Opioids Part Four

 Tim sends along some final thoughts - though I will bet you could keep him engaged if you wanted to.

Longer thoughts on scalability and political feasibility. Probably more than you bargained for but these were thoughts I had on my list of things to start writing out anyways. I know this will be too long for comments but let me know if I should break it up and add them. 

On political feasibility. In New Hampshire, it was a libertarian-leaning Republican member of the House who was also a physician that led the charge on legalizing syringe exchange programs. Governor Sununu has been a proponent of harm reduction and Manchester-based Democrats the biggest opposition while declaring that they support it in theory. So, I think your political read is spot on. The idea of a brave Republican president doing something on principle might be our best shot. The other possibility would be a convicted Democrat serving their last term. But, I'm not holding my breath on that option. 

The one thing that might make it easier is if it didn't need to happen legislatively. Doing anything with heroin is a huge task BUT, expanding what is considered a legitimate medical reason to prescribe substances like morphine and hydromorphone might be possible. Hydromorphone is closest in user experience to heroin and far easier to dose than fentanyl. The FDA and the DEA could allow for a change in prescribing standards and create a pathway to regulated access.  This doesn't answer all the questions of administration but, as Jonathan pointed out, it would allow different states to create models to test the effectiveness of different models and create systems of control. 

In Canada, they are piloting a system that sounds terrible at first but makes sense on further examination... hydromorphone vending machines. At an overdose prevention center, a registered user can receive a pre-selected dose available only through a biometric scan. By removing the human element of administration, you decrease the potential for conflict and increase controls. But the "drug vending machine" attack ads write themselves. 

Unfortunately, I don't see the political winds shifting quickly enough to implement these kinds of solutions before the overdose crisis begins to decline on its own through losing another 700,000 lives over the next 5 to 7 years. But, it's also something I am hoping to dedicate the next few decades of my life to working on. And, my hope is that the changing nature of the illicit drug market brings more costs and benefits into stark relief.

It was easier to pretend like our "supply" side strategies were working in the past. In part, because they worked sometimes. Heroin production and distribution are complex tasks that require significant financial and human capital. Break up the distribution network in a small town in NH and the supply might dry up. Work your way up to some big fish, seize assets and lock up the big bosses and you might be able to disrupt large regional distribution systems. 

And, it did "work" in Australia. An internationally coordinated effort led to a simultaneous dismantling of the three major criminal organizations bringing heroin into Australia. The price of heroin skyrocketed and the percentage of the population using heroin dropped. BUT, for the next few years overdoses, violent crime and property theft all went up. And, meth usage skyrocketed. In terms of decreased crime and overdoses, it was about 10 years of dramatically reduced heroin supply before it was determined there was a net benefit. 

We have no reason to believe something like that could be accomplished and sustained in the United States today. A 22-year-old can set up their own drug trafficking ring and start making big money with a little knowledge of the dark web and a few thousand in starting capital. And, it isn't just illicit fentanyl. If you were motivated, in about 30 minutes of internet searches and a credit card, you can find "research chemicals" that are close cousins to any major illicit substance online. When one substance gets scheduled, a few modifications and a new version is back on the market. And, this new one we know even less about. 

Big drug trafficking groups used to need to train people on how to process these drugs and pass along that knowledge from person to person. Now, you can legally order all the chemicals you need to make meth and learn how to do it in the microwave over the course of an afternoon. The difference between a home chemist and a cartel-trained one is that the cartel guy is less likely to poison you with their product or blow themselves up. 

There also used to be more of a divide between urban and suburban and rural. Creating regulated access to opioids might have benefits in an urban area where you are unlikely to get supply under control and population density makes profitability easy. But, in the past, there would have been downsides in areas where access was more difficult and supply reduction more feasible. For urban areas the switch would be from easily accessible dangerous drugs to accessible safer drugs. For rural areas it might be very limited access to dangerous drugs to expanded access to less dangerous drugs. The positive benefit is clear for urban areas but not clear at all for a rural area. 

Now, that distinction doesn't exist in the same way. So, my hope is that in the coming years, we will have more previously competing interests find some alignment and a clearer sense of the futility of our current system. 

The final shift (that I hope to be a part of) is articulating these ideas in a way that resonates with a broader swath of the public. In continuing with the theme of Haidt's Moral Foundations Theory, arguments concerning "freedom" will fail to beat arguments that appeal to "purity." A counter-culture or libertarian style ethic just won't pass the smell test for most people. 

On to scalability. Again, we don't know the best model but various versions have been tried in the UK, Germany, Canada and the Netherlands. But, the American context is still unique and we are just dealing with a whole lot more people. But a helpful thought experiment is to think through what it would look like for this model to go "wrong" and determine whether or not that is likely to be better or worse than our current reality. 

We know, for example, that drugs would get diverted out of this system and end up being used by people we would otherwise hope to protect. But, we know when that happens likelihood of overdose will be less likely. And, do we have reason to believe there more of these drugs will be available in a diverted "gray market" than in the current black market?

