Heroin use is a public health emergency that calls for legislative solutions

MORE PEOPLE are killed now by drug overdoses than by homicides in many states, prompting alarmed state lawmakers and attorneys general to search for legislative fixes. The sense of urgency, impelled especially by a spike in lethal heroin overdoses, is justified. Some of the measures proposed to address the problem may not be.

The new focus on heroin use coincides with very sharp increases nationally in overdose deaths in middle-class and predominantly white communities. It’s a shame that that’s what it took to rally the authorities to action; still, better late than never.

About 20 states, including Maryland, and the District have enacted bills to ensure that first-responders carry naloxone, a prescription drug also known by the brand name Narcan, which can save the lives of opiate users who have overdosed. Unfortunately, the spike in demand for the antidote has driven up its cost, which is proving a burden for some states and localities. Nonetheless, more states need to step up and recognize heroin use as a public health emergency.

Virginia is a case in point. Heroin-related deaths more than doubled in the commonwealth from 2011 to 2013 and increased at an even faster rate in Northern Virginia. Yet no law requires emergency medical personnel to carry Narcan; some do and some don’t. Worse, some lawmakers apparently believe that making the antidote more accessible will encourage heroin addiction, as if the availability of treatment somehow enables disease.

There are other sensible steps that states can take. They include enacting so-called good Samaritan laws (in place in Maryland and the District but not yet in Virginia) that shield witnesses from prosecution — even if they abuse or sell drugs themselves — if they promptly report and help overdose victims.

States should also consider measures that crack down on unscrupulous doctors and pharmacists who illegally or inappropriately prescribe and dispense opiate pills like OxyContin, which can be a gateway to heroin . And it’s also worth tracking the results of legislation adopted in New York that allows addicts to remain in treatment programs while they appeal decisions by insurance companies that have denied coverage.

However, we are skeptical that some measures to further criminalize already illegal drugs such as heroin will be effective. One idea, pushed by some prosecutors, is to expose drug dealers to homicide charges if they sell what turns out to be a lethal overdose. The experience of the federal war on drugs suggests that harsher penalties fill up jails and prisons without doing much to extinguish the sale of illegal narcotics.

A wiser tack is to treat heroin addiction as a public health emergency. That means establishing more readily available long-term treatment programs, preferably in residential settings that can help shield users from dealers. Such programs cost money. That in itself will be a test for leaders like Maryland Gov.-elect Larry Hogan (R), who has rightly proclaimed that the spike in heroin overdoses is an emergency. In the face of Mr. Hogan’s promise to slash state spending, will he be able to fulfill his promise to come to grips with this epidemic

Jump in Colorado School Drug Cases May be Linked to Marijuana Legalization: Experts

Colorado middle schools reported a 24 percent increase in drug-related incidents last year, according to USA Today. School-based experts tell the newspaper they believe the jump is directly related to marijuana legalization. Recreational sales of marijuana began on January 1, 2014.

Schools do not report which kinds of drugs are involved in the incidents, the article notes. State legislators are now asking school districts to keep track of which drugs they are finding.

John Simmons, the Denver Public Schools’ Executive Director of Student Services, says schools in his city saw a 7 percent increase in drug incidents, from 452 to 482. Almost all of the incidents were related to marijuana, he said.

Middle schools across the state reported a total of 951 drug violations, the highest number in a decade. School officials say while marijuana use has long been a problem, more students are trying it now that it is more easily available and socially accepted.

“We have seen parents come in and say, ‘Oh that’s mine, they just took it out of my room,’ and that sort of thing,” said school resource officer Judy Lutkin of the Aurora Police Department. “Parents have it in their houses more often, and the kids just can take it from home.”

“Middle schoolers are most vulnerable to being confused about marijuana,” said Dr. Christian Thurstone, attending physician for the Denver Health Adolescent Substance Abuse Treatment program. “They think, ‘Well, it’s legal so it must not be a problem.’”

Meg Sanders, owner of MiNDFUL, a marijuana company that operates in Colorado, says her business is very careful not to market to children. “We feel it’s our responsibility as a responsible business to card not just once but twice for any recreational customer, and medical patients have to show several documents before they can purchase marijuana,” she said.

Marijuana Research Review Details Harmful Outcomes of Use

A review of 20 years of marijuana research concludes there are real risks to using the drug, according to researchers. These include increased risk of car crashes, dropping out of high school and cognitive impairment. Marijuana does not produce fatal overdoses, the review notes.

