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Substance abuse, various forms of addiction, and recovery

The Opioid Settlement

Statistical Models vs. Front-Line Workers: Who Knows Best How to Spend Opioid Settlement Cash? (Aneri Pattani, KFF Health News, 3-5-24) A mathematical model designed to direct spending of opioid settlement funds is at the center of a debate over whether to invest in technology to guide long-term decisions or focus on the immediate needs of people in addiction.
---Payback: Tracking the Opioid Settlement Cash (KFF Health News series)
---$50 Billion in Opioid Settlement Cash Is on the Way. We’re Tracking How It’s Spent. (Aneri Pattani, KFF Health News, 3-30-24) That’s an enormous amount of money — double NASA’s budget and five times the revenue of an NBA season.
---Officials Agree: Use Settlement Funds to Curb Youth Addiction. But the ‘How’ Gets Hairy. (Aneri Pattani and Emily Featherston, InvestigateTV, KFF Health News, 9-25-23)
---The Year in Opioid Settlements: 5 Things You Need to Know (Aneri Pattani, 12-21-23)
---Meet the People Deciding How to Spend $50 Billion in Opioid Settlement Cash Meet the People Deciding How to Spend $50 Billion in Opioid Settlement Cash. The Right to Know: Where Does Your State Stand on Public Reporting of Opioid Settlement Cash?
---Millions in Opioid Settlement Funds Sit Untouched as Overdose Deaths Rise (Katheryn Houghton and Aneri Pattani, 12-13-23)
---‘They See a Cash Cow’: Corporations Could Consume $50 Billion of Opioid Settlements (Aneri Pattani)

Payback: Tracking the Opioid Settlement Cash (KFF Health News series) Opioid manufacturers, distributors, and retailers are paying tens of billions of dollars in restitution to settle lawsuits about their role in the overdose epidemic, with little oversight on how the money is spent. We’re tracking how state and local governments use — or misuse — the cash. Includes graphics on
---Millions in Opioid Settlement Funds Sit Untouched as Overdose Deaths Rise (Katheryn Houghton and Aneri Pattani, Payback: Tracking Opioid Cash, KFF Health News, 12-13-23) Some states haven't begun using opioid settlement funds intended to help curb the opioid epidemic. By early December, a cohort of 17 counties in rural eastern Montana had yet to begin official talks about where the money should go. Meanwhile, more than 100,000 Americans died of an overdose last year.
---$50 Billion in Opioid Settlement Cash Is on the Way. We’re Tracking How It’s Spent. (Aneri Pattani, KFF Health News, 3-30-23) Includes The Right to Know: Where Does Your State Stand on Public Reporting of Opioid Settlement Cash?
---What you need to know about the opioid funds (one of several videos)
---Officials Agree: Use Settlement Funds to Curb Youth Addiction. But the ‘How’ Gets Hairy. (Aneri Pattani, KFF Health News, and Emily Featherston, InvestigateTV, 9-25-23)
---The Year in Opioid Settlements: 5 Things You Need to Know (Aneri Pattani, KFF Health News, 12-21-23) In the past year, opioid settlement money has gone from an emerging funding stream for which people had lofty but uncertain aspirations to a coveted pot of billions being invested in remediation efforts. Here are some important and evolving factors to watch going forward.
---Officials Agree: Use Settlement Funds to Curb Youth Addiction. But the ‘How’ Gets Hairy. (Aneri Pattani and Emily Featherston, InvestigateTV, KFF Health News, 9-25-23)
---Watch and Listen: Opioid Settlement Case Triggers Protests Outside the High Court (Aneri Pattani, KFF Health News,12-5-23)

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Evolving Overdose Crisis Shakes Previously Effective Treatments (Taylor Sisk, KFF Health News, 11-21-23) The prevalence of synthetic drugs is undercutting a previously effective and widely embraced opioid use disorder treatment tactic. Now, the model pioneered in Vermont a decade ago and adopted at sites nationwide, especially in hard-to-reach rural areas, is being forced to evolve.
Turmoil of Opioid Epidemic Is Targeted in New Hospital Guide (Martha Bebinger, WBUR, CommonHealth, 6-22-18)Hospitals say there's been little guidance for them about how to screen patients for an opioid addiction, how to manage a patient in detox while treating injuries from a car accident, for example, and where to make naloxone available. To remedy this gap, the Massachusetts Health and Hospital Association is out with what it says is the first statewide "guide for patient management with regards to opioid misuse."
A cure for a crisis: Treating opioid use disorder with scientific solutions (Gina Vitale, report from the AAAS meeting, NASW, 3-9-18) "Vaccinations are one of several possible approaches to combatting the crisis, including new medical therapies, the expansion of access to existing pharmacological treatments, and education for the public as well as prescribing physicians....To help fill that training and knowledge gap, the NIH has collaborated with universities to create educational programs that target both health care providers and the public. The NIDA Centers of Excellence for Physician Information provide information for physicians about substance use disorders. The NIH Pain Consortium’s Centers of Excellence in Pain Education aim to reach the general public. “We have a lot of knowledge, and if we don’t disseminate it, it basically limits its utility,” Volkow said. As NIDA director, Volkow aims to reduce the fatal impacts of this crisis as much as possible with a combination of these science-based solutions, as the opioid crisis has become a front page story nationwide."
Infectious disease (ID) physicians define new role in opioid crisis (Infectious Disease News, via Healio, March 2018) "According to the NIH, studies suggest that people who misuse prescription opioids commonly progress to injection drugs like heroin. Injection drugs, in turn, have fueled a national hepatitis C virus epidemic and continue to expose many to HIV. Opioid abuse can also lead to endocarditis, an infection of the heart chambers and valves, and septic arthritis, an infection of the joints typically caused by bacteria that travel through the bloodstream, among other infectious diseases."
Healio's Opioid Resource Center (news articles and features covering multiple medical specialties provides the latest information on the opioid crisis including treatment strategies, FDA decisions regarding treatments and other important, related announcements)

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Addiction, treatment, and recovery (generally)

"Addiction is giving up everything for 'one' thing.

Recovery is giving up one thing for everything."

        ~Mental Health: We Got This (on Facebook)

Behavioral Health Treatment Services Locator (SAMHSA) A confidential and anonymous source of information for persons seeking treatment facilities in the United States or U.S. Territories for substance abuse/addiction and/or mental health problems. Or Call
SAMHSA’s National Helpline
1-800-662-HELP (4357)
1-800-487-4889 (TDD)
SAMHSA’s Find Help National Helpline: 1-800-662-HELP (4357)
CoHEASAP (Coalition of Higher Education Associations for Substance Abuse Prevention)
Smart Recovery The SMART Recovery Teen & Youth Support Program helps teens and young adults recover from addiction.
• If you or someone you know has a gambling problem, call or text the National Problem Gambling Helpline Network at 1-800-522-4700 or visit ncpg.org.
Hazelden Betty Ford (Call 24 hrs: 1-866-831-5700) Treatment services for addiction and mental health.
Partnership to End Addiction Receive personalized messages of support and guidance. "I’ve heard from countless young people that the reason they got into recovery was because of the connection with a parent who fought for them when they couldn’t figure out how to help themselves."
Walgreens offering cheaper version of opioid reversal drug (Tara Suter, The Hill, 5-15-24) Walgreens is set to offer a cheaper version of an important opioid reversal drug at its stores soon, according to Wednesday press release. “Walgreens today announced it is expanding access to an over the counter, life-saving medication with the launch of Walgreens Brand Naloxone HCI Nasal Spray,” reads the press release from Walgreens’ parent company Walgreens Boots Alliance. Walgreens’ version of the drug is $34.99, according to the release, which the parent company says is “a lower price than the comparable national brand product at Walgreens stores.” The FDA has used its regulatory authority to facilitate greater access to naloxone by encouraging the development of and approving an over-the-counter naloxone product to address the dire public health need," Califf said.

Many NC jails violate legal requirements by skipping meds for opioid use disorder (Rachel Crumpler, North Carolina Health News, 5-16-24) But momentum for the treatment is building. In recent years, more detention centers in the state are starting to provide medications for opioid use disorder, not just because it’s best practice, but because it’s now a legal imperative.
Information about Medication-Assisted Treatment (MAT) (FDA, US Food and Drug Administration) Suboxone, the medication containing buprenorphine and naloxone, is one of the most effective known treatments for opioid use disorder. Provides list of FDA-approved buprenorphine products approved for the treatment of opioid dependence
2020 Guide to Substance Abuse in Veterans (449 Recovery) See diirectory of helpful information and resources along left side.
Voices on Addiciton (The Rumpus) True personal narratives of addiction, essays curated by Kelly Thompson.
The Science of Addiction: Drugs, Brains, and Behavior. Two NIH institutes — the National Institute on Drug Abuse (NIDA) and the National Institute on Alcohol Abuse and Alcoholism (NIAAA) — have joined with HBO to reveal startling new advances in the fight against alcohol and other drug addiction. NIDA is the lead federal agency supporting scientific research on drug use and addiction.
The Painful Legacy of ‘Law and Order’ Treatment of Addiction in Jail (Renuka Rayasam, KFF Health News, 7-19-23) Efforts to improve addiction care in jails and prisons are underway across the country. But a rural Alabama county with one of the nation’s highest overdose rates shows how change is slow, while law enforcement officials continue to treat addiction as a crime rather than a medical condition. Sources inside the system say that more than half of the people placed on the Alabama Department of Mental Health’s waiting list for residential substance abuse treatment either die, drop off the list, or end up incarcerated. xxxx For generations of Americans, addiction prevention was synonymous with D.A.R.E., a Drug Abuse Resistance Education curriculum. But decades of research found those approaches didn’t work. the program has been in place since the '80s, "it's really significantly different" today. The curriculum was redone in 2009 to move away from scare tactics and lectures on specific drugs to focus instead on decision-making skills. Officers undergo intensive training, which includes understanding how children's brains develop.

      Nathaniel Riggs and his colleagues at the Colorado State University Prevention Research Center are developing training for school staff and helping implement the Blues Program, a widely acclaimed intervention for students at risk of depression. Across the country, investments in prevention run the gamut. In some places, officials are frank that they’re not getting enough money to do anything inventive. Opioid settlement funds — money coming from national deals with health care companies like Johnson & Johnson, AmerisourceBergen, and CVS, which were accused of fueling the epidemic via prescription painkillers. The companies are paying out more than $50 billion to state and local governments over 18 years. 
How ERs Fail Patients With Addiction: One Patient’s Tragic Death (Aneri Pattani, KHN, Bill of the Month, 7-15-21) "Nonprofit hospitals are required by the federal government to have financial assistance policies, which lower or eliminate bills for people without the resources to pay. Often called charity care, this assistance is a condition for nonprofit hospitals to maintain their tax-exempt status. But “nonprofits are actually doing less charity care than for-profits”...That’s in part because they have wide leeway to determine who qualifies and often don’t tell patients they may be eligible, despite federal requirements that nonprofit hospitals “widely publicize” their financial assistance policies, including on billing statements and in “conspicuous public displays” in the hospital. One study found that only 50% of hospitals regularly notified patients about eligibility for charity care before initiating debt collection."
‘Hard to Get Sober Young’: Inside One of the Country’s Few Recovery High Schools (Stephanie Daniel, KUNC, NPR, and KHN, 4-5-23) Every weekday at 5280 High School in Denver starts the same way. Students in recovery from drug and alcohol addiction gather on the steps of the school’s indoor auditorium to discuss a topic chosen by staff members. This is Colorado’s only recovery high school — one of 43 nationwide. These secondary schools are designed for students who are recovering from substance use disorder and might also be dealing with related mental health disorders. The first recovery high school opened in Silver Spring, Maryland, in 1979 and similar programs now operate in 21 states. See Find a School (Association of Recovery Schools).
From Uber Vouchers to Patient Advocates: What It Takes to Increase ER Addiction Treatment (Aneri Pattani, KHN, 8-25-21) "A recent report from the Legal Action Center and the Bloomberg American Health Initiative found that despite widespread consensus on the importance of addiction treatment in the ER and an unprecedented rise in overdose deaths, many hospitals fail to screen for substance use, offer medications to treat opioid use disorder or connect patients to follow-up care. Many patients who don’t receive those services die shortly after discharge or within a year of their ER visit, the report said. But a growing number of emergency rooms and health professionals are trying to change that by developing new approaches to address the missed treatment opportunity in ERs."
Treatments for Substance Use Disorders (SAMSHA, the federal Substance Abuse and Mental Health Services Organization)
Narcotics Anonymous (NA)
Alcoholics Anonymous (AA)
Al-Anon Family Groups (strength and hope for friends and families of problem drinkers)
Nar-Anon Family Groups (a 12-step program for families & friends of addicts)
Co-Dependents Anonymous (CoDA) What it was like...we found in each of our lives that codependence is a deeply rooted compulsive behavior born out of our dysfunctional family systems.le.
Tips for analyzing studies, medical evidence, and health care claims
Cochrane Library
Cochrane evidence and systematic reviews
Story reviews
News release reviews
Symphony Health (monitors drug store sales, sells data to drug companies--a good source for journalists)

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Covering the opioid crisis: Addiction, treatment, and recovery (Science and Medical Writing, Writers and Editors site)
Stigma Primer for Journalists: A Guide to Better Reporting on Substance Use and the People It Impacts (Canadian Centre on Substance Abuse and Addiction) Includes links to further resources on the topic.
Expert advice on covering drug addiction (Samuel Thomas, Nieman Storyboard, Power of Narrative Conference, 2022) Veteran social issues reporters Beth Macy and Martha Bebinger balance clear-eyed reporting with sensitive interviewing. The involvement of immersion reporters in the lives of those they write about can be unpredictable and variable. Should they simply document situations, or step in to try to help?
How to find good addiction treatment, according to experts (German Lopez, Vox, 10-29-19) 11 questions to ask any addiction treatment facility.
Family Doctors in Rural America Tackle Crisis of Addiction and Pain (Bram Sable-Smith, KHN and Wisconsin Public Radio, 1-10-2020) “Here was a patient with a family and job who spiraled into addiction due to doctor-prescribed pain pills, yet the community’s barebones health system left him on his own to find treatment…. If that situation was going to change in Necedah, it was up to [family physician Angela] Gatzke-Plamann to change it.”
      "In many ways, rural communities like Necedah have become the face of the nation’s opioid epidemic. Drug overdose deaths are more common by population size in rural areas than in urban ones. Amid a nationwide decline in prescribing rates since 2012, rural doctors prescribe opioids more often by far. Rural Americans have fewer alternatives to treat their very real pain, and they disproportionately lack access to effective addiction medication such as buprenorphine."
Not Equal: Racial Disparities In Addiction/Substance Abuse Treatment (AddictionResource.net) . Identifying how racial disparities show up in addiction treatment settings, and how to address them, is a critical goal for helping all people with substance abuse struggles achieve recovery.
Recognizing Substance Abuse and Addiction in Older Adults—And How to Help (Premier Nursing Academy) Useful resources.
RehabNet.com A rehabilitation organization geared to seniors living with drug and alcohol abuse or addiction, providing resources specific to this population and a 24/7 hotline: 877-888-0552.

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Portugal’s radical drugs policy is working. Why hasn’t the world copied it? (Susana Ferreira, The Guardian, 12-5-17) Since it decriminalized all drugs in 2001, Portugal has seen dramatic drops in overdoses, HIV infection and drug-related crime. You can read a longer (the original) version of this story here: Decriminalization: A Love Story (The Common, 11-1-17)
A Former Opioid Addict at Harvard Says We’re Getting Addiction Wrong (Kathy Jean Schultz, The Daily Beast, 11-27-18) Peter Grinspoon went to rehab for his opioid addiction—and realized that current faith-based abstinence programs often lack scientific research. We’re in the midst of an opioid epidemic and faith-based, abstinence only, approaches to treatment rarely work--—especially given new knowledge about how addiction affects our bodies through our brains. There is also no evidence that diagnosing someone as having an addictive personality is effective. The "uncompromising ‘abstinence-only’ model is a holdover from the very beginnings of the recovery movement, almost 100 years ago, and our understanding has greatly evolved since then,” says Grinspoon.

     The discovery of brain circuits underlying addiction has resulted in development of effective medications — including buprenorphine for opioid addiction, acamprosate for alcoholism, and naltrexone for opiates and/or alcohol. “You treat opiate withdrawal differently than you treat alcohol withdrawal. Yet the rehabs tend to treat every addiction the same.”

      None of these drug treatments were discovered until recently, and definitely weren’t known in 1935, when Alcoholics Anonymous was founded. But implementing change is difficult. "Courts and probation officers, as well as police, prosecutors and local, state and federal agencies, often order OUD-related offenders to attend abstinence-only, faith-based NA or AA meetings, and have done so for decades. Yet people within the U.S. criminal justice system experience high rates of OUD [opioid use disorder] and overdose, according to a recent Johns Hopkins University study."
Addictions in College: What They Are & How to Avoid Them (PsychologyWriting, 10-28-22) An excellent overview of important aspects of all types of substance use and abuse, recommended for college students, who are particularly susceptible to their charms. Excellent references on where to get help.
OxyContin Maker Offers Free Opioid Therapy in Legal Talks ( Jared S Hopkins and Jef Feeley, Bloomberg, 9-11-18) The company that created OxyContin is offering free doses of an opioid-abuse treatment as part of its offer to resolve more than 1,000 lawsuits accusing the drugmaker of helping fuel the opioid crisis, according to people familiar with the negotiations. Purdue Pharma has repeatedly said it will give away doses of a new version of buprenorphine -- which helps wean people addicted to opioids off the drugs -- as part of any settlement, according to four people familiar with the talks sponsored by state attorneys general and a federal judge. They asked not to be cited by name as the negotiations are confidential. Member of family behind Purdue Pharma holds treatment patent.

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Washington Comes Together to Tackle Opioids (Mary Beth Nierengarten, First Report, Managed Care, Oct. 2019) In a rare move that underscores the severity of the US opioid crisis, President Trump signed into law legislation with strong bipartisan support that provides multiple measures to more aggressively address what has become a steady and growing epidemic over decades. A couple key benefits of the bill include leveraging Medicare and Medicaid and making them “part of the addiction treatment infrastructure. Another important provision is allowing for more types of health care providers, such as Certified Registered Nurse Anesthetists (CRNAs), to administer drugs like buprenorphine that ease withdrawal symptoms and improve treatment outcomes, according to Garry Brydges, president, American Association of Nurse Anesthetists.
The 4 Traits That Put Kids at Risk for Addiction (Maia Szalavitz, NY Times, 10-4-16), by the author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction .
This City’s Overdose Deaths Have Plunged. Can Others Learn From It? (Abby Goodnough, NY Times, 11-25-18) Dayton, Ohio, had one of the highest overdose death rates in the nation in 2017. The city made many changes, and fatal overdoses are down more than 50 percent from last year. A variety of factors are believed to have contributed to the sharp drop in mortality from overdoses of heroin and other opioids:

    Medicaid expansion hugely increased access to treatment. (Gov. John Kasich’s decision to expand Medicaid in 2015 gave nearly 700,000 low-income adults access to free addiction and mental health treatment. In Dayton, that’s drawn more than a dozen new treatment providers in the last year alone, including residential programs and outpatient clinics that dispense methadone, buprenorphine and naltrexone, the three medications approved by the F.D.A. to treat opioid addiction.) Carfentanil, an incredibly toxic fentanyl analog, has faded. Naloxone is everywhere. There is more support for people when treatment ends. Police and public health workers actually agree. Excellent piece, full of practical information. Three more pieces in series on The Treatment Gap (exploring the lack of access to effective opioid addiction treatment in America):
---Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get?
---When an Iowa Family Doctor Takes On the Opioid Epidemic "Few primary care doctors are willing to do what Nicole Gastala has: endure the challenges of prescribing buprenorphine, a medication for opioid addiction."
---This E.R. Treats Opioid Addiction on Demand. That’s Very Rare.
---In San Francisco, Opioid Addiction Treatment Offered on the Streets
OD: Naloxone and the Politics of Overdose by Nancy Campbell. The history of an unnatural disaster―drug overdose―and the emergence of naloxone as a social and technological solution.
A Small-Town Plague (Video by The Atlantic, 4-9-2020) In a new documentary from The Atlantic, Nikki King, the founder of Ripley County Courts Addiction & Drug Services (CADS) in rural Kentucky, gives us a glimpse behind the scenes of her one-of-a-kind treatment program. King’s childhood was marred by the effects of the opioid crisis on friends and neighbors in Ripley, which was once what she calls “ground zero” for the epidemic. These days, she says, “I don’t think there’s anybody in any rural community in the country that hasn’t lost someone.”

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It’s time to measure addiction recovery rates, not just addiction rates (Robert D. Ashford, Olivia Pennelle, and Brent Canode, STAT, 8-30-18) 'In the midst of a serious addiction crisis, in which 72,000 people died from overdoses in 2017, it can be easy to forget that recovery is not only possible but is the reality for nearly 10 percent of U.S. adults. Losing sight of that can skew public policy and funding priorities to narrowly focus on preventing deaths instead of aiming more broadly to both reduce unnecessary deaths and promote long-term wellness among the 20 million Americans who have a substance use disorder — barely 4 million of whom receive treatment.

       Since 1971, the Substance Abuse and Mental Health Services Administration (SAMHSA) has tracked the rates of substance use disorder in all 50 states and the District of Columbia....But it has never included questions related to the most positive outcome of having a substance use disorder — recovery from it. Filling this gap has been left to researchers like Harvard University’s John F. Kelly, who directs the Recovery Research Institute, with work like the National Recovery Study. Kelly’s study has one critical limitation though: It provides recovery rates only at the national level and leaves out regional and local estimates...state-specific rates could also be used to help monitor the success of new policies like Good Samaritan and naloxone access laws.''

Students With Addictions Immersed in the Sober Life at ‘Recovery’ High Schools (Anna Gorman, KHN, 1-24-19) At one Seattle public school, students earn their diplomas while attending daily support groups and meeting with counselors to help them stay off drugs and alcohol. There are about 40 similar schools around the country, both public and private, and more are on the drawing board.
Why "Just Say No" Doesn't Work (Scott O. Lilienfeld, Hal Arkowitz, Scientific American, 1-1-14) Why D.A.R.E. doesn't work. Follow that up with The New D.A.R.E. Program—This One Works (Amy Nordrum, Scientific American, 9-10-14) The “keepin’ it REAL” substance-abuse curriculum focuses on elementary and middle-school students’ decisions, not drugs. "If you were one of millions of children who completed the Drug Abuse Resistance Education program, or D.A.R.E., between 1983 and 2009, you may be surprised to learn that scientists have repeatedly shown that the program did not work. But over the past few years prevention scientists have helped D.A.R.E. America, the nonprofit organization that administers the program, replace the old curriculum with a course based on a few concepts that should make the training more effective for today’s students. The new course, called keepin’ it REAL, differs in both form and content from the former D.A.R.E.—replacing long, drug-fact laden lectures with interactive lessons that present stories meant to help kids make smart decisions."

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Kane County treatment program would offer drug users amnesty, 'a way out' of addiction (Megan Jones, Aurora Beacon News, Chicago Tribune, 1-2-19) Kane County Coroner Rob Russell says the “Way Out” program will allow anyone suffering from substance abuse to walk into the lobby of a participating police station and ask for help. They’ll be able to dispose of their unwanted drugs without receiving any possession charges. With the program comes a need for more rehabilitative bed space.
Effective Addiction Treatment (Jane E. Brody, NY Times, 2-4-13) 'Contrary to the 30-day stint typical of inpatient rehab, “people with serious substance abuse disorders commonly require care for months or even years,” she wrote. “The short-term fix mentality partially explains why so many people go back to their old habits.”' "Look for programs using research-validated techniques, like cognitive behavioral therapy, which helps addicts recognize what prompts them to use drugs or alcohol, and learn to redirect their thoughts and reactions away from the abused substance."
"Other validated treatment methods include Community Reinforcement and Family Training, or Craft, an approach developed by Robert J. Meyers and described in his book, Get Your Loved One Sober, with co-author Brenda L. Wolfe. It helps addicts adopt a lifestyle more rewarding than one filled with drugs and alcohol."
People Struggling With Addiction Need Help. Does Forcing Them Into Treatment Work? (Carl Erik Fisher, Slate, 1-18-18) It depends on the type of coercion you use.
Substance Abuse in College: Recognizing, Understanding, and Combatting Alcohol and Drug Abuse on Campus (Kim Dennis, Affordable Colleges Online) Causes, effects, warning signs, getting help, and other practical information and advice.

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Find Help (SAMHSA's links for substance abuse and mental health services)
• Norman Bauman, of the Association of Health Care Journalists, urges (for every recommended path to recovery): " Look at the evidence. Look for a review article in the major peer-reviewed journals (the medical librarians recommended NEJM, JAMA, Lancet, and BMJ to me, and those journals always cite Cochrane). Ask the proponents on all sides for evidence published in the peer-reviewed journals. Go through the HealthNewsReview checklist.

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Babies Dependent On Opioids Need Touch, Not Tech (Alex Smith, KCUR and NPR, 8-20-18) Though Victoria went into recovery before giving birth, Lili was born dependent on the methadone Victoria took to treat her opioid addiction. The symptoms include high-pitched screams, clenched muscles and trouble sleeping. The treatment involves keeping mothers and their infants together in the hospital, making sure babies are held and comforted, and providing opioids as needed in decreasing quantities to ease the baby’s symptoms until she can be weaned off of them. It’s estimated that around 2 percent of infants are now born drug-dependent. In areas gripped by the opioid crisis, the rate is even higher.
A Lost Generation: Opioids and Young Adults (SilverMist Recovery, June 2018) Why young people use opioids, how addiction and dependence develop, how opioid addiction can be treated, etc. A downloadable PDF that can be saved and printed for use with young peop

.• The addiction habit (Marc Lewis, Aeon). By the author of The Biology of Desire: Why Addiction Is Not a Disease (which combines "an account of brain change in addiction with subjective descriptions of what it’s like to live inside addiction"). Medical institutions define addiction as "‘chronic disease of brain reward, motivation, memory and related circuitry." If only the disease model worked. Yet, more and more, we find that it doesn’t. Addiction changes the brain but it's not a disease that can be cured with medicine, writes Lewis. In fact, it's learned – like a habit. Addiction perpetuates the need it was intended to satisfy and the addict learns to satisfy the need by getting and doing more. Neuropsychological habits develop through repetition – not merit, rationality, value or success. Thought-provoking.
Why ‘Substance Abuse’ Is a Label We Should All Reject (Maia Szalavitz, Pacific Standard, 3-26-14) 'Frame addiction as “substance abuse” and it is easy to see why it should be a crime, but call it “substance use disorder” and it sounds like something to be treated medically. If we want to make progress in ending stigma, we should think hard about the words we use....The “substance abuser” label encompasses the whole person, defining him or her by dysfunction. In contrast, the “substance use disorder” tag simply describes one problem, rather than an entire identity.' In a venue for health care journalists, Maia explains: "Addiction, as defined by the National Institute on Drug Abuse and summed up in the DSM, is compulsive drug use despite negative consequences. Substance misuse is just that: taking a drug in a way that it was not intended to be taken....The former "substance abuse" is now "substance use disorder, mild." and the former drug dependence is now 'substance use disorder, moderate to severe.' Personally, I just use addiction and substance misuse." Maia is the author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction. (The reviews on Amazon alone are enlightening.)

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The President's Commission on Combating Drug Addiction and the Opioid Crisis (11-2-17)
Seniors and Addiction: A Brief Guide To Understanding And Helping Seniors Overcome Substance Use Disorders (Truvida, an Orange County, CA, addiction treatment center)
The Parity Act Tracking Project: Making Parity a Reality (Drugfree.org, 6-20-17) At a time of national crisis arising from opioid misuse, abuse and overdose, it is difficult to overstate the urgency of the need for significant improvement in the equitable coverage of addiction treatment benefits, as required by law.
This American War on Drugs (Brooke Gladstone and Bob Garfield, WNYC, On the Media, 4-14-17) Four segments: Breaking News Consumer's Handbook: Drugs Edition, The Man Who Declared War On Drugs (a fascinating and shameful history, in which a man named Harry does a huge disservice to singer Billie Holiday), A (Long) History of American Drug Panics, A Case for Law Enforcement. A whole lot of injustice with various presidents in starring roles. Drug fear often stands in for fear of "the other."
Alternatives to the War on Drugs (Gary Becker, The Beckner-Posner Blog, 5-5-13) The two main alternatives to the war on drugs are decriminalization and legalization of drugs. Decriminalizing drugs means that using drugs would no longer be a criminal activity, while trafficking in drugs would remain a crime. Legalization of drugs means that trafficking in drugs as well as using drugs would not be a crime....The evidence from Portugal, a country that decriminalized all drug use in 2001, offers some support for the claim that decriminalization of drug use will reduce addiction to drugs. A 2010 study in the British Journal of Criminology concluded that decriminalization in Portugal reduced imprisonment on drug-related charges, only slightly increased, if at all, drug experimentation among young persons, increased visits to clinics that help end drug addictions, and reduced deaths from drug overdoses....The retreat from the war on drugs has already begun. The question is whether it will be a sensible retreat with systematic changes in the law toward decriminalization and legalization of drugs, or a disorganized retreat that leaves users and sellers of drugs with unclear legal status."
Making Space for Sobriety (Ryan Caron King, Atavist, published on WNPR). When a person who addicted to drugs or alcohol is discharged from rehab, they’ll sometimes live in what’s called a sober house -- a place where there’s supposed to be no drugs or alcohol around. Same as or similar to How One Agency Is Improving Conditions in Connecticut's Sober Houses (Ryan Caron King, WNPR, 10-4-16) "When someone who is addicted to drugs or alcohol is discharged from rehab, they’ll sometimes pay to live in a privately-owned sober living home like this one, Right Path House. But private sober houses aren’t regulated by the state, and experts in the field say some houses don’t enforce their own sobriety rules -- which can jeopardize the safety of the people that live there and the neighborhood the house is in. So Aligata is working to train and certify sober house owners across the state through a voluntary program. He wants to compile an online database of certified sober houses that he hopes will make it easier for people with addiction to find a place to continue their recovery after rehab."
Cults and Addiction (Mary Carpenter, My Little Bird, 10-5-2020) Unhealthy diets along with sleep restrictions are features of many cults, including the New York-based Nxivm. Nxivm’s recruiters looked for “trust fund babies” and others who struggled with low self-esteem. “The Vow,” now airing on HBO, tells the story of Nxivm (pronounced NEX-ee-um) with former cult members playing some of the roles.
Shattering the Silence (Perry Gaidurgis's video about alcoholism, addiction, children of alcoholics, and recovery)
Understanding Addiction: How Addiction Hijacks the Brain (HelpGuide.org) Addiction involves craving for something intensely, loss of control over its use, and continuing involvement with it despite adverse consequences. Addiction changes the brain, first by subverting the way it registers pleasure and then by corrupting other normal drives such as learning and motivation. Although breaking an addiction is tough, it can be done.

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Help With Addiction and Substance Use Disorders (American Psychiatric Association) Links to useful articles and other resources.
What Is Addiction? (excellent quickie overview of current views and explanations of addiction, from Lumiere, a chain of healing centers)
The AP Learns to Talk About Addiction. Will Other Media Follow? (Maia Szalavitz, UnDark, 6-6-17) The influential stylebook discards ‘addict’ and ‘alcoholic’ for nonjudgmental language that recognizes addiction as a medical disorder. “Addict” should no longer be used as a noun. “Instead,” the stylebook says, “choose phrasing like ‘he was addicted.’” In short, separate the person from the disease. "Language is complicated and often slow to change — and for a group that has been criminalized, fighting stigma and misinformation is a constant struggle. But when the media start treating people with addiction with the same respect that they use for other patients, perhaps the rest of America will start to accept that addiction is a medical problem and that moralizing and punishment have failed." See also Why We Should Say Someone Is A 'Person With An Addiction,' Not An Addict (Maia Szalavitz, Shots, NPR, 6-11-17). On the same message: Journalists, Stop Using Words Like Addict and Drug Abuser (Zachary Siegel, Slate, 6-6-17) Being called an “addict” defines my humanity with one small facet of my identity, essentially erasing the rest of me.
Medicaid Coverage For Addiction Treatment Varies Dramatically (Carmen Heredia Rodriguez, Kaiser Health News, 12-6-16) A study published in the journal "Health Affairs found significant disparities in coverage among the states. Researchers sought to determine the number of substance treatment services available in each state in 2014. They analyzed coverage for the four tiers of services recognized by the American Society for Addiction Medicine, which are classified as outpatient (including group and individual therapy as well as recovery support services), intensive outpatient, short- and long-term residential inpatient and intensive inpatient care for detoxification. At the time of the study, 21 states had expanded Medicaid. The federal health law required states that chose to expand their Medicaid programs to include coverage for substance abuse treatment. But it gave states control to decide the type of treatment and medication that would be covered. Overall, the researchers found the level of Medicaid coverage for substance abuse treatment did not correlate with Medicaid expansion....In particular, states shied away from covering residential interventions, which the federal government had historically chosen not to reimburse for mentally ill patients insured by Medicaid....The coverage disparity across the nation extended to medications used to manage addiction. Every state and the District of Columbia insured buprenorphine, and all but two states covered injectable naltrexone. However, only 32 Medicaid programs covered methadone, one of the most effective drugs in managing addiction, according to the American Society for Addiction Medicine." "But the study also revealed several hurdles in accessing services and life-saving medication. It found many states limited access to substance abuse treatment by requiring preauthorization, imposing annual maximums or asking for patients to pay a share of the costs."
After Addiction Comes Families' Second Blow: Crushing Cost of Rehab (Wall Street Journal, 3-7-18)
How to Choose an Addiction Treatment Program, an excerpt from The Recovery Book: Answers to All Your Questions About Addiction and Alcoholism and Finding Health and Happiness in Sobriety by Al J. Mooney M.D. and Catherine Dold.

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Cognitive-Behavioral Therapy for Substance Use Disorders (R. Kathryn McHugh, Bridget A. Hearon, and Michael W. Otto, Psychiatr Clin North Am. 2010 Sep; 33(3): 511–525.) Cognitive behavioral therapy (CBT) for substance use disorders has demonstrated efficacy as both a monotherapy and as part of combination treatment strategies. This article provides a review of the evidence supporting the use of CBT, clinical elements of its application, novel treatment strategies for improving treatment response, and dissemination efforts.
A physician enters rehab. What happens next should disturb you. (Anonymous doctor, KevinMD, 7-4-15) "The price paid in dollars, reputation, and emotional upheaval in the family might have been justified if these treatment centers had a record of success. Unfortunately, without monitoring and contingency management, there’s no evidence that physician health programs achieve more than the abysmal rates of remission seen with non-MD clients." "Although Alcoholics Anonymous and its many spinoffs do not have a record of success, my medical licensure was contingent upon participation after rehab....without constant and obsessive AA attendance and a relationship with a sponsor that was contingent upon talking about something I had no interest in discussing ad nauseum, the PHP claimed I would not be “in recovery.”
A 20-Year-Old Went to Rehab and Came Home in a Body Bag (Wilbert L. Cooper, Vice, 11-4-14). An expose of the high-end-$$ drug treatment world, through the story of one boy and family it failed: Brandon Jacques, whose dual diagnosis of bulimia and alcohol addiction called for better treatment and medical care than the overpriced "treatment" facility could provide. ("...it's illegal for residential drug and alcohol programs like Morningside to provide any medical care in the State of California, because of an old, controversial law that is a vestige of the rehab industries' AA-based, nonmedical beginnings....Because the State of California has done such a poor job of enforcing the ban on in-house professional medical care, facilities like Morningside get the best of both worlds--they can market themselves as medical facilities to attract more clients without fear of getting shut down, but they don't have to spend the money on medical care or jump through the regulatory hoops required of a facility practicing medicine.") Here is video on the same story: From Rehab to a Body Bag: Dying for Treatment (Vice video, Nov 2014) "Although non-hospital residential treatment serves only about 10 percent of those in recovery in the US, the exorbitant cost of such care--as high as $75,000 a month--has made it extremely lucrative....these centers operate in a gray zone somewhere between legitimate medicine and total quackery, offering things like horseback riding and meditation as solutions to addiction, and often promising medical care that they are unable to provide--sometimes with disastrous results."
Point of Return (experts in recovery from benzodiazepine, sleeping pills, and antidepressants)
Neurobiologic Advances from the Brain Disease Model of Addiction (Volkow ND, Koob GF, McLellan AT. N Engl J Med. 2016 Jan 28;374(4):363-71. DOI: 10.1056/NEJMra1511480) Free full text of a good review article on the science of addiction.

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What’s in a Word? Addiction Versus Dependence in DSM-V (Charles P. O’Brien Nora Volkow T-K Li, American Journal of Psychiatry, 5-1-06) Do not use the word "dependence" to mean addiction," wrote Maia Szalavitz to her fellow health care journalists. DSM dropped that "because dependence can occur without addiction and addiction can occur without dependence. People on maintenance treatment and people in chronic pain can be physically dependent on opioids and people are physically dependent on some antidepressants and blood pressure medications, but if the treatments are working, these are NOT addictions."
The Benefits Of Adopting a Companion Animal While in Addiction Recover (Vertava Health) Animals have an amazing sense of compassion across species lines, and this is especially true when it comes to an owner who’s feeling a little low.
Why It's Wrong to Call Drug Users "Addicts" (Megan Ralston, AlterNet, 3-25-14) We don't say "My mother, the blind" or "my brother, the bipolar."
The Fix (“Addiction and recovery, straight up”). A website about addiction and recovery, featuring a daily mix of breaking news, exclusive interviews, investigative reports, essays and blogs on sober living, lifestyle and cultural resources, as well as knowledge and wisdom from expert counsel. Offers "offer rigorously reported Rehab Reviews ("Zagat-like reviews of rehab facilities"), with input from thousands of alumni, plus extensive directories and practical guides for dealing with addiction and related mental health and life issues." See Challenging the Second ‘A’ in A.A. (David Colman, NY Times, 5-6-11) and Is It Time to Take the Anonymous Out of AA? (Susan Cheever, The Fix, 4-7-11)

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Picking Addiction Help (Jane E. Brody, NY Times, 2-11-13) '“Treatment is not a prerequisite to surviving addiction.” This bold statement opens the treatment chapter in a helpful new book, Now What? An Insider’s Guide to Addiction and Recovery, by William Cope Moyers, a man who nonetheless needed “four intense treatment experiences over five years” before he broke free of alcohol and drugs.'
Substance abuse treatment often impossible to find (Larry Copeland, USA Today) Promising strategies gather dust: 'It's hard to get anyone to pay attention until it happens again.' Joan Ayala now works as a mental health clinician trying to help others avoid her decades-long ordeal.
Pornography: Does it pose a public health crisis? (Sarah Glazer, GQ Reports, 10-21-16) Yes, porn addiction is a problem.

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We must change the way we think about drug addiction in Maryland (Dan Morhaim, Opinion, Wash Post, 2-5-16) An emergency room physician for more than 30 years, Morhaim is introducing four bills that would fundamentally transform drug policy in Maryland. His proposals aim to reduce the harms associated with drug use, including rates of addiction, deadly overdoses, the spread of infectious disease and the incarceration of people who use drugs. One bill would require addiction treatment in ERs. That’s where addiction treatment should begin, and it’s more effective than jail. Another bill would keep drug users who use minimal amounts out of the criminal-justice system, saving critical resources and avoiding the costs of saddling more Maryland citizens with criminal records and the related adverse consequences. The other two bills require a shift in how we think about and treat addicts. One would allow for the administering of pharmaceutical-grade drugs to a small and unresponsive group of heroin abusers, with medical supervision. The final bill calls for the creation of a safe-consumption program that would create supervised spaces for individuals to consume controlled substances, reducing rates of overdose death and the spread of infectious disease and connecting them with rehabilitation programs.
CRAFT: An Alternative to Intervention (Robert J. Meyers, page on the essence of CRAFT, from the HBO program on ADDICTION)
What I Wish I Had Done Differently With My Drug-Addicted Kid (Ron Grover, Drugfree, 8-13-13). Read the comments for a variety of responses.
The Hidden Link Between Autism and Addiction (Maia Szalavitz, The Atlantic, March 2017) It’s believed that people on the spectrum don’t get hooked on alcohol or other drugs. New evidence suggests they do. You can follow Maia on Twitter: https://twitter.com/maiasz
Recovery and Recovery Support (SAMSHA)
Drug Abuse (NIDA, links to many resources, including NIH clinical trials locator)
A to Z list of Programs, Campaigns, Initiatives, Technical Assistance Centers, or Resource Centers (SAMHSA)

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Where do 12-step or self-help programs fit into drug addiction treatment? (National Institute on Drug Abuse, NIDA)
Medication-Assisted Treatment (MAT), including opioid treatment programs (OTPs), combines behavioral therapy and medications to treat substance use disorders.
Treatment centers: 12-step and MAT should coexist (Allison Insinger, Alcoholism Drug Abuse Weekly, 2-24-14, posted by Twin Town Treatment Centers)
DC Calls it Quits (David Zauche, Altarum Institute, Systems for Better Health, 9-24-15). "Smoking is the leading cause of preventable death and disease in the United States, taking more than 480,000 lives annually. The economic costs due to smoking-related illness in the United States are estimated at more than $300 billion each year in direct medical expenses and lost productivity. Many states and cities across the nation are answering the call to action by implementing policies to protect against the devastating effects of tobacco. Altarum's ActionToQuit program supports this DC campaign and hopes that more cities will follow suit." See resources on the Altarum website: Altarum Institute.
A Substance Abuse Guide for Parents (DrugRehab.com)
Substance Abuse: A guide for parents and educators (AddictionResource)
Peer Support and Social Inclusion
Addiction, Heart Disease, and Stroke (Recovery Connection)
Addiction and HIV (Human Immunodeficiency Virus) (Recovery Connection)
Can addiction be treated successfully? (NIDA, or National Institute on Drug Abuse) NIDA states in its Principles of Drug Addiction Treatment, “To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems.”
Drugs, Brains, and Behavior: The Science of Addiction

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Alcohol and Your Health ( NIAAA, or National Institute on Alcohol Abuse and Alcoholism)
Find an AA meeting (Alcoholics Anonymous)
Refuge Recovery (a Buddhist path to recovering from addiction)
Harm reduction (Harm Reduction Coalition -- a set of practical strategies and ideas aimed at reducing negative consequences associated with drug use)
Ayahuasca Can Change Your Life -- As Long as You're Willing to Puke Your Guts Out (LA Weekly, 11-21-13)
Differences Between SMART Recovery and AA (Smart Recovery)
Why SMART Recovery Will Never Replace Alcoholics Anonymous (Matthew Leichter, The Fix, 9-23-14) Five reasons why SMART Recovery will never push out AA as the main model of recovery, despite higher success rates.
Evidence-Based Approaches to Drug Addiction Treatment, read online this chapter from Principles of Drug Addiction Treatment: A Research-Based Guide (National Institute on Drug Abuse)
Managing chronic pain. Pain patients seek other options.

