. Sally Satel's column implies that job security of physicians can be affected thereby. Mark, do you think that there are any good data sources for this phenomenon?

  5. Sally Satel's article rang true with me.

    First, in May of 2012, filled with dread about my upcoming knee replacement surgery, I was "comforted" by friends who said stuff like "Well, at least you get to take some great drugs."

    Then, the orthopedic surgeon recommended some very stiff painkillers. I took far less than the recommended dose and still was slightly addicted. (I had to go onto the deck outside the house in 100 degree weather wearing a bulky sweater just to keep warm.)

    A year later, I had some minor surgery. OxyContin was recommended, but not prescribed when I told the surgeon that I'd have none of it. I managed to get by on Tylenol.

    I'm not a hero or a tough guy. I simply took a slightly longer term view of my recovery than the physicians did.

  6. If I'm not mistaken, P. Hoffman just provided us with the greatest anti-heroin PSA of the 2010s. This is a far greater gift than any of his acting performances.

    This sucks for his friends and family. But maybe they can take solace that he saved some lives.

  7. I’m struck that you are at a loss about what to do. I’d say to focus on users and to some extent their families. Help provide them with steps to educate them and help them reduce harm to themselves. There used to be a hierarchy – if you can stop do so, if you can’t or don’t want to stop switch to a less harmful drug, don’t mix drugs (including alcohol). Never use alone. Another step would be to reduce stigma so that people can access health. Provide other services. If someone is homeless is drug use their number one problem? Create safer spaces. Safe injecting sites – if PSH had been injecting with a nurse watching in some manner would he have ODed? Syringe exchange. They not only reduce HIV but provide access to a range of medical services (nurses doing care for abscesses etc) and alcohol and other drug treatment. There’s plenty of other good ideas out there. It all comes back to treating drug users as individuals with agency (and that means subject to not hurting others allowed to make the “wrong choice” too)

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