According to the review, published in the journal Addiction, research in the past 20 years has shown that driving while marijuana-impaired approximately doubles the risk of car crashes. About 10 percent of regular marijuana users develop dependence. Regular use of the drug during the teenage years doubles the risks of dropping out of high school and of cognitive impairment in adulthood. “Regular adolescent cannabis users have lower educational attainment than non-using peers but we don’t know whether the link is causal,” the researchers note in a press release.

The review looked at marijuana studies conducted from 1993 to 2013. It found marijuana use in teens is strongly associated with the use of other illegal drugs. It is not known whether marijuana use causes teens to start using other drugs, the review noted.

Lead researcher Wayne Hall of the University of Queensland Center for Youth Substance Abuse Research in Australia concluded marijuana use probably increases cardiovascular disease risk in middle-aged adults, “but its effects on respiratory function and respiratory cancer remain unclear, because most cannabis smokers have smoked or still smoke tobacco.”

Hall noted that the amount of THC, the psychoactive ingredient in marijuana, has increased in the past 20 years. “The impacts of increased potency on cannabis use should be a research priority,” he wrote.

The review listed other adverse effects of regular marijuana use, including a twofold risk of experiencing psychotic symptoms and disorders, especially in someone with a personal or family history of psychotic disorders who starts using marijuana in their mid-teens.

Heroin-Linked Deaths Surge 39 Percent, CDC Finds

Overdose deaths linked to heroin jumped 39 percent in 2013 from the year before, according to data released Monday by the Centers for Disease Control and Prevention.

The CDC said 8,257 people died of heroin-related deaths in 2013, compared with 5,925 deaths in 2012. The number of overdose deaths overall increased to 43,982 from 41,340.

Many more Americans die from prescription opioids. But the rise in fatal heroin overdoses came as users of prescription painkillers switched to the cheaper, illicit street drug. The heroin deaths contributed to an overall 6 percent jump in drug overdose deaths in 2013 from 2012.

“These troubling statistics illustrate a grim reality: that drug, and particularly opioid abuse, represents a growing public health crisis,” Attorney General Eric Holder said in a statement.

As states cracked down on the illicit use of prescription painkillers in the 2000s, many users shifted to heroin, which sells for a fraction of the cost. The February 2014 death of actor Philip Seymour Hoffman from a mix of heroin, cocaine, and other drugs dramatized the shift. Deaths from heroin are often also associated with other drugs.

Despite Hoffman’s death and the broad political reaction it sparked, data on heroin abuse has been hard to find. The National Survey on Drug Use and Health found that the number of people who had used heroin in the past year rose from 2012 to 2013, but the number who had used heroin in the past month dropped.

Michael Botticelli, the acting White House drug czar, said the rising overdose deaths underscored the need for a “comprehensive solution” to the nation’s drug problem that includes prevention, education and law enforcement. Both Botticelli and Holder have increasingly emphasized the need for local police to carry naloxone, a drug that can reverse opioid overdoses.

The World Health Organization estimated earlier this month that better distribution of naloxone in the U.S. could save as many as 20,000 lives every year.

Meghan Ralston, the harm-reduction manager for the Drug Policy Alliance, a nonprofit group that aims to end the war on drugs, applauded the increased distribution of naloxone to police. She said she hopes community nonprofits are not left behind.

“Community-based naloxone distribution programs continue to struggle mightily to be able to afford to do this lifesaving work, while police departments have access to a much larger pot of money,” Ralston said.

States like New York and Maine have increased the number of law enforcement agents tasked with drug enforcement while they have expanded naloxone access. Ralston criticized the increased enforcement.

“These tactics are really just the same old, same old,” said Ralston, who had not been able to examine the CDC data in depth. “Any increase in the number of heroin-involved deaths argues loudly in favor of reforms that help save lives and reduce mortality.”

DEA Issues Alert on Fentanyl-Laced Heroin as Overdose Deaths Surge Nationwide

The Drug Enforcement Administration (DEA) has issued a nationwide alert in response to a surge in overdose deaths from heroin laced with the narcotic drug fentanyl, the most potent opioid available for medical use.

“Drug incidents and overdoses related to fentanyl are occurring at an alarming rate throughout the United States and represent a significant threat to public health and safety,” DEA Administrator Michele M. Leonhart said in a statement. “Often laced in heroin, fentanyl and fentanyl analogues produced in illicit clandestine labs are up to 100 times more powerful than morphine and 30-50 times more powerful than heroin.”

Fentanyl is potentially lethal, even at very low levels, according to the DEA.