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The Opioid Settlement

Payback: Tracking the Opioid Settlement Cash (KFF Health News series) Opioid manufacturers, distributors, and retailers are paying tens of billions of dollars in restitution to settle lawsuits about their role in the overdose epidemic, with little oversight on how the money is spent. We’re tracking how state and local governments use — or misuse — the cash. Includes graphics on
---Millions in Opioid Settlement Funds Sit Untouched as Overdose Deaths Rise (Katheryn Houghton and Aneri Pattani, Payback: Tracking Opioid Cash, KFF Health News, 12-13-23) Some states haven't begun using opioid settlement funds intended to help curb the opioid epidemic. By early December, a cohort of 17 counties in rural eastern Montana had yet to begin official talks about where the money should go. Meanwhile, more than 100,000 Americans died of an overdose last year.
---$50 Billion in Opioid Settlement Cash Is on the Way. We’re Tracking How It’s Spent. (Aneri Pattani, KFF Health News, 3-30-23) Includes The Right to Know: Where Does Your State Stand on Public Reporting of Opioid Settlement Cash?
---What you need to know about the opioid funds (one of several videos)
---Officials Agree: Use Settlement Funds to Curb Youth Addiction. But the ‘How’ Gets Hairy. (Aneri Pattani, KFF Health News, and Emily Featherston, InvestigateTV, 9-25-23)
---The Year in Opioid Settlements: 5 Things You Need to Know (Aneri Pattani, KFF Health News, 12-21-23) In the past year, opioid settlement money has gone from an emerging funding stream for which people had lofty but uncertain aspirations to a coveted pot of billions being invested in remediation efforts. Here are some important and evolving factors to watch going forward.
---Officials Agree: Use Settlement Funds to Curb Youth Addiction. But the ‘How’ Gets Hairy. (Aneri Pattani and Emily Featherston, InvestigateTV, KFF Health News, 9-25-23)
Watch and Listen: Opioid Settlement Case Triggers Protests Outside the High Court (Aneri Pattani, KFF Health News,12-5-23)
Evolving Overdose Crisis Shakes Previously Effective Treatments (Taylor Sisk, KFF Health News, 11-21-23) The prevalence of synthetic drugs is undercutting a previously effective and widely embraced opioid use disorder treatment tactic. Now, the model pioneered in Vermont a decade ago and adopted at sites nationwide, especially in hard-to-reach rural areas, is being forced to evolve.

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Turmoil of Opioid Epidemic Is Targeted in New Hospital Guide (Martha Bebinger, WBUR, CommonHealth, 6-22-18)Hospitals say there's been little guidance for them about how to screen patients for an opioid addiction, how to manage a patient in detox while treating injuries from a car accident, for example, and where to make naloxone available. To remedy this gap, the Massachusetts Health and Hospital Association is out with what it says is the first statewide "guide for patient management with regards to opioid misuse."
A cure for a crisis: Treating opioid use disorder with scientific solutions (Gina Vitale, report from the AAAS meeting, NASW, 3-9-18) "Vaccinations are one of several possible approaches to combatting the crisis, including new medical therapies, the expansion of access to existing pharmacological treatments, and education for the public as well as prescribing physicians....To help fill that training and knowledge gap, the NIH has collaborated with universities to create educational programs that target both health care providers and the public. The NIDA Centers of Excellence for Physician Information provide information for physicians about substance use disorders. The NIH Pain Consortium’s Centers of Excellence in Pain Education aim to reach the general public. “We have a lot of knowledge, and if we don’t disseminate it, it basically limits its utility,” Volkow said. As NIDA director, Volkow aims to reduce the fatal impacts of this crisis as much as possible with a combination of these science-based solutions, as the opioid crisis has become a front page story nationwide."
Infectious disease (ID) physicians define new role in opioid crisis (Infectious Disease News, via Healio, March 2018) "According to the NIH, studies suggest that people who misuse prescription opioids commonly progress to injection drugs like heroin. Injection drugs, in turn, have fueled a national hepatitis C virus epidemic and continue to expose many to HIV. Opioid abuse can also lead to endocarditis, an infection of the heart chambers and valves, and septic arthritis, an infection of the joints typically caused by bacteria that travel through the bloodstream, among other infectious diseases."
Healio's Opioid Resource Center (news articles and features covering multiple medical specialties provides the latest information on the opioid crisis including treatment strategies, FDA decisions regarding treatments and other important, related announcements)

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No Quick Fixes: Telling the Story of Long-term Recovery from Opioid Addiction (Susan Stellin, NiemanReports, 1-24-18) Journalists do a good job telling stories about drug addiction, but not about the recovery process.As more people in recovery decide to share their stories, journalists are exploring the under-reported experiences of people who have been drug-free for many years. There has been no shortage of stories documenting the toll of the epidemic, but it is much tougher to report on how the U.S. should address it.
Journalist Norman Bauman urges (for every recommended path to recovery): " Look at the evidence. Look for a review article in the major peer-reviewed journals (the medical librarians recommended NEJM, JAMA, Lancet, and BMJ to me, and those journals always cite Cochrane). Ask the proponents on all sides for evidence published in the peer-reviewed journals. Go through the HealthNewsReview checklist
Tips for analyzing studies, medical evidence, and health care claims
Law Enforcement Assisted Diversion (LEAD, an innovative pilot program in a Seattle neighborhood that was developed with the community to divert low-level drug and prostitution offenders into community-based treatment and support services – including housing, healthcare, job training, treatment and mental health support -- instead of processing them through traditional criminal justice system avenues.
The Secret Lives of Recovered, Dual-Diagnosed Alcoholics (Christine Stapleton, Depression on My Mind, Psych Central, 8-22-16)
Focus on good news in addiction treatment (Palm Beach Post, 9-5-17).
The Healing Forest Project (Derek Wolfe, Medium, August 11, 2016) This series explores how Ann Arbor, Michigan has taken a community-based approach to recovery, the idea being to create a “healing forest” locally rather than sending people for treatment in another state. "The series presents a thorough overview of the factors necessary to create a community supportive of recovery, including access to treatment, affordable housing for people transitioning out of residential care, employers willing to hire staff members in recovery, educational programs that offer an alternative to campus drinking culture, and support groups that provide a sober social network, and role models who are in recovery themselves."~Susan Stellin.
“The thing that bothers me most about addiction coverage is that I don’t think it’s really honest about what happens to people when they’re addicted to drugs. That’s not being covered enough—how much addiction ravages people’s lives in every way.” —Derek Wolfe, author of “The Healing Forest Project”
---Part 1: Addiction and Recovery in America Opioid use has risen dramatically. To reverse this trend, the solution lies in our approach to substance use
---Part 2: What, exactly, is a Healing Forest? It’s more than an abstract concept. Ann Arbor, Michigan, is one.
---Part 3: Access to treatment: A look at Dawn Farm and the role of treatment centers in the Healing… Treatment centers play a crucial role in fostering the Healing Forest.
---Part 4: The housing issue (8-11-16) High rent prices make living in Ann Arbor a challenge
---Part 5: Finding a support group and how to get there The role of meetings and transportation in the recovery community
---Part 6: Zingerman’s and The Lunch Room: An examination of inclusive work cultures Restaurants foster honesty and openness among staff that makes for a positive environment for those in recovery
---Part 7: Access to education can be instrumental for recovery The University of Michigan and Eastern Michigan give opportunities to individuals in recovery to turn around their lives.
---Part 8: Reducing the stigma and growing more Healing Forests Changing the culture around addiction and recovery is within our grasp
Addicts Need Help. Jails Could Have the Answer. (Sam Quinones, NY Times, 6-16-17) This sparked criticism, including Jail Isn’t the Place to Treat Drug Addiction (6-6-17)
What Sobriety Taught Me (So Far) (John Gorman, P.S. I Love You, Medium, 1-26-18) The nature and the nurture of reality. "I want to fully inhabit this body and not be the surveillance camera in the corner monitoring my every move. "

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The addiction paradox (Bruce Bower, Science News, 3-7-14). Drug dependence has two faces — as a chronic disease and a temporary failure to cope
Effective Addiction Treatment (Jane Brody, NY Times, 2-4-13)
Adolescent Brain Cognitive Development Study (Collaborative Research at NIH) The ABCD Study is a national longitudinal study that will assess the short- and long-term impact of substance use on brain development. The project will recruit 10,000 youths before they begin using alcohol, marijuana, tobacco and other drugs, and follow them over 10 years into early adulthood. See frequently asked questions about the study and The CRAN blog.
One Hundred Years Ago Today, Prohibition Began in Earnest. We’re Still Paying. (Maia Szalavitz, Substance.com, 12-17-14). On December 17, 1914, Congress passed the Harrison Act, making nonmedical opium and cocaine illegal. It was really about punishment, not public health. And it set the tone for a disastrous century.
Addiction Medicine: Closing the Gap Between Science and Practice (CasaColumbia, June 2012) “Only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.”
The Clean Slate Addiction Site (maintained by Maia Szalavitz).
Rat Park, Stuart McMillen's comic about a classic study of (experiment about) drug addiction conducted in the late 1970s (and published in 1980) by Canadian psychologist Bruce K. Alexander and his colleagues.
Closing the Addiction Treatment Gap) (CATG, 'Addiction is a disease. Let's treat it that way.") A national program of the Open Society Institute, founded in 2008. This PDF is a 2010 report on three-year $10 million effort to expand treatment by expanding insurance coverage, increasing public funding, and making systems and programs more efficient.
Addiction Recovery Basics
The Recovery Book: Answers to All Your Questions About Addiction and Alcoholism and Finding Health and Happiness in Sobriety by Al J. Mooney M.D. and Catherine Dold
Alcoholics Anonymous: The Big Book, 4th Edition.
Faces & Voices of Recovery (FAVOR) (why living in safe, sober and peer supportive environments matters in recovery) Faces & Voices believes that our nation’s response to the crisis of addiction should be based on sound public health science and the grassroots engagement and involvement of the recovery community – people in recovery, their families, friends and allies – organized in identifiable and mobilized networks of recovery community and allied organizations that foster collaboration, advocacy and public education about the reality of addiction recovery.
ManyFaces1Voice No longer will we remain silent. We want to sensationalize recovery, because recovery is sensational." Together we will change public perception, and ultimately the public response to the addiction crisis.
Gateway Drugs: How Does Addiction Start? (Michael's House).
The Trouble With Tough Love (Maia Szalavitz, Wash Post, 1-29-06) A MUST READ. "The trouble with tough love is twofold. First, the underlying philosophy -- that pain produces growth -- lends itself to abuse of power. Second, and more important, toughness doesn't begin to address the real problem."
NIH State-of-the-Science Conference Statement on Preventing Violence and Related Health-Risking Social Behaviors in Adolescents (NIH, 2004) "Programs that seek to prevent violence through fear and tough treatment appear ineffective. Intensive programs that aim at developing skills and com­petencies can work."
ManyFaces1Voice, a campaign to transform public attitudes and policies affecting people seeking or in recovery from addiction to alcohol and other drugs. Whether behind the scenes or on the front line, every recovery voice is needed. See trailer to the film The Anonymous People.
Crack baby myth goes up in smoke (Todd Reed, America Tonight, Aljazeera, 3-10-15). A Philadelphia study found no gap in health and life outcomes for babies exposed to crack versus ones who weren’t. Poverty, however, posed a major risk.
Exercise: Alternative reward for those battling addiction (James Fell, Chicago Tribune, 6-12-13)
The D.S.M. Gets Addiction Right (Howard Markel, Opinion, NY Times, 6-5-12)
A New Scientific American eBook, Understanding Addiction, Examines the Multifaceted Issue of Substance Abuse (9-17-13)

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Addiction to gambling

aka Compulsive Gambling, Gambling Disorder, the uncontrollable urge to keep gambling despite the toll it takes on your life.

Addiction experts warn: Texas push for online sports betting is a public health gamble (Caroline Covington, Texas Standard, 3-10-22) Lobbyists and some state lawmakers argue making online sports betting legal would be a boon to the Texas economy. But others say it could come with serious public health consequences.
How the Brain Gets Addicted to Gambling (Ferris Jabr, Scientific American) Addictive drugs and gambling rewire neural circuits in similar ways.
Gamblers Anonymous
National Council on Problem Gambling (NCPG)
Call 1-800-522-4700
Chat ncpgambling.org/chat
Text 1-800-522-4700
National Center for Responsible Gaming (NCRG), exclusively devoted to funding research that helps increase understanding of pathological and youth gambling and find effective methods of treatment for the disorder.
Know the Odds (resources for help with gambling problems)
"Slot Whisperer" Lawyer and Accused Scammer Now Gambling In Disguise (Michele McPhee, Los Angeles Magazine, 3-1-23) Accused fraudster Sara King was dubbed "the Anna Delvey of Orange County” after she allegedly scammed friends, family and a Swiss banker to fund a wild $10.2 million-plus Vegas spree. While claiming to hit jackpot after jackpot, King was really, according to a civil lawsuit, siphoning money out of her company, King Family Lending, and using her investor's cash to gamble.
Do You Have a Gambling Problem or Addiction? (HelpGuide)
Understanding gambling addiction (MIT News, 2012) For machine gamblers, it’s not whether they win or lose — it’s how much they play the game.
Gambling addiction linked to brain reward system (BBC News, 10-19-14) he 'high' or feeling of euphoria created by addictive behaviour is less obvious in the brains of problem gamblers, research suggests.
Is Facebook Targeting You? (PBS NewsHour and Reveal, 3-13-19, watch YouTube video, or read text) Facebook recently received a $5 billion fine from the Federal Trade Commission for mishandling users’ personal information. But how does Facebook’s handling of personal information affect its users? PBS and Reveal examine "how Facebook is partnering with social casino games to monitor and analyze the behavior of vulnerable players. The companies are using big data and advanced software to predict which people will spend massive amounts of money on the games and then targeting these people with aggressive marketing. Suzie Kelly, a grandmother from suburban Dallas, ultimately spent $400,000 playing a virtual slot machine game on the Big Fish Casino app on her iPhone. She took out two home equity loans, spent her family inheritance and borrowed money from her husband’s 401(k), all to pay off credit card debt from the game. And the kicker? She can’t win any money in the game. It’s not traditional gambling. Players can never cash out their virtual chips for real money."
Did a blockbuster drug make hundreds gamble compulsively? A legal fight may decide what science can’t confirm (Megan Thielking, STAT, 8-2-18) [Denise] Miley, 41, filed a lawsuit in January 2016 against the drug makers Bristol-Myers Squibb and Otsuka, alleging the drug — one of the best-selling in the world — caused compulsive behavior. The suit contends that the companies knew or should have known it could create such urges, and didn’t adequately warn the thousands of people in the U.S. who use the medication each year. Hundreds more people have since sued the companies, claiming that the drug caused them to gamble, eat, or have sex compulsively. And the Food and Drug Administration signaled its own concern in a 2016 safety warning, saying that uncontrollable urges to gamble, binge eat, shop, and have sex had been reported with use of the antipsychotic.
Losing Everything to Gambling Addiction (Peter Jaret and Bill Hogan, AARP Bulletin, Jan/Feb 2014) "In 2013, for the first time, the American Psychiatric Association officially recognized compulsive gambling as an addiction (rather than a personality disorder), acknowledging that it shares many features with alcoholism and drug addiction....The nation's $40 billion a year gambling industry aggressively targets older customers, as they have accumulated wealth and are especially vulnerable, experts say, to wagering more than they can afford. The enticements range from free bus trips, meals and even discount prescription cards to "comped" hotel accommodations — not to mention the private jets dispatched to pick up high-rollers like O'Connor."
"Older people with dementia are at especially high risk because they are unable to recognize limitations or use appropriate judgments. And dopamine agonists, a class of prescription drugs used to treat the symptoms of Parkinson's disease and restless legs syndrome, seem to be associated with compulsive gambling as a side effect, according to Marc Potenza, M.D., a professor of psychiatry at Yale University who studies problem gambling.
"Psychologists also suspect that people are more likely to run into problems if they turn to gambling for the wrong reasons — to escape loneliness, depression or even chronic pain."
Problem gambling. This Wikipedia entry provides an excellent overview, with plenty of references.
Compulsive Gambling: Symptoms and Causes (Mayo Clinic)
Personal Stories about Problem Gambling (Office of Problem Gambling Services, Mass.gov)
What Is Gambling Disorder? (Geralyn Dexter, VeryWellHealth, 11-15-21) Some individuals can engage in gambling recreationally without developing any compulsion or addiction. However, others may develop maladaptive (negative) gambling behaviors. Signs of trouble: Lying to hide behavior. Risking and losing relationships. Negative effects on work or school. Gambling while experiencing emotional discomfort. Difficulty reducing or controlling behavior. Research reports that up to 4% of the population is personally affected by compulsive gambling.
The Billion-Dollar Jackpot: Engineered to Drain Your Wallet (Jeff Sommer, NY Times, 8-12-16) If your goal is actually to win money, your chances are much better at the blackjack table in a casino. "Mr. Mehta persuaded me to crunch the numbers to see what effects the government-sponsored lotteries are having on people who buy tickets regularly. The results are troubling."
Gambling addiction affects more men and women, seduced by growing casino accessibility (Daniel Bortz, NY Daily News, 3-28-13)
A Prepaid Card for Recovering Addicts The Next Step Prepaid Mastercard, the first prepaid card designed for recovering addicts, allows a caregiver to put money onto the card and then monitor how the money is spent.
Unrelated to addiction, but interesting:
New Yorker writer Maria Konnikova keeps winning at poker (Karen K. Ho, Columbia Journalism Review, 7-12-18) "People want to get into [poker] because they think it’s easy money are absolutely insane. It’s some of the most difficult money in the world."

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Medication-assisted treatment for addiction (MAT)

Biden administration has simple way to cut overdose deaths, experts say: expand methadone access (Lev Facher, STAT, 8-18-22) Methadone saves lives. So why is the government limiting access? "When it comes to fighting opioid addiction, there’s no tool more effective than methadone. Doctors have been prescribing the drug since the 1960s, and patients who use it are far less likely to experience an overdose. But for decades, an archaic web of federal regulations has kept the medication out of reach for countless Americans. The debate surrounding methadone access highlights the urgency of the U.S. addiction crisis, and the fragmented nature of the country’s system for treating substance use.
One of the Best Tools to Manage the Opioid Crisis Already Exists (Emma Yasinski, Undark, 8-4-22) Methadone helps maintain sobriety and reduce the risk of overdose. The pandemic showed us it should be easier to access. Methadone stimulates the opioid receptors in the brain, but its effects are more gradual and long-lasting.
US Experts: Medicines for Opioid Addiction Vastly Underused (Associated Press, NY Times, 3-20-19) Medicines proven to treat opioid addiction remain vastly underused in the U.S., the nation's top medical advisers said Wednesday. Only a fraction of the estimated 2 million people addicted to opioids are getting the medications, according to a report by the National Academies of Sciences, Engineering and Medicine. The influential group, which advises the federal government, called for increased prescribing of the drugs and other changes to reduce barriers to their use.  

        Government-approved medications, which include methadone, buprenorphine and naltrexone, help control cravings and withdrawal symptoms like nausea, muscle aches and pain. Their use is backed by most doctors and medical groups. Yet they still have skeptics, especially among supporters of 12-step programs that favor abstinence-only approaches. The report concludes that patients taking the medicines fare better over the long term and are 50 percent less likely to die than if they weren't on them.

        An "all hands on deck" response is needed — including doctors, law enforcement and family members — to expand access to treatment, it said. The group's conclusions echo similar reports from the U.S. Surgeon General and a presidential commission appointed to make recommendations for curbing the opioid epidemic.
Unbroken Brain: A Revolutionary New Way of Understanding Addiction by Maia Szalavitz. "Challenging both the idea of the addict's 'broken brain; and the notion of a simple 'addictive personality,' Unbroken Brain offers a radical and groundbreaking new perspective, arguing that addictions are learning disorders and shows how seeing the condition this way can untangle our current debates over treatment, prevention and policy.

      Like autistic traits, addictive behaviors fall on a spectrum -- and they can be a normal response to an extreme situation. By illustrating what addiction is, and is not, the book illustrates how timing, history, family, peers, culture and chemicals come together to create both illness and recovery- and why there is no "addictive personality" or single treatment that works for all. Combining Maia's personal story with a distillation of more than 25 years of science and research, Unbroken Brain provides a paradigm-shifting approach to thinking about addiction."
Nurses Step In to Boost Treatment for Opioid Addiction (Christine Vestal, Pew Trusts, 8-31-16) States are eyeing Boston Medical Center’s nurse-managed approach to buprenorphine therapy as a way to treat more people. By taking over the labor-intensive office visits, behavioral health assessments, drug screenings and paperwork that go along with buprenorphine treatment, registered nurses make it easier for physicians to accept more patients and write prescriptions for the medication they want and need.
Only One in Twenty Justice-Referred Adults on Specialty Treatment for Opioid Use Receive Methadone or Buprenorphine (Noa Krawczyk, Caroline E. Picher, Kenneth A. Feder, and Brendan Saloner, Health Affairs, Dec. 2017) "Of all criminal justice sources, courts and diversionary programs were least likely to refer people to agonist treatment. Our findings suggest that an opportunity is being missed to promote effective, evidence-based care for justice-involved people who seek treatment for opioid use disorder."
Commonly Prescribed Meds for Treating Addiction Also Reduce Crime and Suicide (Peter M. Yellowlees, Medscape Psychiatry Minute, 2-6-19) The use of medication-assisted treatment for addictions is becoming increasingly common. An Oxford study of a within-individual population cohort study of 21,281 individuals in Swedish registries who received treatment with at least one of four medications between 2005 and 2013 looked for associations between medications for alcohol and opioid use disorders (acamprosate, naltrexone, methadone, and buprenorphine) and suicidal behavior, accidental overdoses, and crime.

      They found that naltrexone was associated with a reduction in accidental overdoses. Buprenorphine was associated with reduced arrest rates for all crime categories, as well as a reduction in accidental overdoses. For methadone, there were significant reductions in the rate of suicidal behaviors as well as reductions in all crime categories. The authors concluded that medications currently used to treat alcohol and opioid use disorders also appear to reduce suicidality and crime during treatment.
Convening: Medication Assisted Treatment for Justice-Involved Populations The Office of National Drug Control Policy (ONDCP) convened a meeting to raise awareness of the importance of incorporating medication assisted treatment (MAT) as part of a comprehensive treatment regimen for incarcerated persons with opioid use disorder (OUD). "We should all remember that we have evidence-based community-standard medications that work for the disease of opioid addiction, and this should become the standard of care in corrections, and the criminal justice system broadly."-Dr. Kathleen Maurer, Connecticut Department of Corrections
'Unbroken Brain' Explains Why 'Tough' Treatment Doesn't Help Drug Addicts (Terry Gross interviews Maia Szalavitz, author of Unbroken Brain, 7-7-16) Tough love, interventions and 12-step programs are some of the most common methods of treating drug addiction, but journalist Maia Szalavitz says they're often counterproductive. Maia challenges traditional notions of addiction and treatment, argues from research and experience; she was addicted to cocaine and heroin from the age of 17 until she was 23. She 'is a proponent of "harm reduction" programs that take a nonpunitive approach to helping addicts and "treat people with addiction like human beings." In her own case, she says that getting "some kind of hope that I could change" enabled her to get the help she needed.' The premise of the self-help 12-step programs, she argues, is that they make people think addiction is a moral problem, a sin, with treatment involving "prayer, restitution and confession."

          "Buprenorphine and methadone are the two most effective treatments that we have for opioid addiction, and that is when they are taken indefinitely and possibly for a lifetime....these medications are opioids themselves. They each have slightly different properties ... but what they do is they allow you to function completely normally. You can drive. You can love. You can work. You can do everything that anybody else does....The way they are able to do that is because if you take an opioid in a regular steady dose every day at the same time and the dose is adjusted right for you, you will not experience any intoxication. The way people with addiction experience intoxication is that they take more and more and more, they take it irregularly, the dosing pattern is completely different. But if you do take it in a steady-state way — which is what happens when you are given it at a clinic every day at the same time — you then have a tolerance to opioids which will protect you if you relapse, and will mean that the death rate from overdose in people who are in maintenance is 50 to 70 percent lower than the death rate for people who are using other methods of treatment, and that includes all of the abstinence treatments."
        On a health journalists listserv, Maia argues: For years, the addiction field got by on claiming that 12 step based abstinence treatment was superior to every other approach for all addictions. Inpatient rehabs made fortunes because you hire a bunch of low cost formerly addicted people with maybe a high school education as counselors and charge hospitalization level rates as if they are being treated by doctors rather than basically getting a whole day of what you could get for free in church basements.

       It's a bit better now, with some actually providing some semblance of evidence based counseling, psychiatric care (50% have another diagnosis), trauma care (2/3 have experienced at least one potentially traumatic childhood event, much higher rates of trauma than general population. These however, are difficult to find. Nonetheless, because the field didn't bother to create evidence based care and in fact based the 28 day model on the maximum of what insurance would then cover, rather than data, it's hardly surprising that insurance companies don't want to pay for it and that determining parity is hard. A good start would be to require that no 12 step content be included in paid rehab. That way, they can't argue they're paying for what you can get elsewhere for free, nor will people be forcibly subjected to things like 'surrender to a higher power' and 'moral inventory' when they are supposedly getting treatment for a disease."
There’s a highly successful treatment for opioid addiction. But stigma is holding it back. (German Lopez, Vox Science and Health, 7-20-17) Over the past few years, America’s harrowing opioid epidemic — now the deadliest drug overdose crisis in the country’s history — has led to a lot of rethinking about how to deal with addiction. For addiction treatment providers, that’s led to new debates about the merits of the abstinence-only model — many of which essentially consider addiction a failure of willpower — so long supported in the US....The Hazelden Betty Ford Foundation, for example, used to subscribe almost exclusively to the abstinence-only model, based on an interpretation of the 12 steps of Alcoholics Anonymous and Narcotics Anonymous popularized in American addiction treatment in the past several decades. But in 2012, Hazelden announced a big switch: It would provide medication-assisted treatment....With so many people dying from drug overdoses — tens of thousands a year — and hundreds of thousands more expected to die in the next decade, America is finally considering how its response to addiction can be better rooted in science instead of the moralistic stigmatization that’s existed for so long. The research is clear: Medication-assisted treatment works. Lopez compares the safety, ease of use, and effectiveness of methadone, buprenorphine (also known as Suboxone), and Naltrexone.
         "The first US-based study comparing naltrexone and buprenorphine found that once people get on either, they are similarly effective. But that comes with a major caveat: It was much harder to get people started on naltrexone than buprenorphine because naltrexone requires a detox period. So buprenorphine is, on average, more accessible and effective than naltrexone — although results can vary from individual to individual."
• “There’s so much data from so many different places that if you add methadone or Suboxone in, deaths go down, and if you take it away, deaths go up.” Maia Szalavitz, a longtime addiction journalist and author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction
Medication-aided opioid care slow to catch on in state (Kat Stromquist, Arkansas Democrat Gazette, 9-23-19) Drugs as addiction tool faces skeptics.
Narcan Opioid Overdose Spray Is Now Stocked By All Walgreens Pharmacies (Bill Chappell, The Two-Way, National Public Radio, 10-26-17)
You Can Rely on Drugs Without Being an Addict (Maia Szalavitz, Vice, 12-20-16) "It may seem like a trivial or academic distinction, but addiction is not dependence, and dependence is not necessarily a problem...if addiction is properly understood as compulsive drug use despite negative consequences, maintenance cannot be seen as addiction. What maintenance does, in fact, when it works most effectively, is replace compulsive drug-seeking (in the face of harm) with simple physical dependence. This is not a problem if someone has a safe, regular supply."
Why taking drugs to treat addiction doesn’t mean you’re ‘still addicted’ (Sarah E. Wakeman and Maia Szalavitz, STAT, 5-18-17) Among other things, "people stabilized on medications like methadone are not addicted — they don’t engage in compulsive use despite consequences — but merely dependent. (When opioids are taken in a steady, regular dose appropriate for a particular patient, that person will not be impaired and can safely drive, work, and parent.)"..."confusing “dependence” and “addiction” spurs bias against the most effective known treatment for opioid addiction: long-term use of methadone or buprenorphine (Suboxone). Decades of research show that these medications dramatically reduce the risk of death, HIV infection, and recurrence of drug use....Yet the common myth is that people taking these medications are 'still addicted' and that residential treatment is a better option....Mistaking dependence for addiction can also harm patients with chronic pain. Those who benefit from opioid therapy can be mislabelGet Off Methadone and Subutex for Gooded as addicted, when, in fact, they are physically dependent. This can lead to cessation of an effective treatment — and sometimes even suicide."
Get Off Methadone and Subutex for Good (Compass Recovery) Brutal truths about methadone maintenance therapy.
OxyContin Maker Offers Free Opioid Therapy in Legal Talks (Jared S Hopkins and Jef Feeley, Bloomberg, 9-11-18) The company that created OxyContin is offering free doses of an opioid-abuse treatment as part of its offer to resolve more than 1,000 lawsuits accusing the drugmaker of helping fuel the opioid crisis, according to people familiar with the negotiations. Purdue Pharma has repeatedly said it will give away doses of a new version of buprenorphine -- which helps wean people addicted to opioids off the drugs -- as part of any settlement, according to four people familiar with the talks sponsored by state attorneys general and a federal judge. They asked not to be cited by name as the negotiations are confidential. Member of family behind Purdue Pharma holds treatment patent.
A prison system offered all inmates addiction treatment. Overdose deaths dropped sharply (Andrew Joseph, STAT, 2-14-18) Experts have long advocated for expanding the use of medication-assisted treatment, or MAT, in correctional facilities, but for the most part, jails and prisons remain treatment deserts.
Massachusetts Issues Guidelines After Boston Nurse Was Denied Life Insurance For Carrying Naloxone (Martha Bebinger, CommonHealth, WBUR, 2-12-19) Massachusetts is advising life and disability insurers not to deny coverage to good Samaritans who carry the overdose-reversal drug naloxone. The guidelines, issued earlier this month, follow a WBUR story in December about a Boston nurse who was denied life insurance because she carries the drug.
Why It’s Easier to Be Prescribed an Opioid Painkiller Than the Treatment for Opioid Addiction (Jeffrey Hom and Krisda Chaiyachati, Health Policy$ense, UPenn LDI, 5-31-16) Despite alarming statistics about opioid abuse and the significant attention focused on the epidemic, a hidden regulatory imbalance exists between two types of opioids – those prescribed for pain and those prescribed to treat opioid addiction. "As physicians, we need to obtain only a license from the Drug Enforcement Agency (DEA) in order to prescribe opioid painkillers. Maintaining it requires a licensing fee every three years, but there is no mandatory training on how to safely prescribe these medications and no requirements to monitor patients who receive them. There is, in short, little oversight.
"In contrast, heavy regulations restrict those providers wishing to treat addiction by prescribing buprenorphine, the mainstay of medication-assisted treatment for opioid addiction outside of methadone clinics. Although buprenorphine was approved by the FDA in 2002, it remains underused, far below the levels needed to meet the growing number of individuals requiring treatment."
Primary Care and the Opioid-Overdose Crisis - Buprenorphine Myths and Realities. (SE Wakeman and ML Barnett, N Engl J Med, 7-5-18) Makes a strong case for overturning the bureaucratic roadblocks that limit the prescribing of buprenorphine.
Moving Addiction Care to the Mainstream — Improving the Quality of Buprenorphine Treatment (Brendan Saloner, Kenneth B. Stoller, and G. Caleb Alexander, N Engl J Med, 7-5-18) "In the United States, methadone can be dispensed only at regulated opioid-treatment programs (see the Perspective article by Samet et al.), and naltrexone requires complete abstinence before treatment begins. Buprenorphine treatment, by contrast, can begin in a physician’s office while a patient is in withdrawal. Expanding buprenorphine provision could have population-wide benefits, but as currently delivered, this treatment is not fully living up to its promise. Buprenorphine treatment is generally more effective with longer duration, yet many patients receive it for very short periods."

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Addiction to opioids and psychoactive drugs

Causes and how to deal with the problem

Psychoactive drugs are typically categorized as stimulants, depressants, opiates & opioids, and hallucinogens. As explained on Castle Craig Hospital's very helpful (UK) website:

STIMULANTS--cocaine, crack cocaine, amphetamines (speed) and ecstasy (also a hallucinogen).
These "act on the central nervous system and are associated with feelings of extreme well-being, increased mental and motor activity."

DEPRESSANTS--alcohol and cannabis, in particular, as well as barbiturates and benzodiazepines (e.g. valium, temazepam).
These "slow down the central nervous system and suppress brain activity causing relief from anxiety."

OPIATES & OPIOIDS--heroin, morphine, opium, methadone, dipipanone, and pethidine.

Opioids "provide pain relief, euphoria, sedation and in increasing doses induce coma."
Fentanyl is a powerful synthetic opioid that is similar to morphine but 50 to 100 times more potent, is highly addictive, and can cause respiratory distress and death in high doses or combined with other substances.
As with any opiate, the main symptoms of fentanyl abuse are euphoria, drowsiness, lethargy and mellowness.

HALLUCINOGENS--cannabis, LSD, ecstasy and psilocybin ("magic mushrooms").
These "cause changes in a person's perception of reality."

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The focus here is on the opioid crisis.

OPIATES & OPIOIDS--heroin, morphine, opium, methadone, dipipanone, and pethidine.
These "provide pain relief, euphoria, sedation and in increasing doses induce coma."
Prince search warrants lay bare struggle with opioids (Amy Forliti, AP, WaPo, 4-18-17) At the time of Prince’s death, his Paisley Park home and recording compound in Minnesota were strewn with “a sizable amount” of narcotic painkillers for which he did not have prescriptions, including some hidden in over-the-counter vitamin and aspirin bottles and others issued in the name of a close aide, according to newly released court documents. Those documents "sketch a picture of how this musician, a strict proponent of clean living who suffered from chronic hip pain, concealed his opioid addiction using a variety of methods, including mixing various prescription pills in bottles for everyday products like Bayer and Aleve." He died from a "fatal amount of fentanyl, which is often used to manufacture counterfeit pills that are sold on the black market as oxycodone and other pain relievers."Associates at Paisley Park also told investigators that Prince was recently “going through withdrawals, which are believed to be the result of the abuse of prescription medication,” an affidavit said. Search warrants and affidavits shed no new light on how Prince got the fentanyl that killed him. In practice, laws against prescribing drugs for someone under a false name are not usually enforced when a doctor intends to protect a celebrity’s privacy, said Los Angeles attorney Ellyn Garofalo. They would be indicting every pharmacist in Beverly Hills if this were strictly enforced,” Garofalo said.

• Opioid Treatment Program Directory (SAMHSA)
Painkiller (Netflix series, Sept. 2023) The causes and consequences of America's opioid epidemic unfold in this drama following its perpetrators, victims and an investigator seeking the truth. 'Matthew Broderick plays the Purdue Pharma president Richard Sackler in “Painkiller,” a six-episode mini-series based on reporting by Barry Meier and Patrick Radden Keefe. In the framing scenes, Uzo Aduba plays an investigator who spends years looking into the widespread overprescribing of opioids, tracing the problem back to the drug companies who misled doctors — and thus patients — about the addictiveness of palliative pills.' (NY Times review)
Going Beyond the Script of ‘Dopesick’ and America’s Real-Life Opioid Crisis (KHN, 10-18-21) KHN and policy colleagues at parent organization KFF teamed up with Hulu for a discussion of America’s opioid crisis, following the Oct. 13 premiere of the online streaming service’s new series “Dopesick.” The discussion explored how the series’ writers worked with journalist Beth Macy, author of the book Dopesick: Dealers, Doctors, and the Drug Company That Addicted America, and showrunner Danny Strong to create and fact-check scripts and develop characters. It quickly moved on to a deeper discussion of how the fictionalized version of the opioid epidemic portrayed in the Hulu series dovetailed with the broader reality KFF’s journalists and analysts have been documenting in their work for the past few years.

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Five signs a loved one is abusing painkillers (Dr. Carlos Tirado and CBS News, 2-20-13) 1. Drowsiness, lack of energy; 2. Inability to concentrate, lack of motivation; 3. Social behavioral changes; 4. Changes in appearance; 5. Increased secrecy.
How to Tell If Someone Is Shooting Up: Signs of IV Drug Abuse (Arrow Passage Recovery)



Opioids and Paternalism (David Brown, American Scholar, Autumn 2017) "The proliferation of opioid use in the United States is called an epidemic, but it more resembles metastatic cancer. The malignant effects extend far beyond the 300,000 Americans who’ve died since 2000. Prescription opioids are creating a pharmaceutically damaged underclass, trapping millions of people in a culture of victimhood and economic dependence, or for the unlucky, a world of criminal behavior and lethal illicit drugs. At the same time, opioids are damaging the medical profession and its practitioners in ways that will take years to acknowledge and redress....The opioid epidemic is entangled with economic and cultural forces, but it begins with pain. People—physicians especially—are going to have to think differently about pain for the epidemic to end."

How the government can fight the opioid epidemic under a public health emergency (Lenny Bernstein, Washington Post, 10-26-17) At this point in the nation's opioid epidemic, fighting back is mainly about quickly making money available: Money for treatment. Money for the overdose antidote naloxone. Money to hire more people to help overwhelmed cities and states battle a crisis that killed an estimated 64,000 Americans last year.
The surgeon general and his brother: A family’s painful reckoning with addiction (Andrew Joseph, STAT, 12-7-17)
STAT forecast: Opioids could kill nearly 500,000 Americans in the next decade (Max Blau, STAT, 6-27-17)
Relaxing privacy rules to fight opioid addiction draws fire from treatment advocates (Erin Mershon, STAT, 9-27-17)
A Mother's Perspective on Her Son's Addiction (Angela Haupt, US News, her half of a two-part series, 7-24-13). Anita Devlin’s son was a drug addict. She explains how she helped him get better. See also: One Man's Story: How I Beat Addiction Mike Devlin overcame his addiction to painkillers, cocaine, heroin and more. He shares his story. (Newsweek, his half of a two-part series, 7-24-13)
America Addicted (PBS Newshour series, October 2017) 91 Americans die every day from opioid overdose. The opioid crisis is devastating communities across the nation. Overdose deaths are at record highs. How can the epidemic be stopped?


The Problem: America’s communities weren’t built to handle the opioid crisis. Across the nation, public services, health care providers and civil servants are overwhelmed by the shared burden of addiction. At their worst, opioids damage communities as severely as they damage individuals.
---At an innovative high school, students get support battling their addictions while they learn (PBS, 10-3-17)
---Opioid addiction is the biggest drug epidemic in U.S. history. How’d we get here? (PBS, 9-29-17) Every day brings another story about the depth of the country’s opioid crisis. A rise of pain killer prescriptions from doctors and a pharmaceutical industry eager to boost sales in the 1990s sparked a wave of addiction that shot up by almost 500 percent in the last 15 years.
---A community overwhelmed by opioids (PBS, 10-2-17) In Huntington, West Virginia, first responders face burnout after repeated calls, the foster care system strains to support the children of addicts and even the rain sewers are clogged with discarded needles. How can the community cope?
---Saving the babies of the opioid epidemic (Laura Santhanam, PBS, 10-2-17) One in five babies born in West Virginia’s Cabell County-Huntington Hospital were exposed to controlled substances during pregnancy, and as many as 400 require medication for withdrawal. Sara Murray opened a special neonatal unit five years ago to help care for the babies being weaned off opioids.
---Poll: Most Americans think Trump hasn’t done enough to fix opioid crisis (Laura Santhanam, PBS, 10-3-17) The nation’s outlook for the opioid crisis is pessimistic. Four out of 10 Americans foresee no difference in the level of addiction to pain medication a year from now, while another third of U.S. adults only see things getting worse. “There’s quite a gap between people’s awareness of this being a problem and the sense that someone’s actually stepping up to the plate and addressing it.”
---Column: How to talk to your kids about opioids (Margie Skeer, Tufts University, PBS, 10-2-17)
THE DRUGS. "We're talking about a substance that is poison. It's manufactured death." Where do the drugs come from? How do they infiltrate communities? How do opiates alter the minds of users? Understanding the drugs is the first step in understanding the crisis.

Evidence on Strategies for Addressing the Opioid Epidemic, chapter 5 of Pain Management and the Opioid Epidemic: Balancing Societal and Individual Benefits and Risks of Prescription Opioid Use edited by Jonathan K. Phillips, Morgan A. Ford, and Richard J. Bonnie, National Academies of Sciences, Engineering, and Medicine, 2017). If you don't have time to read the whole invaluable chapter/book, skim and read the summaries of sections and the final summary of recommendations.




Jury’s In: Opioids Are Not Better Than Other Medicines for Chronic Pain (Alex Smith, KCUR, NPR, and Kaiser Health News. 3-6-18) Dr. Erin Krebs is lead author of a year-long study that involved 240 veterans with chronic back pain or osteoarthritis of the knee or hip whose pain was ongoing and intense. Half were treated with opioids and half with non-opioid medications — either common over-the-counter drugs like acetaminophen or naproxen, or prescription drugs like topical lidocaine or meloxicam. Doctors and patients knew what group they were in, which was deliberate because people’s expectations can influence how they feel. And "after as little as six months, the non-opioid group reported their pain was slightly less severe than the opioid group’s collective assessment. By the end of the year, Krebs said, “there was really no difference between the groups in terms of pain interference with activities. And over time, the non-opioid group had less pain intensity, and the opioid group had more side effects,” such as constipation, fatigue and nausea. “This study adds the long-term evidence that shows that opioids really don’t have any advantages in terms of pain relief that might outweigh the known harms that they cause,” she said. “The bottom line for people who have chronic back pain or arthritis pain is just that you shouldn’t start opioids.”
New tip sheet for journalists explores substance use disorders in older adults (Liz Seegert, Covering Health, Association of Health Care Journalists, 3-29-22) "Although many prescribed medications have the potential to be abused or misused, several drugs are chiefly involved in misuse: opioids, frequently provided for pain relief; central nervous system depressants, prescribed for anxiety and sleep disorders; and stimulants, prescribed to treat sleep disorder narcolepsy and attention-deficit hyperactivity disorder (ADHD). These three drugs can alter the brain’s activity leading to addiction."
Opioids Kaiser Family Foundation resources and fact sheets and key questions and answers about nearly every aspect of opioid use, abuse, survival, deaths, coverage by Medicaid, profiles, and statistics. "Nearly half of all adults with opioid addiction are under age 35."
We Didn’t Stand a Chance Against Opioids (Joshua Hunt, The New Republic, 9-18-19) Alaska’s health clinics were founded to help indigenous people like my family. Thanks to the FDA and Big Pharma, the clinics unwittingly enabled a crisis instead.