A few areas of concern for me and how I would respond...

Teens: We want to limit access to alcohol and other drugs for teens in general. Behavioral risks are high and long-term issues for developing a substance use disorder are a concern as well. It is possible that this system would increase the availability of diverted opioids to this population. And, if they believe the substances are "safe" they are more likely to use them as kids are more likely to pop an oxy pill than just straight to IV drug use. So, even if we decrease teen overdoses in the short term by making sure the diverted supply is safer, are we creating a larger population who will have severe problems by the time they are 22? 

I couldn't say with confidence that this won't increase diverted drugs to teens. But, we have seen lessons with cannabis that teen use has dropped even as states have legalized it. The worst I have read is a study that argues that legalization has slowed the rate of declining cannabis use among teens. Overall, I think this shows that legality may be a factor but is not THE driving force for trends in teen drug use. The most successful anti-teen smoking campaign was the one that framed smoking as the thing the "establishment" wanted you to do. Then vaping became a fad and has already dropped down again dramatically.

I imagine two different kinds of teens at risk. The first is the risk taking teen highly motivated to purchase and use drugs. They are likely to live in unstable situations, probably around parents, guardians or siblings who are already using. They are the kind of teens that might know an actual drug dealer, buy from them, and sell at school or through social events. The second is the casual teen who goes to some parties and experiments with drinking and drug use.

It's possible that this system grows the pool of the second kind of teen as access to a regulated supply decreases risk to a level that more teens would be interested in trying. But, probably wouldn't have much of an effect on the first kind of teen as it doesn't take much motivation or know how to source under the current system. 

But, the potential benefit is removing the user/dealer population. Who is the kind of person that sells drugs knowingly to teenagers? Someone slightly older who really needs the money and is in a situation where they feel they have nothing to lose. Put that person into a system where they have regulated access to their own supply of opioids and suddenly they do have something to lose for diverting a portion of their supply. Or, the employees administering the program have the possibility of losing a good job, license or career. 

I think it is highly likely a regulated system reduces the population willing to sell to teenagers. 

Cultural Capital: Another risk is widespread cultural shifts in the role of a particular drug in building cultural capital. I'm thinking about smoking cigarettes in the 50's and 60's, cocaine in the 70's, heroin in the 90's or alcohol at pretty much anytime in the past 100 years. If using opioids had the same cultural cache as using alcohol, I think we'd have a huge issue. 

But, I don't see a lot of evidence that this is happening with opioids or stimulants. Feel free to correct me if you see evidence otherwise. The one area that I think could be problematic in the coming years is teenage experimentation with psychedelics. These are substances that are gaining cultural cache. While I'm personally very positive on potential therapeutic use of psychedelics, there are lots of ways that can go wrong for teens and adults. 

I think this will be trickier to address. Teen participants in the old DARE program were shown to be more likely to use drugs than their counterparts and use of psychedelics drove those shifts. This is a potential downside and trickier to address. But, ultimately, I don't think legality is what will really make an effect on this trend. There are currently multiple kinds of powerful psychedelics that are widely available like the San Pedro cactus, salvia divinorum, morning glory seeds and... nutmeg. Nutmeg, believe it or not, was big in the Jazz scene in the 40's and 50s. 

Recovery: Another concern would be people in some kind of recovery. Would people who had a long fight to find their own sobriety be more likely to begin using again if there was a means of regulated legal access to opioids? 

I don't think so. Right now one of the big issues are people coming out of rehab and immediately getting text messages from their old friends/dealers. They face incredible social pressures from existing peer networks so much so that I hear a lot of stories of people moving across country to remove those temptations. In a system of regulated access, people would need to jump through some hoops to get in. And, it would be possible to voluntarily place yourself on a restricted list that won't allow you to do that. 

Low-income neighborhoods: One possible concern is that services like overdose prevention centers tend to get located in service heavy and resource poor neighborhoods. This can attract the populations dependent on those resources and increase crime and add fuel to the fire of a cycle of poverty. 

This is another very real concern and one that I could see going wrong. This certainly happens in Manchester and is a big reason why Manchester Dems have been so resistant to harm reduction. Folks from across the state get sent to a recovery program in Manchester and end up on the streets afterwards. As someone who owns a home in downtown Manchester about 75 yards from the primary homeless shelter, I have "skin in the game" on this one. In all likelihood, a program like this would be located within half a mile of where I live, if not a few hundred yards. 

But, I know from experience, I stopped having to pick up syringes as regularly after the local syringe exchange program went it. But, I still see people injecting drugs directly around my house multiple times per week. And, the behavioral and mental health issues from bad methamphetamines keep getting worse. In my neighborhood, at least, I'd see it as a net benefit to set up regulated access and an overdose prevention center. 

There are other neighborhoods where people might legitimately feel differently than I do. Overall, it will be crucial for these solutions to be implemented with state or region wide plans in order to mitigate these sorts of concerns.

Are there any other major areas of concern you'd list?