Last year, Philadelphia officials announced at least 28 people died after using heroin laced with fentanyl in March and April. Earlier in 2014, law enforcement officials said heroin laced with fentanyl was suspected in at least 50 fatal overdoses in Pennsylvania, Maryland and Michigan.

Seizures of illegal drugs containing fentanyl more than tripled between 2013 and 2014, according to USA Today. The National Forensic Laboratory Information System, which collects data from police labs, received 3,344 fentanyl submissions last year, up from 942 the previous year.

Between 2005 and 2007, more than 1,000 U.S. deaths were attributed to fentanyl, many of them in Chicago, Detroit and Philadelphia. The source of the drug was traced to a single lab in Mexico. The surge of deaths ended when the lab was identified and dismantled, the DEA said.

DOES AA WORK THE SAME FOR YOUNG ADULTS AS IT DOES FOR OLDER ADULTS?

Involvement in Alcoholics Anonymous (AA) is known to be beneficial for adults, however, less is known about the effects and ways in which AA helps young adults recover from substance use disorder (SUD). Arguably, young adults face more recovery challenges than their older adult counterparts for several reasons. They are more likely to be exposed to alcohol and drug cues in social situations because the prevalence of substance use during this life stage is the highest of any developmental period. Additionally, those under 30 tend to be less interested in spirituality and religion, therefore, the spiritual focus of AA might be less appealing compared to older individuals. Compared to adults, those under 30 face different psychosocial stressors, too, including a more transient lifestyle, sexual and romantic challenges, and financial stressors.
The researchers examined whether young adults (18-29 yrs) benefit from AA attendance as much and in the same ways as those over age 30. The authors tested six different potential mediators of AA’s effects which were chosen because they were found to be mediators in previous AA studies with adults. They asked whether AA helped people recover via its ability to: increase individuals’ confidence in their ability to abstain in high risk social contexts, and when experiencing negative affect; to increase spiritual/religious practices; decrease depression symptoms; and, increase the number of pro-abstainers and decrease the number of pro-drinkers in individuals’ social networks. Data was from a 12-week outpatient treatment trial called Project MATCH, where participants were individuals with alcohol use disorder (N=1726). Participants in Project MATCH received either cognitive behavioral therapy (CBT), motivational enhancement therapy (MET) or 12-step facilitation therapy at one of nine outpatient clinics around the US. The authors compared young adults 18-29 yrs (n=266) with adults over 30 (n=1460) at 3-, 9- and 15-month follow-up points on two outcomes: percentage of days abstinent (PDA) and the number of drinks per drinking day (DDD).
At baseline, the young adult group was found to have less clinical severity (e.g. higher PDA, fewer DDD, and a lower number of prior alcohol treatments), lower religiousness and a stronger pro-drinking network compared to the older group. Both groups were found to benefit equally from AA attendance, however, the six mediators explained more of the effect that AA attendance has on PDA and DDD for those over 30 than young adults. This suggests that there are additional mediators for the relationship between AA attendance and the outcomes for those under 30, however, this study did not examine what those mediators may be.
Confidence in the ability to abstain in social situations and pro-drinking social networks were found to explain the effect of AA attendance on drinking outcomes for the young adult group. The indirect effects explained more of the drinking outcome variance in the older group even when accounting for similar attendance rates between the groups, therefore suggesting that there are additional pathways for the younger group that were not tested in this study. The authors speculate that other potential pathways include that AA attendance increases abstinence motivation for young adults, increased feelings of hope and belonging through membership, or a feeling of empowerment by attending meetings.
In Context
Young adults (18-29 years old) carry a disproportionate share of the SUD-related burden. According to the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), more than 16% of young adults meet past-year criteria for an alcohol use disorder, about 1.5 times that of middle aged adults and twice that of older adults. AA attendance has been found to be equally beneficial for individuals over and under the age of 30. This is very good news, however, AA attendance seems to help these age groups in different ways. Another way of saying this is that these age groups use AA in different ways. AA attendance in older adults boosts the number of pro-abstinent members in their social network, whereas while younger adults, who are attending AA at a similar rate and who are also adding pro-abstinent members to their social network, are adding sober new social network members not from AA. Finding where those new pro-abstinent social network members are being added from is key, and more research is needed to further examine this. A barrier for some individuals under the age of 30 may be the lack of similar-aged peers in recovery and this is something that AA and other mutual-help groups have worked to overcome by holding youth focused meetings. AA and other mutual-help organizations (MHOs) are a low-cost resource for individuals in recovery. Additionally, some MHOs have meetings that are geared towards young adults. Developing pro-abstinent relationships for young adults may help to aid in recovery, though AA does not appear to help with this.