Seven Days of Heroin: What an Epidemic Looks Like The Enquirer sent more than 60 reporters, photographers and videographers into their communities to chronicle an ordinary week in this extraordinary time. Powerful. Listen: SEVEN DAYS OF HEROIN: 911 calls for overdoses at a library and at a park (Video, Cincinnati.com, 9-8-17) About the series writers: Notable Narrative: The Cincinnati Enquirer’s stunning “Seven Days of Heroin> (Katia Savchuk, Nieman Storyboard, 9-25-17) As far as Terry DeMio knows, she’s the only journalist in the country with the title “heroin reporter.” She’s been covering the opioid epidemic for The Cincinnati Enquirer for five years, including two on the beat full time. Over one week in July, the paper sent out more than 60 reporters, photographers and videographers to document the impact of heroin in Greater Cincinnati. “We just wanted to show people: This is what a heroin epidemic looks like.”
‘Pure incompetence’ (Peter Jamison, WaPo, 12-19-18) More people died of opioid overdoses than homicides last year in the District of Columbia. As fatal heroin overdoses exploded in black neighborhoods, D.C. officials ignored life-saving strategies and misspent millions of federal grant dollars. More than 800 deaths later, the city is still reckoning with the damage it failed to prevent.
How to Tell If Someone Is Shooting Up: Signs of IV Drug Abuse (Arrow Passage Recovery)

States Shifting Toward Offering Medication-Assisted Treatment For Inmates With Opioid Addiction (KHN Morning Briefing, 4-4-18) A study of a new program in Rhode Island that offers inmates addiction medications found that opioid overdose deaths dropped by nearly two-thirds among recently incarcerated people in the first year of the initiative, which could provide a road map to other states struggling with the same issue.
Modeling Health Benefits and Harms of Public Policy Responses to the US Opioid Epidemic (Allison L. Pitt, Keith Humphreys, Margaret L. Brandeau, American Journal of Public Health, 9-12-18) "Policies focused on services for addicted people improve population health without harming any groups. Policies that reduce the prescription opioid supply may increase heroin use and reduce quality of life in the short term, but in the long term could generate positive health benefits. A portfolio of interventions will be needed for eventual mitigation." "Wider availability of naloxone could prevent 21,000 deaths over the next decade — more than expanding access to medications for addiction or reducing painkiller prescriptions could," writes the Times.
Suicides, Drug Addiction and High School Football (Juliet Macur, NY Times, 3-8-18) "Madison, in southeastern Indiana, is at the center of a drug-trafficking triangle connecting Indianapolis, Cincinnati and Louisville. It is battling life-or-death problems....Madison is one of the places that have been hit especially hard by the opioid crisis, which has been declared a national emergency. There’s no single reason for it....The tourists who travel here see Madison’s antique shops and frequent its art, music, food and boat-racing festivals. But beneath all that are the crises that threaten to drag this town under: suicide, depression, child neglect, abuse and addiction to drugs." The suicide rate is a startling 3.2 times higher than the national average. "No one can explain why suicide has become a realistic option." In such a place, a football team becomes an oasis. "Madison is a swing-shift town where it’s not uncommon for parents to work two or more jobs. So if a child is looking for an available adult role model, a football coach — a Patric Morrison — can be a last, best hope."
Seven Days of Heroin: 911 calls for overdoses at a library and at a park (Video, Cincinnati.com, 9-8-17) 911 calls for overdoses Monday, July 10 at the Covedale Library and Rapid Run Park in Cincinnati.
Notable Narrative: The Cincinnati Enquirer’s stunning “Seven Days of Heroin” (Katia Savchuk, Nieman Storyboard, 9-25-17) As far as Terry DeMio knows, she’s the only journalist in the country with the title “heroin reporter.” She’s been covering the opioid epidemic for The Cincinnati Enquirer for five years, including two on the beat full time. Over one week in July, the paper sent out more than 60 reporters, photographers and videographers to document the impact of heroin in Greater Cincinnati. “We just wanted to show people: This is what a heroin epidemic looks like.”

Mother's obituary for Kelsey Grace Endicott, who died from a heroin overdose. "The disease of addiction is merciless. It is up to us to open our minds and hearts to those who are still sick and suffering." (See story by Buzzfeed (ignore the glaring graphics).
Chasing Heroin (video, Frontline documentary, 2-23-16) A searing, two-hour investigation of America's heroin crisis.
America's Heroin Epidemic (Kate Snow and Janet Klein, NBC, 4-7-14). An award-winning series. Click on links to many related stories in the series. Here, Infographic: America's Heroin Epidemic (Janet Klein and Ronnie Polidoro).
Be the Death of Me (Kate Silver, Chicago Health, 8-29-15. Award winner.) Heroin deaths are rising as state-funded treatment falls in Illinois. "Heroin is the second most addictive drug there is--behind nicotine." "On those streets, he says, the DEA is seeing a higher demand coming from younger, wealthier, suburban folks who have been abusing painkillers. They turn to heroin for a simple reason: price."
Prescription For Death: How Painkillers Destroyed the Town of War, West Virginia (Vince Beiser, Playboy, 3-1-14) Prescription pills—especially painkillers—now kill more Americans every year than heroin, cocaine and all other illegal drugs combined. The overdose death rate in the backwater Appalachian town in which this award-winning story takes place is 16 times the national average.
Russia finally admits to its hidden heroin epidemic (Shaun Walker, Independent, 3-10-09) Surge in abuse blamed on West's failings in Afghanistan, but addicts go untreated
Painkiller politics: Effort to curb prescribing under fire (Matthew Perrone, Associated Press, 12-20-15). Perrone examines struggling efforts by the Centers for Disease Control and Prevention to rein in opioid abuse by releasing new guidelines on their use. Facing pushback from the drug industry and the FDA, CDC moved its deadline. Read the story! Also, read While heroin use grabs headlines, don’t forget coverage of prescription pain meds (Susan Heavey, Covering Health, Association of Health Care Journalists, 1-11-16)
A Mother's Story of Dealing With Her Daughter's Opioid Addiction (Deborah Becker and Jamie Bologna, Radio Boston, 9-26-18) Maureen Cavanagh is perhaps best known in the Massachusetts recovery community for starting the nonprofit Magnolia New Beginnings, which helps families dealing with addiction. In her book If You Love Me: A Mother's Journey Through Her Daughter's Opioid Addiction, tells the story of her daughter Katie's addiction, something she says she initially denied was happening.


Face to Face With Fentanyl (Edwin Leap, MedPage Today, 6-23-23) Fentanyl. The potent synthetic opioid that brings death in its wake. It is ubiquitous, it seems; taken on its own or mixed with other drugs by illegal manufacturers.The price we pay for fentanyl infiltrating the drug supply is more than the cost of an ER visit or a dose of naloxone. It's devastating a nation and generations.We aren't funding addiction programs nearly enough. We aren't facing the fact that a vast amount of homelessness is either mental illness or drug addiction. Couching it in the easy, tired condemnation of financial inequality isn't solving the problem.
As Opioids Mixed With Animal Tranquilizers Arrive in Kensington, So Do Alarming Health Challenges (Courtenay Harris Bond, Postcard from a Philadelphia Neighborhood, KHN, 2-15-23) The veterinary tranquilizer xylazine, the choice du jour of local drug dealers to cut fentanyl, leads to necrotic ulcers and leaves street medics and physicians confused about how best to deal with this wave of the opioid crisis.
Prescription opioids destroyed families. Now, victims worry addiction stigma may keep them from getting justice. (Christopher Rowland, WaPo,12-2-19)
1 Son, 4 Overdoses, 6 Hours (Katharine Q. Seelye, NY Times, 1-21-18) Drug deaths draw the most notice, but more addicted people live than die. For them and their families, life can be a relentless cycle of worry, hope and chaos. Far more, like Patrick Griffin, are snared for years in a consuming, grinding, unending cycle of addiction. "In Patrick’s home state of New Hampshire, which leads the country in deaths per capita from fentanyl, almost 500 people died of overdoses in 2016. The government estimates that 10 percent of New Hampshire residents — about 130,000 people — are addicted to drugs or alcohol. The overall burden to the state, including health care and criminal justice costs and lost worker productivity, has ballooned into the billions of dollars. Some people do recover, usually after multiple relapses. But the opioid scourge, here and elsewhere, has overwhelmed police and fire departments, hospitals, prosecutors, public defenders, courts, jails and the foster care system. Most of all, though, it has upended families. All of the Griffins speak of nonstop stress." A Surgeon General’s report in 2016 said that the younger people are when they start taking drugs, the more likely they are to become addicted long-term. See also How a ‘Perfect Storm’ in New Hampshire Has Fueled an Opioid Crisis (Katharine Q. Seelye, NY Times, 1-21-18)
Facing some unpleasant truths about opioids (David Juurlink, Making Evidence Matter, also Globe & Mail) "Despite the best of intentions, we flooded North American homes with opioids purer and often stronger than heroin. These drugs increasingly fell into the wrong hands, destroying young lives and countless families in the process. But another unfortunate truth is that even when patients with chronic pain followed our instructions, we caused more harm than we anticipated. By some estimates, 10 percent spiraled into addiction, even though we’d been told this would happen only rarely."



How OxyContin Kicked Off the Heroin Epidemic (Tanya Basu, Daily Beast, 4-12-18) The FDA was trying to make OxyContin safer. Purdue Pharma’s attempt to stem a mushrooming opioid crisis by reformulating OxyContin is the reason why heroin replaced it and took off, causing the crisis to explode into a full-blown epidemic. Once OxyContin’s formula changed, it became too expensive to get high off the drug, making heroin the obvious choice as its replacement. The change happened in August/September 2010.
‘You want a description of hell?’ OxyContin’s 12-hour problem (Harriet Ryan, Lisa Girion and Scott Glover, Los Angeles Times investigative series, 5-5-16). The Times investigation into how America's bestselling prescriptive painkiller helped fuel a nationwide opioid epidemic won a Barlett & Steele bronze award. The Times reporters discovered that marketers at Purdue Pharma had knowingly misrepresented the drug as providing 12-hour relief from pain, an exaggeration that led to abuse and addiction. Here's Sally Kilbridge's story of How They Did It.
My Life Ruined By Oxycodone in 2 Weeks (Healthy Living) Her life is nearly destroyed by two weeks of oxycodone prescribed by a well-meaning physician for arthritis.

Prescription Drug Abuse Among Older Adults Is Harder to Detect ) Constance, Gustke, NY Times, 6-10-16) The death of Prince highlighted the extent of prescription drug abuse among older adults, particularly those with plenty of money to spend. More older adults are becoming addicted to powerful pain pills like OxyContin and Percocet to drown out the aches and pains of aging. By 10 days of usage, you can be addicted. The loss of self-worth that sometimes comes with retirement, especially after a lifetime of achievement and accolades, can be the spark. Moreover, addiction thrives on a lack of structure and accountability. A lot of baby boomers are now retired, anxious and have trouble sleeping. Add in arthritis, multiple prescription drugs and more drinks, and that can be the beginning of addiction. “It’s the perfect storm,” sai





See also Culprits in the Opioid Crisis (a section of its own)

The opioid epidemic: It’s time to place blame where it belongs (Ronald Hirsch, MD, Kevin MD, 4-6-16) "Healthy Living magazine recently published a heart-wrenching story of a woman whose life was nearly destroyed by two weeks of oxycodone prescribed by a well-meaning physician for arthritis. These physicians can best be described as innocent bystanders. But “pill mill” doctors who set up shop, accept cash as the only payment, and are willing to prescribe to anyone for any ailment, real or feigned, are criminals and need to be stopped. They cast a long shadow on the work of every other physician trying to help patients."

1) Physicians ...overprescribe opioids, just as they overprescribe antibiotics.

2) Despite a lack of increased efficacy in treating pain compared to older medications, Purdue Pharmaceuticals, Oxycontin's manufacturer, mounted an aggressive marketing campaign (using scare tactics) which doctors fell for.

3) The "American Pain Society, introduced the “pain as the 5th vital sign” campaign, followed soon thereafter by the VA adopting that campaign as part of their national pain management strategy."

4) The Joint Commission issued "standards requiring the use of a pain scale and stressing the safety of opioids. According to the Wall Street Journal, they even published a guide sponsored by Purdue Pharma....The Joint Commission framed pain as a patient’s rights issue, inferring that inadequate control of pain would lead to sanctions."

5) "Press Ganey deserves a place with their emphasis on patient satisfaction. They monetized their concept, selling not only surveys but also consulting services to help hospitals improve their scores."

6) "Because CMS was now attaching significant reimbursement to patient satisfaction, hospital administrators developed initiatives to improve their scores and avoid a penalty." Making patient satisfaction a comparative advantage has boosted the "business" of medicine but harmed patient safety.

He makes important points. Read Dr. Hirsch's article!

Addiction Medicine Mostly Prescribed To Whites, Even As Opioid Deaths Rose Among Blacks (Martha Bebinger, KHN, 5-8-19) White drug users addicted to heroin, fentanyl and other opioids have had near-exclusive access to buprenorphine (Suboxone), a drug that curbs the craving for opioids and reduces the chance of a fatal overdose. “White populations are almost 35 times as likely to have a buprenorphine-related visit than black Americans,” said Dr. Pooja Lagisetty, an assistant professor of medicine at the University of Michigan Medical School and lead author on a study of 13.4 million medical encounters involving the drug. Meanwhile, opioid overdose deaths were rising faster for blacks than for whites.
Medicare Survey Could Be Contributing To Opioid Epidemic (Jacquelyn Corley, HuffPost, 6-23-16) 'The tragic growth in opioid-related deaths is not an aberration; it’s part of a 15-year-long trend the Centers for Disease Control and Prevention says is now a “national epidemic.” Researchers have identified numerous contributing factors related to the opioid crisis, including the changing dynamics of the doctor-patient relationship, the creation of more potent and long-acting drugs, and trends started by influential medical experts and academic societies in the late 1990s suggesting total pain control should be treated as an attainable medical ideal—the so-called “fifth vital sign.” "Doctors are faced with the challenge of curing patients and treating their pain, but they must also avoid unsafe prescribing practices that could lead to drug tolerance, addiction, or both. The HCAHPS survey inadvertently adds to this dilemma by making patients’ pain management effectively more important than their long-term health."
Nearly 1 in 3 on Medicare Got Commonly Abused Opioids (Carla K. Johnson, ABC News, 6-22-16) The leading opioids taken by Medicare patients were OxyContin, Percocet, Vicodin, fentanyl or their generic equivalents. Overdose risk for older Americans is heightened by medication interactions and alcohol.

Behind the luxury: Turmoil and shoddy care inside five-star addiction treatment centers (David Armstrong, STAT, and Evan Allen, Boston Globe, 8-25-17) "The marketing blitz and an infusion of private equity money have helped make Recovery Centers of America into the self-described fastest-growing addiction treatment provider in the country. Launched less than three years ago by a high-end real estate developer, it’s part of a rush of entrepreneurs who see opportunity in the treatment business as the opioid crisis sweeps the country." Armstrong and Allen report on "shoddy care and turmoil inside the walls of the company’s two Massachusetts treatment centers."
Physicians are being murdered for not prescribing opioids (Jessica Jameson, KevinMD, 8-15-17) "Until we as a society learn how to be present with negative emotions and to effectively deal with and process the things life brings our way we cannot and will not solve this crisis. Sure, we may prescribe fewer opioids, but people will turn to other substances, good physicians will continue to be murdered, and I and my colleagues will continue to look over our shoulders."
Trump Declares Opioid Crisis a ‘Health Emergency’ but Requests No Funds (Julie Hirschfeld Davis, NY Times, 10-26-17) "President Trump on Thursday directed the Department of Health and Human Services to declare the opioid crisis a public health emergency, taking long-anticipated action to address a rapidly escalating epidemic of drug use. But even as he vowed to alleviate the scourge of drug addiction and abuse that has swept the country — a priority that resonated strongly with the working-class voters who supported his presidential campaign — Mr. Trump fell short of fulfilling his promise in August to declare “a national emergency” on opioids, which would have prompted the rapid allocation of federal funding to address the issue." The video that comes up on this story provides an excellent brief account of what opioids are and what caused the current opioid crisis.
****Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. (L. Sordo et all, BMJ, PubMed, 4-26-17). "Retention in methadone and buprenorphine treatment is associated with substantial reductions in the risk for all cause and overdose mortality in people dependent on opioids. The induction phase onto methadone treatment and the time immediately after leaving treatment with both drugs are periods of particularly increased mortality risk, which should be dealt with by both public health and clinical strategies to mitigate such risk. These findings are potentially important, but further research must be conducted to properly account for potential confounding and selection bias in comparisons of mortality risk between opioid substitution treatments, as well as throughout periods in and out of each treatment."
Taylor Wilson’s parents fought for 41 days to get their daughter treatment. They couldn’t stop another overdose (Max Blau, STAT, 3-16-17)
Dope Sick: A harrowing story of best friends, addiction — and a stealth killer (David Armstrong, STAT, 8-2-16) A long-form story.
Down The Rabbit Hole: A Chronic Pain Sufferer Navigates the Maze of Opioid Use (Janice Lynch Schuster, My Narrative Matters, Health Affairs, July 2014). Read full story. See also http://www.pbs.org/newshour/updates/one-woman-manages-chronic-pain-invisible-affliction/ (Ruth Tam's interview with Schuster on PBS Newshour, 7-9-14).
The Truth About Suboxone (Maia Szalavitz, The Fix, 12-01-11) Studies show that maintenance therapy is the most effective treatment for opiate addiction. So why are abstinence fundamentalists so bitterly against it?... an outdated and stigmatizing attitude towards maintenance treatment can—and frequently does—kill hundreds of struggling addicts who depend on these meds to stay off the streets....Even the Betty Ford Center agrees that people taking daily methadone or buprenorphine should be considered every bit as "in recovery" as those who just “don’t drink and go to meetings.” A 2007 consensus panel to define recovery convened by that august facility put it plainly: "To be explicit, formerly opioid-dependent individuals who take naltrexone, buprenorphine or methadone as prescribed and are abstinent from alcohol and all other non-prescribed drugs would meet this consensus definition of sobriety." Some in abstinence-based recovery feel compelled to proselytize about the dangers of the substances they once could not live without. This “drug-free” rhetoric helps them avoid temptation. It also gives the added buzz of self-righteousness that comes from feeling superior to others. [But] It’s not necessary for maintenance to be bad to make abstinence good.

Five signs a loved one is abusing painkillers (Dr. Carlos Tirado and CBS News, 2-20-13) 1. Drowsiness, lack of energy; 2. Inability to concentrate, lack of motivation; 3. Social behavioral changes; 4. Changes in appearance; 5. Increased secrecy.
Confessions of a 75-Year-Old Drug Addict (Arlene Silverman, Pulse, 1-22-10) "There's sort of a war going on in the field of pain management, he continues. One camp worries about opiate addiction; the other is more concerned about the effects of long-term pain. It seems that, given my pain's severity, my doctors opted for opiates." This personal story conveys what an elder's addiction and attempts to withdraw feel like. Physicians: Please read.
Medical historian looks back on role of opiates, personal physician in Elvis’ death (Howard Markel, Michigan Radio, 8-20-18) The toxicology screen came back filled with various opiate drugs as well as quaaludes and antihistamines and laxatives. "So he was taking a lot of drugs and they also found evidence of a big floppy heart, so probably diabetes, type II diabetes” -- and major constipation, common with opiate use.
New Approaches Help Babies Get Through Opioid Withdrawal (Liz Highleyman, MedPageToday, 5-12-17) Newer meds, more time with mom yielded better outcomes.
How Prince Concealed His Addiction: Aspirin Bottles of Opiates (Joe Coscarelli and Serge F. Kovaleski, NY Times, 4-17-17)

•Making pain a vital sign caused the opioid crisis. Here’s how. (orthopedic surgeon Thomas D. Guastavino, Kevin MD, 10-6-16) "I place the blame where it started. Those, no matter how well intended, who convinced themselves and had the power to pressure others that pain was a disease onto itself, not what it really is: a symptom. If health care has any hope of getting a handle on this crisis, then we have to go back to a time when physicians first determined why their patients have pain instead of just shooting the messenger. While we’re at it get rid of pain scales, fifth vital signs, and anonymous patient satisfaction scores. If we have not learned by now that these have caused more problems than they have solved, I don’t know what will."

Opioids Contribute to a Rising Death Toll: 28,647 in 2014 (Nicholas Bakalar, Science, NY Times, 12-24-16) In 2014, according to the Centers for Disease Control and Prevention, there were 47,055 deaths from accidental drug overdoses. Opioids were implicated in 28,647 of them, 60.9 percent of the total. "Morphine and codeine are natural opioids found in the opium poppy. Semi-synthetic opioids like oxycodone, hydrocodone and hydromorphone are derived from them. Many opioids are familiar under brand names — oxycodone is sold as Percocet and Percodan, for example, and hydrocodone as Vicodin." The report suggested several steps, including continuing the careful control of opioid prescriptions and intensifying efforts to distribute naloxone, a drug that reverses an opioid overdose.
Counterfeit Opioid Poisonings Spread To Bay Area (Barbara Feder Ostrov, Kaiser Health News, 4-28-16) In March and April 2016 patients were treated for overdoses after taking what they thought were tablets of Norco, a brand-name painkiller that combines acetaminophen and hydrocodone. But the counterfeit Norco, which the patients bought off the street, mostly contained the opiate fentanyl, which is 100 times more powerful than morphine, according to the CDC. They also contained promethazine, an allergy drug that’s believed to intensify the effects of fentanyl. The only safe prescription to take is one prescribed to you by your doctor and received from a legitimate pharmacy – not from a coworker, a friend or off the street. 
Drug Overdoses Propel Rise in Mortality Rates of Young Whites (Gina Kolata and Sarah Cohen, NY Times, 1-16-16)
Organ Donation and the Opioid Epidemic: ‘An Unexpected Life-Saving Legacy’ (Martha Bebinger, WBUR, Kaiser Health News, 10-19-16) So far this year, more than one in four, or 27 percent, of organ donations in New England are from people who died after a drug overdose. Nationally, that rate is 12 percent for the same time period. Alexandra Glazier, president and CEO of the New England Organ Bank said the 12 transplant centers in that region may be more aggressive about finding a match for patients with failing hearts, livers or kidneys. And she said New Englanders tend to be pragmatic about end-of-life decisions.d Brenda J. Iliff, executive director of Hazelden Betty Ford Foundation in Naples, Fla.
How the Epidemic of Drug Overdose Deaths Ripples Across America (Haeyoun Park and Matthew Bloch, NY Times, 1-19-16)

Strict opioids laws hit chronic pain sufferers hard (Felice J. Freyer, Boston Globe, 6-18-16) This is the other side of America’s war on opioids. As federal and state regulators rush to curtail access to drugs that have claimed thousands of lives, the rules they’ve enacted fall hard on people who legitimately need relief from pain.
The Lonely Road of Staying Clean (Anne Hull, WaPo, 6-11-16) Jasper, Ala. In a town where pills are currency, opioid addicts have few options. "During a high school volleyball game in the 10th grade, she injured her spinal cord and was prescribed OxyContin. By 17, Jessica was crushing and snorting the pills. With a copy of her MRI, Jessica said she could leave a doctor’s office with prescriptions for 120 Roxicodone pills in 30-milligram strength, 90 additional Roxicodones in 15 mg strength, and 120 blue bars of Xanax — a total of 330 pills with fresh refills in a month."
Nearly six in 10 Americans have leftover narcotics at home (Lenny Bernstein, WaPo, 6-13-16)
CDC warns doctors about the dangers of prescribing opioid painkillers (Karoun Demirjian and Lenny Bernstein, WaPo, 3-15-16) “Starting a patient on opiates is a momentous decision, and it should only be done if the patient and the doctor have a full understanding of the substantial risks involved.” The CDC is encouraging patients to question doctors who prescribe opioids for chronic pain.
For Teenagers, Adult-Sized Opioid Addiction Treatment Doesn't Fit (Heidi Benson, Shots, NPR, 1-15-16) "While a wide range of evidence-based screening, intervention, treatment and disease management tools and practices exist, they are rarely employed," reported the National Center on Addiction and Substance Abuse. And lack of effective treatment in the teen years can blight an entire life. This piece reports on evidence-based treatments--treatments that work. These include Screening, Brief Intervention and Referral to Treatment (SBIRT), a preventative protocol for early detection; Motivational Interviewing (MINT), a counseling approach that guides individuals to set goals; and Functional Family Therapy (FFT), which treats teens in a family setting.
The Opioid Crisis: Facts that news coverage is missing (Alan Cassels, Health News Review, 1-27-16)
Most Americans See Personal Tie toRising Prescription Painkiller Abuse (Lisa Gillespie, Kaiser Health News, 11-24-15) More than 56 percent of the public say they have a personal connection to the issue, reports the latest monthly tracking poll of the Kaiser Family Foundation. That share includes those who say they know someone who died from a painkiller overdose, have been addicted themselves or know someone who has and those who know someone who took painkillers not prescribed to them, the poll’s results show.
How I Learned to Stop Worrying and Love Methadone (Maia Szalavitz, The Fix, 8-19-12) 'Just like ex-junkie Russell Brand, I used to believe that “maintenance” was as bad—if not worse—than active addiction. Here’s how I came to understand how fatally wrong I was.' Maia is the author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, to be released in 2016
Experts Highlight a Growing Problem of Substance Abuse Among Older Vermonters (Peter Hirschfeld, Vermont Public Radio, 11-5-15)
Covering the growing, underreported problem of elder substance abuse (Liz Seegert, Association of Health Care Journalists, 11-9-15)
Increases in Drug and Opioid Overdose Deaths — United States, 2000–2014 (CDC, Morbidity and Mortality Weekly Report (MMWR), 1-1-16)
Using Patient Review and Restriction Programs to Protect Patients at Risk of Opioid Misuse and Abuse (a fact sheet from PEW Charitable Trusts, July 2015). As one strategy for minimizing deaths from opioids overdoses associated with prescription drug abuse, public and private insurance plans are using patient review and restriction (PRR) programs to encourage the safe use of opioids and other controlled substances. PRR programs identify patients who are at risk for prescription drug abuse and ensure that they receive controlled substance prescriptions only from designated pharmacies and prescribers. These programs have the potential to save lives and reduce health care costs by helping state Medicaid programs and private health plans better coordinate patient care and prevent inappropriate access to medications susceptible to abuse. Medicare beneficiaries could also benefit from PRR programs, but current federal law prohibits their use in this group of enrollees.
Two Acres of Hope for Recovering Addicts (Cara Buckley, NY Times, 8-14-09)
For teens with opioid use disorders, buprenorphine maintenance better than detox (Alison Knopf, Alcoholism Drug Abuse Weekly, 11-24-14)

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Fentanyl's death toll

Fentanyl is a powerful synthetic opioid that is similar to morphine but 50 to 100 times more potent, is highly addictive, and can cause respiratory distress and death in high doses or combined with other substances. As with any opiate, the main symptoms of fentanyl use are euphoria, drowsiness, lethargy, and mellowness, but death can also be instant, with strong doses. In a sense, it is poison.

Counterfeit fentanyl pills are becoming a lot more common in law enforcement seizures (Emma Bowman, NPR, 5-13-24) Last year, more than 115 million pills containing illicit fentanyl were seized by law enforcement, compared to over 71 million in 2022. The number of pills seized last year was 2,300 times greater than the roughly 50,000 seized in 2017. The counterfeit pills are made to look like legit prescription opioid medications — like oxycodone or benzodiazepines — but are often far deadlier. The counterfeit pills are cheap to make and buy, and social media and the dark web have made them easier to buy online. Fentanyl also delivers a very powerful but very brief high, so people consume more of it than they would other opioids.
Fueled by fentanyl, drug overdose deaths have quadrupled in past 2 decades (Sara Chernikoff, USA Today, 3-27-24) Overdoses from illicit street drugs are the cause of tens of thousands of deaths each year. Here's how the drug overdose death rate has changed since the 2000s.
How a Friend’s Death Turned Colorado Teens Into Anti-Overdose Activists (Rae Ellen Bichell, KFF Health News, 3-1-24) High school students in Colorado are pushing for a change they say is necessary to combat fentanyl poisoning: ensuring students can't get in trouble for carrying the overdose reversal drug naloxone wherever they go, including at school.
Cartel: Fentanyl’s deadly surge (Washington Post series, starting 12-15-22) 107,622 died of drug overdoses in the U.S. in 2021.The number of Americans killed by the drug has jumped 94 percent since 2019. On average, one person dies of a fentanyl overdose in the United States every seven minutes. Fentanyl kills more people than automobile accidents, or gunshots, or suicides. 
---Overview: From Mexican labs to U.S. streets, a lethal pipeline (Washington Post, 12-15-22)
---Fentanyl in High School: A Texas Community Grapples With the Reach of the Deadly Opioid (Colleen DeGuzman, KHN, 11-10-22)
---Shifting Operations: The flow of fentanyl: In the mail, over the border
---They call him the Eagle: How the U.S. lost a key ally in Mexico as fentanyl took off
---A DEA agent tracked the source of fentanyl in Mormon country — a Mexican cartel
---Inside the daunting hunt for the ingredients of fentanyl and meth
---To live and die in Tijuana
---Five down in Apt. 307: Mass fentanyl deaths test a Colorado prosecutor
---Why is fentanyl so dangerous? The powerful opioid is the leading cause of overdose deaths in America.
---Follow The Post’s investigation of the opioid epidemic.

Reporters on the series: Courtney Kan, Nick Miroff, Scott Higham, Steven Rich, Tyler Remmel, Julie Vitkovskaya,Sari Horwitz, Meryl Kornfield, Kevin Sieff, Salwan Georges, Erin Patrick O'Connor, Rekha Tenjarla, Mary Beth Sheridan, Eva Herscowitz, Alejandra Ibarra Chaoul.

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Up close and too personal with America’s fentanyl epidemic — where New York is ground zero (NY Post, 4-4-24) The drug that in 2022 alone killed nearly 110,000 Americans is readily available right here on the streets of this city.
Douglas Murray Investigates: America's Drug Crisis (YouTube video) Speech: As the U.S. has turned away from “the war on drugs,” many cities have sought more “humane” approaches to dealing with addiction. They’re not working.
To Stop Fentanyl Deaths in Philadelphia, Knocking on Doors and Handing Out Overdose Kits ( Nicole Leonard, WHYY, KFF Health News, 4-17-24) Facing widening racial disparities in overdose deaths, Philadelphia officials are sending workers and volunteers to knock on doors across the city, aiming to equip households with naloxone and other drug overdose prevention supplies. City officials hope a proactive approach will normalize naloxone as an everyday item in people’s medicine cabinets and prevent overdoses, especially among Black residents.
The Blackfeet Nation’s Plight Underscores the Fentanyl Crisis on Reservations (Aaron Bolton, Montana Public Radio, NPR and KHN, 5-25-22)
Deadly fentanyl bought online from China being shipped through the mail (Scott Pelley, 60 Minutes, 9-15-19) Fentanyl is 50 times more potent than heroin, is now available on the internet, and can be delivered through the mail--shipped in containers from China, from which separate mailing packets are put in the U.S. mail.
Falling out (Peter Jamison, WaPo, 12-18-18) generation of African American heroin users is dying in the opioid epidemic nobody talks about. The nation’s capital is ground zero. America’s opioid epidemic has changed. And what changed it was fentanyl. Inexpensive and easy to produce, compared with the opium poppy, fentanyl arrived at the right moment for drug distributors seeking to stretch their inventory for the U.S. market. But it came with a drawback: Its extreme potency makes even slight miscalculations deadly when it is added to heroin. Fentanyl has decimated opioid users of every demographic. But its effects are especially pronounced among older African Americans caught off guard by the sudden lethality of heroin they had learned to use with relative safety. Those veteran, urban users — who typically dread and seek to avoid fentanyl — are still left out of policy discussions about the opioid epidemic....For African Americans, said Kathie Kane-Willis of the Chicago Urban League, government intervention in the opioid epidemic remains synonymous with harsh law enforcement policies pioneered in the 1970s and 1980s. By contrast, white users today are often viewed as victims — of drug companies, of unscrupulous doctors, of addiction as a physically based disease — and targeted with public-health campaigns to prevent overdoses and help them enter treatment."
America's Killer New Drug: A 2019 Guide to Fentanyl (Laguna Shores Behavioral Health)
The $1 Tool That Might Curb the Overdose Epidemic (Olga Khazan, The Atlantic, 10-3-18) Fentanyl, which is 50 times as potent as heroin, laces many batches of heroin and cocaine, and it is now involved in at least half of all opioid overdose deaths. More than 70,000 people died of drug overdoses last year—the equivalent of about three 747 plane crashes each week. However, there’s evidence that a two-inch fentanyl test strip can help drug users avoid overdosing. A new study shows that fentanyl test strips nudge drug users to take extra precautions.


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Another Circle of Hell: Surviving Opioids in the Fentanyl Era (Martha Bebinger, WBUR, KHN, 4-7-17) More powerful and more deadly than heroin, the synthetic opioid fentanyl has sparked a new set of survival rules among people who abuse opioids. "Fentanyl is an opioid 50 times more powerful than heroin. There’s a legal, Food and Drug Administration-approved version. But labs in China are churning out cheap versions of fentanyl that dealers are selling on the streets mixed with fillers, heroin or other drugs. Buyers have no idea how much fentanyl they are getting or how much risk they are taking with every injection." Fentanyl may be especially lethal because it’s strong, it’s mixed with other drugs in varying amounts unknown to the user, and it can trigger an overdose within seconds. Unlike heroin, fentanyl routinely shuts down breathing in seconds, and it’s becoming more common.
Fentanyl overdose deaths in the U.S. have been doubling every year (Melissa Healy, Science Now, Los Angeles Times, 3-10-19) If you want to know what it means for something to grow exponentially, consider the death toll of fentanyl. This powerful synthetic opioid seemingly came out of nowhere and is now killing tens of thousands of Americans each year. A new report from the Centers for Disease Control and Prevention details the meteoric rise of a drug that was first approved by the Food and Drug Administration back in 1968. It shows that fentanyl’s role as a driver of the opioid epidemic can be traced to late 2013.

Fentanyl drug overdose deaths rising most sharply among African Americans (Joel Achenbach, WaPo, 3-21-19) The synthetic opioid fentanyl has been driving up the rate of fatal drug overdoses across racial and social lines in the United States, with the sharpest increase among African Americans, according to a new analysis by the Centers for Disease Control and Prevention. The death rate among African Americans from fentanyl-involved drug overdoses rose 141 percent each year, on average, from 2011 to 2016, the study showed, with a particularly dramatic spike starting in 2014. The death rate for Hispanics rose 118 percent in that period every year on average, and 61 percent for non-Hispanic whites. The CDC did not have reliable data on Asian Americans and Native Americans. The report released early Thursday represents the first time the CDC has managed to isolate the role of fentanyl in the drug epidemic that is killing about 70,000 Americans a year.
Fentanyl-Linked Deaths: The U.S. Opioid Epidemic's Third Wave Begins (Martha Bebinger, Morning Edition, NPR, 3-21-19) Increased trafficking of the drug and increased use are both fueling the spike in fentanyl deaths. For drug dealers, fentanyl is easier to produce than some other opioids. Unlike the poppies needed for heroin, which can be spoiled by weather or a bad harvest, fentanyl's ingredients are easily supplied; it's a synthetic combination of chemicals, often produced in China and packaged in Mexico, according to the U.S. Drug Enforcement Administration. And because fentanyl can be 50 times more powerful than heroin, smaller amounts translate to bigger profits.
Did a Medical Education Course for Doctors Favor Fentanyl Products? (Ed Silverman, STAT, 3-20-19) As the opioid crisis dawned in the U.S., continuing educational material that doctors are required to review may have contributed to the burgeoning problem, according to a newly published study. How so? The study compared a continuing medical education module, or course, that was funded by a drug maker that sold a fentanyl lollipop and lozenge with practice guidelines issued by a medical society. The scope of the two publications was not completely identical, but both focused on the use of opioids in treating non-cancer pain. And the study found the industry-funded course contained a “subtle bias.”
Prosecutors Portray Drug Company Founder As Greedy In Day 1 Of Opioid Kickback Trial (Jerome Campbell, CommonHealth, WBUR, 1-28-19) A federal prosecutor said a pharmaceutical company founder “put profits over people” by bribing doctors around the country to prescribe a highly addictive fentanyl spray. In the first day of a closely-watched trial, Assistant U.S. Attorney David Lazarus told jurors Monday in Boston’s federal court that John Kapoor, founder of Arizona-based Insys Therapeutics Inc., created a “criminal conspiracy” that paid eight doctors and other prescribers more than $1.1 million to prescribe its drug, Subsys. Kapoor and four other defendants face charges of conspiracy to commit racketeering for operating the company as a “criminal enterprise from top to bottom,” said Lazarus. Prosecutors said the kickbacks took several forms including lavish dinners provided through a speaker program, paying for doctors’ staff from the company's own budget and providing bonuses. In addition, Lazarus said Insys ran an in-house call center where employees frequently pretended to call from doctors' offices and defrauded insurance companies to cover claims for Subsys.
Delivered ‘Like A Pizza’: Why Killer Drug Fentanyl Is So Hard To Stop (Martha Bebinger, WBUR/KHN, 12-2-16) Just a few grains of pure fentanyl is enough to kill most users. But law enforcement sources say stopping the supply of the deadly synthetic opioid from China and Mexico is very difficult.

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Prosecuting drug crimes

Many of these articles may require a subscription or a fee. Thanks to Norman Bauman for the links.
The Opioid Crisis (Thomas Palermo, Criminal Justice, Winter 2019) A survey of today's opioid crisis from the viewpoint of a federal prosecutor.
The Opioid Epidemic (Mark Rosenblum, Criminal Justice, American Bar Association, Winter 2019) The opioid epidemic, and the congruent emphasis being placed on prosecuting opioid-related crimes by the Department of Justice, is having an effect on a wide-range of people who find themselves on the 'business end' of a serious federal indictment. Some of those charged are familiar with, and to, the criminal justice system, but others who never dreamed that they would be charged with a criminal offense are facing years in federal prison.
Ethical Responsibilities of Physicians in the Opioid Crisis (Mark Rosenblum, The Journal of Law, Medicine,& Ethics, 1-10-18) The effect of the opioid crisis on the physician-pateint relationship, including the physician's role in the pain management and treatment of opioid use disorder (OUD)
Preying on Prescribers (and Their Patients)--Pharmaceutical Marketing, Iatrogenic Epidemics, and the Sackler Legacy (Scott H. Podolsky, David Herzberg, and Jeremy A. Greene, New England Journal of Medicine, 4-10-19) Though the Sackler family did not invent the practice of selling drugs to physicians, they were pioneers whose story illustrates the ways marketers developed, naturalized, and monetized the interface between the pharmaceutical industry and prescribing physicians.
Opioid Use Disorder and Incarceration — Hope for Ensuring the Continuity of Treatment (Ingrid A. Binswanger,, New England Journal of Medicine, 3-18-19) A complex web of legal, policy, and structural barriers has led to persistent gaps in access to treatment for opioid use disorder in jail facilities in the United States and prevented the delivery of coordinated care.
More stories on this topic from the New England Journal of Medicine.
Structural Iatrogenesis — A 43-Year-Old Man with "Opioid Misuse" (Scott Stonington and Diana Coffa, New England Journal of Medicine, 2-21-19)When he gets tangled in new restrictive policies on opioid prescribing, a factory worker with severe rheumatoid arthritis, whose pain must be managed for him to perform his job, ends up buying oxycodone from a friend
Cost of Processing a Drug Offender Through the Criminal Justice System (D E Olson and L S Stout, National Criinal Justice Reference Service, 1991)
Prosecuting Drug Overdose Cases: A Paradigm Shift (Mark Neil,National Association of Attorneys General, Feb. 2018) Arizona and Oklahoma, among others, list drug offenses as crimes which, when a death occurs during the commission of that offense, is treated as murder....Prosecuting overdose deaths as homicides will not be the silver bullet to the public health crisis this nation faces. However, it is one tool in the law enforcement arsenal which, if used appropriately, can assist locally in focusing on the drug dealers who take advantage of those who have become addicted to opioids. But to make the shift to treating overdose deaths as homicides, it is imperative that investigators and prosecutors find not only the correct legal scheme under which to proceed, but also be mindful of the causation element embedded in a statute or required by a jurisdiction’s case law.

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Methamphetamine addiction on the rise

Even as opioids ravage WNC, mountain folks say meth never went away (Liora Engel-Smith, North Carolina Health News,12-3-19) “A lot of people think it is definitely heroin that is a problem, but meth, you can’t OD on it,” Brayson said. “It’s cheaper and lasts longer and gives you energy to where you can still maintain. You can still go to work.”
Crank a novel (indeed a trilogy) by Ellen Hopkins, chronicles 16-year-old Kristina Snow’s descent into methamphetamine addiction and its consequences. Loosely based on the experiences of the author’s daughter, who became addicted to methamphetamine as a teenager, the novel is both a cautionary tale and a source of support and comfort for families affected by addiction. Crank was a number one NY Times Best Seller and has won 14 national and regional awards.
Meth’s Resurgence Spotlights Lack of Meds to Combat the Addiction (Carmen Heredia Rodriguez, KHN, 1-14-19) "Their behavior, marked by twitchy suspicion, a poor memory and the feeling that someone was following them, signaled that the people coming through the center’s doors were increasingly hooked on a different drug: methamphetamine...even as the opioid epidemic continues, the toll of methamphetamine use, also known as meth or crystal meth, is on the rise, too....But unlike the opioid epidemic — for which medications exist to help combat addiction — medical providers have few such tools to help methamphetamine users survive and recover. A drug such as naloxone, which can reverse an opioid overdose, does not exist for meth. And there are no drugs approved by the Food and Drug Administration that can treat a meth addiction....Meth revs up the human body, causing euphoria, elevated blood pressure and energy that enables users to go for days without sleeping or eating. In some cases, long-term use alters the user’s brain and causes psychotic symptoms that can take up to one year after the person has stopped using it to dissipate.Overdosing can trigger heart attacks, strokes and seizures, which can make pinpointing the drug’s involvement difficult. Meth users also tend to abuse other substances, which complicates first responders’ efforts to treat a patient in the event of an overdose...DEA reported that the price of meth is the lowest the agency has seen in years. It is increasingly available in the eastern region of the United States. Primary suppliers are Mexican drug cartels. And the meth on the streets is now more than 90 percent pure. “So, the meth we’re looking at today is much more potent than it was 10 years ago.”
Overshadowed By Opioids, Meth Is Back and Hospitalizations Surge (Anna Gorman, KHN, 11-26-18) Amphetamine-related hospitalizations jumped by about 245 percent from 2008 to 2015, dwarfing the rise in hospitalizations from other drugs, such as opioids, which were up by about 46 percent. The most significant increases were in Western states. Doctors see evidence of the drug’s comeback in emergency departments, where patients arrive agitated, paranoid and aggressive. Paramedics and police officers see it on the streets, where suspects’ heart rates are so high that they need to be taken to the hospital for medical clearance before being booked into jail. And medical examiners see it in the morgue, where in a few states, such as Texas and Colorado, overdoses from meth have surpassed those from the opioid heroin. Amphetamines are stimulant drugs, which are both legally prescribed to treat attention deficit hyperactivity disorder and produced illegally into methamphetamine. Most of the hospitalizations in the study are believed to be due to methamphetamine use. Commonly known as crystal meth, methamphetamine was popular in the 1990s before laws made it more difficult to access the pseudoephedrine, a common cold medicine, needed to produce it. In recent years, law enforcement officials said, there are fewer domestic meth labs and more meth is smuggled in from south of the border.
More drug treatment resources needed, Texas House report finds (Mary Huber, Austin-American Statesman, 12-10-18) While opioids remain at the forefront of drug discussions nationwide, the 108-page report from the House Select Committee on Opioids and Substance Use also found that methamphetamine was the state’s biggest problem, saying it should be labeled a “Texas crisis.” More people died from methamphetamine use in Texas in 2016 than from opioids, according to data from a recent University of Texas report.
What is methamphetamine? (Drug Facts, National Institute on Drug Abuse, NIDA)
Wikipedia on Methamphetamine (useful links)
Across Rural America, Drug Casts a Grim Shadow (Fox Butterfield, NY Times, 1-4-04) Lovell, population 2,264, and two nearby towns have become infested by methamphetamine. "What is happening in Lovell is happening across much of Wyoming, the least populated state in the country, where methamphetamine use is now more than twice the national average, according to the federal Substance Abuse and Mental Health Services Administration. Methamphetamine use and crime are also overrunning rural counties in Iowa, Nebraska, Kansas, Colorado, North Dakota and the Texas Panhandle, law enforcement officials say." "To the experts, methamphetamine is both a symptom of rural decline, as people give up on faltering farms and factories, and a cause that makes the decline worse."
History of Methamphetamine (Foundation for a Drug-Free World)
As Medicaid Expands, Court-Ordered Drug Rehab Loses Steam (Brian Rinker, KHN and Governing, 10-3-18) Because of a new county policy in Santa Cruz, California, that took effect at the beginning of the year, treatment for low-income residents like Haynes, with drug-related criminal charges, must be decided by clinicians and providers — not the court. Judges can order whatever they want in terms of treatment, and prosecutors can block designated treatment they deem too risky, but essentially the type and length of treatment deemed appropriate is out of their hands. When conflicts arise between what the court orders and the providers decide, felons can languish in jail with no treatment at all. Court-ordered rehab is increasingly falling out of fashion in California as Santa Cruz and 18 other counties begin to treat addiction like any other health condition — with the Medicaid program relying on evidence-based practices and trained personnel to make decisions on care. That has upended the status quo for judges, attorneys and defendants who often had agreed to residential treatment in lieu of jail — or at least to reduced sentences so inmates could get that treatment. The California program appears to be unique in many respects, but other states — including Utah, Indiana, Kentucky, West Virginia, Virginia, Maryland, New Jersey and Massachusetts — also have sought federal permission to experiment with innovations in Medicaid-funded drug treatment....Advocates of the new approach — a Medicaid-funded pilot program that eventually is expected to be implemented in 40 California counties — say residential treatment is the most expensive and invasive option, and in many cases, outpatient treatment works as well, if not better. If clinicians don’t approve residential treatment and prosecutors or judges won’t allow a release to outpatient treatment, the case can stall and felons become doomed to spend more time in jail....Because of the policy change, some prosecutors say they are less likely to accept anything but jail time....Los Angeles County implemented the new Medi-Cal program just over a year ago and indicates it is running relatively smoothly. “L.A. County got in front of it early on,” said Albert Senella, president and CEO of Tarzana Treatment Centers. “Treatment is now driven by medical necessity.” But educating the courts on the new procedures can be a time-consuming process, and experts say it may take months or longer in some counties before the new rules sink in.
Meth Trip Or Mental Illness? Police Who Need To Know Often Can’t Tell (Martha Bebinger, WBUR, KHN, 11-1-19)Unnecessary Epidemic: A Five-Part Series (Oregonian archive, 2004) This series of articles, written largely by Steve Suo, exposed how Congress and the Drug Enforcement Administration could have stopped the growth of meth abuse by aggressively regulating the import of the chemicals necessary to make it. It illuminated and encouraged Oregon’s legal strategy toward addiction which uses an institutional punishment approach versus a medical approach which might offer an individual’s recovery as a primary goal.
The Neurobiology of Cocaine Addiction (Eric J. Nestler, NCBI, Sci Pract Perspect. Dec 2005; 3(1): 4–10).
Treatment for amphetamine psychosis. (Shoptaw SJ, Kao U, Ling W., Cochrane Database of Systematic Review, on PubMed, 1-21-09)
Crack: The Drug That Consumed the Nation's Capital (listen online to WAMU-FM, NPR). 25 years ago, dealers sold crack at hundreds of open-air drug markets, addiction swept across entire neighborhoods, and D.C. came to be known as the "Nation's Murder Capital." In this five-part series, WAMU 88.5 explores the legacy of that era and how D.C. continues to grapple with an epidemic that affected families, neighborhoods, politicians, policemen, and schools. Read transcript here.

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The complexities of heroin addiction

This is what heroin addiction looks like (Debbie Moore-Black, RN, Kevin MD, 4-6-17) What can I tell you? It started out innocently. College exams were over. And that meant one thing — party time! Bubbly, shots, beer, cocaine and Percocet. Pam came from a pretty strict religious family: no alcohol, no premarital sex and no crazy music growing up....How could I tell this woman what happened to her son?
Here’s how the White House plans to address rural America’s struggle with heroin (Juliet Eilperin, Washington Post, 1-14-16) The rural poor are “most stricken by the epidemic and have the least access to treatment.” Obama picks Tom Vilsack to address heroin spike (Kevin Liptak, CNN, 1-15-16) Four in five heroin users started out using prescription drugs, says Obama. So prescription drugs are the gateway to heroin addiction.
Falling out ( Peter Jamison, Video by Whitney Shefte, photos by André Chung, WaPo, 12-18-18) A generation of African American heroin users is dying in the opioid epidemic nobody talks about. The nation’s capital is ground zero.
The drug Suboxone could combat the heroin epidemic. So why is it so hard to get? (Susan Svrluga, Washington Post, 1-13-15)
Dying To Be Free (Jason Cherkis, Huff Post, 1-28-15) There’s A Treatment For Heroin Addiction That Actually Works. Why Aren’t We Using It?
In Heroin Crisis, White Families Seek Gentler War on Drugs (Katharine Q. Seelye, NY Times, 10-30-15) "When the nation’s long-running war against drugs was defined by the crack epidemic and based in poor, predominantly black urban areas, the public response was defined by zero tolerance and stiff prison sentences. But today’s heroin crisis is different. While heroin use has climbed among all demographic groups, it has skyrocketed among whites; nearly 90 percent of those who tried heroin for the first time in the last decade were white....Over all, drug overdoses now cause more deaths than car crashes, with opioids like OxyContin and other pain medications killing 44 people a day."
‘How’s Amanda?’: A story of lies, truth and American addiction (Eli Saslow, Unnatural Causes: Sick and Dying in Small-Town America, The Washington Post’s series exploring rising death rates for white women in rural America continues with a story about Amanda Wendler — a 31-year-old woman struggling to get clean in the eleventh year of her opiate addiction. The days of waiting — for a key injection (of a drug called naltrexone) that could help curb Amanda’s heroin cravings — seem to go on forever. "... the fact that matters most for a chronic user is what it takes for just one addict to get clean. The relapse rate for heroin has been reported in various studies to be as high as 97 percent. The average active user dies of an overdose in about 10 years, and Amanda’s opiate addiction was going on year 11."
A Long and Winding Road: Kicking Heroin in an Opioid ‘Treatment Desert’ (Brian Rinker, Kaiser Health News, 8-11-17) Experts recommend medication-assisted treatment for drug users like Menzel, one of nearly 2 million Americans struggling with opioid addiction, whether to prescription pills or heroin. MAT, as the therapy is known, has been proven far more effective — and less dangerous and miserable — than cold-turkey quitting. Drugs like methadone and buprenorphine can help suppress opioid cravings and stave off the physical and psychological symptoms of withdrawal. When carefully managed, MAT can cut the risk of overdose death by half, research shows. But not all medical providers are properly trained and approved to provide the treatments, which themselves are opioids (albeit less likely to be abused). Lake Isabella sits in the Kern River Valley, home to 32 churches but not a single methadone clinic or doctor able or willing to prescribe buprenorphine. Like half the counties in California, the valley is an opioid “treatment desert.”
Opioid Overdose. U.S. County Prescribing Rates, 2016. U.S. Prescribing Rate Maps (CDC) As Maia Szalavitz has pointed out, "most overdose deaths are not related to prescription opioids--they are caused by heroin and 'illicitly made' fentanyl." Originally the crisis was drive by overprescription of opioids, but "many people who once had a medical supply have been driven to street drugs."
How effective is medication-assisted treatment for addiction? Here’s the science (Kate Sheridan, STAT, 5-15-17) 'Understanding what heroin does in the brain and in the body is crucial to understanding why medication-assisted treatment — sometimes called medication-assisted therapy— works...MAT can work in one of two ways. Doctors can give people opiates that activate the same receptors but are absorbed into the blood over a longer period of time — staving off withdrawal symptoms and breaking a psychological link between taking a drug and immediately feeling high. Doctors can also give someone an opioid antagonist — a non-opioid drug that sits on those same receptors and blocks them — so that if someone relapses, he or she won’t feel anything....One big gap in the research is how to pick the right drug and the right dose for an individual patient....Each drug does carry different risks and benefits' (see article for discussion of them).
How a ‘Perfect Storm’ in New Hampshire Has Fueled an Opioid Crisis (Katharine Q. Seelye, NY Times, 1-21-18) New Hampshire "leads the nation in overdose deaths per capita from fentanyl, a powerful synthetic opioid that has virtually replaced heroin across New England. Because fentanyl is so potent, the risk of overdose is high....An astonishing 53 percent of adults said in a Granite State poll last year that drugs were the biggest problem facing the state...Researchers at Dartmouth College in Hanover, N.H., have been studying the issue to try to understand why the state’s opioid problem is so dire. One big reason, they say, is the proximity to an abundant drug supply in neighboring Massachusetts, the center of drug distribution networks that traffic opioids throughout New England....Another, they say, is New Hampshire’s low per capita spending on services to help drug users break free from addiction....The researchers also noted that the state has pockets of “economic degradation,” especially in rural areas where jobs are few, and that may contribute to the problem. Beyond that, the researchers say, doctors here have long prescribed “significantly higher rates” of opioid pain relievers, almost twice the national average. The researchers noted other factors, too: A shortage of workers in addiction and recovery. No needle exchanges. For some the state’s “Live Free or Die” motto might justify risky behaviors.
Dreamland: The True Tale of America's Opiate Epidemic by Sam Quinones. "Journalist Sam Quinones weaves together two classic tales of capitalism run amok whose unintentional collision has been catastrophic. The unfettered prescribing of pain medications during the 1990s reached its peak in Purdue Pharma’s campaign to market OxyContin, its new, expensive--extremely addictive--miracle painkiller. Meanwhile, a massive influx of black tar heroin--cheap, potent, and originating from one small county on Mexico’s west coast, independent of any drug cartel--assaulted small town and mid-sized cities across the country, driven by a brilliant, almost unbeatable marketing and distribution system. Together these phenomena continue to lay waste to communities from Tennessee to Oregon, Indiana to New Mexico." See How Heroin Made Its Way from Rural Mexico to Small-Town America (NPR's interview with the author, 5-19-15)\
The economic case for decriminalizing heroin (Dylan Matthews, WaPo, 1-8-13) The University of Chicago's Gary Becker and Kevin Murphy, who generally lean right on matters of public finance, made some waves by calling for the full decriminalization of drugs in the Wall Street Journal. They don't want to just, say, decriminalize the use of marijuana while still banning its sale, as Massachusetts does. They want to decriminalize the sale and use of heroin, and meth, and crack, and other hard drugs." (See The Market for Illegal Goods: The Case of Drugs, a PDF.) They argue, in brief: "Drug addiction is a major social malady, and one way to reduce its prevalence is to make drugs more expensive. You can do that via taxes, à la taxes on alcohol or cigarettes, or you can do it by making drugs illegal. Due to the costs associated with evading law enforcement [including huge social costs like mass incarceration], the production costs of illegal goods are higher than those for legal goods, and this shows up in the price consumers pay." They argue that " the best form of prohibition is still worse than legalize-and-tax."
Prisons fight opioids with $1,000 injection: Does it work? (Carla K. Johnson, AP, AARP, 11-14-16) "The evidence for giving Vivitrol to inmates is thin but promising. In the biggest study, sponsored by the National Institute on Drug Abuse, about 300 offenders — most of them heroin users on probation or parole — were randomly assigned to receive either Vivitrol or brief counseling and referral to a treatment program. The evidence for giving Vivitrol to inmates is thin but promising. In the biggest study, sponsored by the National Institute on Drug Abuse, about 300 offenders — most of them heroin users on probation or parole — were randomly assigned to receive either Vivitrol or brief counseling and referral to a treatment program. After six months, the Vivitrol group had a lower rate of relapse, 43 percent compared with 64 percent. A year after treatment stopped, there had been no overdoses in the Vivitrol group and seven overdoses, including three deaths, in the other group.... Yet addiction is stubborn. When the injections stopped, many in the study relapsed. A year later, relapse rates looked the same in the two groups."
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STIMULANTS--cocaine, crack cocaine, amphetamines (speed) and ecstasy (also a hallucinogen).
These "act on the central nervous system and are associated with feelings of extreme well-being, increased mental and motor activity."
Drug Facts: What is methamphetamine? (National Institute on Drug Abuse, an excellent one-page set of facts)
Meth use is on the rise: What journalists should know (Chloe Reichel, Journalist's Resource,
Key Findings of the 2017Domestic Methamphetamine Threat Assessment (DEA)
Methamphetamine Trafficking (United States Sentencing Commission)
DEA Facts and Statistics (Drug Enforcement Administration)

Generation Adderall (Casey Schwartz, NY Times Magazine, 10-12-16) Like many of my friends, I spent years using prescription stimulants to get through school and start my career. Then I tried to get off them. I was terrified I had done something irreversible to my brain, terrified that I was going to discover that I couldn’t write at all without my special pills.
How Stimulants Affect the Brain and Behavior (Chapter 2 from Treatment for Stimulant Use Disorders (free from SAMHSA
Understanding Stimulants (Addiction Center.com (855) 993-5977)
The most common prescription stimulants are amphetamines and methylphenidates. Prescription stimulants are used to treat attention deficit hyperactivity disorder (ADHD), narcolepsy and sometimes obesity.
Treating addiction to prescription stimulants (National Institute on Drug Abuse, NIDA) "Treatment of addiction to prescription stimulants, such as Adderall and Concerta, is based on behavioral therapies used in treating cocaine and methamphetamine addiction. At this time, there are no medications that are FDA-approved for treating stimulant addiction. Thus, NIDA is supporting research in this area."
ADHD and Substance Abuse (WebMD) See ADHD and Drug Abuse Directory
Overcoming cocaine or stimulant addiction (Harvard Mental Health Letter)

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Needle exchange programs

Needle exchange programs save lives.
CDC: Needle exchange sharply reduced sharing in an Indiana city wracked by an HIV outbreak (Laura Ungar, Louisville Courier, 3-7-18) A new federal study shows that needle sharing plummeted in Austin, Indiana after people who shoot up drugs began using a syringe exchange started in response to the largest drug-fueled HIV outbreak ever to hit rural America. "Cooke said he's glad the syringe exchange has linked more residents to medical care. Most HIV patients also have hepatitis C, and the state has a new program to help them, which allows rural doctors like him to consult remotely about cases with experts at Indiana University School of Public Health." Norman Bauman observed recently on a journalist's listserv: "But the more important question is, why did they have 181 HIV infections in the first place? A lot of the public health people criticized Governor Pence for not implementing what that BMJ article called 'Standard-of-care addiction treatment,' which includes needle exchanges. Indiana gave us a teaching model of how an IV drug epidemic predictably turned into a HCV epidemic and then into an HIV epidemic....How do you feel about spending $23,000 a year per HIV patient? How do you feel about spending $80,000 to cure a case of HCV? (CDC figuresWhere are you going to get that money? Are you going to take it out of your general hospital operating budget?" See also Syringe exchange program played key role in controlling HIV outbreak (Press release, Indiana University, 6-14-18)
Needle Exchange Tries to Keep Pace With Rising Drug Use (Anna Gorman, Here and Now, WBUR, 2-10-16) Needle exchanges could receive a financial boost this year following a decision by Congress to lift a ban on federal funding. As abuse of prescription drugs and opiates continues to spread across the nation, more states are considering exchanges as a way to save lives. The change in federal policy, part of a spending bill approved earlier this month, allows funding only in areas where drug-related cases of hepatitis and HIV are rising or are likely to. State and city health departments will make that determination along with the federal Centers for Disease Control and Prevention, according to the legislation. The money can be used to pay for staff and programs, but not for syringes. “It is really an important and historic moment for us at syringe exchanges,” said Mark Casanova, executive director of Homeless Healthcare Los Angeles, which runs the syringe exchange on Skid Row, known as the Harm Reduction Center. “But it doesn’t go far enough.” Casanova said about a third of his $350,000 budget for the exchange program is spent on the 1.2 million syringes he hands out each year, and he will have to continue relying heavily on private donations to pay for them.
Sexually active? Get tested. (Kathy Jean Schultz, VC Reporter, Ventura County, California, 6-13-18) More than 20 years after widespread AIDS deaths, county HIV infection rates climb. A physician told Schultz "that needle exchange programs cut infection rates, which decrease the spread within the community, resulting in a positive public health outcome. The program includes giving out sharps containers so participants can return the used needles inside the containers, and they are not supposed to get new needles each week unless they return the containers with their used needles from the last week. The goal is to cut down on the number of needles found by police officers, and in playgrounds by children. It works somewhat, but not all the time."
‘We’re in a mess.’ Why Florida is struggling with an unusually severe HIV/AIDS problem (Jon Cohen, Science Magazine, 6-13-18) 'Other public health measures also have lagged here. Needle and syringe exchanges that now are in 32 other states—they were endorsed by the U.S. National Commission on AIDS in 1991—only became legal here in 2016. "We were decades late," says UM clinician Hansel Tookes, who, while still a med student at the school, led a 4-year lobbying campaign that persuaded legislators to change the law.'
In a state of denial (Norman Bauman, New Scientist, 10-7-95) Politicians say they want studies before initiating a needle exchange. One group found that regular participation in exchange programmes cut an individual’s risk of HIV infection by half.
Pharmacists’ role in harm reduction: a survey assessment of Kentucky community pharmacists’ willingness to participate in syringe/needle exchange (Amie Goodin, Amanda Fallin-Bennett, Traci Green and Patricia R. Freeman, Harm Reduction Journal, 1-19-18) Kentucky community pharmacists were more willing to provide clean needles than to dispose of used needles. Strategies to mitigate barriers to participation in syringe/needle exchange are warranted.
Needle exchange programme (Wikipedia's good overview and links, with an international perspective)

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Drug overdoses (and reversing overdoses)

Dealing with an Overdose (Inpatient.org)
Poll: Most Americans Know About Opioid Antidote And Are Willing To Use It (Scott Hensley, Shots, NPR, 8-21-18) "U.S. Surgeon General Jerome Adams made a plea in April for more Americans to be prepared to administer naloxone, an opioid antidote, in case they or people close to them suffer an overdose. Nearly every state has made it easier for people to get naloxone by allowing pharmacists to dispense the drug without an individual prescription. Public health officials are able to write what are called standing orders, essentially prescriptions that cover everyone in their jurisdiction. Some states require training in how to use naloxone, typically given as a nasal spray called Narcan or with an EpiPen-like automatic injection, in order for someone to pick up naloxone. But the medicine is simple to use either way." (emphasis added)
Odds of dying: For the first time, opioid overdoses exceed car crashes (Shanley Pierce, Texas Medical Center, 1-17-19) According to the National Safety Council’s new report on preventable deaths, a person born in 2017 has a greater chance of dying from an accidental opioid overdose—one in 96— than the one-in-103 odds of dying from a motor vehicle crash. This now makes opioid overdose, considered accidental, a Top 5 cause of death behind heart disease, cancer, chronic lower respiratory disease and suicide. “For the longest time, injury had been one of the leading causes of lost life in young people. Now opioid overdoses and other drug overdoses are overtaking that." The opioid epidemic in the country has mainly been driven by illicit fentanyl.
Overdose Death Rates (National Institute on Drug Abuse, NIH)
Cities Again See More Overdose Deaths Than Country Town (AP, NY Times, 8-2-19) U.S. drug overdose deaths had been most common in Appalachia and other rural areas in recent years, but they are back to being more concentrated in big cities, according to a government report Friday. The CDC found that both urban and rural overdose death rates have been rising, but the urban rate shot up more dramatically after 2015. The epidemic was initially driven by opioid pain pills, which were often as widely available in the country as in the city. But then many drug users shifted to heroin and fentanyl, and the illegal drug distribution system for those drugs is more developed in cities. "Early on, this was seen as an epidemic affecting whites more than other groups," he said. "Increasingly, deaths in urban areas are starting to look brown and black." said Dr. Daniel Ciccarone, a drug policy expert at the University of California, SF.
Portugal’s radical drugs policy is working. Why hasn’t the world copied it? (Susana Ferreira, The Guardian, 12-5-17) Since it decriminalized all drugs in 2001, Portugal has seen dramatic drops in overdoses, HIV infection and drug-related crime. You can read a longer (the original) version of this story here: Decriminalization: A Love Story (The Common, 11-1-17)
This City’s Overdose Deaths Have Plunged. Can Others Learn From It? (Abby Goodnough, NY Times, 11-25-18) Dayton, Ohio, had one of the highest overdose death rates in the nation in 2017. The city made many changes, and fatal overdoses are down more than 50 percent from last year. A variety of factors are believed to have contributed to the sharp drop in mortality from overdoses of heroin and other opioids: Medicaid expansion hugely increased access to treatment. (Gov. John Kasich’s decision to expand Medicaid in 2015 gave nearly 700,000 low-income adults access to free addiction and mental health treatment. In Dayton, that’s drawn more than a dozen new treatment providers in the last year alone, including residential programs and outpatient clinics that dispense methadone, buprenorphine and naltrexone, the three medications approved by the F.D.A. to treat opioid addiction. ) Carfentanil, an incredibly toxic fentanyl analog, has faded. Naloxone is everywhere. There is more support for people when treatment ends. Police and public health workers actually agree.
Cocaine, Meth, Opioids All Fuel Rise in Drug-Overdose Deaths ( Josh Ulick and Betsy McKay, Wall Street Journal,9-20-18) Study shows complexity of long-term trend beyond current headlines about opioids. It isn’t just opioids behind a surge in deaths from drug overdoses in the U.S. Death rates from overdoses have been on an exponential-growth curve for nearly 40 years, involving methamphetamines, cocaine and other drugs in shifting patterns around the country and involving different age groups, a new analysis of federal data shows. When use of one drug has declined, another has moved in to fill the void, researchers at the University of Pittsburgh Graduate School of Public Health found in the analysis, published Thursday in the journal Science.
Over four decades, an 'inexorable' epidemic of drug overdoses reveals its inner secrets (Melissa Healy, LA Times, 9-20-18) "Americans have long construed drugs of abuse as choices. Poor choices that can cost users their lives, to be sure, but choices nonetheless. But what if drugs of abuse are more like predators atop a nationwide ecosystem of potential prey? Or like shape-shifting viruses that seek defenseless people to infect? If public health experts could detect a recognizable pattern, perhaps they could find ways to immunize the uninfected, or protect those most vulnerable to the whims of predators’ appetites....The drugs that exact this toll have changed: Methamphetamine, cocaine, prescription narcotics and heroin have all dominated the killing fields of American drug use at some particular time and place....Put those disparate trend lines together, though, and the curve representing fatal overdoses grows sharply steeper between 1979 and 2016. The death toll from drugs has doubled every eight years, according to the report published Thursday in the journal Science....“Those details are very valuable,” Woolf said. “But we shouldn’t miss the forest for the trees. The larger question is, why is it that Americans have been dying at greater rates of drug overdose since the 1980s?”
Insurance company red tape: a potentially deadly barrier to opioid addiction treatment (Jill U. Adams, HealthNewsReview, 4-26-18) “I think a combination of stigma and misinformation has guided a lot of the barriers to effective treatment with medications for opioid use disorder,” Wakeman says. “Many insurance companies are coming around on this issue and are aware of the evidence showing that medication treatment is more clinically and cost effective, which is a long time coming.” Indeed insurance giant Aetna dropped its prior authorization requirement for buprenorphine last year. France is a good case study; the country dropped prescribing restrictions on buprenorphine in 1995 and dramatically reduced the rates of opioid overdose deaths.
This City’s Overdose Deaths Have Plunged. Can Others Learn From It? (Abby Goodnough, NY Times, 11-25-18) Dayton, Ohio, had one of the highest overdose death rates in the nation in 2017. The city made many changes, and fatal overdoses are down more than 50 percent from last year. A variety of factors are believed to have contributed to the sharp drop in mortality from overdoses of heroin and other opioids: Medicaid expansion hugely increased access to treatment. (Gov. John Kasich’s decision to expand Medicaid in 2015 gave nearly 700,000 low-income adults access to free addiction and mental health treatment.
Insurers are making it harder for me to treat my opioid-addicted patients. (Brian Barnett, WashPost, 4-24-18) "Buprenorphine-naloxone, commonly known by the brand name Suboxone, and other medications, such as methadone and naltrexone, are used in combination with therapy and mutual-help groups to offer a new life for patients with opioid addiction. These medications have been shown to at least double a patient’s chances of remaining abstinent from illicit opioids and dramatically reduce overdose deaths. Without them, about 80 percent of patients using heroin relapse within the first month after detoxification....Thanks to medication-assisted treatment, I have personally witnessed dramatic transformations. It’s like watching chemotherapy curing a patient with cancer....The prior-authorization process is so cumbersome that many doctors choose not to prescribe medications such as Suboxone at all....All the while, my patient is waiting at high risk of relapse due to the horrific effects of opioid withdrawal. In this era of fentanyl-laced heroin, one relapse can mean death."
Reversing An Overdose Isn’t Complicated, But Getting The Antidote Can Be (Jake Harper, Side Effects Public Media, WFYI, and NPR, 5-26-18) Last month, U.S. Surgeon General Jerome Adams urged more Americans to carry and learn to use naloxone, which can save someone from an opioid overdose. But the drug, brand-name Narcan, can be difficult to get and expensive.
White House is urged to sidestep patents on opioid overdose treatment (Ed Silverman, STAT, 4-2-18) The White House is being urged to sidestep patents on a high-priced opioid overdose antidote as one way to stem the rising cost of combating the opioid crisis. In a letter sent last Thursday, an advocacy group argues the White House should use a little-known federal law that would permit the government to take title to patents on Evzio. This is a decades-old version of naloxone, which is widely used to reverse the effect of opioid and heroin overdoses. The federal law: PDF, UScode-2011-Title 28 (Patent and Copyright Cases)
In White House opioid plan, advocates see a major puzzle piece missing: naloxone (Lev Fatcher and Andrew Joseph, STAT, 10-27-17)
How the government can fight the opioid epidemic under a public health emergency (Lenny Bernstein, Washington Post, 10-26-17) At this point in the nation's opioid epidemic, fighting back is mainly about quickly making money available: Money for treatment. Money for the overdose antidote naloxone. Money to hire more people to help overwhelmed cities and states battle a crisis that killed an estimated 64,000 Americans last year.
The $4,500 injection to stop heroin overdoses (Shefali Luthra, Kaiser Health News, Business, Washington Post, 1-29-17). "Evzio is used to deliver naloxone, a life-saving antidote to overdoses of opioids. As demand for the product has grown, Kaleo has raised its twin-pack price to $4,500, from $690 in 2014....The problem...is that policymakers haven’t found a solution to get people needed medication and keep pricing in line with value. “EpiPen happened, and everyone was like, ‘Wow, this is terrible, we shouldn’t allow this to happen,’ ” he said. “And we haven’t done anything about that, and it’s not clear what the solution is. Now, shocker, it’s happening again.”
Surgeon General’s Advisory on Naloxone and Opioid Overdose I, Surgeon General of the United States Public Health Service, VADM Jerome Adams, am emphasizing the importance of the overdose-reversing drug naloxone. For patients currently taking high doses of opioids as prescribed for pain, individuals misusing prescription opioids, individuals using illicit opioids such as heroin or fentanyl, health care practitioners, family and friends of people who have an opioid use disorder, and community members who come into contact with people at risk for opioid overdose, knowing how to use naloxone and keeping it within reach can save a life.
Drug Overdose Immunity and Good Samaritan Laws (National Conference of State Legislatures, 6-5-17)
First Responders Spending More On Overdose Reversal Drug (Alison Kodjak, NPR, 8-8-17)
Opioids Contribute to a Rising Death Toll: 28,647 in 2014 (Nicholas Bakalar, Science, NY Times, 12-24-16) In 2014, according to the Centers for Disease Control and Prevention, there were 47,055 deaths from accidental drug overdoses. Opioids were implicated in 28,647 of them, 60.9 percent of the total. "Morphine and codeine are natural opioids found in the opium poppy. Semi-synthetic opioids like oxycodone, hydrocodone and hydromorphone are derived from them. Many opioids are familiar under brand names — oxycodone is sold as Percocet and Percodan, for example, and hydrocodone as Vicodin." The report suggested several steps, including continuing the careful control of opioid prescriptions and intensifying efforts to distribute naloxone, a drug that reverses an opioid overdose.

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Culprits in the opioid crisis

Who caused what? Who worsened the situation? How can we effectively resolve the crisis?

The opioid epidemic in the United States has been triggered argely by prescription drugs, exacerbated by heavy marketing of drugs for pain relief (and doctors being persuaded to emphasize treatment of pain, in the 1990s). There is no question we're in the midst of an opioid crisis. The question is, how do we best control or end it? How do we identify and address the chief and underlying causes and culprits? The articles below shed some light on the situation.
New Documents Show How Drug Companies Targeted Doctors to Increase Opioid Prescriptions (Charles Ornstein, ProPublica, 5-17-22) A trove of documents published as part of a legal settlement offers an unvarnished look inside the financial relationships between pharmaceutical companies and the medical community — from the perspective of drug companies themselves. 'The Washington Post mined the records and found that more than a quarter of the 239 medical professionals ranked as top prescribers by opioid maker Mallinckrodt Pharmaceuticals in 2013 “were later convicted of crimes related to their medical practices, had their medical licenses suspended or revoked, or paid state or federal fines after being accused of wrongdoing.” The article was replete with examples of doctors whose problems were well known but who were targeted anyway by sales representatives.'
Death in Mud Lick: A Coal Country Fight against the Drug Companies That Delivered the Opioid Epidemic by Eric Eyre. "“Eyre won a Pulitzer Prize for investigative reporting in 2017, for a revelatory series of articles on West Virginia’s opioid epidemic. His new book is a well-written account of that reporting [which] reads like a simmering John Grisham thriller. Eyre begins with the story of a single pharmacy in Kermit, W.Va., population 382. In just two years in the mid-aughts, it distributed nearly nine million opioid pain pills to customers. We meet some of those customers, and this story expands until it takes in corruption and greed on a gruesome scale.” " He shamed an industry and saved lives."
Drug company executives face prison time for role in opioid epidemic (PBS NewsHour, 1-24-2020) "The drug was designed specifically for end-stage cancer patients. The main ingredient? Fentanyl, which is 50 to 100 times stronger than morphine. The company wanted doctors to write as many prescriptions as possible, and for as high a dose as possible....several executives at Insys Therapeutics were sentenced to prison for a bribery scheme that paid doctors to prescribe the company’s lucrative and addictive painkiller....The key way the company made money was through its speaker program. Speaker programs allow doctors to educate other medical professionals about drug uses, and they typically get paid for it. That isn't illegal. But prosecutors say Insys broke the law by tying speaker payments to the number of prescriptions doctors wrote....Insys took a legal industry practice and, according to the prosecutors, corrupted it even further, sometimes paying doctors thousands of dollars for programs they didn't even speak at." Alec Burlakoff: "The whole company is premised on incentivizing doctors to prescribe our medication. The task that Dr. Kapoor is asking me to pull off, one, bribe doctors, and then, two, dictate how they actually prescribe the medication, it's not an easy one. Doctors pocketed the cash and promised to write more prescriptions for new patients."
The Family That Built an Empire of Pain (Patrick Radden Keefe, New Yorker, 10-30-17) The Sackler dynasty’s ruthless marketing of painkillers has generated billions of dollars—and millions of addicts.
McKinsey to pay $573M for role in opioid crisis (Geoff Mulvihill, AP, 2-4-21) 'The global business consulting firm McKinsey & Company has agreed to a $573 million settlement over its role in advising companies on how to “supercharge” opioid sales amid an overdose crisis, a person with knowledge of the deal told The Associated Press... State and local governments have been filing lawsuits over the past few years against companies that make and sell prescription opioids for their role in the crisis. But going after a consulting firm is a new wrinkle in the litigation.'
I told my doctors my drug history. Yet they gave me opioids without counseling (Seth Mnookin, STAT, 6-9-16) "Why isn’t every patient who receives an opioid prescription given information on physical dependence, as the Massachusetts Medical Society recommended back in March? And why aren’t patients in recovery already receiving the same screening and evaluation as those in active addiction?"
In Guilty Plea, OxyContin Maker to Pay $600 Million (Barry Meier, NY Times, 5-10-07) "OxyContin is a powerful, long-acting narcotic that provides relief of serious pain for up to 12 hours. Initially, Purdue Pharma contended that OxyContin, because of its time-release formulation, posed a lower threat of abuse and addiction to patients than do traditional, shorter-acting painkillers like Percocet or Vicodin.That claim became the linchpin of the most aggressive marketing campaign ever undertaken by a pharmaceutical company for a narcotic painkiller. ...Purdue Pharma heavily promoted OxyContin to doctors like general practitioners, who had often had little training in the treatment of serious pain or in recognizing signs of drug abuse in patients. But both experienced drug abusers and novices, including teenagers, soon discovered that chewing an OxyContin tablet or crushing one and then snorting the powder or injecting it with a needle produced a high as powerful as heroin. By 2000, parts of the United States, particularly rural areas, began to see skyrocketing rates of addiction and crime related to use of the drug....Federal officials said that internal Purdue Pharma documents show that company officials recognized even before the drug was marketed that they would face stiff resistance from doctors who were concerned about the potential of a high-powered narcotic like OxyContin to be abused by patients or cause addiction. As a result, company officials developed a fraudulent marketing campaign designed to promote OxyContin as a time-released drug that was less prone to such problems....Purdue Pharma acknowledged in the court proceeding today that “with the intent to defraud or mislead,” it marketed and promoted OxyContin as a drug that was less addictive, less subject to abuse and less likely to cause other narcotic side effects than other pain medications." See also Purdue’s Richard Sackler proposed plan to play down OxyContin risks, and wanted drug maker feared ‘like a tiger,’ files show (Casey Ross, STAT, 12-2-19) and The history of OxyContin, told through unsealed Purdue documents (Shraddha Chakradhar and Casey Ross, STAT, 12-3-19) and The Sackler family is trying to shield billions in opioid profits through Purdue Pharma bankruptcy, states say (Christopher Rowland, WaPo, 10-4-19) Two dozen states and the District of Columbia sought to block the family from winning a nine-month reprieve against OxyContin lawsuits.
How Germany Averted An Opioid Crisis (Shefali Luthra, KHN, 11-11-19) Unlike in the United States, where opioids are commonly dispensed after surgeries and medical procedures, opioids have never emerged as a front-line medical treatment in Germany. Doctors must first try alternative treatments, which the nation’s universal health insurance system typically covers. Before prescribing opioids, physicians must get special permission and screen patients to make sure they aren’t at risk for addiction. In the United States, in 2008, the government-administered National Survey on Drug Use and Health found that about 10,700 people took pain relievers or heroin for nonmedical purposes (even if they weren’t necessarily addicted). Because of Germany’s health system ― which emphasizes primary care and keeps cost sharing low ― people who are prescribed opioids are more likely to keep up with their doctors’ visits. If they exhibit warning signs of addiction, physicians have a better chance of noticing.
3,271 Pill Bottles, a Town of 2,831: Court Filings Say Corporations Fed Opioid Epidemic (Jan Hoffman, Katie Thomas and Danny Hakim, NY Times, 7-19-19) "The Walgreens employee was bewildered by the quantity of opioids the company was shipping to just one store. Its pharmacy in Port Richey, Fla. (population 2,831) was ordering 3,271 bottles of oxycodone a month.... Little-known manufacturers of generic pills, superstores like Walmart and chain retailers like Rite Aid also flooded the country with billions of pills." Cities and counties are suing major drugstore chains and Walmart, contending they distributed billions of painkillers that devastated communities. "Failure to identify suspicious orders was their business model," plaintiffs said of the defendants. 
A Nun, a Doctor and a Lawyer — and Deep Regret Over the Nation’s Handling of Opioids (Barry Meier, NY Times, 8-18-19) In an Appalachian town, an unlikely group of activists recognized the early stages of the deadly drug epidemic, and fought in vain to stem its rise. Before you read the article, jot down who you think the main culprits in the crisis are, and see if Barry Meier agrees.
Johnson & Johnson’s Brand Falters Over Its Role in the Opioid Crisis (Katie Thomas and Tiffany Hsu, NY Times, 8-27-19) In the 1980s, Johnson & Johnson needed a reliable supply of opium for a popular product, Tylenol with codeine. So the health care conglomerate, better known for baby shampoo and Band-Aids, bought a business that grew and processed opium poppies in faraway Tasmania, off the coast of Australia. By 2015, at the height of the nation’s opioid epidemic, Johnson & Johnson was the leading supplier for the raw ingredients in painkillers in the United States. It even developed a special strain of poppy, called Norman, that produced a core painkilling agent used in OxyContin, which would become Purdue Pharma’s blockbuster drug...on Monday, a judge in Oklahoma singled out Johnson & Johnson, ordering it to pay the state $572 million and ruling that the company should be held responsible for decades of opioid addiction and the thousands of overdose deaths in the state. The Times looks at the company's history and where it got involved in the epidemic.
Johnson and Johnson's Latest Ethical Misadventures: Settled Kickback Allegations, Reportedly Concealed Knowledge of Adverse Effects of a "Sacred Cow" Product (Health Care Renewal, 12-15-18) Scroll down for a list of all J&J's alleged crimes against medical consumers and medical practitioners between 2010 and 2016.
Sacklers Directed Efforts to Mislead Public About OxyContin, New Documents Indicate (Barry Meier, NY Times, 1-15-19) Members of the Sackler family, which owns [Purdue Pharma,] the company that makes OxyContin, directed years of efforts to mislead doctors and patients about the dangers of the powerful opioid painkiller, a court filing citing previously undisclosed documents contends. When evidence of growing abuse of the drug became clear in the early 2000s, one of them, Richard Sackler, advised pushing blame onto people who had become addicted. “We have to hammer on abusers in every way possible,” Mr. Sackler wrote in an email in 2001, when he was president of the company, Purdue Pharma. “They are the culprits and the problem. They are reckless criminals.” That email and other internal Purdue communications are cited by the attorney general of Massachusetts in a new court filing against the company...They represent the first evidence that appears to tie the Sacklers to specific decisions made by the company about the marketing of OxyContin. The aggressive promotion of the drug helped ignite the opioid epidemic."
From an AP story: Filing: OxyContin Maker Forecast 'Blizzard of Prescriptions' (1-15-19) Massachusetts Attorney General Maura Healey accuses Purdue Pharma, its executives and members of the Sackler family of deceiving patients and doctors about the risks of opioids and pushing prescribers to keep patients on the drug longer....The drug and the closely held Connecticut company that sells it are at the center of a lawsuit in Massachusetts and hundreds of others across the country in which government entities are trying to find the drug industry responsible for an opioid crisis that killed 72,000 Americans in 2017. The Massachusetts litigation is separate from some 1,500 federal lawsuits filed by governments being overseen by a judge in Cleveland.
76 billion opioid pills: Newly released federal data unmasks the epidemic (Scott Higham, Sari Horwitz and Steven Rich, an investigative piece for the Washington Post, 7-16-19) The DEA keeps a database of where every prescription opioid shipment goes across the country. The full national database has never been public. Until now. Just six companies distributed 75 percent of the pills during this period: McKesson Corp., Walgreens, Cardinal Health, AmerisourceBergen, CVS and Walmart. Three companies manufactured 88 percent of the opioids: SpecGx, a subsidiary of Mallinckrodt; ­Actavis Pharma; and Par Pharmaceutical, a subsidiary of Endo Pharmaceuticals. "In case after case, the companies allowed the drugs to reach the streets of communities large and small, despite persistent red flags that those pills were being sold in apparent violation of federal law and diverted to the black market, according to the lawsuits....Three companies distributed nearly half of the pills: McKesson with 14.1 billion, Walgreens with 12.6 billion and Cardinal Health with 10.7 billion. The leading manufacturer was Mallinckrodt’s SpecGx with nearly 28.9 billion pills, or nearly 38 percent of the market." Also reported: the states with the highest concentration of pills per person (the rural market hit hardest), the states known for "pill mills," and more about the crackdown on, and the big court case against, the opioid industry. "Transparency will lead to accountability.”
American Pain Society Goes Belly Up (Cheryl Clark, Medpage Today, 6-28-19) Saying it is beleaguered by legal debt fighting lawsuits alleging that its policies contributed to the nation's opioid crisis, the American Pain Society has voted to cease operations and on Friday, filed for bankruptcy protection under Chapter 7. Numerous legal filings have accused the organization, along with other companies and associations, of acting as "front groups" for opioid drugmakers because many of them regularly contributed significant financial support to professional groups such as the APS.
Indictment: Ex-CEO ignored red flags as opioid crisis raged (Michael R. Sisak, AP 5-23-19) Laurence Doud III, the retired CEO of the Rochester Drug Co-Operative, operated in the fringes of the drug business, obliterating red flags to turn his small New York firm into a supplier of last resort for independent pharmacies whose dubious practices got them cut off by other distributors, an indictment unsealed Tuesday alleges. Apparently in pursuit of bigger profits for the company and fatter bonuses for himself, Doud encouraged his sales force to sign up new customers with no questions asked, picking up competitors’ rejects as he boasted that his company was “the knight in shining armor” for independent pharmacies, the indictment said. When Rochester’s largest customer went from buying 70,000 units of oxycodone per month in October 2012 to more than 200,000 units per month a year later, Doud had its back — overruling his own compliance officers and ordering that the pills keep flowing because it was a “big account.” According to federal prosecutors, these are the first criminal charges against a drug company executive to stem from the opioid crisis.
County by County, Researchers Link Opioid Deaths to Drugmakers’ Marketing (Victoria Knight, KHN, 1-18-19) A study published in JAMA Network Open looked at county-specific federal data and found that the more opioid-related marketing dollars were spent in a county, the higher the rates of doctors who prescribed those drugs and, ultimately, the more overdose deaths occurred in that county.
Former Insys CEO says Founder Pushed Fentanyl Sales On Doctors (Bob Oakes, CommonHealth, WBUR, 2-14-19) Former Insys CEO Michael Babich, who has already pleaded guilty in the case, claimed the company's founder John Kapoor encouraged sales reps to reward doctors who prescribed the spray more often and at higher doses. Kapoor is accused of a major kickback scheme to push a highly addictive spray form of fentanyl.
How the VA Fueled the National Opioid Crisis and Is Killing Thousands of Veterans (Art Levine, Newsweek, 10-12-17) For over a decade, the VA killed thousands of vets and fueled the national opioid addiction crisis by recklessly throwing pills at a problem. "Since mid-2012, though, it has swung dangerously in the other direction, ordering a drastic cutback of opioids for chronic pain patients, but it is bungling that program and again putting veterans at risk." "A 2012 JAMA (formerly the Journal of the American Medical Association) study showed that veterans with mental health disorders and PTSD were three times more likely to receive opioids for pain diagnoses than other veterans." See Levine's book Mental Health Inc: How Corruption, Lax Oversight and Failed Reforms Endanger Our Most Vulnerable Citizens. "By some measures, 20 percent of Americans have some sort of mental health condition, including the most vulnerable among us―veterans, children, the elderly, prisoners, the homeless.With Mental Health, Inc., award-winning investigative journalist Art Levine delivers a Shock Doctrine-style exposé of the failures of our out of control, profit-driven mental health system, with a special emphasis on dangerous residential treatment facilities and the failures of the pharmaceutical industry, including the overdrugging of children with antipsychotics and the disastrous maltreatment of veterans with PTSD by the scandal-wracked VA."
‘Death Certificate Project’ Aims At Opioid Crisis, But Doctors Cry Foul (April Dembosky, All Things Considered, KQED, KHN, 1-23-19) On “All Things Considered” Thursday, KQED’s April Dembosky reports on the California medical board’s Death Certificate Project, which collected almost 3,000 death certificates of people who died of opioid overdoses, then cross-referenced those with the state’s drug prescription database. The board then sent letters to more than 500 doctors throughout the state who had prescribed the drugs to the people who died. The board has filed formal charges against 25 doctors, and left hundreds more waiting to learn their fate.
House Dems fire first salvo in drug pricing fight (Nathaniel Weixel, The Hill, 1-16-19) House Democrats this week fired a shot across the bow of the nation’s pharmaceutical companies as they begin a long-anticipated effort to cut down on high drug prices. The House Oversight and Reform Committee launched a sweeping investigation into how the industry sets its prices, in what is being seen as one of the broadest drug pricing investigations in decades. Committee Chairman Elijah Cummings (D-Md.) sent letters to a dozen different companies seeking detailed
information and documents about how the companies price their medications. In his sights are some of the largest branded drug companies, as well as the three primary insulin manufacturers in the world.
Two nurses died of overdoses inside a Dallas hospital. What went wrong? (Sue Ambrose and Holly K. Hacker, Investigations, Dallas News, 11-2-18) " The nurse lay in a bathroom stall, a syringe in her hand and track marks on her arm. She died from an overdose of fentanyl, a potent painkiller meant for patients. It was a rare accident two years ago at UT Southwestern Medical Center’s Clements hospital in Dallas. Until it happened again....experts say that when health care workers abuse drugs, they almost always steal the medicines from their workplace. The hospital’s own reports and medical examiner records show that’s a likely explanation, according to an investigation by The Dallas Morning News. This kind of theft, known as drug diversion, is a serious matter for hospitals, especially amid the nation's opioid epidemic. In the last four years, for example, Texas hospitals have reported more than 200 thefts by employees. But the government doesn't track drug thefts that lead to overdoses or deaths....“You can have really good systems in place and still be defeated by a diversion,” said Keith Berge, a doctor at the Mayo Clinic in Minnesota who studies the issue....The News found the state pharmacy board reports do not reflect every theft."
How America Got Hooked On A Deadly Drug (Fred Schulte, KHN, 6-13-18) An inside look at how Purdue Pharma pushed OxyContin despite risks of addiction and fatalities. 'A case filed in April by Baltimore County in Maryland makes an argument common to many of the suits: “From the mid-’90s to the present, manufacturing defendants aggressively marketed and falsely promoted liberal opioid prescribing as presenting little to no risk of addiction, even when used long term for chronic pain. They infiltrated academic medicine and regulatory agencies to convince doctors that treating chronic pain with long-term opioids was evidence-based medicine when, in fact, it was not. Huge profits resulted from these efforts — as did the present addiction and overdose crisis.”
Prescriptions for Millions of Opioid Pills Lead to Charges Against 5 Doctors (Benjamin Weiser, NY Times, 10-11-18) It was not hard to tell when the doctor was in at the Staten Island office of Carl Anderson. Noisy crowds of people, some with visible signs of drug addiction, stood in long lines at all hours of the night, seeking prescriptions for oxycodone pills, the authorities said Thursday. Sometimes, the noise outside Dr. Anderson’s office got so loud that it prompted neighbors to call the police, and more than once ambulances were called to treat pill-seeking patients, a series of new indictments show. Several patients, including two of his employees, overdosed and died, the authorities said. “Instead of caring for their patients, these doctors were drug dealers in white coats,” said Geoffrey S. Berman, the United States attorney for the Southern District of New York. See also Snaring Doctors and Drug Dealers, Justice Dept. Intensifies Opioid Fight (Katie Benner, NY Times, 8-22-18) 'While prosecutions do not necessarily reduce the number of Americans addicted to opioids, “these cases are important because they push more people to seek treatment,” said Dr. Andrew Kolodny, a co-director of opioid policy research at the Heller School for Social Policy and Management at Brandeis University. Although the government estimates that 2.5 million Americans are addicted to opioids, Dr. Kolodny said he believes the number is probably between five million and 10 million....“If the Justice Department really means business, we’ll see criminal charges brought against executives who run the pharmaceuticals companies that have flooded the market with opioids, not just small-time doctors who overprescribe,” Dr. Kolodny said.'
Meet 60 Minutes' DEA whistleblower (60 Minutes, CBS, a joint investigation with Washington Post, aired 6-25-18, but you can watch online) Joe Rannazzisi may be the most important whistleblower ever to appear on 60 Minutes. "Bill Whitaker’s interview with Rannazzisi, a former high-ranking DEA agent who saw the opioid epidemic killing hundreds of thousands of Americans, tried to stop it, and ran into a brick wall — in the form of Congress. JOE RANNAZZISI: "This is an industry that allowed millions and millions of drugs to go into bad pharmacies and doctors’ offices, that distributed them out to people who had no legitimate need for those drugs."... BILL WHITAKER: "It seems that some investigators with the DEA were aware that these pills were getting out of the pharmacies and into the streets, and they tried to ring the alarm bells. But not only did no one pay attention to them, it seems that members of Congress took steps to try to limit the DEA’s abilities to stop this. And the result was a bill in Congress that actually ended up taking away the most potent tool that the DEA had to go after the distribution of so many drugs." About Joe R: "If you talk to his investigators, the people who worked in the field for him, they love him. You talk to some people in Washington– at the DEA– his higher-ups at the DEA or at the Justice Department, certainly in Congress, they think he was too aggressive, to the point of being boorish."
     "His greatest ire is reserved for the distributors -- some of them multibillion dollar, Fortune 500 companies. They are the middlemen that ship the pain pills from manufacturers, like Purdue Pharma and Johnson & Johnson to drug stores all over the country. Rannazzisi accuses the distributors of fueling the opioid epidemic by turning a blind eye to pain pills being diverted to illicit use....The three largest distributors are Cardinal Health, McKesson, and AmerisourceBergen. They control probably 85 or 90 percent of the drugs going downstream." "Purdue Executive to Congress in 2001: Addiction is not common, addiction is rare in the pain patient who is properly managed. With many doctors convinced the drugs posed few risks, prescriptions skyrocketed and so did addiction." "As cases nearly ground to a halt at DEA (the Drug Enforcement Administration), the drug industry began lobbying Congress for legislation that would destroy DEA's enforcement powers....With the help of members of Congress, the drug industry began to quietly pave the way for legislation that essentially would strip the DEA of its most potent tool in fighting the spread of dangerous narcotics....The bill, introduced in the House by Pennsylvania Congressman Tom Marino and Congresswoman Marsha Blackburn of Tennessee, was promoted as a way to ensure that patients had access to the pain medication they needed. Jonathan Novak, who worked in the DEA's legal office, says what the bill really did was strip the agency of its ability to immediately freeze suspicious shipments of prescription narcotics to keep drugs off U.S. streets -- what the DEA calls diversion....Eric Holder was the attorney general at the time, he warned the new law would undermine law enforcement efforts to ''prevent communities and families from falling prey to dangerous drugs.'' The major drug companies -- distributors, chain drug stores and pharmaceutical manufacturers -- mobilized too. According to federal filings, during the two years the legislation was considered and amended, they spent $106 million lobbying Congress on the bill and other legislation, claiming the DEA was out of control, making it harder for patients to get needed medication. A particular thorn for the drug industry and the bill's sponsors was Joe Rannazzisi. He had been a witness before Congress more than 30 times and was called on again to testify about this bill....Majority Leader Mitch McConnell brought the legislation to the floor and it passed the Senate through unanimous consent with no objections and no recorded votes....Because I think that the drug industry -- the manufacturers, wholesalers, distributors and chain drugstores -- have an influence over Congress that has never been seen before."

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Despite Warnings, FDA Approves Potent New Opioid Painkiller (Jake Harper, WBUR News, 11-2-18) The Food and Drug Administration has approved a potent new opioid painkiller, Dsuvia, despite warnings from physician critics who say the drug will contribute to the addiction epidemic. "There are very tight restrictions being placed on the distribution and use of this product," said FDA Commissioner Scott Gottlieb in a written statement Friday regarding his agency's approval of Dsuvia. But vocal critics, including the chair of the FDA advisory committee and the consumer advocacy group Public Citizen, had urged the FDA to reject Dsuvia.
Ex-DEA agent: Opioid crisis fueled by drug industry and Congress (CBS News, 6-17-18: Watch online)
Why 60 Minutes' story on the DEA made Americans so angry (Jacqueline Kalil, CBS News, 10-17-18) Since 60 Minutes aired a bombshell investigation on how Congress helped fuel the opioid crisis, there’s been a whirlwind of public reaction
How Rival Opioid Makers Sought to Cash In on Alarm Over OxyContin’s Dangers (Fred Schulte, KHN, 8-2-18) As Purdue Pharma faced mounting criticism over deaths linked to OxyContin, rival drugmakers saw a chance to boost sales by stepping up marketing of similarly dangerous painkillers, such as fentanyl, morphine and methadone, Purdue internal documents reveal. Purdue’s 1996-2002 marketing plans for OxyContin, which Kaiser Health News made public this year for the first time, offer an unprecedented look at how that company spent millions of dollars to push opioids for growing legions of pain sufferers. A wave of lawsuits demanding reimbursement and accountability for the opioid crisis now ravaging communities has heightened awareness about how and when drug makers realized the potential dangers of their products.
Facing Wave of Opioid Lawsuits, Drug Companies Sprinkle Charity on Hard-Hit Areas (Jared S Hopkins, Bloomberg, 8-2-18) The drug industry is dishing out millions in grants and donations to organizations in cities, counties and states that have sued the companies over the deadly U.S. opioid epidemic. The efforts could help makers and distributors of prescription painkillers, who face hundreds of lawsuits by communities across the country, reduce their tax bills and build goodwill ahead of a potential multibillion-dollar settlement over their role in a crisis that kills more than 100 Americans a day.
Companies Shipped 1.6 Billion Opioids to Missouri From 2012 to 2017, Report Says (Katie Zezima, Wash Post, 7-12-18) "The report, released by Sen. Claire McCaskill (D-Mo.), shows that drug distributors Cardinal Health, McKesson Corp. and Amerisource Bergen funneled the equivalent of about 260 opioid pills for every person in Missouri in the six-year period, during which time the opioid epidemic raged there — and nationwide."
Opioid Makers, Blamed for Overdose Epidemic, Cut Back on Marketing Payments to Doctors (Charles Ornstein and Ryann Grochowski Jones, Dollars for Docs, ProPublica and NPR Shots, 6-28-18) Updating Dollars for Docs, ProPublica found that drugmakers spent less money to market opioids to doctors in 2016 than in prior years. Studies have shown that payments to doctors by opioid makers are linked to more prescribing of the drugs. Among opioids, the biggest decreases in spending were for Subsys, the fentanyl spray that has spawned criminal charges against officials and sales representatives at drug maker Insys (down from more than $6 million in 2015 to less than $2.4 million in 2015) , and Hysingla ER, an extended-release version of hydrocodone made by Purdue Pharma (down from about $6.3 million in 2015 to $2.2 million in 2016). Many more pharmaceuticals continued to get heavy promotional spending to doctors.
Protesters Stage 'Die-In' at Harvard Museum to Criticize Namesake's Link to Opioid Crisis (Justin Kaplan, WBUR, CommonHealth, 7-20-18) "Dozens of protesters gathered in Cambridge Friday afternoon to stage a "die-in" inside a Harvard University museum in protest of its ties to a family the demonstrators say profited off the opioid crisis.... Once inside the museum, the activists chanted "Shame on Sackler," as they marched in a circle and threw mock Oxycontin pill bottles and empty Narcan — the brand name of an opioid-reversal drug — boxes on the ground.... The group called upon the Sackler family to use its Purdue Pharma fortunes to fund several initiatives aimed at curbing the opioid epidemic. These include controversial harm reduction tools such as safe injection facilities, expanded access to Narcan and medically-assisted treatment for those struggling with addiction."

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Dollars for Docs ( Mike Tigas, Ryann Grochowski Jones, Charles Ornstein, and Lena Groeger, ProPublica, updated 6-28-18) Has Your Doctor Received Drug or Device Company Money? Pharmaceutical and medical device companies are required by law to release details of their payments to a variety of doctors and U.S. teaching hospitals for promotional talks, research and consulting, among other categories. Use this tool to search for general payments (excluding research and ownership interests) made from August 2013 to December 2016. Search for payments made by 17 drug companies between 2009 and 2013.
System for reporting suspicious opioid orders repeatedly failed, report finds (Lev Facher, STAT News, 7-12-18) "A Senate report released Thursday lays out systematic failures in the reporting system for suspicious opioid orders, faulting some drug distributors and manufacturers for their roles and criticizing the Drug Enforcement Administration for a years-long lull in enforcement actions" Two distributors, McKesson and AmerisourceBergen, shipped nearly identical volumes of opioids to Missouri between 2012 and 2017: roughly 650 million doses each. But AmerisourceBergen flagged 224 orders as suspicious and McKesson flagged 16,714. "The two overlapping trends described in this report — disparities in industry compliance behavior and declining DEA enforcement — suggest, at the very least, a connection between weak DEA oversight and varying anti-diversion efforts,” the report read.\
‘Unfettered greed’: Pulaski County seeks damages for opioid crisis from Big Pharma (Dominick Mastrangelo, Roanoke Times, 7-16-18) The suit filed Monday against America’s largest pharmaceutical companies (including AmerisourceBergen Drug Corporation, Cardinal Health and Purdue Pharma) lists eight counts against the drug makers and distributors, including racketeering, fraud, negligence, and public nuisance. “This is an indication of unfettered greed,” Chafin said. “They’ve just been making so much money for so long that they’ve built their business model around it. The money has just continued to flow.” Pulaski is the sixth of several Southwest Virginia counties that have filed similar “mass action” lawsuits against Big Pharma.
Bars and Pies Make Better Desserts Than Figures (Thomas M. Annesley, Clinical Chemistry, Aug 2010)
Pain as a vital sign has contributed to the opioid epidemic (Skeptical Scalpel, KevinMD, 9-10-14) "Vital signs are the following: heart rate, blood pressure, respiratory rate, temperature.
What do those four signs have in common?
They can be measured. A sign is defined as something that can be measured. On the other hand, pain is subjective."
And that's where a major crisis started. Pain was added as a vital sign. And pain is subjective. And that's how Big Pharma milked the U.S. public and is getting away with murder.

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Origins of an Epidemic: Purdue Pharma Knew Its Opioids Were Widely Abused (Barry Meier, NY Times, 5-29-18) A confidential Justice Department report found the company was aware early on that OxyContin was being crushed and snorted for its powerful narcotic, but continued to promote it as less addictive. Federal prosecutors said the company knew of “significant” abuse of OxyContin soon after it came on the market, but hid that information.
Now We See: How The Opioid Crisis Has Laid Bare Deep Flaws In American Medicine (Dr. Elisabeth Poorman, WBUR, CommonHealth, 6-15-18) "We had been taught that patients were either in pain or they were drug-seeking addicts -- never both. Patients with chronic pain who started to show addictive behaviors, we were told, were not addicted but “pseudo-addicted,” suffering because we were not giving them enough opioids....It’s hard to understand now why I couldn’t recognize that Danny was suffering from chronic pain and addiction, or that the two commonly coexisted. It is even more painful to acknowledge that during most of my medical training, the teaching I received was so thoroughly dominated by corporate interests pushing pain prescriptions that we let it blind us to flimsy data and even our own clinical experience....there has never been empirical evidence that pseudoaddiction is a legitimate diagnosis. Yet, in spite of its questionable assumptions, the term was doctrine in pain treatment while I was in medical training, spread throughout the medical community by pharma-sponsored lectures and educational materials....We have failed to come to grips with the scale of destruction we have created ... and the work we have to do to combat this epidemic and prevent future ones...."Every generation of physicians has to work to undo the mistakes of its predecessors. It is the nature of working in a constantly evolving field. But the physician-fueled opioid epidemic is something different: the result of an effective marketing campaign that has killed hundreds of thousands of people."
Purdue and the Oxycontin Files (KHN, 6-13-18) Purdue Pharma planned an extensive marketing campaign for the launch and promotion of the painkiller OxyContin. Here are Purdue’s internal budget documents from 1996 to 2002 — files released by the Florida attorney general’s office — that detail the company’s early strategy to sell and expand use of the drug. Note that marketing materials included information about the drug that was not true.
Minnesota sues pharma firm over 'brazen' marketing of opioid painkiller (Jon Collins, Minnesota Public Radio, NorthfieldNews.com, 5-30-18) 'The lawsuit says the painkiller was approved by the U.S. Food and Drug administration to treat pain in cancer patients but that Arizona-based Insys Therapeutics marketed it for other conditions and at higher doses....Attorney General Lori Swanson said Insys “encouraged physicians to prescribe this highly-potent fentanyl product to patients who didn’t have cancer, even though it was only approved for severe breakthrough pain in cancer patients.”'

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‘You want a description of hell?’ OxyContin’s 12-hour problem (Harriet Ryan, Lisa Girion and Scott Glover, A Times Investigation, Los Angeles Times, 5-5-16) The drugmaker Purdue Pharma launched OxyContin two decades ago with a bold marketing claim: One dose relieves pain for 12 hours, more than twice as long as generic medications. Before OxyContin, doctors had viewed narcotic painkillers as dangerously addictive and primarily reserved their long-term use for cancer patients and the terminally ill. Purdue envisioned a bigger market. Sales reps pitched the drug to family doctors and general practitioners to treat common conditions such as back aches and knee pain. Their hook was the convenience of twice-a­-day dosing. If a doctor complained that OxyContin didn’t last, Purdue reps were to recommend increasing the strength of the dose rather than the frequency. There is no ceiling on the amount of OxyContin a patient can be prescribed, sales reps were to remind doctors, according to the presentation and other training materials. In the training materials reviewed by The Times, little was said about the effect of higher doses on patient health. Those on higher doses of opioids are more likely to overdose, according to numerous research studies.
Another Insys Sales Rep Pleads Guilty To Bribing Docs To Prescribe Subsys (Ed Silverman, @Pharmalot, STAT, 5-31-18) Yet another former Insys Therapeutics (INSY) sales rep has pleaded guilty to bribing doctors to write prescriptions for the Subsys opioid painkiller, which contains fentanyl and carries a high risk of dependency. Michelle Breitenbach, 38, who worked in New Jersey for the drug maker, paid kickbacks and bribes to an unspecified number of physicians in the form of speaking fees for purported education events, according to the New Jersey attorney general. She faces up to five years in prison
'People are dying every day': Drug distributors to face lawmakers (Theodoric Meyer, Politico, 5-8-18) Lawyers suing the companies hope to turn a hearing Tuesday into a modern equivalent of the 1994 tobacco hearings, which helped turn the tide of public opinion.
Distributor executive apologizes for large opioid shipments (Rachel Roubein, The Hill, 5-8-18) From 2007 to 2012, distributors sent more than 780 million hydrocodone and oxycodone pills to West Virginia, about half of which came from AmerisourceBergen, Cardinal Health and McKesson, according to a memo from the Energy and Commerce Committee’s majority staff. Rep. Gregg Harper (R-Miss.) asked a pointed question: “Do you believe that the actions you or your company took contributed to the opioid epidemic?” One company executive — Joseph Mastandrea, the chairman of the board of Miami-Luken — responded "yes." The others said they believed their company had not contributed.
Drug Supply Firm Execs Say They Didn't Cause Opioids Crisis (Alan Fram, AP, 5-8-18) Top executives of the nation's three leading wholesale drug distributors told Congress under oath Tuesday that their companies didn't help cause the nation's deadly opioid epidemic, drawing bipartisan wrath that included one lawmaker suggesting prison terms for some company officials. The confrontation came at a House subcommittee hearing at which legislators asked why huge numbers of potentially addictive prescription opioid pills had been shipped to West Virginia, among the states hardest hit by the drug crisis. Lawmakers are making an election-year push for legislation aimed at curbing a growing epidemic that saw nearly 64,000 people die last year from drug overdoses, two-thirds from opioids.

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Opioid Crisis: Drug Executives Express Regret to Congress on Tuesday, One Says His Company Contributed to the Epidemic (Katie Zezima and Scott Higham, Wash Post, 5-8-18) A major distributor of powerful painkillers apologized Tuesday for the company’s role in facilitating the flow of highly addictive painkillers into U.S. communities, the first time a corporation has expressed regret for involvement in the opioid crisis. George Barrett, executive chairman of Cardinal Health, said he is sorry the company did not act faster to impede the shipping of millions of hydrocodone and oxycodone pills to two small pharmacies in West Virginia, but he and three other drug-distribution executives (out of five) denied responsibility for contributing to the epidemic. Lawyers representing municipalities said their cases will show that the distributors skirted their legal responsibility in order to profit.
Federal kickback law might be used to bring down drug prices, FDA commissioner suggests (Ike Swetlitz, STAT, 5-3-18) 'Drug companies are currently being sued by lawyers who believe that the Byzantine system of rebates that flow between pharmacy benefit managers, drug manufactures, and insurers are really kickbacks. The current interpretation of the federal law shields these rebates from legal scrutiny." FDA commissioner Scott Gottlieb signaled that might change....Drug companies are currently being sued by lawyers who believe that the Byzantine system of rebates that flow between pharmacy benefit managers, drug manufactures, and insurers are really kickbacks. The current interpretation of the federal law shields these rebates from legal scrutiny.But Gottlieb, in remarks delivered at the annual conference of the Food and Drug Law Institute, signaled that might change....“One of the dynamics I’ve talked about before that’s driving higher and higher list prices, is the system of rebates between payers and manufacturers,” Gottlieb said. “And so what if we took on this system directly, by having the federal government reexamine the current safe harbor for drug rebates under the Anti-Kickback Statute?”...The pharmaceutical industry has engaged in a massive lobbying campaign to shift the blame for high drug prices from the manufacturers, who set the list prices, to pharmacy benefit managers and insurers, who help determine how the products are paid for through a system of rebates. It’s an issue that has also vexed lawmakers, who are questioning the “black box” of drug pricing.'
Documents reveal subversive campaign to defeat legislation (Saul Hubbard, The Register-Guard, 2-9-18) Pharmaceutical industry interests retain a Virginia company to recruit Oregonians to make calls to 13 lawmakers to derail House Bill 4005. A Washington, D.C.-based advocacy group funded by ­pharmaceutical interests is spending big money to drum up a secretive ­citizen letter-­writing campaign in Oregon to help kill a drug pricing transparency bill in the legislature. Internal documents "show the pharmaceutical industry’s involvement was ­intended to be kept secret, both from Oregonians enlisted to sign the prewritten letters and legislators who would receive them. A script for the cold calls shows that callers are instructed to say they’re reaching out “to protect patients’ rights” and that House Bill 4005 is intended to 'only pad the profits of health insurers.' ”

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The Pain Hustlers: The Opioid that Made a Fortune for Its Maker - and for Its Prescribers (Evan Hughes, NY Times Magazine, 5-2-18) Insys Therapeutics paid millions of dollars to doctors. The company called it a “speaker program,” but prosecutors now call it something else: a kickback scheme. To build the sales force, Insys hired a number of notably attractive people in their 20s and 30s, mostly women - not an uncommon tactic in the industry. An assistant district attorney in upstate New York said that it’s easy to identify a pill-mill doctor, but ‘it can take five years to get to that guy.’ One star Insys rep said that she looked for people ‘that are just going through divorce, or doctors opening up a new clinic, doctors who are procedure-heavy. All those guys are money hungry.’ This story clearly owes a lot to these people: The Southern Investigative Reporting Foundation's Investigations into corruption in the pharmaceutical industry (Roddy Boyd's work)
(a) Mr. Schiller’s $9 million reasons to work cheaply (Valeant has become the most closely followed company in the capital markets–attributable in part to the SIRF’s revelations of its hidden ownership of Philidor). The Pawn Isolated: Valeant, Philidor and the Annals of Fraud
(b) Murder Incorporated and The Brotherhood of Thieves: Insys Therapeutics, Parts 1-3.
Executives at Insys Therapeutics have continued to pressure its employees to develop new ways to mislead insurance companies into granting coverage to patients prescribed its drug Subsys. Insys’ prior authorization unit (also known internally as the insurance reimbursement center) employees were trained and rewarded for saying anything, including purportedly inventing patient diagnoses, to get Subsys approved. Executives were frantically brainstorming new ways to get around increasingly stringent pharmacy benefit manager rule enforcement.
CNN Exclusive: The more opioids doctors prescribe, the more money they make (Aaron Kessler, Elizabeth Cohen and Katherine Grise, CNN, 3-11-18) Video by Elizabeth Cohen and John Bonifield). As tens of thousands of Americans die from prescription opioid overdoses each year, an exclusive analysis by CNN and researchers at Harvard University found that opioid manufactures are more likely to pay doctors who write the most opioid prescriptions. The company that makes Subsys paid one doctor more than $200,000, according to Open Payments, the federal government database that tracks payments from pharmaceutical companies to doctors.

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Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers (Kath Thomas and Charles Ornstein, NY Times, 9-17-17) Drug companies and doctors have been accused of fueling the opioid crisis, but some question whether insurers have played a role, too.
Pharma backing of advocacy groups: a call for transparency (Michael Joyce, HealthNewsReview, 3-7-18) Lawmakers concerned about a mounting opioid crisis are pushing for the pharmaceutical industry to fully disclose their financial influence on patient advocacy groups. 14 nonprofit groups (mostly representing pain patients/specialists) received nearly $9 million from the drug companies and affiliated physicians received roughly $1.6 million. Purdue Pharma (maker of Oxycontin) contributed the most: $4.7 million (mostly to the Academy of Integrative Pain Management). Insys had the 2nd highest contribution — just over $3 million — mostly to the US Pain Foundation and the National Pain Foundation.
Because patient advocacy groups aren’t always what they seem: A quick guide to nonprofit sleuthing (Mary Chris Jaklevic, HealthNewsReview, 10-12-17)" Journalists shouldn’t take organizations they report on at face value. Rather, they should ask who calls the shots and who provides the funding. And they should report findings that call into question a group’s credibility." A helpful guide for deep reporting on nonprofits.
Why Insurance Companies are Saying No to Opioid Alternatives (BackerNation, 9-4-17) Alternatives to opioids include steroid epidural injections, joint injections, fluid injections, physical therapy, nerve blocks, aquatic therapy, aquatic therapy, massage therapy, chiropractic care, acupuncture, medical marijuana, and cannabidiol (CBD) oil. But insurance companies often refuse to cover these. "The problem isn't with doctors not wanting to prescribe anything other than pills per se, but rather the failure of insurance companies to not cover any costs from these therapies, and they aren't cheap...."
The Insurance Company Paid For Opioids, But Not Cold Therapy (Lauren Kafka, Shots, NPR, 11-25-17) I dealt with shoulder pain for decades, treating it with bags of frozen peas, physical therapy, cortisone shots and even experimental treatments like platelet-rich plasma. After MRI showed two full-thickness rotator-cuff tears, I finally called a surgeon....Unlike the type of physical therapy I was used to for sports injuries — the kind that immediately reduces pain — the therapy regimen after rotator-cuff surgery is absolutely excruciating for several weeks, sometimes months. The ice machine helped me taper my drug use from oxycodone to tramadol, a less powerful painkiller, and now I'm using primarily acetaminophen. More than six weeks after surgery, I'm still relying on the Game Ready machine and dread the day when I'll have to give it up." Cigna refused to cover the machine. "Although the use of cryotherapy devices is still considered experimental by many insurance companies, doctors in other specialties besides orthopedics agree that methods to manage pain without opioids should be a top priority.

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Opioid makers gave millions to patient advocacy groups to sway prescribing (Ed Silverman, STAT, 2-12-18) As the nation grapples with a worsening opioid crisis, a new report suggests that drug makers provided substantial funding to patient advocacy groups and physicians in recent years in order to influence the controversial debate over appropriate usage and prescribing. Specifically, five drug companies funneled nearly $9 million to 14 groups working on chronic pain and issues related to opioid use between 2012 and 2017. At the same time, physicians affiliated with these groups accepted more than $1.6 million from the same companies. In total, the drug makers made more than $10 million in payments since January 2012. “The fact that these same manufacturers provided millions of dollars to the groups suggests, at the very least, a direct link between corporate donations and the advancement of opioid-friendly messaging,” according to the report released on Monday night by U.S. Sen. Claire McCaskill, who has been probing opioid makers and wholesalers. “The pharmaceutical industry spent a generation downplaying the risks of opioid addiction and trying to expand their customer base for these incredibly dangerous medications and this report makes clear they made investments in third-party organizations that could further those goals,” McCaskill said. The report noted that, at various times, the groups issued guidelines and policies “minimizing the risk of opioid addiction and promoting opioids for chronic pain, lobbied to change laws directed at curbing opioid use, and argued against accountability for physicians and industry executives responsible for over-prescription and misbranding.”
A Puzzling Opioid-Linked Killing Points to a Dangerous Trend (Brian Rinker, The Atlantic, 3-9-18) What led an addiction doctor to keep a gun in his desk? "The tragedy that played out in Zong’s office speaks to a dangerous trend: In many parts of the United States, the number of people addicted to opioids far exceeds the capacity of doctors willing and authorized to treat them. That is particularly true when it comes to professionals like Zong who dispense Suboxone or Subutex, both formulations of buprenorphine, which is widely considered the optimal addiction treatment because it all but erases opioid-withdrawal symptoms without creating a significant high. One reason for the shortage of providers is that doctors must take eight hours of training to prescribe the medication and apply for a waiver from the Drug Enforcement Administration, because the medicine is itself an opioid. Few doctors are willing to check all those boxes and take on the sometimes difficult patients who seek the drug....More problematic, some clinics, like Zong’s, offer a mix of services—treatment for both opiate addiction and pain. Patients being prescribed potentially dangerous narcotics are mixed in the waiting area with those struggling to kick addiction."

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The drug industry’s triumph over the DEA (Scott Higham and Lenny Bernstein, Washington Post and 60 Minutes, 10-15-17) In April 2016, at the height of the deadliest drug epidemic in U.S. history, Congress effectively stripped the Drug Enforcement Administration of its most potent weapon against large drug companies suspected of spilling prescription narcotics onto the nation’s streets. The chief advocate of the law that hobbled the DEA was Rep. Tom Marino, a Pennsylvania Republican who is now President Trump’s nominee to become the nation’s next drug czar. He and other members of Congress, allied with the nation’s major drug distributors, prevailed upon the DEA and the Justice Department to agree to a more industry-friendly law, undermining efforts to stanch the flow of pain pills....The law was the crowning achievement of a multifaceted campaign by the drug industry to weaken aggressive DEA enforcement efforts against drug distribution companies that were supplying corrupt doctors and pharmacists who peddled narcotics to the black market. The industry worked behind the scenes with lobbyists and key members of Congress, pouring more than a million dollars into their election campaigns. The chief advocate of the law that hobbled the DEA was Rep. Tom Marino, a Pennsylvania Republican who was President Trump’s nominee to become the nation’s next drug czar, but withdrew it when this story broke, thanks to whistleblowers.
The opioid epidemic: It’s time to place blame where it belongs (Ronald Hirsch, Kevin MD, 4-6-16) "I call on Congress to hold hearings and compel the top executives from Purdue Pharmaceutical, the Joint Commission, Press Ganey, and CMS and hospital administrators to appear and testify as to their role in this national epidemic." (Charles Ornstein, ProPublica, 9-26-17) The move follows a story by ProPublica and The New York Times detailing how insurance companies and pharmacy benefit managers have made it easier to get opioid painkillers than less risky alternatives. "Only one-third of the people covered, for example, had any access to Butrans. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval from the insurer for them. Moreover, we found that many plans make it easier to get opioids than medications to treat addiction, such as Suboxone."

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In recovery, Nan Goldin calls on Harvard to reject money from family tied to OxyContin,(Mark Shanahan, Boston Globe, 1-22-18) Celebrated photographer Nan Goldin says the benefactor of Harvard's Arthur M. Sackler Museum should be shunned by US arts organizations. Goldin, who's been drug-free for 10 months after entering a Massachusetts rehab center for an addiction to Oxycontin, believes museums should no longer accept money from the Sacklers due to the family’s role in the manufacture of the powerful pain medication.
Senator Calls on Insurers to Improve Access to Non-Opioid Pain Treatments
John Oliver Explains How Drug Companies Helped Cause Our Opiate Epidemic (Bryan Menegus, Gizmodo, 10-24-16) "In John Oliver’s latest report, he unpacks the alarming history of the epidemic, and how the drug companies we entrust with our health helped create it....Opiates were hardly prescribed in the 90s except in the most extreme cases of pain management. How did we go from that to nearly half a million opiate-related deaths between 2000 and 2014? The answer, as John Oliver explains, lies in greedy drug companies. When Oxycontin was developed by Purdue in the late 90s, the company marketed it aggressively—in itself not unusual. Oliver points out that what made Purdue’s campaign bad was how grossly it misrepresented the product’s addiction potential. Not only did the company invent the term “pseudo-addiction” to discredit the seriousness of patient dependence, but it also claimed actual addiction befell “less than 1 percent” of those prescribed Oxycontin."...
"Easily the shadiest and most disgusting example Oliver gives involves the company Insys getting fentanyl into the hands of people who didn’t really need it. Easily the shadiest and most disgusting example Oliver gives involves the company Insys getting fentanyl into the hands of people who didn’t really need it. While only approved for use in treating cancer pain, Insys found a loophole to get this powerful drug prescribed to patients, and to get insurance companies to pay for it."

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Online Sales of Illegal Opioids from China Surge in U.S. (Ron Nixon, NY Times, 1-24-18) Nearly $800 million worth of fentanyl pills were illegally sold to online customers in the United States over two years by Chinese distributors who took advantage of internet anonymity and an explosive growth in e-commerce, according to a Senate report released on Wednesday. A yearlong Senate investigation found that American buyers of the illegal drugs lived mostly in Ohio, Pennsylvania and Florida.
American Pain: How a Young Felon and His Ring of Doctors Unleashed America’s Deadliest Drug Epidemic by John Temple. “John Temple’s American Pain takes you on a hysterically funny, yet equally tragic, tour of Florida’s pill mill industry as the painkiller epidemic was reaching a fever pitch.... a must-read for anyone trying to understand this government-sanctioned drug and the destructive power of Big Pharma.” —Melisa Wallack, co-writer of Dallas Buyers Club
Pressure Mounts on Insurance Companies to Consider Their Role in Opioid Epidemic (Charles Ornstein, ProPublica, 10-19-17) Another lawmaker is asking insurers whether their policies have made it easier for patients to access cheaper, more addictive drugs over less addictive alternatives. Meanwhile, the insurance industry trade group pledged additional steps to combat inappropriate prescribing.
Amid Opioid Crisis, Insurers Restrict Pricey, Less Addictive Painkillers (Katie Thomas, NY Times, and Charles Ornstein, Pro Publica, 9-17-17) Opioid drugs are generally cheap while safer alternatives are often more expensive. "ProPublica and The New York Times analyzed Medicare prescription drug plans covering 35.7 million people in the second quarter of this year. Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them. In contrast, almost every plan covered common opioids and very few required any prior approval. The insurers have also erected more hurdles to approving addiction treatments than for the addictive substances themselves, the analysis found."

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Politics of pain: Drugmakers fought state opioid limits amid crisis (Liz Essley Whyte, Geoff Mulvihill, and Ben Wiederemail, The Center for Public Integrity and Associated Press, 9-18-16) Who’s Calling the Shots in State Politics? Makers of prescription painkillers tried to kill state measures aimed at stemming the tide of opioid drugs. An investigation revealed that drug companies and allied advocates spent more than $880 million on lobbying and political contributions over a decade, and that drugs for which they racked up billions in sales would cost government-funded health programs hundreds of millions in higher medication costs. Judges for an AHCJ journalism award called this "a tour de force about the politics, lobbying, and influence-peddling that have helped cause the American opioid epidemic."
No, High Workers Aren't What's Wrong with America's Economy (Maia Szalavitz, Vice, 8-10-17) According to one study, "the regions where the epidemic is most serious are often also the ones in which deindustrialization has wrought the most havoc. In these despairing environs, existing jobs often pay rock-bottom wages, and many workers with the means and skills to take higher-paid positions have taken off in search of education and opportunity elsewhere. It's not exactly surprising that businesses remaining in these extremely depressed areas would have difficulty hiring....Regardless of your view on the merits of drug testing, it's clearly wrong to suggest rampant drug use is holding back the growth of the middle class. A better bet is greedy bosses, and a political class that hasn't responded to workers' needs."
Unable To Arrest Opioid Epidemic, Red States Warm To Needle Exchanges (Shefali Luthra, KHN, 6-14-17) The North Carolina Harm Reduction Coalition has advanced a local shift from a tough-on-drugs approach to harm-reduction philosophy. Other red states signal they may follow suit.

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The opioid epidemic may be even deadlier than we think (German Lopez, Vox, 4-26-17) The current drug crisis already kills more people than guns or cars. But a new study suggests it’s even worse than the current numbers say. See section labeled "The opioid epidemic, explained in fewer than 600 words."
Public Restrooms Become Ground Zero in the Opioid Epidemic (Martha Bebinger, WBUR, Kaiser Health News, 5-11-17) People often turn to public restrooms as a place to get high on opioids. It has led some establishments to close their facilities, while others are training employees to help people who overdose.
Getting Patients Hooked On An Opioid Overdose Antidote, Then Raising The Price (Shefali Luthra, Kaiser Health News, ) First came Martin Shkreli, the brash young pharmaceutical entrepreneur who raised the price for an AIDS treatment by 5,000 percent. Then, Heather Bresch, the CEO of Mylan, who oversaw the price hike for its signature Epi-Pen to more than $600 for a twin-pack, though its active ingredient costs pennies by comparison. Now comes Evzio, a device that administers just enough naloxone (Vivitrol) to stabilize someone who has overdosed on drugs. Its manufacturer, Kaleo, may be positioning itself to find profits in a dire health care crisis. (Will Republicans, who are heavily supported by the pharmaceutical industry, be willing to limit price-gouging on life-saving medicine and devices?)
Drug Epidemic: 1 Small-Town Mayor Takes on Pill Distributors (AP, NY Times, 4-7-17) In this once prosperous West Virginia coal town of 1,900 people, residents say it's not just the decades-long demise of mining that hurt the community — it's the scourge of drug use that came with it. Here, almost everyone knows someone who became addicted. And the Appalachian town is fighting back by suing some of the biggest U.S. drug distributors, hoping to make them pay for the damage done by addiction. Lawyers say growing pushback by communities, many in West Virginia, could ultimately rival the scope of litigation against tobacco companies over smoking.
Here’s What’s Wrong With How US Doctors Respond to Painkiller Misuse(Maia Szalavitz, Substance.com, 1-13-15). Too often, Americans with painful medical conditions who misuse pain pills like Oxycontin are denied further treatment and even prosecuted. There are more effective, enlightened responses—as the UK has shown for decades.
The Other Victims of the Opioid Epidemic (Susan A. Glod, New England Journal of Medicine, 6-1-17) Solving the problem of the opioid epidemic "will require careful thought, consideration, and most important, development of meaningful interventions to improve both pain management and substance-misuse prevention. These interventions should not come at a cost to the epidemic’s other victims — hospice patients who are too afraid to take the medications they need to control their symptoms; people whose history of substance abuse, no matter how remote, determines whether their pain will be treated; patients like Jerry, who, dying from cancer, his body containing more tumor than anything else, was told he is a monster. He, too, is a victim of this epidemic."

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‘You want a description of hell?’ OxyContin’s 12-hour problem (Harriet Ryan, Lisa Girion and Scott Glover, LA Times, 5-5-16--Part 1 of a 4-part series). See also More than 1 million OxyContin pills ended up in the hands of criminals and addicts. What the drugmaker knew (Harriet Ryan, Scott Glover and Lisa Girion, Part 2 of series, LA Times, 7-10-16). OxyContin goes global — “We’re only just getting started” (Harriet Ryan, Scott Glover and Lisa Girion, Part 3 o series, LA Times, 12-18-16). And How black-market OxyContin spurred a town's descent into crime, addiction and heartbreak (Harriet Ryan, Scott Glover and Lisa Girion, LA Times, 7-10-16).
Update on Medication Assisted Treatment (MAT) in a County Health and Behavioral Health System (Robert Paul Cabaj, MD, San Mateo County report to SAMHSA) San Mateo reported a dramatic drop in ER visits (from 5.8 to 0.2) and number of drinking days for the patients they treated with Vivitrol.
Former Addict: What Indiana Can Learn From New York About Needle Exchanges (Maia Szalavitz, Time, 4-5-15) "The fact that in 2015, federal funding is still banned for needle exchange and 25 states still require people to get a prescription to buy needles is an outrage — both from the human and from the economic perspective. But what’s even more frustrating is that politicians and many journalists still see needle exchanges as controversial when the data on their safety and efficacy is actually stronger than for virtually any other public health intervention, including condoms."
Nonprofit Provides Financial Assistance For Opioid Treatment (Zoe Mitchell, Deborah Becker, WBUR, 2-22-17) Despite efforts to stem the tide of opioid overdose deaths in Massachusetts, the latest numbers suggest that a record number — some 2,000 people — died of overdoses last year. One of the grassroots groups working to make a dent in this crisis is called Magnolia New Beginnings. It was formed by parents on the North Shore a few years ago to provide support to other parents and to help financially, providing scholarships for long term substance use treatment, which typically is not covered by health insurance.
Facing Pressure, Insurance Plans Loosen Rules For Covering Addiction Treatment (Shefali Luthra, Kaiser Health News, 2-21-17) Insurance companies slowly reconsidering the insurance practice of requiring "prior approval" before doctors prescribe particular medications-- such as Suboxone--that are used to mitigate withdrawal symptoms, drugs typically given along with steady counseling. Addiction specialists say this red tape puts people’s ability to get well at risk. It gives them a window of time to change their minds or go into withdrawal symptoms, causing them to relapse. “If someone shows up in your office and says, ‘I’m ready,’ and you can make it happen right then and there--that’s great.

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Pharmacies Thrive Selling Opioids For Depressed Small Town Pain (Phil Galewitz, Kaiser Health News, 2-8-17) Most pharmacies here and in surrounding Clay County, Kentucky (population 21,000) lack the convenience-store trappings of national chains like CVS or Walgreen's. Eleven drug stores, mostly independents, sell few items over the counter, focusing on prescriptions and little else. Clay's residents filled prescriptions for 2.2 million doses of hydrocodone and about 617,000 doses of oxycodone in the 12-month period ending last September — that's about 150 doses for every man, woman and child. 

Fraudulent practices in addiction treatment

The Rehab Racket

She wanted addiction treatment. She ended up in the relapse capital of America. (German Lopez, Vox, 3-2-2020) Brianna Jaynes asked for help for her drug addiction. Then Florida’s rehab industry exploited her for profit. See also She spent more than $110,000 on drug rehab. Her son still died. (German Lopez, Vox, 9-3-19) In story after story, the same experience was repeated over and over: of patients and families getting sucked into an American rehab industry that is largely unregulated, shockingly ineffective, and ruinously expensive. And read She lost her son to addiction, then lost her house to save her daughter ( German Lopez, Vox, 10-31-19) A mother’s story on the grave cost of addiction treatment in America. Vox is investigating America’s addiction treatment system. Help them by sharing your stories.
Agencies target 'illegal, unapproved' products that claim to treat opioid addiction (Laurie McGinley, WashPost, 1-24-18) Federal regulators said Wednesday that they are cracking down on marketers and distributors selling a dozen products that “illegally” claimed to treat or cure opioid addiction and withdrawal. In letters sent earlier this month, the Food and Drug Administration and the Federal Trade Commission cited products that target people desperate to find relief from their addictions. They include “Opiate Freedom 5-Pack,” “CalmSupport” and “Soothedrawal.” Most of the 12 items are marketed as dietary supplements, while two are homeopathic remedies, the FDA said.
How a Rehab Boss Exploited the Drug Epidemic--With Impunity (AP, NY Times, 5-21-18) For years, a drug rehab program in North Carolina sent people with addictions to work for free as caregivers for elderly and disabled patients, often with disastrous results, a new Reveal investigation has found. Participants at Recovery Connections Community bathed patients, changed diapers and sometimes dispensed the same drugs that sent them spiraling into addiction, according to interviews with dozens of former participants. Rather than getting treatment, they worked 16-hour days at care homes across the state, with little training or sleep, internal documents show. Full story here: All Work. No Pay. (Amy Julia Harris and Shoshana Walter, Reveal, Center for Investigative Reporting, 5-21-18) Drug users got exploited. Disabled patients got hurt. One woman, Jennifer Warren, benefited from it all.
Street Hustle: The Truth Behind the ‘New’ Police Tool for Confronting Fentanyl Menace (Ryan Gabrielson, ProPublica, 12-22-16) Drug test manufacturer repackages old, error-prone chemical formula as cutting-edge product. "In Houston, field tests contributed to more than 300 wrongful convictions the past decade, prompting prosecutors to now require lab analysis before reaching a plea deal. Despite volumes of scientific literature, and the regular discovery by formal crime labs of errors in field test results, many police officers and prosecutors believe the kits to be highly reliable.
The Giant, Under Attack (Michael Corkery and Jessica Silvr Greenberg, NY Times, 12-27-17) of America’s biggest rehab companies built an empire. But after a patient named Gary Benefield died, its enemies — investors and business rivals alike — struck hard. "Mr. Cartwright’s company, American Addiction Centers, operates treatment centers in eight states around the country. That was how Mr. Benefield ended up in a treatment facility in California: Eager to get sober, he and his wife searched online from their home in Arizona for a clinic, found A Better Tomorrow — which eventually became part of Mr. Cartwright’s business — and then called up to book a spot. This account of Mr. Benefield’s final days, and the battle over American Addiction Centers, draws on interviews with executives, front-line employees, addicts, police and investors, as well as thousands of court documents."
Rogue doctors exploit loopholes to let a powerful drug ‘devastate a community’ (Laura Ungar, Courier Journal, 6-8-17) 'How a medication intended to curb opioid cravings and ease withdrawal was being prescribed by doctors with disciplinary records, fueling misuse and the rise of rogue clinics that Kentucky’s attorney general called “the second coming of our pill mills.”~Susan Stellin
Arizona lawsuit opens window into lucrative drug rehab business — and allegations of fraud (Ken Alltucker, The Republic, AZCentral, 12-4-17) Nine alcohol and drug rehabilitation centers claim in a Maricopa County Superior Court lawsuit that the health insurance company Health Net of Arizona improperly withheld or delayed lucrative payments for treatment of people struggling with addiction. But Health Net says in a counterclaim that there was widespread fraud among Arizona and California drug rehab centers in 2015 and 2016, when it alleges "teams of brokers" recruited out-of-state clients to fraudulently obtain insurance policies and to seek treatment in Arizona. Those actions have cost the insurance company — and Arizona consumers through higher monthly premiums — tens of millions of dollars, the Health Net counterclaim say...The growth of rehab centers corresponds with the rise of residential “sober homes” that have sprouted in upscale neighborhoods of Phoenix, Paradise Valley, Scottsdale and other communities in metro Phoenix. The proliferation of these homes pits residential neighbors against rehab entrepreneurs in standoffs that have created headaches for local government officials as they try to determine how to manage the unregulated industry....A key funding source for the rehab centers, which often work in tandem with sober homes, has been urinalysis testing. These tests, for which the centers charged large and repetitive fees, proved lucrative from 2014 through 2016."
Searching for help She turned to Google for help getting sober. Then she had to escape a nightmare. As a NiemanReports article reported, "deep-pocketed and sometimes unethical treatment providers can manipulate Google’s advertising program to attract clients. For instance, an online search for a rehab center could lead to a site with a toll-free phone number for a business selling patient referrals to the highest bidder." After the Verge article appeared, "Google announced a crackdown on rehab ads, a business Bloomberg reported may have added up to $1 billion a year in revenue for Google, which charged $100 or more in fees for clicks on ads linked to searches like “heroin rehab near me.” See Why It Took Google So Long to End Shady Rehab Center Ads (Bloomberg Business Week, 9-26-17) and Exclusive: Google is cracking down on sketchy rehab ads (Cat Ferguson, The Verge, 9-14-17) "Following a Verge report about rehabs gaming Google, the company has begun pulling AdWords." (Journalism, not law enforcement, brought about change.)
Doctors Make Big Money Testing Urine For Drugs, Then Ignore Abnormal Results (Fred Schulte, Kaiser Health News, 11-29-17) A KHN investigation earlier this year found that dozens of pain doctors with their own labs took in $1 million or more in 2015 from Medicare for running urine and, in some cases, genetic drug tests. Some doctors derived at least 80 percent of their Medicare income this way. Medicare and other insurers pay for urine tests with the expectation that clinics will use the results to detect and curb dangerous drug abuse. But some doctors have taken no action when patients are caught misusing pharmaceuticals, or taking street drugs such as cocaine or heroin. Medicare and private insurers acknowledge that they lack the resources to routinely verify that doctors who order a high volume of drug-related tests do so to improve patient care, not fatten the bottom line.
Called ‘hogwash,’ a gene test for addiction risk exploits opioid fears (Charles Piller, STAT News, 12-13-16) Proove Biosciences, a Southern California company that markets an unproven “opioid risk” test, claims its test can predict, with 93 percent accuracy, which patients will become addicted to or misuse prescribed opioid pain pills. But STAT has found that the opioid risk test lacks a firm scientific basis. Genetics and addiction experts — including one of Proove’s medical advisers — said genetic testing isn’t able to predict addiction, and questioned the evidence used to back up the company’s accuracy claim. Erroneous results could misinform doctors and lead them to unnecessarily refuse opioids to patients suffering severe pain, the experts warned. (Follow-up for journalists: Story about genetic testing company’s problems shows how good reporting stands up to criticism (Joseph Burns, Covering Health, AHCJ, 11-17-17) Piller wrote four articles about Proove over eight months that questioned the validity of the test and the company’s marketing practices. Piller addresses common issues in reporting this kind of story and offers suggestions for journalists seeking to gain the trust of sources who might be unwilling to speak on the record and how to identify clinical lab testing companies that might be selling questionable tests.
Addiction Inc. (NY Times, 1-3-18) Marketing wizards and urine-testing millionaires: Inside the lucrative business of America’s opioid crisis.
"Desperate for addiction treatment, patients are pawns in lucrative insurance fraud scheme (David Armstrong and Evan Allen, STAT and Boston Globe, 7-27-17) Drug users, desperate to break addictions to heroin or pain pills, are pawns in a sprawling national network of insurance fraud, an investigation by STAT and the Boston Globe has found. They are being sent to treatment centers hundreds of miles from home for expensive, but often shoddy, care that is paid for by premium health insurance benefits procured with fake addresses. Patient brokers are paid a fee to place insured people in treatment centers, which pocket thousands of dollars in claims for each patient. They often target certain Blue Cross Blue Shield plans, because of their generous benefits and few restrictions on seeking care from out-of-network treatment programs."
The addict brokers: Middlemen profit as desperate patients are ‘treated like paychecks’ (David Armstrong and Evan Allen, STAT and Boston Globe, 5-28-17) "Patient brokers can earn up to tens of thousands of dollars a year by wooing vulnerable addicts for treatment centers that often provide few services and sometimes are run by disreputable operators with no training or expertise in drug treatment, according to Florida law enforcement officials and two individuals who worked as brokers in Massachusetts. Cleggett refused to say whether he was paid to find customers for Florida treatment centers. The facilities are tapping into a flood of dollars made available to combat the opioid epidemic and exploiting a shortage of treatment beds in many states. As center owners and brokers profit, many patients get substandard treatment and relapse."
Profit-Mining the Opioid Crisis: Targeted by an addiction treatment center, union workers feel trapped as their benefits are drained (David Armstrong and Evan Allen, STAT and Boston Globe, 11-10-17) "One after another, New Jersey public school teachers arrived at the Recovery Institute of South Florida after asking their union to find them addiction or mental health treatment. Instead of getting the help they needed, many said they were essentially trapped at the facility while their health insurance was billed tens of thousands of dollars....The teachers’ experience is a stark example of what’s happening around the country to union members fighting addiction. Treatment center operators and middlemen who act as brokers for those facilities are targeting these workers because they usually have generous insurance benefits that pay for long stays in rehab. They also often need a health care provider’s clearance to return to work, handing the centers tremendous power over patients....teachers, mostly from New Jersey, as well as school custodians and social workers or their relatives. Most said they were allowed only limited contact with family. They complained about inadequate and cookie-cutter treatment, consisting mostly of group counseling and 12-step meetings, massages at a local chiropractor’s office, and plenty of free time."
Some Addiction Treatment Practices Are Making Me Sick (Deni Carise, HuffPost, 3-13-17) There are " unscrupulous people trying to make a profit off of our nation’s current drug epidemic with unethical and shocking practices like patient brokering, identity theft, kickbacks and insurance fraud. It’s not widespread abuse – fortunately, there are still many high-quality, ethical treatment programs in this country – but it is happening often enough for us all to be concerned."
Addicts For Sale (Cat Ferguson, BuzzFeedNews, 3-19-16) In the rehab capital of America (Del Ray, Florida), addicts are bought, sold, and stolen for their insurance policies, and many women are coerced into sex. They are kids who are often broke and far from home, with limited support from family and friends; they can be mentally and physically unstable; and they’re frequently running from parole or pending court cases. The people targeting them are variously called “marketers,” “body brokers,” and even “junkie hunters.” They know addicts better than anyone (and many used to be addicts themselves).
Preying on the Vulnerable: Sober Home Fraud (Jean Lyon, HMS, 4-27-17) A sober living home is generally defined as an alcohol- and drug-free living environment for newly sober individuals who are trying to abstain. Because sober homes can be an important step between inpatient rehabilitation and an independent living environment, many insurers provide coverage for not only the SLH, but also for related services such as outpatient rehab, counseling, and drug testing to monitor the patient’s sobriety. But a variety of schemes have been perpetrated in sober homes, including patient brokering, kickbacks, not being a sober home, identity theft, billing for services not needed or rendered, predatory marketing practices, and waiver of the co-pay.
Addiction Treatment: Inside the Gold Rush (Palm Beach Post
County’s $1 billion gold rush: Addiction treatment draws FBI (Pat Beall, Palm Beach Post, 8-14-15) t took Frank Cid just six years to create a lucrative, one-stop addiction recovery empire big enough to bring Wall Street to town. And Wall Street brought cash. Last September, an affiliate of Goldman Sachs was preparing to shell out $32.5 million for the real estate investor’s portfolio of high-end treatment programs: detox, rehab, outpatient sober living rentals and a lab to test his clients’ urine. Post reporters investigated corruption, patient brokering, and insurance fraud in the sober home industry since 2015. Also known as halfway houses, sober homes offer transitional housing for people who have completed in-patient rehabilitation, typically requiring drug testing and imposing other rules. The series includes "articles about sober home residents openly using drugs, allegations that one owner was using clients as part of a prostitution business, and reports that some owners are cashing in on the chance to bill insurance companies for urine samples collected from residents for drug testing—earning $150 for each sample collected as many as five times per week." In other words, about corruption in the sober home industry.
New Law Aims To Prevent Fraud In Florida Recovery Industry (Victoria Kim, The Fix, 7-06-17) The billion-dollar addiction recovery industry, especially prevalent in South Florida’s Palm Beach County, has come under fire for reports of fraud and abuse. "Florida officials say many of South Florida’s private treatment centers “aggressively” market recovery services in other parts of the United States like the Northeast and Midwest, hoping to draw clients to the Sunshine State with promises of lasting results. According to the Sun Sentinel, every three out of four clients in private treatment for substance use disorder in Florida are from out of state....The law establishes tighter rules and penalties on sober living homes that falsely advertise its services and companies that scam clients. Sober home telemarketers must also register with the state to prevent patient brokering, and background checks are now mandatory for any owners, directors and clinical supervisors at treatment centers."

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Practical issues in solutions to the opioid crisis

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Children of the Opioid Epidemic (Jennifer Egan, NY Times Magazine, 5-9-18) In the midst of a national opioid crisis, mothers addicted to drugs struggle to get off them — for their babies’ sake, and their own. While there is little doubt that drug and alcohol dependency can compromise a person’s ability to parent, for the child, being separated from a parent is hugely traumatic.
Federal Prisons Were Told to Provide Addiction Medications. Instead, They Punish People Who Use Them. (Beth Schwartzapfel and Keri Blakinger, The Marshall Project, 12-12-22) Congress directed the Bureau of Prisons to make Suboxone and other medications widely available, but only a small fraction of those who need the help have received it. The bureau would not discuss the barriers to rolling out the program more widely, but prisoners and people who work in the system described a widespread misperception among prison staff that Suboxone substitutes one addiction for another. There's broad discretion among prison staff about who qualifies for treatment. The bureau also requires patients to get approval from multiple health care providers, and each step has its own lengthy waitlist. See also
---These Meds Prevent Overdoses. Few Federal Prisoners Are Getting Them (Beth Schwartzapfel, The Marshall Project and USA Today, 8-10-21) Three years after the First Step Act required the Bureau of Prisons to treat more people with medications for opioid addiction, only a tiny fraction are receiving them. (Scroll down for more stories on this topic.)
---When Going to Jail Means Giving Up The Meds That Saved Your Life (Beth Schwartzapfel. The Marshall Project, 1-29-19) Most jails and prisons around the country forbid methadone and a newer addiction medication, buprenorphine, even when legitimately prescribed, on the grounds that they pose safety and security concerns. The drugs are frequently smuggled into facilities and sold or traded among prisoners. How the Americans With Disabilities Act could change the way the nation’s jails and prisons treat addiction.
---A Better Way to Treat Addiction in Jail (Beth Schwartzapfel, The Marshall Project, 3-1-17) Medications are effective, but jails are still slow to provide them.
---The Anti-Heroin (Alysia Santo, The Marshall Project, 2-17-15) Is Vivitrol an answer to addiction? A drug-plagued county thinks so.
Opioid Crisis Compels New York to Look North for Answers (J. David Goodman, NY Times, 3-21-18) Supervised injection sites for heroin users have prevented overdose deaths in Canada. But is New York City ready for the scenes that come with them?
How Will Governments Spend Their Opioid Settlements From Drug Companies? (Liz Farmer, Governing, 5-17-19) As they start to roll in, some say the tobacco settlement offers a cautionary tale. "Most of those proceeds have disappeared into state general funds, leaving just a portion left over to help defray the public health costs of smoking. According to a 2007 report from the Government Accounting Office, states on average had allocated just 30 percent of their settlement money to health care. Nearly as much -- 23 percent -- went to cover budget deficits."
From Twitter to Treatment Guidelines, Industry Influence Permeates Medicine (Charles Ornstein, Shots, NPR, 1-17-17) The long arm of the pharmaceutical industry continues to pervade practically every area of medicine, reaching those who write guidelines that shape doctors' practices, patient advocacy organizations, letter writers to the Centers for Disease Control and Prevention and even oncologists on Twitter, according to a series of papers on money and influence published Tuesday in JAMA Internal Medicine. Check whether your physician receives money from drug or device companies through ProPublica's 'Dollars for Docs' search tool.
Financial Conflicts of Interest and the Centers for Disease Control and Prevention’s 2016 Guideline for Prescribing Opioids for Chronic Pain (Dora H. Lin, Eleanor Lucas, Irene B. Murimi, et al., JAMA Internal Medicine, March 2017) When the CDC released its 2016 guidelines for prescribing opioids for chronic pain, some organizations argued that development of the guidelines was not transparent and the recommendations were based on weak evidence. When the CDC opened them to public comment, then analyzed the comments to identify levels of support for the guidelines and whether financial relationships with opioid manufacturers were associated with opposition to the guidelines. Opposition to regulatory, payment, or clinical policies to reduce opioid use may originate from groups that stand to lose financially if sales of opioids decline. The CDC findings demonstrate that greater transparency is required about the financial relationships between opioid manufacturers and patient and professional groups. In the future, the CDC should request or require such information, just as the US Food and Drug Administration suggests that such information be provided as part of public comments to the agency.
Chronic Pain Patients Angry Over ‘Opioid Contracts’ (Shawn Radcliffe, Healthline, 5-2-18) More patients with chronic pain are being asked to agree to random urine drug screens, pill counts, and other conditions before they’re prescribed opioids. Many concerns, little evidence that the contracts are effective.
Addiction and Substance Abuse Among Persons with Disabilities (Disabled World)
Can We Disinherit Our Addicted Son? (Kwame Anthony Appiah, The Ethicist column, NY Times, 11-6-18) "Under other circumstances, we would split everything equally among our children, but for our addicted son, this would be like throwing gasoline on a fire. Even the process of distributing family treasures is fraught, knowing our son would head straight to a pawnshop. We are thinking of putting his share into a trust to be used exclusively for his future health needs, rehab and, hopefully, sobriety. But again, we love our son, and it is heartbreaking to realize we are essentially leaving him nothing tangible. What is the ethical thing for us to do?"
Infectious disease outbreaks rise with opioid epidemic (Bara Vaida, Covering Health, 8-27-18) Cases of infectious diseases such as hepatitis A, B and C, sexually transmitted diseases (STDs) and human immunodeficiency virus (HIV) have surged as the opioid epidemic has worsened over the past several years. The increasing number of infectious disease cases are likely due to infected needle injections, unprotected sex, homelessness, lack of access to medical care and other socioeconomic challenges associated with people who have physical addictions to drugs and opioids.
Washington nurses, health care workers are dying of opioid overdoses (Rachel Alexander, Spokesman-Review, 2-4-18) Health care workers aren't immune from the opioid epidemic. 'Though doctors, nurses and pharmacists are among the people best-equipped to see the consequences of drug addiction, they’re also susceptible to drug abuse thanks to an intersection of factors: high-stress jobs, odd hours and a belief that they know how to stay in control of the drugs they prescribe or administer routinely. Doctors with an addiction problem tend to abuse alcohol most frequently...Nurses are far more likely to abuse opioids or other prescription drugs...Cleveland believes Beth’s addiction started shortly after her marriage, when her migraines began getting worse. She would be in so much pain that she’d have to sit in the dark in bed all day, unable to look at lights or a screen....anyone, from any background, can become addicted to narcotics. But that’s not always enough to make people willing to seek help....stigma around addiction...Mas “There’s oftentimes a message that addiction is about people making a choice, a bad choice, and people could choose not to be addicted if they wanted to but they don’t want to.”'
How Germany Averted An Opioid Crisis (Shefali Luthra, KHN, 11-11-19) "Unlike in the United States, where these pills are commonly dispensed after surgeries and medical procedures, opioids have never emerged as a front-line medical treatment in Germany....Doctors must first try alternative treatments, which the nation’s universal health insurance system typically covers. Before prescribing opioids, physicians must get special permission and screen patients to make sure they aren’t at risk for addiction."
Does evidence support supervised injection sites? (Jennifer Ng, Christy Sutherland, Michael R. Kolber, Can Fam Physician, Nov 2017) It is saving lives.
Injecting Drugs Can Ruin a Heart. How Many Second Chances Should a User Get? (Abby Goodnough, NY Times, 4-29-18) A life-threatening heart infection (endocarditis) afflicts a growing number of people who inject opioids or meth. Costly surgery can fix it, but the addiction often goes unaddressed.
The Other Opioid Crisis: Hospital Shortages Lead to Patient Pain, Medical Errors (Pauline Bartolone, KHN, 3-16-18) A nationwide shortage of injectable opioid painkillers has left hospitals scrambling to find alternatives — in some cases leading to dosage mistakes that may harm patients.
Measuring the Toll of the Opioid Epidemic Is Tougher Than It Seems (Charles Ornstein, ProPublica, 3-13-18) One of our editors set out to create an ambitious list of data sources on the opioid epidemic. Much of what he found was out of date, and some data contradicted other data.
Death in the Family: An Uncle’s Overdose Spurs Medicaid Official to Change Course (Emmarie Huetteman, KHN, 1-29-18) Andrey Ostrovsky’s family did not discuss what killed his uncle. He was young, not quite two weeks past his 45th birthday, when he died, and he had lost touch with loved ones in his final months. Ostrovsky speculated he had committed suicide. Almost two years later, Ostrovsky was Medicaid’s chief medical officer, grappling with an opioid crisis that kills about 115 Americans each day, when he learned the truth: His uncle died of a drug overdose.
There Is More Than One Opioid Crisis (Kathryn Casteel, FiveThirtyEight, 1-17-18) To better tackle the epidemic, Kentucky needed to know which drugs were causing lethal overdoses.
What to Make of a Head-to-Head Test of Addiction Treatments (Jake Harper, NPR, 11-16-17) The largest study so far to directly compare the widely used treatment Suboxone with relative newcomer Vivitrol found them equally effective once treatment started. But there are fundamental differences in the way treatment begins, which makes these findings difficult to interpret. Vivitrol, an injection of naltrexone that lasts 28 days, has gained a foothold among treatment providers, especially those working with the criminal justice system. Until recently, no major study had compared it to Suboxone, a combination of buprenorphine and naloxone that is taken by mouth daily. Now researchers have found the two medications to be equally effective at preventing relapse once patients start treatment, but a Lancet study highlights a limitation for patients starting on extended-release naltrexone: Patients have to detox before receiving their first dose of Vivitrol (which is also far more expensive). That requirement creates a significant barrier to beginning treatment, says Dr. Joshua Lee. Clearly there is a place for both treatments.
Q&A: The Death Penalty for Drug Trafficking? (Vanessa Schipani and Robert Farley, FactCheck.Org, 4-5-18) 'Statutorily, the Trump Administration has the authority to pursue the death penalty"... but "Robert Dunham, executive director of the Death Penalty Information Center, told us in a phone interview: “No administration, Republican or Democrat, has acted on that statutory authority.”And that’s because of questions about whether such a case would withstand a constitutional challenge before the Supreme Court.'
We asked overdose survivors about the dangerous trend of mixing opioids with depressants or stimulants, a key part of America's larger crisis. (Maia Szalavitz, Vice, 2-21-18) 'America’s so-called “opioid overdose epidemic” may be more accurately defined as a kind of “multiple drug poisoning” crisis, one that needs to be much better understood in order to save lives....Even with the lack of data on polydrug use, we do know that for opioid users, drug mixing is the rule rather than the exception. And while childhood trauma and pre-existing mental illness are ubiquitous among people with addiction in general, they are even more so here.' And other explanations of the complexity of mixing drugs.
Senators Introduce Legislation To Fight Fentanyl (Senate.gov, 3-22-18) Senators Tom Cotton (R-Arkansas), Lindsey Graham (R-South Carolina), John Kennedy (R-Louisiana), Bill Cassidy, M.D. (R-Louisiana), Dean Heller (R-Nevada), and Ben Sasse (R-Nebraska) introduced legislation to fight the opioid epidemic by strengthening penalties for fentanyl distribution and trafficking to ensure they better reflect the serious nature of the crime.
Like Less Crime? Thank Mandatory Minimums (William Otis, US NEws, 9-2-13)
Five Things About Deterrence (National Institute of Justice) Drawn from Daniel S. Nagin's 2013 essay, "Deterrence in the Twenty-First Century." Research shows that 1. The certainty of being caught is a vastly more powerful deterrent than the punishment. 3. Police deter crime by increasing the perception that criminals will be caught and punished.
Sam Quinones testifying at a hearing on the opioid epidemic (1-9-18). Quinones is the author of Dreamland: The True Tale of America’s Opiate Epidemic
"Everything You Know About Addiction Is Wrong" (video, Johann Hari's TED Talk) You can read the trancript. Johann Hari spent three years researching the war on drugs; along the way, he discovered that addiction is not what we think it is.
How Trump Is Mishandling the Opioid Crisis: The Daily Show (Trevor Noah, 10-26-17)
Trevor Noah weighs in on how President Trump's response to opioid abuse is a small, meaningless gesture in the public health crisis.
Trump opioid plan writes in favoritism to single company’s addiction medication (Lev Facher, STAT, 3-26-18) "The White House’s national strategy to combat the opioid crisis, unveiled last week, would expand a particular kind of addiction treatment in federal criminal justice settings: a single drug, manufactured by a single company, with mixed views on the evidence regarding its use. The document referred specifically to naltrexone in its injectable form....Only one manufacturer makes a drug fitting that description: Alkermes, a Massachusetts pharmaceutical company that makes Vivitrol, a monthly injectable drug that blocks the effects of opioids and reduces cravings. The company has been criticized for aggressive tactics in pitching its product — which can cost over $1,000 per dose — to criminal justice systems."
Is 20.8 Million Pain Pills Over a Decade a Lot for One Town? It Depends. (Alex Barasch, Slate, 1-30-18) Over-prescription is a real danger, but reducing the opioid crisis to a numbers game won’t bring about a solution. Some pain patients are being cut off from medications that can help them.
Opioid Drug Users Tell Of Rarely Discussed Injury: Rape (Martha Bebinger, CommonHealth, WBUR, 9-6-17) How sexual assault is becoming 'normalized' in a crisis. "It's an injury active drug users often don't report out of shame, distrust of police or fear they'll be labeled a "cop caller" and have trouble buying heroin. It's an injury women say they can't figure out how to prevent. And it's one few doctors think to ask about, and thus do not treat. The road to trouble starts many mornings, says Kristin, when she wakes up, sick and desperate for heroin but afraid to shoplift, sell the goods, and seek a dealer on her own. So she finds a male buddy, someone she calls a running partner....Sometimes that strong man with a good reputation turns out to be another danger. Kristin cringes at the memory of falling into a drug-induced sleep near a running partner she’d come to trust."
Underground Needle Exchange Helps Iowans Who Inject Drugs (Katarina Sostaric, Iowa Public Radio, 1-25-18) Staff from the nonprofit Iowa Harm Reduction Coalition meet clients wherever they are to provide several services, including on-site blood tests for HIV and hepatitis C. Volunteers from a collective called Prairie Works sometimes join the nonprofit and give out clean needles and syringes to prevent the spread of those diseases. That’s the illegal part. This illegal needle exchange is trying to prevent diseases among injection drug users while Iowa lawmakers consider a bill to legalize that kind of program.
Opioid Crisis Blamed For Sharp Increase In Accidental Deaths In U.S. (Scott Neuman, The Two-Way, NPR, 1-17-18) Accidental deaths in the United States rose significantly in 2016, becoming the third-leading cause of fatalities for the first time in more than a century – a trend fueled by the steep rise in opioid overdoses, the National Safety Council reports. Accidents — defined by the council as unintentional, preventable injuries — claimed a record 161,374 lives in 2016, a 10 percent increase over 2015. They include motor vehicle crashes, falls, drowning, choking and poisoning, a category that encompasses accidental overdoses.

Is America’s opioid epidemic killing the economy? (Michael E. Kanell, Atlanta Journal-Constitution, 9-5-17) Estimates are that abuse of legal drugs cost more than $70 billion last year – and that doesn’t include the surge of heroin and fentanyl. ... And it is so widespread and so damaging that it seems to be a partial answer to some big puzzles that economists have been grappling with. “We are missing about 3 million people out of the labor force,” Korzenik said. “If we had a participation rate – for each demographic – that we had in 2003, we would have 3 million more people working. That is adjusting for the baby boomer retirement. So if it is not the people aging out, what else is it?” There are other explanations, but the more he looked at it, the more the data drove him toward opioids as explanation. “Eight years of economic expansion and we are running out of labor. We are in the end game of the economic expansion. And we have never had anything like the opioid epidemic hit the labor force. Maybe the 1918 influenza epidemic, otherwise nothing.”• Bridgewater State Says It Will Be First US University To Make Narcan Publicly Available (Ben Thompson, Boston Globe, 9-5-17) Bridgewater State University will offer public access to Narcan in locations across campus to combat potential overdoses, the university said. The university’s police department is launching an “aggressive” opioid overdose prevention program, making the overdose-reversing drug available in 50 defibrillator boxes across campus buildings, including all 11 residence halls, university officials said.
Mapping How the Opioid Epidemic Sparked an HIV Outbreak (Heather Boerner, Shots, Public Health, NPR, 1-14-18) Genetic data has been used to track HIV before. But now, the technology is being used to map HIV outbreaks in real time, lending molecular weight to the in-person interviews that public health officials have used for centuries to track and stop outbreaks. The Austin reconstruction is an example of what it can do....the CDC decided to use the same kind of molecular sleuthing that ferreted out Dugas's real place in the epidemic, and layer those results over the data health workers collected in interviews. The idea was that they'd test it on the Indiana outbreak first, and then offer the technology, which uses multiple programs and takes partner interviews into account, for free to public health departments across the country....At each step in this outbreak, officials could have intervened without the DNA map, Cooke says. If that early person with HIV were able to access treatment, the risk of transmitting the virus in the first place would have been negligible. If there had been a syringe access program, there would have been less needle sharing and even injecting drugs wouldn't have transmitted the virus. If there was adequate mental health care, people might deal with childhood traumas differently. If addiction treatment were more readily available, if HIV prevention tools like Truvada were available everywhere — all of these could have deescalated the outbreak, he says."
Some of the best opioid coverage is not where you’d expect (Anna Clark, Columbia Journalism Review, 10-17-17) Stories about the opioid crisis aren’t just being told in expansive features and smartly reported articles. They’re being told in the obituaries. They carry the most weight across the huge swaths of the country that are near-news deserts, like southwest Michigan, where the Jonatzkes live. In these places, there aren’t any deeply reported local stories about heroin use. But there are obituaries. Lots of them. These obituaries track the devastating human cost of a modern-day plague, challenge the stigma of addiction, and build a case for better public policy and social services. In some cases, the person who died specifically requested that their story be told honestly.
Seeking Payback for Opioid Costs, Manchester Files Suit Against Drug Makers (Casey McDermott, New Hampshire Public Radio, 9-6-17) Opioid-related overdoses rose more than 80 percent in August compared to a year earlier, but the number of deaths dropped by more than half, authorities said Tuesday. Such overdoses were up slightly during the first eight months of this year over the same period last year, but the number of fatalities fell by more than a third, according to city fire department figures. "New Hampshire became the latest state to go after Purdue Pharma, alleging the company’s marketing practices were partially to blame for the state’s opioid epidemic. Now, the city of Manchester is also suing Purdue — as well as other opioid manufacturers and distributors — seeking payback for the cost it's incurred because of the drug crisis. The city’s 234-page complaint, filed Friday in Hillsborough County Court North, minces no words. It begins: 'This case is about one thing: Corporate greed. Defendants put their desire for profits above the health and well-being of the City of Manchester, its residents and consumers, all at the cost of the plaintiff.' Defendants in this case include Purdue Pharma as well as several other opioid manufacturers and distributors: Teva Pharmaceuticals, Johnson & Johnson, Cephalon, Allergan and Endo Pharmaceuticals, among others. [Emphasis added.]
Second patient says doctor under FBI investigation pushed opioid spray (Andy Marso, Kansas City Star, 9-5-17) "A lawsuit filed Friday alleges that Steven Simon urged Johnson County resident Carey Ballou to take Subsys, an oral fentanyl product with a high potential for addiction, even though less risky, less expensive alternatives existed, and she was reluctant to take the drug. The complaint was similar to a lawsuit filed the same day on behalf of Olathe resident James Whiting, who told the Star in July that Simon pressured him to take Subsys without informing Whiting that he was being paid by the drug’s Arizona-based manufacturer, Insys Therapeutics."
Jobs are here; Ky.’s workforce needs addiction treatment (Dave Adkisson, Lexington Herald Leader, ) Among the many health challenges facing America, none has hit Kentucky harder than opioid addiction. The impact of the opioid crisis on Kentuckians’ health is staggering, with more than 1,400 overdose deaths reported last year. Less obvious, however, is the toll it has taken on the state’s economic growth and development. In Kentucky, the opioid crisis has contributed to a workforce participation challenge that undermines the competitiveness of existing businesses while creating barriers to new investments.
My Fellow Conservatives Should Protect Medical Marijuana From The Government ((Rep. Dana Rohrabacher (R-Calif.), Washington Post, 9-5-17)) "I should not need to remind our chief law enforcement officer nor my fellow Republicans that our system of federalism, also known as states’ rights, was designed to resolve just such a fractious issue. Our party still bears a blemish for wielding the “states’ rights” cudgel against civil rights. If we bury state autonomy in order to deny patients an alternative to opioids, and ominously federalize our police, our hypocrisy will deserve the American people’s contempt."

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Alcoholism, binge drinking, and approaches to treatment

"To many, total abstinence is easier than perfect moderation." ~Saint Augustine


Tough to Swallow: Clinicians Are Neglecting Alcohol Use (Katie Witkiewitz and Hannah Carlon, MedPage Today, 3-4-23) More widespread screening and support for reduced drinking are essential. "Most American adults drink alcohol, and 45% binge drink-- five or more drinks per occasion for men, 4 or more drinks per occasion for women -- at least monthly....Importantly, reductions in alcohol consumption -- even without abstaining completely -- are associated with clinically meaningful improvements in health and functioning.

     The Healthcare Professional's Core Resource on Alcohol (National Institute on Alcohol Abuse and Alcoholism (NIAAA), NIH) provides step-by-step instructions on how to screen for alcohol use and what to do if somebody screens positive. You can also earn free continuing medical education credits for moving through the online resource.
      Healthcare providers have a range of tools available to support patients who are experiencing difficulties related to alcohol use.
      Naltrexone, acamprosate, and disulfiram are all FDA approved for alcohol use; none of these prescriptions require specialized training or licensure to prescribe safely and effectively. Naltrexone can be prescribed via an injectable, daily dosing, or on an as-needed basis to reduce heavy drinking. Disulfiram should only be prescribed for those who want to abstain completely from alcohol. Topiramate, baclofen, varenicline (Chantix), and gabapentin are commonly used off-label; varenicline might be particularly helpful for heavy drinkers who also smoke cigarettes.   

      The NIAAA Health Professional's Core Resource on Alcohol (also mentioned above) and the American Psychiatric Association Practice Guideline provides more information on these medications
      The NIAAA's Alcohol Treatment Navigator provides an overview of different treatments and links for treatment programs throughout the U.S. For patients who may be contemplating changing their drinking, the free, online Rethinking Drinking provides worksheets and self-paced tips for drinking reductions and the Kaiser Permanente patient decision aid offers a range of resources. There are also a number of mutual support groups, many of which offer online programs for those who cannot access in-person groups. Go here for the full article. (Hat tip to MedPage Today, a property of EveryDay Health Group, for an excellent article. I've exceeded fair use here mostly because it will be super-helpful to people who suspect they have a drinking problem.)


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But Maybe I Can Drink Again Someday (Sydney Lea, The Small Bow newsletter, 5-30-23) The Small Bow is a recovery newsletter, mostly.

Blind Drunk (Ted Alcorn, New Mexico In Depth, 7-24-22) Alcohol is killing New Mexicans at a higher rate than anywhere else in the country — yet the state has largely neglected the growing crisis. In this seven-part series, New Mexico In Depth investigates the state’s blind spots and shines a light on solutions.
---An Emergency Hiding in Plain Sight Drinking kills New Mexicans at a far higher rate than anywhere else in the nation, and the crisis is escalating.
---Eyes on the Road In New Mexico’s war on DWI, the relentless focus on drunk drivers misses the bigger problem of addiction.
---A Missing Ingredient As violence in New Mexico spikes, state leaders overlook alcohol’s integral role.
---Poisonous Myths Stereotypes about alcohol and Native people are hiding a crisis that’s bigger than any single group.
---Every Door Is the Right Door Alcohol dependence is New Mexico’s biggest untreated substance use problem. Doctors can do more to treat it.
---Paying the Tab Scientists say policies can help the state cut excess drinking, but lawmakers listen to alcohol interests instead.
---A Sober Appraisal Reducing New Mexico’s extraordinary alcohol death rate will require a whole-of-society approach. Eleven recommendations.
---Alcohol and Your Health When it comes to drinking, how much is too much?
---Resources for Reporters Tools for reporters, whether your beat is health, crime, business, or politics.
Alcohol Does More Harm than Heroin and Crack (Temma Ehrenfeld. YourCareEverywhere, 6-3-15) 'Legal drugs are the deadliest. Alcohol use causes more than 4 percent all deaths worldwide, more than the number caused by HIV/AIDS, violence, or tuberculosis, according to a 2011 report by the World Health Organization. It is associated with violence, child neglect and abuse, crime, missing work-days, and of course, traffic accidents. ”Yet, despite all these problems, the harmful use of alcohol remains a low priority in public policy, including in health policy,” the authors write. We spend huge sums on fighting a war on illegal drugs and pay little attention to the misuse of a legal one.'

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Alcohol Deaths Claim Lives of Working-Age Americans (Ted Alcorn, NY Times, 11-1-22) A C.D.C. study estimates that, over five years, one in eight deaths of people ages 20 to 64 in the years 2015-19 was the result of injuries or illness caused by excessive alcohol use.
Is Alcoholism Genetic? A Look at Hereditary Factors and Predisposition (Emily Guarnotta, GoodRx Health, 3-7-22) About half of a person’s risk of developing alcoholism is due to genetic factors. Environmental factors also play a role, such as life experiences, including trauma. What you can do to reduce your chances of becoming addicted to alcohol.
The overlooked toll of drinking alcohol while pregnant. (National Geographic, 8-22) Estimates suggest up to 5 percent of people in the U.S. have fetal alcohol spectrum
Alcoholism and me: ‘I was an addicted doctor, the worst kind of patient’ (Carl Erik Fisher, The Guardian, 2-8-22) My drinking and drug use pushed me over the edge into a complete breakdown. Then a stint in rehab made me question how much we really understand about addiction.
Harmful Interactions: Mixing Alcohol with Medicines (National Institute on Alcohol Abuse and Alcoholism) Some medicines that you might never have suspected can react with alcohol, including many medications which can be purchased “over-the-counter”—that is, without a prescription. Even some herbal remedies can have harmful effects when combined with alcohol. A list of common medications seniors take and how each interacts dangerously with alcohol. H/T Drug and Alcohol Treatment Resources for the Elderly (Recovery Village)
8 tips on how to cover drinking responsibly (Chloe Reichel, Journalist's Resource, 6-3-19) Tip #6: Report on the scientific nature of issues related to drinking--for example, how blackouts affect memories of bad behavior associated with excessive drinking.
Calculate Your Blood Alcohol Content (BAC) (Rates for Insurance) DUI laws make it vital for anyone drinking outside of their home to be aware of their blood alcohol content before hopping in the car.
A Public Radio Listener Walks into a Bar: Your Stories About Drinking Alcohol (1a, NPR, 8-12-19) Listeners talk about their relationships with alcohol, which vary greatly. An interesting discussion.

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Nothing Good Can Come from This by Kristi Coulter. "Kristi Coulter charts the raw, unvarnished, and quietly riveting terrain of new sobriety with wit and warmth. Nothing Good Can Come from This is a book about generative discomfort, surprising sources of beauty, and the odd, often hilarious, business of being human." ~ Leslie Jamison
The Recovering: Intoxication and Its Aftermath by Leslie Jamison. "With its deeply personal and seamless blend of memoir, cultural history, literary criticism, and reportage, The Recovering turns our understanding of the traditional addiction narrative on its head, demonstrating that the story of recovery can be every bit as electrifying as the train wreck itself."
Quitting alcohol can be deadly: Hundreds in the US die each year (Jayne O'Donnell, USA Today, 11-27-18) Doctors say alcohol is often the most dangerous substance for the body to withdraw from – and still more so, when attempted without medical supervision. About 16 million people in the United States have alcohol use disorder, which the National Institutes of Alcohol Abuse and Alcoholism define as "compulsive alcohol use, loss of control over alcohol intake, and a negative emotional state when not using." For those experiencing the most serious symptom of withdrawal – the shaking, shivering, sweating and confusion of delirium tremens, or the DTs – the death rate has been estimated as high as 4 percent, or 1 in 25. Of patients admitted to one hospital in Spain with alcohol withdrawal syndrome from 1987 to 2003, a research team there found, 6.6 percent died. That's roughly 1 in 15. In the U.S., total alcohol deaths – through cancer, liver cirrhosis, pancreatitis, suicide and other causes – increased 35 percent from 2007 to 2017.

Enabling an Alcoholic (The Alcoholism Guide) Most people who enable an alcohol dependent don't even realize they are doing it. They might even have an enabling addiction. Enabling addiction suggests that you make it possible for an alcoholic to drink. You do this unwittingly; you truly believe that you are trying to help. Read about how to stop enabling an alcoholic.

How alcohol causes blackouts and blocks memories (Carolyn Y. Johnson and Joel Achenbach, WaPo, 9-26-18) 'Alcohol not only changes behavior — sometimes with disastrous consequences — it can also interfere with memory formation, creating gaps that experts refer to as blackouts. “In the moment, the person can be functioning normally, with no sign there’s going to be memory impairment. But because those memories never get consolidated and stored, it’s like they never occurred, so you can’t recall them later on,” said Kate Carey, a clinical psychologist at Brown University School of Public Health. “Which doesn’t mean it didn’t happen."...“High quantities in short periods of time — that’s exactly the kind of drinking that’s likely to raise blood alcohol concentration to high levels, and raise it quickly. And a rapid rise is predictive of having memory impairment,” Silveri said. But even before then, alcohol can lead to impulsive behavior, including sexual disinhibition.'

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Vox thoroughly covers study on treatment alternatives to Alcoholics Anonymous (HealthNewsReview gives a high rating to the story, 3-7-18). Here's the story: Alcoholics Anonymous works for some people. A new study suggests the alternatives do too. (German Lopez, Vox, 3-5-18) The study shows why we need more addiction treatment options in America. looked at how people’s self-reported outcomes with AA and 12-step programs compare with the three biggest alternative mutual help groups — Women for Sobriety, SMART Recovery, and LifeRing. It concluded that these other groups perform about as well as 12-step programs.

Alcoholics Anonymous: The Big Book and Twelve Steps and Twelve Traditions (Alcoholics Anonymous). Or go to a meeting. Eleven of the steps do not mention alcohol. As one reviewer, Barry, writes, "Sobriety is about a new way of life free of alcohol, and this life is meant to be happy, joyous and free, not merely 'dry' and miserable. The best way to achieve this is to get a sponsor and make use of that sponsor, which will likely involve reading these books and considerable other action as well."
AA Keeps People From Drinking Alcohol Longer Than Other Tools, Cochrane Review Finds (Deborah Becker, WBUR, CommonHealth, 3-11-2020) The review found AA can sometimes be more effective than many other forms of professional addiction treatment. "The reason why AA works is because it actually mobilizes the same kinds of therapeutic mechanisms that are mobilized by formal treatment," Kelly said. "It helps people shift their social network away from people who are heavy drinkers and drug users toward individuals who are in recovery. And it boosts cognitive behavioral coping skills, self-efficacy and reduces craving and impulsivity. These are the kinds of things that we try and target in formal treatment."

SAMHSA (Substance Abuse and Mental Health Services Administration) Search for help with treatment.

Al-Anon (friends and relatives of someone with a drinking problem)

Alcohol Addiction Center (scroll down for links to resources for drinking problems on campus, for teenagers and college students)

Answers for Teens ( information for teenagers seeking help if they are living with a parent who may be misusing alcohol or drugs). Builds from Edith Lynn Hornik-Beer’s book For Teenagers Living With a Parent Who Abuses Alcohol/Drugs
Chasing Drinks with Lies, and Lies with Drinks (Katie McBride, Longreads, April 2018) "This is the scariest part of being a blackout drinker: not the inability to remember, the fear that someone else does. The worst thing you can do to a blackout drinker is tell them the truth."

All About Alcoholics Anonymous A positive account of what the AA process involves.

Does Recovery Kill Great Writing? As I emerged from alcoholism, I had to face down a terrifying question. (Leslie Jamison, NY Times Magazine, 3-13-18) 'In an excerpt from her new memoir, Leslie Jamison wrestles with a dark fear that haunted her recovery from alcoholism: would her creative energies dissipate once she was clean? It’s a brave and honest piece of introspective writing that’s hard to put down. It’s also full of really interesting literary history, as Leslie explores the ups and downs of famous writer-drunks of the past — John Berryman, Charles Jackson, Denis Johnson and others (mostly men, as Leslie notes).' "I was afraid that loving the drunk story best meant some part of me still wanted to keep living it. And of course, some part of me did." You can read Denis Johnson's story about recovery, Beverly Home online at the Paris Review (with a subscription) or in the collection of his stories Jesus' Son.

Hiding Addiction Behind Depression (Temma Ehrenfeld, The Fix, 03/03/16) Alcoholism cost him his life, after professionals said. my partner was just depressed. A must read if someone you love is struggling with both depression and a tendency to drink too much.

Does Alcoholics Anonymous Work? (Scott O. Lilienfeld and Hal Arkowitz, Scientific American 2-17-11) For some heavy drinkers, the answer is a tentative yes.

After 75 Years of Alcoholics Anonymous, It's Time to Admit We Have a Problem (Maia Szalavitz, Pacific Standard, 2-10-14) Challenging the 12-step hegemony -- a review of several books on addiction treatment and thereby a survey of treatment. Definitely read this one.

The Recovery Book: Answers to All Your Questions About Addiction and Alcoholism and Finding Health and Happiness in Sobriety by Al J. Mooney MD and Catherine Dold

Alcoholics Anonymous (AA) is self-help group, organised through an international organization of recovering alcoholics, that offers emotional support and a model of abstinence for people recovering from alcohol dependence using a 12-step approach. (M Ferri, L Amato, M Davoli, Cochrane Primary Review Group, 7-19-06). "No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [twelve-step] approaches for reducing alcohol dependence or problems. One large study focused on the prognostic factors associated with interventions that were assumed to be successful rather than on the effectiveness of interventions themselves, so more efficacy studies are needed."

Twelve Steps to Danger: How Alcoholics Anonymous Can Be a Playground for Violence-Prone Members (ProPublica, 11-29-14) Karla Brada Mendez thought that she was getting a second chance on life when she started going to AA meetings. But instead she met Eric Allen Earle, an AA old-timer with a violent past. As HealthNewsReview points out, "some who participate in AA meetings are forced to do so by the criminal justice system. This group of mandatory members may include violent felons who are trading attendance for a lighter sentence."

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Why some people swear by Alcoholics Anonymous — and others despise it (German Lopez, Vox, 1-2-18) An excellent overview of various approaches to treating alcohol addiction. Years of evidence show that the 12 steps, on average, really can help treat alcohol addiction for some people. Whether the 12 steps work for other kinds of addiction — and whether non-AA programs like Narcotics Anonymous are effective at all — remains an open question in the research. Lopez reports on various research studies and assessments of 12-step programs vs. other approaches. One of the non-spiritual reasons 12-step treatment and AA work for some people is that they help foster changes in a person’s social network, one that provides support for sobriety and a way to socialize without using drugs. AA can also "find coping mechanisms to overcome triggers for drinking, from exercises to staying in close contact with other attendees to simply drinking a lot of club soda at social events in which drinking was happening. [Participants learn] how to deal with environmental cues and social stress without resorting to alcohol and other drugs.... The biggest sticking point seems to be the 12 steps’ spiritual element. Critics such as Maia Szalavitz, an addiction journalist and author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, have focused on this part of the program to argue that the 12 steps really shouldn’t be considered treatment at all. Another approach, cognitive behavioral therapy, "teaches a person how to resist alcohol and drugs when offered, how to deal with difficult life events without resorting to drugs, how to cope with stigma about addiction, and on and on. It essentially teaches the patient how to develop the attitudes and behaviors that may be needed to resist relapse." Other treatment approaches also discussed as well as common obstracles to recovery.
How Alcoholics Anonymous Psychologically Abuses the Marginalized (The Establishment, 5-24-17) In some ways, AA helped me. But as an afrolatin trans woman, it also hurt me. I was typically the only trans person in the room. 62% of AA members are male, and 89% are white. "There are also underlying issues with the 12-step ideology itself, with fundamental program principles effectively encouraging abuse against the marginalized." As alternatives, if AA doesn't work for you, she recommends "SMART Recovery, Women for Sobriety, LifeRing Secular Sobriety, Moderation Management, the Sinclair Method, and drug replacement therapies are all viable options. Hell, seek someone like me out, someone who lives by the 12 steps but doesn’t attend AA."
How Smart Is Smart Recovery? (Joe Schrank, The Fix, 8-30-12) The leader of the largest alternative to AA sounds off on the disease model of addiction, whether crack can be smoked in moderation, and why the 12 Steps shouldn't be the only path to sobriety.
Non 12-Step Fellowships and Programs (The Fix) LifeRing, Moderation Management, Rational Recovery, Secular Organizations for Sobriety (SOS), SOS Behind Bars, Women For Sobriety.

Silkworth.net (for those interested in AA history and resources)

Alcoholism In-Depth Report (NY Times)

Trading Alcoholism for Sugar Addiction: Here’s the Not-So-Sweet Truth (Promises Treatment Center). See also The Importance of Nutrition in Addiction Recovery

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5 Things I Miss About Alcoholism (Emerson Dameron, Be Yourself, 12-6-16) A look at life viewed through those rose-colored glasses he took off when he went sober.

A daughter’s lifetime with a father’s slow self-destruction (Alisa Schindler, WaPo, 2-29-16) "Amazingly, a small glimmer of childhood idolization lingers. Forget the hospital stays, the dependencies, the self-destruction, the emotional manipulation, the cries for help that always leave me crying. I want to believe that this 73-year-old man will somehow find his way back..."

Alcoholism: The Science Made Easy (free, Addiction Technology Transfer Center Network)

Alcoholism and alcohol abuse (Medline Plus)

Resources for Alcoholics and Problem Drinkers (Alcohol Addiction Center)

Giving up alcohol opened my eyes to the infuriating truth about why women drink (Kristi Coulter, 24-Hour Women, Quartz, 8-21-16) I’m newly sober and dog-paddling through the booze all around me. It’s summer, and Whole Foods has planted rosé throughout the store....

Why SMART Recovery Will Never Replace Alcoholics Anonymous (Matthew Leichter, The Fix, 9-23-14) "Alcoholics Anonymous thrives as a social network, more than a recovery program. In terms of being a place where someone can go on a daily basis to socialize, Alcoholics Anonymous kicks everyone else into the dirt. Clubhouses, halfway houses, and thousands of meetings a day all across the United States place this goliath as #1 in accessibility. Regardless of anything else, their mere size and emphasis on constant contact and socialization is something that no other program has been able to replicate....While recovery rates are better for SMART Recovery in clinical settings, SMART Recovery® fails to embrace the idea of building a social network. While they encourage a healthy support group, they really don’t do anything about it....While AA is rather zealous in its demands for attending meetings, the fact is that some people do need a new daily social structure to start their new life. Even Dr. Lance Dodes in his book The Sober Truth, a brutally critical account of AA, recognizes that the social aspect of AA is valuable."

Mom's Night in the Slammer (Leslie Schwartz, Narratively, 6-4-14) A recovering alcoholic rebuilds her life and becomes the perfect doting mother, until a fateful relapse sparks a downward spiral and a tumultuous night in jail.

The little pill that could cure alcoholism When an alcoholic doctor began experimenting with Baclofen, he made what could be the medical breakthrough of the century. Is alcoholism "a physical condition with a spiritual solution," as Alcoholics Anonymous has long insisted? Dr Olivier Ameisen no longer thinks so --having successfully ended his own debilitating addiction, he thinks he's found a revolutionary cure for the disease in the form of a widely available pill. His book: The End of My Addiction: How One Man Cured Himself of Alcoholism.

The Drunk's Club: A.A., the Cult that Cures (PDF, Clancy Martin, Harper's, Jan. 2011)

Surviving an Alcoholic (Paula Ganzi Licata, NY Times, 5-27-16) Shame is just one challenge for survivors of alcoholics. But it’s nothing compared with the guilt.


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Drinking Causes Gut Microbe Imbalance Linked to Liver Disease (Bob Roehr, Scientific American, 2-10-16)

Alcohol and Cirrhosis of the Liver (Recovery Connection)

A 20-Year-Old Went to Rehab and Came Home in a Body Bag (Wilbert L. Cooper, Vice, 11-4-14). An expose of the high-end-$$ drug treatment world, through the story of one boy and family it failed: Brandon Jacques, whose dual diagnosis of bulimia and alcohol addiction called for better treatment and medical care than the overpriced "treatment" facility could provide. ("...it's illegal for residential drug and alcohol programs like Morningside to provide any medical care in the State of California, because of an old, controversial law that is a vestige of the rehab industries' AA-based, nonmedical beginnings....Because the State of California has done such a poor job of enforcing the ban on in-house professional medical care, facilities like Morningside get the best of both worlds--they can market themselves as medical facilities to attract more clients without fear of getting shut down, but they don't have to spend the money on medical care or jump through the regulatory hoops required of a facility practicing medicine.") Here is video on the same story: From Rehab to a Body Bag | Dying for Treatment (Vice video, Nov 2014) From Rehab to a Body Bag | Dying for Treatment. "Although non-hospital residential treatment serves only about 10 percent of those in recovery in the US, the exorbitant cost of such care--as high as $75,000 a month--has made it extremely lucrative....these centers operate in a gray zone somewhere between legitimate medicine and total quackery, offering things like horseback riding and meditation as solutions to addiction, and often promising medical care that they are unable to provide--sometimes with disastrous results." (I've repeated this entry from general section above on addiction, treatment, and recovery, generally, because it makes an important point.)

The scientific effects of drunk driving (Substance.com infographic)

Is your health care provider an addict? The problem we can’t ignore (Judi Kanne, Georgia Health News, 9-11-16)

50 Essential Tips To Help You Stay Clean And Sober and Alternatives To AA and Is There Such Thing As An Alcoholic Personality? (Clean and Sober Live)

Did Alcoholism Kill Joan Didion's Daughter? (Jenna Sauer, Jezebel, 12-13-11)

Not Like You a Young Adult novel by Deborah Davis, about a 15-year-old girl whose mother is an alcoholic, who moves them from town to town.

The pseudo-science of Alcoholics Anonymous: There’s a better way to treat addiction (Dr. Lance Dodes and Zachary Dodes, Salon, 3-23-12). An excerpt from their book The Sober Truth: Debunking the Bad Science Behind 12-Step Programs and the Rehab Industry. Read the comments on Amazon, for views pro and con, including "one size does not fit all."
Acute alcohol use temporally increases the odds of male perpetrated dating violence: a 90-day diary analysis (PubMed Jan. 2014)

Alcohol Awareness. Emphasizes how alcohol is often abused as a way to deal with depression, which may make the symptoms worse, and lead to suicide.
This Naked Mind: Control Alcohol, Find Freedom, Discover Happiness & Change Your Life by Annie Grace. Get the first 40 pages free.
The Fart Party’s Over (story and illustrations by Julia Wertz) "Her success as a professional funny person grew hand-in-hand with depression and alcoholism, until she found herself lying in a rehab clinic, drawing fart jokes, and wondering if this was really the life she'd always wanted."

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Controversial NIH study of ‘moderate drinking’ will be terminated after scathing report (Sharon Begley and Andrew Joseph, STAT, 6-15-18) 'The National Institutes of Health will shut down a controversial industry-funded study of moderate drinking and heart disease after a task force found severe ethical and scientific lapses in the study’s planning and execution, the agency’s director said Friday....The group examining the Moderate Alcohol and Cardiovascular Health (MACH) Trial also found that, starting in 2013, “there was early and frequent engagement” between NIH officials and the alcohol industry that appeared to be “an attempt to persuade industry to support the project. Several members of NIAAA staff kept key facts hidden from other institute staff members.” ... The decision “is the appropriate response to the egregious violation of NIH policy” by the National Institute on Alcohol Abuse and Alcoholism, which greenlighted the study, said public health scientist Michael Siegel of Boston University. “NIAAA undermined its own scientific integrity by soliciting and accepting alcohol industry funding to study the health ‘benefits’ of alcohol.” Ending MACH “will help ensure that this fiasco is never repeated.” See also NIH cancels $100 million study of moderate drinking as inescapably compromised (William Wan and Lenny Bernstein, Wash Post, 6-15-18) NIH Director Francis S. Collins said the results of the 10-year, $100 million study would not be trusted because of the secretive way in which staff at an institute under NIH met with major liquor companies, talked to them about the trial’s design and convinced them to pick up most of the tab for it. “Many people who have seen this working-group report were frankly shocked to see so many lines crossed,” he said, calling the staff interaction with the alcohol industry “far out of bounds.” Earlier stories on the subject: Federal Agency Courted Alcohol Industry to Fund Study on Benefits of Moderate Drinking (Roni Caryn Rabin, NY Times, 3-17-18) Scientists and National Institute of Health officials waged a concerted campaign to obtain funding from the alcohol industry for research that may enshrine alcohol as a part of a healthy diet. The 10-year government trial is now underway, and Anheuser Busch InBev, Heineken and other alcohol companies are picking up most of the tab, through donations to a private foundation that raises money for the National Institutes of Health.

      The documents and interviews show that the institute waged a vigorous campaign to court the alcohol industry, paying for scientists to travel to meetings with executives, where they gave talks strongly suggesting that the study’s results would endorse moderate drinking as healthy. The fund-raising may have violated N.I.H. policy, which prohibits employees from soliciting or suggesting donations, funds or other resources intended to support activities. At the least, the campaign is bound to raise more questions about the independence of the investigators and the scientific integrity of the huge trial.

       See also A Massive Health Study on Booze, Brought to You by Big Alcohol (Miriam Schuchman, Wired, 10-26-17) "The Moderate Alcohol and Cardiovascular Health study, now in progress on four continents, is poised to be a breakthrough in public health: the first time that researchers have followed a group of people randomized to receive a daily drink or nothing at all....The study has its origin, strangely enough, in tea. Back in 2006, researchers thought tea drinkers might have fewer heart attacks....After six months, they ran the numbers: Tea had virtually no effect on a person’s cardiovascular risk." And see Big Booze helped plan $100 million NIH study on alcohol–here’s how they’ve also tried to influence journalists (Kevin Lomangino, HealthNewsReview.org, 3-19-18) News of federal researchers courting liquor company executives for funding leaves a bad taste in the mouth of many who care about the quality and independence of science at the National Institutes of Health. See earlier story, also: Alcohol industry isn’t just funding studies; it’s also funding journalism to sway public opinion (Gary Schwitzer, HealthNewsReview, 7-6-17)

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Opioid addiction treatment with a dark side

Racial disparities in opioid addiction treatment: a primer and research roundup (Naseem S. Miller, Journalist's Resource, 5-17-21) The story of how systemic racism took root in policy and addiction treatment dates back to the 1800s. Disparities persist today in the prescription of methadone and buprenorphine. Here's what history and research reveal.
Addiction Treatment With a Dark Side (Deborah Sontag, NY Times, 11-16-13) The Double-Edged Drug. Many addicts credit buprenorphine, sold mostly in a compound called Suboxone, with saving their lives. "Suboxone is the blockbuster drug most people have never heard of. Surpassing well-known medications like Viagra and Adderall, it generated $1.55 billion in United States sales last year, its success fueled by an exploding opioid abuse epidemic and the embrace of federal officials who helped finance its development and promoted it as a safer, less stigmatized alternative to methadone. But more than a decade after Suboxone went on the market, and with the Affordable Care Act poised to bring many more addicts into treatment, the high hopes have been tempered by a messy reality. Buprenorphine has become both medication and dope: a treatment with considerable successes and also failures, as well as a street and prison drug bedeviling local authorities. It has attracted unscrupulous doctors and caused more health complications and deaths than its advocates acknowledge. It has also become a lucrative commodity, creating moneymaking opportunities — for manufacturers, doctors, drug dealers and even patients — that have undermined a public health innovation meant for social good."
"Intended as a long-term treatment for people addicted to opioids — heroin as well as painkillers — buprenorphine, like methadone, is an opioid itself that can produce euphoria and cause dependency. Its effects are milder, however, and they plateau, making overdoses less likely and less deadly."
In other words, Methadone and buprenorphine are subject to "street use" and abuse -- partly because of the hoops we make people jump through to get access to them.
The Giant, Under Attack (Michael Corkery and Jessica Silver-Greenberg, NY Times, 12-27-17) One of America’s biggest rehab companies built an empire. But after a patient named
Gary Benefield died, its enemies — investors and business rivals alike — struck hard....The doctor prescribed Mr. Hill buprenorphine, which satisfies the craving for opiates but does not result in a high. Mr. Hill’s successful treatment with buprenorphine was for him a revelation. Mr. Cartwright, by contrast, believes that ultimately “abstinence has to be the goal.” That is only the start of their differences. Mr. Hill prefers an outpatient approach that is close to the patient’s support network... believes the inpatient model is motivated more by greed than doing good. Inpatient providers can bill insurers up to $10,000 for 28 days of services; Mr. Hill charges $1,400 a month for his outpatient treatments. "Mr. Hill’s concerns about American Addiction Centers were not just about the debate between inpatient vs. outpatient philosophies of treatment. He told Mr. Drose about patients who had died in rehab homes around Temecula and nearby Murrieta that Mr. Cartwright later acquired.The deaths, Mr. Hill contended, showed how the company was unequipped to deal with medically fragile addicts."...The driver and other employees also testified that staff members were discouraged from taking patients to a hospital emergency room — even when they appeared to be in distress — because A Better Tomorrow might risk losing a paying customer. The feeling was, “they are taking our clients,” the driver said of the hospital....On and off in the years since Mr. Benefield’s death, a cast of characters — the empire builder Mr. Cartwright, the budding short-seller Mr. Drose, the crosstown rival Mr. Hill — had made A Better Tomorrow and American Addiction Centers a focus of their lives. Some hoped to build it up. Others dreamed of tearing it down. Mr. Cartwright and Mr. Drose, in particular, saw fortunes to be made...."
Prisons fight opioids with $1,000 injection: Does it work? (Carla K. Johnson, AP, AARP, 11-14-16) "The evidence for giving Vivitrol to inmates is thin but promising. In the biggest study, sponsored by the National Institute on Drug Abuse, about 300 offenders — most of them heroin users on probation or parole — were randomly assigned to receive either Vivitrol or brief counseling and referral to a treatment program. The evidence for giving Vivitrol to inmates is thin but promising. In the biggest study, sponsored by the National Institute on Drug Abuse, about 300 offenders — most of them heroin users on probation or parole — were randomly assigned to receive either Vivitrol or brief counseling and referral to a treatment program. After six months, the Vivitrol group had a lower rate of relapse, 43 percent compared with 64 percent. A year after treatment stopped, there had been no overdoses in the Vivitrol group and seven overdoses, including three deaths, in the other group.... Yet addiction is stubborn. When the injections stopped, many in the study relapsed. A year later, relapse rates looked the same in the two groups."
A little explanation (drawn from website of The National Alliance of Advocates for Buprenorphine Treatment): "An agonist is a drug that activates certain receptors in the brain. Full agonist opioids activate the opioid receptors in the brain fully resulting in the full opioid effect. Examples of full agonists are heroin, oxycodone, methadone, hydrocodone, morphine, opium and others."
"An antagonist is a drug that blocks opioids by attaching to the opioid receptors without activating them. Antagonists cause no opioid effect and block full agonist opioids. Examples are naltrexone and naloxone. Naloxone is sometimes used to reverse a heroin overdose."
Methadone and buprenorphine are "agonists." Vivitrol is an extended release formulation of naltrexone, an opioid receptor "antagonist." Buprenorphine is a "partial agonist," meaning it activates the opioid receptors in the brain, but to a much lesser degree than a full agonist. Buprenorphine also acts as an antagonist, meaning it blocks other opioids, while allowing for some opioid effect of its own to suppress withdrawal symptoms and cravings....Buprenorphine is in a category of its own and therefore should not be seen as “replacement” or "substitution" for anything else.
Tighter prescribing regulations drive illicit opioid sales (Scott E Hadland and Leo Beletsky, BMJ, 6-13-18) The predictable consequence of cutting supply without tackling demand. "The overdose crisis will likely worsen so long as supply side interventions are not coupled with evidence based measures to cut demand and reduce harm."
At Clinics, Tumultuous Lives and Turbulent Care (Deborah Sontag, NY Times, 11-17-13) "Buprenorphine was developed as a safer alternative to methadone for treating heroin and painkiller addiction, a take-home medication that could be prescribed by doctors in offices rather than dispensed daily in clinics. But in some areas a de facto clinic scene, unregulated, has developed, and it has a split personality — nonprofit treatment programs versus moneymaking enterprises built by individual doctors, some with troubled records....Since March, The New York Times has visited and tracked the patients of two of the largest buprenorphine programs in this region, where addiction rates are high, for-profit clinics have proliferated, doctors go in and out of business and the black market is thriving."
• In a discussion among health journalists in March 2017, Elizabeth Leary (MSN, RN) explained : "Vivitrol at least is not an opioid and, for patients who are so addicted that they are in the criminal justice system, not having to give a daily dose is actually more effective for what is essentially a homeless and transient street population. Good luck getting them into clinic every day for observed drug therapy. With Vivitrol you can reduce the cravings by not trading one opioid for another, and the patient's thought process begins to change. The real downside to Vivitrol is if the patient happens to need surgery within the 28 days that the shot lasts, because these are high risk patients (often GI bleeders from alcohol abuse for example) where the need for surgery is a real risk and you can't give them opioids for pain control with Vivitrol on board. You basically have to control the pain with anesthesia, which is less than ideal."
When you stop using Vivitrol for opioid treatment, you have a very high risk of death from relapse to opioid use. You don't have that same risk of death using Vivitrol to treat alcoholism, because alcohol relapses are rarely deadly, says journalist Maia Szalavitz, author of Unbroken Brain: A Revolutionary New Way of Understanding Addiction, who has written extensively on addiction and treatments for it.
A Shot in the Dark: Can Vivitrol Help Us Control Our Addictions? (Walter Armstrong, The Fix, via Pacific Standard, 5-7-13) "Called Vivitrol and made by Boston-based biotech Alkermes, it has been on the market for alcoholism since 2006 and for opiate addiction since 2010. It is not, however, a new drug. It is a new injectable formulation of an old drug called naltrexone, a once-a-day pill prescribed since the mid-‘90s for addiction. The newsiest thing about Vivitrol may be its price tag. While naltrexone, a generic, has an insurance copay averaging $11 a month, Vivitrol costs — deep breath! — about $1,100 a month. A growing number of health insurers are covering all or part of the bill." "Many doctors, when faced with a patient with a drinking problem, don’t think to offer it as a treatment option. Likewise, this addiction medication often gets short shrift in rehabs and 12-step programs. But being a patient means advocating for yourself, so if you want to, you may have to demand to give this shot a shot....The prevailing treatment philosophy is that no single approach is best for everyone. Tailoring the treatment to the individual is the standard of care, even if doing so can involve trial and error." An exploratory article worth reading.

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Helpful books and stories about addiction and recovery

Untamed by Glennon Doyle. "This book is about the author's struggles with bulimia and alcoholism and how she finally let herself out of the cage of being 'a good girl.' " ~Amanda Long
~ “Some books shake you by the shoulder while others steal your heart. In Untamed, Glennon does both at the exact same time.”—Brené Brown
Unbroken Brain: A Revolutionary New Way of Understanding Addiction by Maia Szalavitz (2016). She argues "that addictions are learning disorders and shows how seeing the condition this way can untangle our current debates over treatment, prevention and policy. Like autistic traits, addictive behaviors fall on a spectrum -- and they can be a normal response to an extreme situation. By illustrating what addiction is, and is not, the book illustrates how timing, history, family, peers, culture and chemicals come together to create both illness and recovery-- and why there is no "addictive personality" or single treatment that works for all." Writes the Wall Street Journal reviewer: "Ms. Szalavitz deftly threads her life story through the book to illustrate the dynamics that put people at risk of addiction."
Whole30: Melissa Urban (fascinating personal story on How I Built This with Guy Raz, 1 hour, 6 min). Whole30 began as a dietary experiment: For 30 days, Melissa Urban went without grains, dairy, legumes, alcohol and added sugar (a paleolithic diet). She was trying to address several health problems (including drug addiction), and the results were so extraordinary that she decided to share the diet (and her experiences with CrossFit) with others. Worth listening to, although I kept wondering what she COULD eat (and bought the book, about their "elimination diet"--especially to reduce chronic, systemic inflammation of the body--where your immune system is fired up all throughout the body, where it doesn't need to be).

    So I bought the book about her experience and I'll let you know if it works for me: It Starts With Food: Discover the Whole30 and Change Your Life in Unexpected Ways by Dallas Hartwig and Melissa Hartwig (aka Melissa Urban). Several follow-up books in more detail followed.
With Rare Candor, Lovato Chronicled Her Recovery and Relapse (Mesfin Fekadu, AP, WashPost, 7-25-18) 'While most celebrities tend to hide their struggles with drugs and battles with depression, Demi Lovato not only acknowledged her issues, she’s shared them with the world. Lovato has been an open book since she announced in 2010 that she was checking into a rehabilitation center to deal with an eating disorder, self-mutilation and other issues. Over the next eight years, she became a role model and bona fide pop star, releasing multi-platinum songs and albums that range from playful to serious with lyrical content about her battles with drugs and alcohol.... "She’s always kind of keeping it at the forefront ... and showing people that it’s OK to be open about having struggles whether it’s mental health issues, substance abuse (or) body positivity,” said Jason Lipshutz, the editorial director at Billboard. “By opening herself up and sharing herself she has given the signal to a lot of people — either young listeners or adult listeners — that they can do the same.”'
Go Ask Alice Is a Lie. But Bookstores Won't Stop Selling It. (Jonathan Russell Clark, Esquire, 7-5-22) Fifty years after its publication, this literary fraud about a drug-addled girl is still on the shelves. Can its damaging lies about addiction ever be undone?
Codependent No More by Melody Beattie. How to Stop Controlling Others and Start Caring for Yourself
Inside Rehab: The Surprising Truth About Addiction Treatment--and How to Get Help That Works by Anne M. Fletcher (2013). Review from Publishers Weekly: "Some things never change. And as Fletcher (Sober for Good) finds in this bold report on 15 rehab facilities—from high-end, celebrity-friendly outposts to those treating people on welfare—that fact especially pertains to addiction treatment. Collecting stories from more than 100 interviews, Fletcher methodically dissects the myths about the programs that treat 2.5 million people every year. She finds, for example, that rehab isn't necessary for recovery—some heal on their own, attend self-help groups, or see therapists; that most of the treatment in rehab programs is handled not by highly trained pros but by counselors with varying levels of education and training. She debunks myths, such as that the 12 steps of Alcoholics Anonymous are essential for recovery. Fletcher concludes that traditional programs, such as group treatment, 12 step programs, and counseling, work for some but not for all. Dimitri, for instance, began abusing drugs at 15 and cycled in and out of programs that failed to help him. Fletcher also highlights the exorbitant cost of rehab: one young woman's treatment drained her parents.... Fletcher presents what works, why, where to find it, and how much it costs. It's startling, difficult, and important information for those traveling toward recovery, and anyone who wants to help."
‘I Am Going to Die if I Keep Living the Way I Am.’ She Was Right. (Beth Macy, NY Times, 7-20-18) Tess Henry’s body was found in a Las Vegas dumpster on Christmas Eve. This is the story of the six years of addiction that led her there.
Clean: Overcoming Addiction and Ending America’s Greatest Tragedy by David Sheff, author of Beautiful Boy: A Father's Journey Through His Son's Addiction. "Addiction is a preventable, treatable disease, not a moral failing. As with other illnesses, the approaches most likely to work are based on science — not on faith, tradition, contrition, or wishful thinking. These facts are the foundation of Clean, a myth-shattering look at drug abuse by the author of Beautiful Boy. Based on the latest research in psychology, neuroscience, and medicine, Clean is a leap beyond the traditional approaches to prevention and treatment of addiction and the mental illnesses that usually accompany it. The existing treatment system, including Twelve Step programs and rehabs, has helped some, but it has failed to help many more, and David Sheff explains why. He spent time with scores of scientists, doctors, counselors, and addicts and their families to learn how addiction works and what can effectively treat it. Clean offers clear, cogent counsel for parents and others who want to prevent drug problems and for addicts and their loved ones no matter what stage of the illness they’re in. But it is also a book for all of us — a powerful rethinking of the greatest public health challenge of our time."

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Rehab facilities

First, the bad news
10 things rehab centers won’t tell you (Charles Passy, MarketWatch, MSN, 5-16-04). They aren't always effective, their success rates may mean little, a pricier program is not necessarily a better program, their staff may not be all that well-schooled. they'll invade your neighborhood, they may be a scam, you may be better off at home, etc. "The month-or-longer stint in rehab may be the classic treatment model, but it’s far from the only option. And depending on a patient’s needs and situation, it may not even be the best, according to many in the field. In fact, some studies have shown that success rates – in terms of maintaining sobriety – are just as high for outpatient programs (which are often much more affordable) as inpatient ones. On top of that, Fletcher, author of Inside Rehab raises the notion that some addicts may also do just as well with one-on-one counseling or self-help programs. Or to quote a subheading in one of the chapters of her book: 'Does anyone need residential rehab?'"
American Rehab (Reveal, NPR, from the Center for Investigative Reporting, 8 chapters of superb audio, July and August 2020) In this fascinating and revealing radio/podcast series, Reveal exposes how a treatment for drug addiction has turned tens of thousands of people into an unpaid, shadow workforce. Chapter 1: A Desperate Call. Penny Rawlings is relieved to finally get her brother into rehab at a place called Cenikor. She doesn’t realize that getting him out of treatment is going to be the bigger problem. Chapter 2: Miracle on the Beach. Cenikor’s bizarre form of rehab has its roots in Synanon: a group that started on a beach in California in the 1950s, and mesmerized the nation by claiming that recovery from heroin addiction is possible. 8 chapters in all, airing through July and August 2020.
The Rehab Racket: The Way We Treat Addiction Is a Costly, Dangerous Mess (John Hill, Mother Jones, May.June 2015 issue) On December 30, 2012, as part of a series called Drugged, the National Geographic Channel aired an hourlong documentary about a 28-year-old named Ryan Rogers. It appeared to be a classic tale of a drunk trying against the odds to sober up, albeit with especially harrowing footage and an unusually charismatic protagonist, often shown with a radiant smile on his handsome face. Ryan Rogers was a 28-year-old alcoholic who entered a posh rehab facility to sober up. "Ryan took a courageous step," the narrator intoned. "But 17 days into rehab, he died."
"What transpired at Bay Recovery is one example of why the rehab regulatory system is so often described as fragmented. DADP was responsible for licensing the facility, but it's unclear whether it knew about Rand's earlier probations. And while the medical board had charged that Rand was admitting patients who were too medically and psychologically unstable to be treated at his facility, DADP never addressed this issue while Ryan was alive."
Rehab Racket (Center for Investigative Reporting) The programs are supposed to help struggling addicts. But scammers make millions running troubled rehab clinics, even inventing fake clients to rip off taxpayers. The Center for Investigative Reporting teamed with CNN to expose fraud in California's taxpayer-funded drug and alcohol counseling program.
---Bill seeking background checks for rehab clinic owners advances (Will Evans, 4-24-14)
---California rehab clinics bill taxpayers for fake clients, addictions (Will Evans, Christina Jewett, 7-29-13)
---Lax oversight leaves California drug rehab funds vulnerable to fraud (Christina Jewett, Will Evans, 7-29-13)
---Clinic leaders tied to fraud in LA reap taxpayer funds in Riverside County (Christina Jewett, Will Evans, 7-29-13)
---Video: Watch CNN's three-part series "Rehab Racket."
---Amid fraud allegations, rehab doctor OKs treatment without seeing patients (Will Evans, Christina Jewett, Special to CNN, 10-22-13)

I am still trying to figure out how to guide others on how to find the good rehab facilities. Advice welcome.

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Kratom is an opioid

Clearly, this is a story that changed midstream.
Kratom Now an Opioid, FDA Says (Megan Brooks, Medscape, 2-7-18) "A new analysis by scientists at the US Food and Drug Administration (FDA) shows that compounds in kratom act like prescription-strength opioids, the agency said today. The agency also said kratom has now been linked to 44 deaths, up from 36 reported in November.The scientific data and adverse event reports have "clearly revealed" that compounds in kratom make it "not just a plant — it's an opioid," FDA Commissioner Scott Gottlieb, MD, said. "And it's an opioid that's associated with novel risks because of the variability in how it's being formulated, sold, and used recreationally and by those who are seeking to self-medicate for pain or who use kratom to treat opioid withdrawal symptoms," added Dr Gottlieb.
CDC warns about salmonella infections traced to kratom (Laurie McGinley, Wash Post, 2-20-18) Kratom is "an unregulated herbal supplement that is sometimes used for pain, anxiety and opioid-withdrawal symptoms." The CDC, which has "urged consumers to not use kratom in any form because of the possibility of contamination, said the infections started in October and have affected 20 states. Eleven people have been hospitalized, and no one has died. Most of the people sickened have reported consuming kratom in pills, powder or tea....Recently, the FDA has supported a kratom crackdown, saying the botanical is potentially dangerous and addictive....The FDA said recently that a new computer model it developed shows that kratom contains opioid compounds that can cause potentially lethal side effects such as seizures and depressed breathing. The agency said there is no evidence that kratom is safe for any medical use, including for the treatment of opioid-withdrawal symptoms."
Kratom-Related Salmonella Outbreak Spreads to 35 States (Alicia Ault, Medscape, 3-16-18)
The following stories were published before FDA ruled kratom an opioid.
Why Banning the Controversial Painkiller Kratom Could Be Bad News for America's Heroin Addicts (Maia Szalavitz, Vice, 1-20-16) "It sounds like the perfect drug. At low doses, it's stimulating, like a strong cup of coffee; at higher doses, it's sedating and kills pain. And it's a legal, natural plant that has been used in Asian medicine for centuries. Indeed, a growing number of Americans are finding it to be a useful alternative to heroin and prescription pain relievers. But of course, there's a catch. Like the opioid drugs it is used to replace, this stuff can be addictive, and it can also cause serious nausea. Unlike other opioids, however, it seems to have an extremely low overdose risk, which has caught the eye of people working to fight the record high level of overdose deaths." We need new, more flexible ways of regulating drugs—especially opioids—in order to truly protect the public.
Kratom with a side of cheesesteak: A sub shop’s vending machine draws customers desperate to kick opioids (Eric Boodman, STAT News, 6-1-17) Customers at this Tucson sub shop keep "heading for a vending machine that they hope will keep them off opioids. Kratom is the pulverized version of a plant from Southeast Asia. Last fall, the Drug Enforcement Administration nearly made kratom as illegal as the federal government can make a substance, on par with heroin and LSD, because of an increase in poison center calls about the substance, as well as worries that it might be addictive. “A lot of people found out about kratom because of all the bad publicity. … People were like, ‘Wow, if the government doesn’t want me to have it, I want to try it.’”
Turning to Kratom For Opioid Withdrawal (Jennifer Clopton, WebMD, 10-26-17) One of the most talked about methods for opioid withdrawal is using kratom, a little-known herb made from the leaves of a tree that grows on the other side of the world. A recent survey found that nearly 70% of people using kratom were doing so to cut back on or get off of opioids or heroin. But there’s little research on the herb’s effects on people, and some experts say it also can be addictive. The herb is illegal in six states and the District of Columbia, and the Drug Enforcement Administration is considering labeling it as a Schedule I drug -- a category that includes heroin, ecstasy, marijuana, and LSD. For now, the agency calls it a “drug of concern.”...“It is probably addictive, but its addictive equivalent is something like coffee, which isn’t surprising because the leaf is in the coffee family,” says Christopher R. McCurdy, PhD, a professor of medicinal chemistry at University of Florida’s College of Pharmacy in Gainesville. “We firmly believe that it will be very good for treating opioid withdrawal and may be a possible solution to the opioid epidemic we are facing as a country.” But he says that would require testing kratom in clinical trials and controlled studies. He’s hopeful that will happen in the next 5 to 10 years. For now, he warns buyers to beware.
What’s Next for Kratom after the DEA Blinks on Its Emergency Ban? (Angus Chen, Scientific American, 10-17-16) "Public pressure keeps the herbal supplement unregulated for now, encouraging users and researchers seeking a safer alternative to opioids. The DEA’s about-face comes about a month and a half after it first announced its intent to put kratom in its most restrictive drug category, Schedule I, which is reserved for substances deemed to have no currently accepted medical use and a high risk of abuse. It also includes heroin and LSD....For its next step, the DEA is opening a six-week period for the public to comment on concerns, research and science related to kratom. After that the agency will look to the Food and Drug Administration to complete an evaluation of kratom’s medical and scientific potential."
Kratom Drug Ban May Cripple Promising Painkiller Research (Angus Chen, Scientific American, 9-27-16) Compounds from the Southeast Asian tree offer hope for a safer opioid alternative, but research could slow to a crawl as the DEA steps in.
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Sober living housing options

Making Space for Sobriety (Ryan Caron King, Atavist, published on WNPR). When a person who addicted to drugs or alcohol is discharged from rehab, they’ll sometimes live in what’s called a sober house -- a place where there’s supposed to be no drugs or alcohol around. Same as or similar to How One Agency Is Improving Conditions in Connecticut's Sober Houses (Ryan Caron King, WNPR, 10-4-16) "When someone who is addicted to drugs or alcohol is discharged from rehab, they’ll sometimes pay to live in a privately-owned sober living home like this one, Right Path House. But private sober houses aren’t regulated by the state, and experts in the field say some houses don’t enforce their own sobriety rules -- which can jeopardize the safety of the people that live there and the neighborhood the house is in. So Aligata is working to train and certify sober house owners across the state through a voluntary program. He wants to compile an online database of certified sober houses that he hopes will make it easier for people with addiction to find a place to continue their recovery after rehab."
Sober Living Homes and Housing Options (Rehabs.com) What are sober living homes? How are they different from rehab centers? Why types of rules do sober living facilities require? Who can live in a sober living house? How much does it cost?
Living With a Recovering Drug Addict or Alcoholic (Recovery.org)

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Issues associated with addiction and the drug industry

The attack in Buffalo, Minnesota: a primary care physician’s perspective (KevinMD, 2-10-21) A cogent and compelling presentation of the issues physicians and the medical system face in addressing substance abuse.
Prescription Drug Costs Are on the Rise; So Are the TV Ads Promoting Them (Bruce Horovitz and Julie Appleby, Kaiser Health News, 3-20-17) Pharmaceutical advertising exceeded $6 billion in 2016, with television picking up the lion’s share. Critics say the ads encourage patients to ask their doctors for expensive, often marginal — and sometimes inappropriate — drugs that are fueling spiraling health care spending. The American Medical Association called for a ban on such ads, but "Such a prohibition is unlikely. Previous efforts to push such an outcome have stalled, generally on free-speech arguments by the powerful drug lobby and assertions that such ads provide valuable information to patients about treatment options." “A lot of these ads target the caregivers and the children of older folks." The United States is one of two countries — the other is New Zealand — that allows direct-to-consumer drug advertising.
US sees drop in life expectancy, largely due to opioid crisis among young adults (Fiza Pirani, Atlanta Journal-Constitution, 8-21-18) The United States is among 14 high-income countries with declining life expectancy rates, according to new research recently published in the British Medical Journal. The research features findings from two separate observational studies, one pointing to the ongoing opioid crisis in the U.S. as a key contributor to recent declines, and another suggesting the declines in both the U.S. and the United Kingdom transcend the opioid epidemic among diverse populations.
I Spent a Week in the Colombian Jungle Harvesting Cocaine (Felipe Chica Jiménez, trans. by Jenna Cgy, Narratively, 8-4-17) To understand the drug that has shaped her country's history, she sets her fear aside and gets to work. The family she works with, "like so many other campesino families, whether they have their own crops or buy the leaves loose, they have taken the risk of installing their own homemade processing lab. The real money lies in not only growing and harvesting the plant, but preparing paste from the leaves.... In the end, this family is nothing more than a small and fragile link in the immense chain that continues to mark Colombia’s history."
Taking A Page From Pharma’s Playbook To Fight The Opioid Crisis, ( Pauline Bartolone, KHN, 11-4-27) Dr. Mary Meengs remembers the days, a couple of decades ago, when pharmaceutical salespeople would drop into her family practice in Chicago, eager to catch a moment between patients so they could pitch her a new drug. She is one of 10 California doctors and pharmacists funded by Obama-era federal grants to persuade medical colleagues in Northern California to help curb opioid addiction by altering their prescribing habits. This one-on-one, personalized medical education is called “academic detailing” — lifted from the term “pharmaceutical detailing” used by industry salespeople.Detailing is “like fighting fire with fire,” said Dr. Jerry Avorn, a Harvard Medical School professor who helped develop the concept 38 years ago. “There is some poetic justice in the fact that these programs are using the same kind of marketing approach to disseminate helpful evidence-based information as some [drug] companies were using … to disseminate less helpful and occasionally distorted information.”
The blurred boundaries of mothering an addict (Erika Sauter, Motherwell, 4-26-17) "This wasn’t the first time my daughter had stolen from me."
Desperate for addiction treatment, patients are pawns in lucrative insurance fraud scheme ( David Armstrong for STAT and Evan Allen for Boston Globe, 7-7-17) Drug users, desperate to break addictions to heroin or pain pills, are pawns in a sprawling national network of insurance fraud, an investigation by STAT and the Boston Globe has found. They are being sent to treatment centers hundreds of miles from home for expensive, but often shoddy, care that is paid for by premium health insurance benefits procured with fake addresses. The fraud is now so commonplace that brokers use a simple play on words to describe how it works: “Do you want to Blue Cross the country?” Peter SanAngelo found himself another victim of a system in which people profited off him every step of the way. The one person left with nothing was Peter SanAngelo.
Just Say Know: Norman Bauman passes his urine test (orig. published in New Scientist vol 141 issue 1907 - 08 January 94, page 43) In 1986, President Ronald Reagan decided to test government workers for drugs. He excluded tobacco and alcohol, despite the serious health and safety problems to which they contribute. ("The 'War on Drugs' is a morality campaign by social conservatives to impose their own drugs preferences - alcohol and nicotine - on everyone else.") Norman questions the efficacy of drug screening (particularly noting the frequency of false positive results for those taking bupropion, an antidepressant often used as an aid for smoking cessation--see Casey -- and other substances that can affect test results, and see this, too) but takes the test anyway.
The Health Effects of Cannabis and Cannabinoids: The Current State of Evidence and Recommendations for Research (National Academies Press). Read online free, or download PDF.
New York Announces Health Insurance Reforms to Combat Opioid Crisis (Insurance Journal, 12-30-16)
My Damn Mind. Act 1: When Your Hospital-Borne Infection Is a Bullet. (This American Life, 2-12-16) The story of patient Alan Pean and how his delusions lead him to a situation that's just as strange as the worst thoughts his mind is cooking up. This story is a collaboration with the following NY Times story.
When the Hospital Fires the Bullet (Elisabeth Rosenthal, NY Times, 2-12-16) More and more hospital guards across the country carry weapons. For Alan Pean, seeking help for mental distress, that resulted in a gunshot to the chest."Like Mr. Pean, [mentally ill] patients seeking help at hospitals across the country have instead been injured or killed by those guarding the institutions. Medical centers are not required to report such encounters, so little data is available and health experts suspect that some cases go unnoticed. Police blotters, court documents and government health reports have identified more than a dozen in recent years. They have occurred as more and more American hospitals are arming guards with guns and Tasers, setting off a fierce debate among health care officials about whether such steps — along with greater reliance on law enforcement or military veterans — improve safety or endanger patients." (See also the preceding radio story on This American Life.)
No, Native Americans aren't genetically more susceptible to alcoholism (Maia Szalavitz, The Verge, 10-2-15) Time to retire the 'firewater' fairytale. There’s "no evidence that Native Americans are more biologically susceptible to substance use disorders than any other group, says Joseph Gone, associate professor of psychology at the University of Michigan. American Indians don’t metabolize or react to alcohol differently than whites do, and they don’t have higher prevalence of any known risk genes."
The President's Commission on Combating Drug Addiction and the Opioid Crisis (11-2-17)
The Parity Act Tracking Project: Making Parity a Reality (Drugfree.org, 6-20-17) At a time of national crisis arising from opioid misuse, abuse and overdose, it is difficult to overstate the urgency of the need for significant improvement in the equitable coverage of addiction treatment benefits, as required by law.
The Brave New World of Precision Addiction Medicine (Kathy Jean Schultz, The Fix, 2-9-17) "New medical techniques can isolate substance-damaged brain tissue, pinpoint cravings and predict relapse: Is this a good thing?...The irony is that if substance misusers learn they have a solid chance of relapse, the emotions that follow—hopelessness, anger, depression—might themselves trigger relapse. A prediction of relapse could itself breed relapse. Finding out that one will relapse does not exactly light up the reward neurons, but it might light up the need to escape reality."

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Smoking and smoking cessation

Nonsmokers benefit under the Affordable Care Act, but quitting smoking is not easy and most interventions have a low success rate. Although the U.S. spends more on health care than any other country, we rank 43rd in health globally. "Tobacco remains the #1 cause of preventable death in America, accounting for 1 in 5 deaths, and costs the U.S. economy more than $300 billion per year," according to Tobacco in America, a report from Action on Smoking and Health (ASH), which you can download here.
How does smoking affect your heart health? (FDA, HHS.gov) Just 12 hours after you #QuitSmoking, your body gains more oxygen to vital organs like your heart.
Tobacco. It's about a billion lives worldwide (UCSF Center for Tobacco Control Research and Education)
To gin up opposition to the proposed menthol ban, tobacco companies are turning to gas station ads (Nicholas Florko, STAT News, 11-17-22) Citizens for Tobacco Rights is run by Philip Morris USA. It is circulating the poster “The FDA Is Trying To Ban Menthol Cigarettes and Flavored Cigars” thruough tobacco distributors, like gas stations and smoke shops. Proponents of the ban say it will save hundreds of thousands of lives and help rectify racial disparities, given Black smokers’ preference for menthol cigarettes. Opponents of the ban say it will limit adults’ choices and will lead to an illicit market for such products.
‘Scary’ Lung Disease Now Afflicts More Women Than Men In U.S. (Anna Gorman, KHN, Chronic obstructive pulmonary disease (COPD) traditionally was considered a man’s disease, but women now account for 58 percent of the 14.7 million people in the U.S. living with the disease and 53 percent of those who die from it, according to the American Lung Association. “This is one of the top killers of women in the country.” And it is not a pleasant way to die.
Tobacco's 'Special Friend': What Internal Documents Say About Mitch McConnell (Tom Dreisbach, NPR, 6-17-19) 'The disclosure of millions of once-secret tobacco industry documents — which are now readily searchable online — has opened a window into McConnell's interactions with tobacco executives and lobbyists.... In 1999, McConnell introduced the Litigation Fairness Act to protect companies from government lawsuits. He said publicly that the legislation was "not about tobacco." But internal documents show that the legislation was drafted with the help of tobacco company attorneys and was a part of a Philip Morris lobbying plan to attack the Justice Department's lawsuit.' "NPR also found that vaping and tobacco companies are currently employing McConnell's former policy adviser, his former policy director and his former chief of staff to lobby on their behalf."
The Cigarette: A Political History by Sarah Milov (pub date: 10-2-19) "After the Great Depression, public officials and organized tobacco farmers worked together to ensure that the government’s regulatory muscle was more often deployed to promote tobacco than to protect the public from its harms....The tobacco industry flourished with the help of the state, but it was the concerted efforts of citizen nonsmokers who organized to fight for their right to clean air that led to its undoing."
F.D.A. Aims to Cut Down on Smoking by Slashing Nicotine Levels in Cigarettes (Christina Jewett and Andrew Jacobs, NY Times, 6-21-22) The move would be an effort to further wean Americans from addictive tobacco products and reduce smoking-related illnesses. The proposal, which could take years to go into effect, would put the United States at the forefront of global antismoking efforts. Only one other nation, New Zealand, has advanced such a plan.

      "The headwinds are fierce. Tobacco companies have already indicated that any plan with significant reductions in nicotine would violate the law. And some conservative lawmakers might consider such a policy another example of government overreach, ammunition that could spill over into the midterm elections.

     "A 2018 study led by Dr. Hatsukami that followed the habits of 1,250 smokers found that participants who had been randomly assigned cigarettes with ultralow nicotine smoked less and exhibited fewer signs of dependency than those who had been given cigarettes with nicotine levels that were gradually reduced over the course of 20 weeks.

F.D.A. Plans to Seek a Ban on Menthol Cigarettes (Sheila Kaplan, NY Times, 11-9-18) "In a landmark move bound to further shake the tobacco industry, the Food and Drug Administration plans to propose a ban on menthol cigarettes next week as part of its aggressive campaign against flavored e-cigarettes and some tobacco products, agency officials said. The proposal would have to go through the F.D.A. regulatory maze, and it could be several years before such a restriction took effect, especially if the major tobacco companies contest the agency’s authority to do so."
Childhood Exposure to Secondhand Smoke Is Linked to Lung Disease Decades Later (Kate Furby, WaPo, 8-17-18) Childhood exposure to secondhand smoke is linked to lung disease decades later, according to a study published last week by the American Cancer Society. For 22 years, researchers have been following more than 70,000 adults who have never smoked. At the beginning of the study, the participants were asked whether they lived in a household with a smoker while they were children. Those who did were 31 percent more likely to die of chronic obstructive pulmonary disease, or COPD. This is the first study to find a correlation between the two.
A Tip from a Former Smoker — Terrie: Little Things I Miss (CDC video, on YouTube, part of a series of tips from former smokers). Warning: Shows the drastic effects of smoking in one life.
DA Takes 'Historic First Step' Toward Cutting Nicotine In Cigarettes To Non-Addictive Levels (Kaiser Health News Morning Briefing, 3-16-18) Coverage from major news organizations. The move garnered praise from anti-smoking advocates. “There is no other single action our country can take that would prevent more young people from smoking or save more lives,” said Matthew Myers, president of the Campaign for Tobacco-Free Kids.
Cape Town Declaration on Human Rights and a Tobacco-free World (Action on Smoking and Health, ASH) A call to action. 154 organizations agree: Tobacco industry violates human rights. "The evidence is irrefutable, cigarettes kill more than five million people every year, yet the tobacco industry continues to produce, market, sell and profit from products that they know will kill when used as intended and that they have engineered to be highly addictive, preventing smokers from quitting."
The strategy behind Florida's “truth” campaign (Jeffrey J. Hicks, BMJ, 2001) Florida's settlement with the tobacco companies totalled $11.3 billion dollars and included provisions for the funding of a two year $200 million dollar youth anti-tobacco education and marketing programme. With the launch of “truth” in early 1998, Florida became the first state to use substantial settlement dollars in tobacco control....Unlike some anti-tobacco efforts of the past, due to its funding level, the Florida programme had the benefit of all the tools of modern marketing. Advertisements were produced with some of the hottest commercial directors in the industry, web sites were created using the newest types of animation, and research was conducted by companies that had perfected their craft while working on some of the largest teen targeted private sector brands in the country....Rather than run for free at midnight or in programming with little teen viewership, “truth” aired on MTV, during the broadcasting of the Superbowl (the US football premiership), and in those programmes that youth most wanted to see." To counter youth's distaste for anti-tobacco efforts that pass judgment on tobacco users, and tell teens what to do, they presented "facts," often with humor. "'Truth' needed a message other than 'don't'." To provide an alternative tool of rebellion, they attacked the "duplicity and manipulation of the tobacco industry."
Are There Risks From Secondhand Marijuana Smoke? Early Science Says Yes (Marissa Ortega-Welch, Shots, Morning Edition, NPR, 3-19-18)
Anti-Smoking ads to finally debut on TV (AP, video) Decades after they were banned from the airwaves, Big Tobacco companies return to prime-time television this weekend — but not by choice. Under court order, the tobacco industry for the first time will be forced to advertise the deadly, addictive effects of smoking, more than 11 years after a judge ruled that the companies had misled the public about the dangers of cigarettes. The corrective messages come more than a decade after a judge ruled that the industry had lied about the risks. "More people die every year from smoking than from murder, AIDS, suicide, drugs, car crashes, and alcohol, combined."
Smoking Cessation (Graham McMahon, New England Journal of Medicine blog, 9-30-11) "The prevalence of smoking has declined dramatically in the United States over the past half century, decreasing from about 42% in the 1960s to about 20% today. However, this decline has stalled recently, and higher prevalence rates are concentrated in populations with low incomes, low educational levels, and psychiatric conditions."
CDC statistics on which groups smoke the most (by race, ethnicity, gender, age, education level, and poverty status)
Tips from former smokers (CDC)
Campaign for Tobacco-Free Kids
Whether a pack or a puff, smoking habits pose significant risk ( Chloe Reichel, Journalist's Resource, 1-29-18) Smoking just one cigarette a day puts people at a much higher risk of heart disease and stroke than those who abstain entirely.
Amendment 3: A choice between cheap cigarettes or kids (Melissa Randol, St. Louis Post-Dispatch, 11-3-16) Unfortunately, there is a considerable amount of inaccurate information being circulated about Amendment 3, the initiative petition to increase investments in early childhood health and education through a 60-cent-per-pack increase on cigarettes. ... The primary opposition to Amendment 3 is being driven by the cheap cigarette industry and for good reason. They have a lot to lose. They are being subsidized by Missouri’s taxpayers to the tune of $80 million every year.
Truth Initiative (inspiring tobacco-free lives). Click on "explore by topic" to see the breadth of coverage. Helped bring teen cigarette use down from 23 percent in 2000 to 6 percent in 2016. Established as part of the 1998 Master Settlement Agreement between major U.S. tobacco companies and 46 U.S. states, the District of Columbia and five territories.'
United States v. Philip Morris (D.O.J. Lawsuit) (Public Health Law Center) On August 17, 2006 Judge Kessler issued a 1,683 page opinion holding the tobacco companies liable for violating RICO by fraudulently covering up the health risks associated with smoking and for marketing their products to children.
Graphic images influence intentions to quit smoking (Science Daily) Marketing researchers surveyed more than 500 U.S. and Canadian smokers and found that the highly graphic images of the negative consequences of smoking have the greatest impact on smokers' intentions to quit. The most graphic images, such as those showing severe mouth diseases, including disfigured, blackened and cancerous tissue, evoked fear about the consequences of smoking and thus influenced consumer intentions to quit.
Diseases and conditions through which smoking can kill you (CDC) Smoking leads to disease and disability and harms nearly every organ of the body. It is the leading cause of preventable death. Learn the facts about asthma, second-hand smoke, cancer, chronic obstructive pulmonary disease (COPD), gum disease, vision loss and blindness, and so on.
Psilocybin Sessions: Psychedelics could help people with addiction and anxiety (Anderson Cooper, 60 Minutes,10-13-19) Study participants at some of the country's leading medical research centers are going through intense therapy and six-hour psychedelic journeys deep into their minds to do things like quit smoking and worry less. The early results are impressive, as are the experiences of the studies' volunteers who go on a six-hour, sometimes terrifying, but often life-changing psychedelic journey deep into their own minds. For nearly two decades now, Roland Griffiths. and his colleague Matthew Johnson have been giving what they call "heroic doses" of psilocybin to more than 350 volunteers, many struggling with addiction, depression and anxiety. About a third have what they would call a "bad trip," but for most that was key to the experience. In 1970, President Richard Nixon signed the controlled substances act and nearly all scientific research in the U.S. Into the effects of psychedelics on people stopped. It wasn't until 2000 that scientist Roland Griffiths won FDA approval to study psilocybin. "This whole area of research has been in the deep freeze for 25 or 30 years," says Griffiths.
Smokefree.gov , links to resources for people who want to quit smoking.
Smoke and mirrors (Deborah Arnott and Ian Willmore, The Guardian, 7-19-06). "The law banning smoking in public places [in England] is the culmination of one of the most successful social change campaigns in recent years. When Action on Smoking and Health (Ash) started campaigning for smoke-free legislation in 2003, we were told by politicians, civil servants and commentators that there was no chance. So how does a controversial social change go from being "an extreme solution" (Labour party official) to a "historic piece of legislation" (Labour minister) in under three years?" Interesting and informative.
Why Tobacco Companies Are Spending Millions To Boost A Cigarette Tax (Alex Smith, KCUR, Kaiser Health News, 11-3-16) Interesting insight into the politics of smoking taxes. Tobacco companies are backing a low (60-cent) cigarette tax, and anti-smoking groups are against it, because they worry that creating such a small tax now might eliminate the chance of future tax that would be big enough to significantly change smokers’ behavior. Linda Rallo and early education advocates proposed a 60-cent tax to help fund early education in Missouri, but public health researchers say the size of the tax in Rallo’s amendment is too small to make a difference in smoking rates. Meanwhile Amendment 3 pits the Big Tobacco giant against smaller manufactures, known collectively as “Little Tobacco.” "At 17 cents for a pack of cigarettes, Missouri’s tax is the lowest in the country — a fraction of what you’d pay in many states. New York’s tax is the highest at $4.35 a pack, for example, and Florida ranks around the middle of the states at $1.34 a pack. Missouri’s cigarette tax hasn’t changed since 1993."
Treating Smokers in the Health Care Setting (Michael C. Fiore, M.D., M.P.H., M.B.A., and Timothy B. Baker, Ph.D., New England Journal of Medicine, 9-29-11). This Journal feature begins with a case vignette highlighting a common clinical problem. Then follows evidence supporting various strategies, a review of formal guidelines, when they exist, and the authors' clinical recommendations.

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Vaping: a modern horror story.

Are Juul e-cigs killing people? Read these stories.

E-Cigs Are Still Flooding the US, Addicting Teens With Higher Nicotine Doses (Liz Szabo, KFF News, 6-26-23) When the FDA first asserted the authority to regulate e-cigarettes in 2016, many people assumed the agency would quickly get rid of vapes with flavors like cotton candy, gummy bears, and Froot Loops that appeal to kids. Instead, the FDA allowed all e-cigarettes already on the market to stay while their manufacturers applied for the OK to market them. Seven years later, vaping has ballooned into an $8.2 billion industry, and manufacturers are flooding the market with thousands of products — most sold illegally and without FDA permission — that can be far more addictive.
E-Cigarettes Went Unchecked in 10 Years of Federal Inaction (Katie Thomas and Sheila Kaplan, NY Times, 10-14-19) A decade after Congress gave the F.D.A. the power to regulate tobacco products like e-cigarettes, the federal government has repeatedly delayed or weakened efforts that could have protected teenagers. The missed opportunities to regulate e-cigarettes span two administrations.
Vaping Illness Tracker (Jonathan Corum, NY Times) 2,290 Cases and 47 Deaths as of 11-21-19.
What to Know About the New Mass. Law Banning Flavored Vapes and Menthol Cigarettes (Steve Brown and Angus Chen, CommonHealth, WBUR, 11-27-19) The ban on flavored e-cigarettes takes effect immediately, while sales of menthol cigarettes will cease on June 1st, 2020.
Is It Safe to Vape CBD? ( Lisa L. Gill, Consumer Reports, 1-31-22) At least 26 people have been hospitalized by vaping CBD, and more were sickened. Here's what to know about possible risks.

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E-Cigarettes: The New Addiction and Why Physicians Must be Concerned (Christina Bennett, Patient Care, 5-22-19) "Contrary to common belief, the use of e-cigarettes is not necessarily associated with quitting or avoiding smoking tobacco, and may have the opposite effect. A systematic review and meta-analysis among adolescents and young adults found that e-cigarette users had a more than three times greater risk of starting cigarette smoking than those who had never used e-cigarettes."
As FDA toils over how to regulate CBD, frustration builds on all sides (Nicholas Florko, STAT, 11-22-19) See also Dude, where’s my regulatory framework? As CBD gains popularity, Washington struggles to keep up (Nicholas Florko, STAT, 5-17-19)
Special Report: Juul Disregarded Early Evidence It Was Hooking Teens (Reuters, NY Times, 11-5-19) The San Francisco startup that invented the groundbreaking Juul e-cigarette had a central goal during its development: captivating users with the first hit. The company had concluded that consumers had largely rejected earlier e-cigarettes, former employees told Reuters, because the devices either failed to deliver enough nicotine or delivered it with a harsh taste. Developers of the Juul tackled both problems with a strategy they found scouring old tobacco-company research and patents: adding organic acids to nicotine, which allowed for a unique combination of smooth taste and a potent dose.

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The Complex Realm of Cloud Chasers, Coil Builders and Other Vape Modders (Chaseedaw Giles, KHN, 11-26-19) A Juul pod is not an e-cigarette is not a vape pen is not a mod. Ask any serious vaper, but then, what kind of vaper to ask? There are the nicotine casuals and those drawn to THC, the psychoactive ingredient in marijuana. There are the hobbyists with all their sub-genres: do-it-yourselfers, cloud chasers, sub-ohmers, coil builders and other device modifiers, called moders, not to mention vape lifestyle models and social media influencers.
Searching for a killer: Inside the CDC’s scramble to solve a mysterious vaping disease (Lena H. Sun, WaPo, 11-25-19) Scientists were ecstatic. The test results were in. For the first time, the lab team at the Centers for Disease Control and Prevention had direct evidence that a chemical compound, vitamin E acetate, was a likely culprit in the disease that has sickened nearly 2,300 people and killed 47. Officials set a date to share the news. But as the lab team raced to test a last batch of lung fluid samples, the tool needed for the chemical analysis suddenly crashed. Scientists feared their precious samples would be destroyed.
The Promise and Peril of Vaping, Part 1: A Mystery in Nebraska (The Daily podcast, 10-28-30, host Michael Barbaro). Fascinating radio. Julie Bosman, a national correspondent for The New York Times, speaks with Kathleen Fimple and her daughter, Dulcia Steffen, in Omaha, Nebraska, learning how one man’s mysterious death changed our understanding of vaping and its consequences. The federal government has repeatedly delayed or weakened efforts to regulate e-cigarettes, allowing a new generation to become addicted to nicotine. In Part 2 (Mchael Barbaro, on The Daily, 10-30-19) Juul pledged to help people stop smoking. Instead, it created a new generation of nicotine addicts — and a public health scare.
Vaping Illness Tracker: 1,604 Cases and 34 Deaths (Jonathan Corum, NY Times, 10-24-19) The Centers for Disease Control and Prevention and state agencies have reported 1,604 lung injury cases and 34 deaths linked to vaping. The rising case count includes both recent cases and earlier pneumonia-like cases that are only now being recognized as related to vaping. The maps show where cases are turning up.
The New American Addiction: How Juul Hooked Kids and Ignited a Public Health Crisis (Jamie Ducharme, Time, 9-19-19) "Juul says that it does not make health claims and that it has never marketed to youth." Uh-huh. "Critics argue that Juul has assiduously followed Big Tobacco’s playbook: aggressively marketing to youth and making implied health claims a central pillar of its business plan."

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A Regulatory Haze: Vape Marketers Are Online, Creating New Headaches For Feds (Shefali Luthra and Chaseedaw Giles, KHN and Daily Beast, 11-14-19) As Washington scrambles to crack down on the nascent vaping industry — particularly how it courts young users — so-called vaping influencers, whose online personas exist in a haze of glamour and celebrity, are exposing critical gaps in how government officials regulate the marketing of electronic cigarettes.
More Vapers Are Making Their Own Juice, But Not Without Risks (Jenny Gold, California Healthline, 11-12-19) Danielle Jones studies the recipe for Nerd Lyfe (v2) vape juice, preparing for the worst-case scenario: a ban on the sale of the e-liquids she depends on to avoid cigarettes. Says Dr. Michael Siegel, a professor of community health sciences at Boston University, “This is just what happens when you use prohibition as a regulatory approach. What’s really needed in this situation is actual regulation of these products to try to make them as safe as possible.”
How to Get Teens to Stop Vaping: A Guide For Parents and Educators In 2019 (Sunshine Behavioral Health) Surprisingly helpful, with links to many other articles on vaping.
Meet the Health Officials Who Alerted the World to the Alarming Vaping Illness (Lauren Weber, KHN, 9-25-19) Doctors and regional officials in Wisconsin, Illinois and elsewhere pieced together that this mysterious illness was much larger than it appeared. It’s a tale of teamwork, communication and long-serving public health officials tapping into their networks in an era of limited public health funding, diminished public health infrastructure and high turnover. Although isolated cases of vaping-related respiratory problems were spotted elsewhere (as early as 2015 in West Virginia), a new wave of cases began popping up across the country starting in mid-April. Otherwise healthy patients, many of them teenagers, complained of shortness of breath. unexplained weight loss, fatigue and gastrointestinal issues. They were often diagnosed with acute respiratory distress syndrome — essentially a lung injury from an unknown cause. The cases baffled health providers nationwide. Wisconsin is home to Juul vaping pod manufacturing sites, and one of its U.S. senators, Republican Ron Johnson, credits his win to vaping advocates. And yet the state’s officials discovered the outbreak, which shows no signs of stopping.
Former Juul executive sues company over contaminated e-cigarette pods (Morgan Winsor, ABC News, 10-30-19) Siddharth Breja, a former senior vice president of global finance at Juul who worked at the San Francisco-based company from May 2018 to March 2019, filed the lawsuit in the U.S. District Court for the Northern District of California on Tuesday. The complaint alleges that Juul sent to market at least "one million mint-flavored e-cigarette nicotine pods that it admits were contaminated, and against Mr. Breja's insistence and protests, refused to recall those contaminated pods or even issue a product health and safety warning."
Mysterious vaping illnesses are causing life-threatening lung injuries and death. Here’s what we know about the people who have been affected so far. (Julia Naftulin, Insider, 9-6-19) A lack of FDA regulation and the sheer number of different e-cigarettes and juices on the market have made it difficult for health experts to pinpoint the cause of each of the lung illnesses, or see if a common cause links all of the cases. Here are details on some cases.

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‘We Vape, We Vote’: How Vaping Crackdowns Are Politicizing Vapers (Rachel Bluth and Lauren Weber, KHN, 10-10-19) Political groups are noticing that vaping is an identity, not just a hobby. Vaping activists have already claimed success in a handful of races. Now some advocates say this burgeoning anger could shape the votes of the nation’s more than 10 million adult vapers and 20,000 vape shop owners. The Libertarian Party has capitalized on, selling “I Vape I Vote” T-shirts online alongside a pledge to “vote for candidates who support vaping.” The pro-vaping victors cited are all Republicans. (Is this nuts???)
At Raucous Hearing, No Unity On Vaping Issues (Rachel Bluth, KHN, 9-24-19) The House subcommittee hearing on vaping, ostensibly about public health, grew tense and political at unexpected moments. Committee Republicans called witness Vicki Porter, a 51-year-old former smoker and current vaper from Lake Mills, Wis., who insisted vaping allowed her to break her 23-year cigarette habit. Expert witnesses were clear that vapes and e-cigarettes are not acceptable or approved ways to quit smoking traditional cigarettes. “Switching is not quitting,” said Dr. Albert Rizzo, chief medical officer at the American Lung Association.

     While Democrats brought up youth vaping, calling it an epidemic, Republicans like Grothman and Rep. Jim Jordan (R-Ohio) wanted to focus the hearing on marijuana vaping and the harm of adulterated or counterfeit products. Dr. Anne Schuchat, principal deputy secretary of the Centers for Disease Control and Prevention, was careful to say that the CDC was classifying the outbreak as vaping-related injuries, not illnesses, because the condition was not responding to antibiotics and clearly was not an infection. She said the culprit could be the nicotine found in regular vaping liquids, the THC found in marijuana vaping products, or something else entirely, like the additives common to both kinds of vaping supplies.
Vitamin E Suspected In Serious Lung Problems Among People Who Vaped Cannabis (Joe Neel, Allison Aubrey, Shots, NPR, 9-5-19) There have been at least 215 reported cases of severe respiratory illnesses in 25 states, and many samples tested contained Vitamin E acetate, an oil that, inhaled, seems to damage the lungs.

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Reports Of Vaping-Related Illnesses Heighten Public Health Concerns (Kojo Nnandi interviews Moriah Balingit and Clifford Mitchell on the Kojo Nnamdi Show, WAMU, 9-4-19). Listen or read transcript. Lots of teenagers are smoking Juul cigarettes because they are easy to conceal--they can be smoked in the classroom! Nobody knows yet if the deaths from JUUL smoking are from excessive nicotine or from THC mixed in the flavored products. "[E]ven if we weren't talking about these significant pulmonary risk associated with this lung disease, there's a lot we don't know about the long term health consequences of vaping." Balingit: "So the symptoms that have been associated with some of these teens with addiction to e-cigarettes are far more acute and far more severe than we've typically seen with tobacco. And the doctors I spoke to believe that it may be linked to the fact that a person can Juul or they can vape far more nicotine than they might be able to with cigarettes. So, for example, because Juulmanufactured its product to be smoother to be easier on the throat, it's possible for a teenager, who would never be able to chain smoke a pack of cigarettes to Juul an entire pod, which is about equivalent to that amount of nicotine. So we're starting to see for the first time what are the impacts of these extremely high levels of nicotine on an adolescent brain." Schools see punishment as ineffective: Send a kid home for the day so they can smoke their Juul?
Mystery youth vaping disease reveals gaping holes in regulation (Sarah Owermohle, Brianna Ehley, and Rachel Roubein, Politico, 8-28-19) "A mysterious outbreak of critical lung disease in scores of teenagers and young adults is forcing federal agencies to grapple with a vast, nearly unregulated market of nicotine- and marijuana-based vaping products. At least 193 potential cases, including one death, have been reported to the federal government this summer. Yet since the first case was logged in June, agencies have released no product recalls, nor any details or broad public awareness campaigns about which specific vaping products might be causing the illness.
"Leading scientists and public health experts, including former FDA commissioners, want the CDC and FDA to step in and warn people about certain vapes, or even pull some products off the market. Key congressional chairs want FDA to step in with regulations now to halt a growing youth vaping epidemic that has taken a tragic turn. Meanwhile, federal officials are struggling with few concrete leads — sometimes nothing more than an unlabeled plastic vaping tube — as they try to find answers."

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Vaping Sicknesses Rising: 153 Cases Reported in 16 States (Sheila Kaplan, NY Times, 8-21-19) Sixteen states have now reported 153 cases of serious, vaping-related respiratory illnesses in the past two months, and many of the patients are teenagers or young adults. The CDC said that all of the cases occurred in people who acknowledged vaping either nicotine or tetrahydrocannabinol, known as THC, the high-inducing chemical in marijuana. The CDC said that while more study was needed, vaping either cannabis or nicotine could be dangerous.
With teen vaping on the rise, health officials target schools, stores (David Wahlberg, Wisconsin State Journal, 10-9-18) “It seems the intent is to start them on these products, and eventually they will switch to traditional tobacco products,” said Sara Sahli, Wisconsin government relations director for the American Cancer Society Cancer Action Network. “It’s a gateway to addicting a whole new generation.” Juul has become so popular that many young people refer to vaping as “Juuling.” More than 16 million Juul devices were sold at retail stores last year, up from about 2 million the year before, according to the Centers for Disease Control and Prevention.
Juul Says It Doesn’t Target Kids. But Its E-Cigarettes Pull Them In. (David A. Kessler, Opinion, NY Times, 7-31-19) The design (more nicotine and less harshness) makes it easier for young people to use. And a long and tragic history has taught us that nicotine addiction often begins as a pediatric disease.
As States With Legal Weed Embrace Vaping Bans, Black-Market Risks Linger (Will Stone, KHN, 11-6-19) “Something has just changed, and no one really knows what it is,” he said.
Repeal of SF e-cigarette ban, once backed by Juul, is overwhelmingly rejected by voters (Catherine Ho, SF Chronicle, 11-5-19) San Francisco’s upcoming ban on the sale of e-cigarettes will remain in place, as voters soundly rejected a ballot measure Tuesday that would have overturned the prohibition approved by the Board of Supervisors in June. Proposition C was losing by 4-1. The measure would have allowed the sale of vaping devices and nicotine cartridges with some new restrictions. It would have limited the number of vaping products a person could buy to two devices and five packs of cartridges per transaction in brick-and-mortar stores, and two devices and 60 milliliters of nicotine liquid each month online.

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Tobacco's 'Special Friend': What Internal Documents Say About Mitch McConnell (Tom Dreisbach, NPR, 6-17-19) 'The disclosure of millions of once-secret tobacco industry documents — which are now readily searchable online — has opened a window into McConnell's interactions with tobacco executives and lobbyists.... NPR also found that vaping and tobacco companies are currently employing McConnell's former policy adviser, his former policy director and his former chief of staff to lobby on their behalf."
Teen Vaping Sparks FDA Crackdown (John Daley, Colorado Public Radio, 11-9-18)The FDA plans to block convenience stores and gas stations from selling flavored e-cigarettes sold by Juul and other brands. The Juul vaping device, which looks like a flash drive, is popular among teens. They also want to require anyone buying e-cigarettes online to verify their age.
The FDA’s Mango-Flavored Trolley Problem (Amanda Mull, The Atlantic, 11-10-18) Can the agency simultaneously push e-cigarettes away from eager teens and toward longtime smokers who might benefit from them?
Why Marlboro Maker Bet on Juul, the Vaping Upstart Aiming to Kill CigarettesTobacco-giant Altria says its $12.8 billion investment in the hot e-cigarette company will give it a piece of the fast-growing segment of the market. Altria's stated goal is to get smokers to drop cigarettes. The calculated gamble: The move will help the Marlboro maker keep up with a quickly changing market. The risk: It could hasten its own decline. Facing an accelerating fall in cigarette sales, Altria Group Inc. in December put billions into Juul Labs Inc., a controversial startup whose sleek, nicotine-packed vaporizers have fueled a surge in the e-cigarette market. FDA scrutiny poses risks.
Vaping ‘Is Our Demon’: Where E-Cigarettes Help Adults Kick A Habit, Students Are Getting Hooked (Kaiser Health News, 4-3-18)
He Started Vaping as a Teen and Now Says Habit Is ‘Impossible to Let Go’ (John Daley, Colorado Public Radio and KHN, 6-8-18) Julien Lavandier, now a student at Colorado State University, started vaping when he was a sophomore in high school. He said he’d go to parties where it was common to smoke an e-cigarette. When Juul arrived on the market, he took that up too, and found it habit-forming. Stores aren’t supposed to sell e-cigarettes to minors, but Lavandier said he has been buying them for years and was never once carded.

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FDA Launches Campaign to Deter Kids from Vaping, and Puts Pressure on E-Cig Companies (Zoë Mitchell and Anthony Brooks, WBUR, Radio Boston, 9-19-18) "Juul and four other e-cigarette companies — which combined make up about 97 percent of the market — will have 60 days to say how they will address teen use of their products or face removal from the market...What lessons can be learned from past campaigns against big tobacco? Will messages that resemble the Truth Campaign resonate with young e-cigarette users?"
Know the Risks: E-cigarettes and young people (U.S. Surgeon General) Statement from Action on Smoking and Health on E-Cigarettes Following the U.S. Surgeon General’s Report: E-Cigarette Use Among Youth and Young Adults. U.S. Surgeon General Vivek Murthy released a report Dec. 8, 2016, explaining that while electronic cigarettes are less harmful than cigarettes, they are not harmless. “While alternative nicotine delivery devices may have a role in cessation, this role needs to be supported by science. In addition, there is a worrying trend that major tobacco companies such as Philip Morris (Altria), British American Tobacco, Japan Tobacco International, RJ Reynolds and others are aggressively expanding into the electronic cigarette markets, in part due to the less strenuous regulatory environment.” "E-cigarette use poses a significant – and avoidable – health risk to young people in the United States. Besides increasing the possibility of addiction and long-term harm to brain development and respiratory health, e-cigarette use is associated with the use of other tobacco products that can do even more damage to the body. Even breathing e-cigarette aerosol that someone else has exhaled poses potential health risks."
Parent Alert! Your Kid May Be Vaping More Than Tobacco(Ana B. Ibarra, California HealthLine, 8-22-18) The parent company of the Juul, a vape pen for tobacco use, also manufactures a popular marijuana pen-and-pod device called the Pax Era. But tech-savvy teens are also learning how to refill their Juul pods with different blends, including marijuana oils. "The California Department of Public Health says researchers do not fully understand how using cannabis oils and waxes with vapes affects health. What they do know is that vaporized cannabis can contain a lot more THC, the cannabis ingredient responsible for psychoactive effects such as anxiety and paranoia. “When you make it into an oil or wax, the [THC] concentration can be very high,” Vascones-Gatski said. “This is when psychotic symptoms are intensified.”

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E-cigarettes and health — here's what the evidence actually says (Julia Belluz, Vox, 5-5-16) "If you're a chronic smoker looking for a nicotine fix and trying to decide between smoking and vaping, most experts would agree there’s a compelling case that e-cigarettes are less harmful. But a nonsmoker, or an ex-smoker, should think twice before taking up the habit. Even if e-cigarettes are safer than regular cigarettes, that doesn't mean they're totally safe....There are about 500 e-cigarette brands and more than 7,000 flavors on the market, and they work in different ways, delivering varying amounts of nicotine, toxins, and carcinogens....The state of the science on e-cigarettes, in short, is crap."
Inspector’s report suggests potential for vape shop quality control issues (Mary Otto, Covering Health, AHCJ, 9-19-18) "A recent report on the results of a series of unannounced “vape shop” visits by federal inspectors raises questions about quality-assurance in the preparation of some e-cigarette products. Vape shops typically sell products, including electronic nicotine delivery devices and “e-liquids” solutions that are atomized by heating elements within the devices. When inhaled, the resulting vapor delivers nicotine, flavorings and other additives to the user. See Notes from the Field (Corinne G. Husten, Morbidity and Mortality Weekly Report, 8-31-18) "Among the 28 manufacturers inspected...None of the establishments had quality assurance programs or practices, standard operating procedures, or standardized job training for manufacturing house brands of tobacco products. Workers received on-the-job training and used recipes."
Flavors Hook Kids The tobacco industry has a kids menu. E-cigarettes and flavored nicotine liquids also have caught the attention of public health officers and local governments. California’s Department of Public Health in April launched its “Flavors Hook Kids” campaign to educate parents about some of these products.
Facebook Live: Vaping Unveiled (California Healthline, 5-31-18) What could be in that whipped cream can if not the sundae topping itself? Nicotine. Nicotine-loaded e-cig juices that spoof popular treats — marketed to help adults kick the smoking habit— instead may be luring youths into addiction. California Healthline’s Facebook Live peeled back the curtains on this wolf in sheep’s clothing. “E-juice,” or “vape juice,” is a flavored liquid that contains nicotine and is inserted into, and heated by, electronic cigarettes or vapes, which deliver the nicotine as vapor that users inhale. And they come in thousands of kid-friendly flavors, including rainbow candy, peanut butter and jelly, strawberry melon, and chocolate milk.
‘I Can’t Stop’: Schools Struggle With Vaping Explosion(Kate Zernike, NYTimes, 4-2-18) School officials, struggling to control an explosion of vaping among high school and middle school students across the country, fear that the devices are creating a new generation of nicotine addicts.

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Schools and Parents Fight a Juul E-Cigarette (Anne Marie Chaker, Wall Street Journal, 4-2-18) As illicit Juul use sweeps through high schools and middle schools, administrators and parents struggle to stem teens’ access to the vaping device, which delivers a powerful dose of nicotine.
VAPing and Parenting Guide (Mig Vapor) Using e-cigarettes, also known as vaporizers or just e-cigs, is many times safer than smoking. But do you want your kids to vape? No, and here's why. See also What is vaping? Myths vs. facts Mig Vapor is an online store selling ecig starter kits, vape mods, refillable ecig tanks, custom e-liquid, etc. and boy, can they use an editor, but there is also information here. See also The Potential Dangers of E-Cigs for Teens and Young Adults(Quitsmokingcommunity.org)
Vaping Can Be Addictive and May Lure Teenagers to Smoking, Science Panel Concludes (Sheila Caplan, NY Times, 1-23-18) A national panel of public health experts concluded in a report released on Tuesday that vaping with e-cigarettes that contain nicotine can be addictive and that teenagers who use the devices may be at higher risk of smoking. Whether teenage use of e-cigarettes leads to conventional smoking has been intensely debated in the United States and elsewhere. While the industry argues that vaping is not a steppingstone to conventional cigarettes or addiction, some antismoking advocates contend that young people become hooked on nicotine, and are enticed to use cancer-causing tobacco-based cigarettes over time.
The Vape Debate: What You Need to Know (Regina Boyle Wheeler, WebMD, 7-24-16) The pros and cons, but especially the dangers.
E-cigarette critics get research dollars from industry competitors(Kathy Hoekstra, MinnesotaWatchdog.org, 4-10-17) The nicotine patch "is one of four nicotine replacement therapies (NRT) approved by the FDA to help people quit smoking. Three others are prescription-only. Nicotrol NS is a nicotine nasal spray, while Chantix and Zyban are non-nicotine medications. The FDA, however, does not report success rates for these products. And the best Smokefree.gov can do is say they “increase your chances of quitting successfully.” FDA doesn't report success statistics on quitting smoking, doesn't list e-cigarettes as a way of quitting smoking (despite a known success rate), and the research criticizing e-cigarettes is funded by pharmaceutical firms.
3 Timely Stories to Report Now on Vaping (Dorianne Perrucci, Business Journalism, 4-25-18) Two million middle and high school students are vaping. Why? Reporters: Interview students who vape, to get to the heart of this story. Marketing messages have persuaded young people that vaping can help them quite smoking; they often don’t understand the health risks involved with e-cigarettes, including nicotine addiction. And "vaping can lead youth to try smoking, which is the single largest, preventable cause of disease and death in the U.S."

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Virtual addiction -- to smartphones, the internet, video games, online technology

(aka dependence syndrome, technology addiction)

Why Video Game Addiction Is Different for Asians (Ryan Fan, Good Men Project, 2-10-24) VThe WHO classification of gaming disorder was largely driven by pressure from Southeast Asian countries, which include not only China but South Korea, Singapore, and Taiwan, where video game addiction is often seen as a public health problem, sometimes subject to very strict limits or controls." China "tried to ban sales of consoles like the Xbox and PlayStation from 2000 to 2015, but this was futile since young Chinese people tended to be very savvy in getting the consoles in other ways, just like young Chinese people are also savvy about knowing how to get on YouTube and Facebook by using VPNs."
The Digital Drug: Internet Addiction Spawns U.S. Treatment Programs (Reuters, NY Times, 1-27-19) When Danny Reagan was 13, he began exhibiting signs of what doctors usually associate with drug addiction. He became agitated, secretive and withdrew from friends. He had quit baseball and Boy Scouts, and he stopped doing homework and showering. But he was not using drugs. He was hooked on YouTube and video games, to the point where he could do nothing else. As doctors would confirm, he was addicted to his electronics.... The "Reboot" program at the Lindner Center for Hope offers inpatient treatment for 11 to 17-year-olds who, like Danny, have addictions including online gaming, gambling, social media, pornography and sexting, often to escape from symptoms of mental illnesses such as depression and anxiety.
How Smartphones Are Making Kids Unhappy (Audie Cornish, All Things Considered, NPR, 8-7-17) "Jean Twenge, a professor of psychology at San Diego State University, has a name for these young people born between 1995 and 2012: "iGen." "She says members of this generation are physically safer than those who came before them. They drink less, they learn to drive later and they're holding off on having sex. But psychologically, she argues, they are far more vulnerable....

     "Given that using social media for more hours is linked to more loneliness, and that smartphones were used by the majority of Americans around 2012, and that's the same time loneliness increases, that's very suspicious. You can't absolutely prove causation, but by a bunch of different studies, there's this connection between spending a lot of time on social media and feeling lonely."

     For parents, "I think it is [a] good idea to put off giving your child a smartphone as long as you can. If you feel they need a phone, say, for riding a bus, you can get them a flip phone. They still sell them. And then once your teen has a smartphone, there are apps that allow parents to restrict the number of hours a day that teens are on the smartphone, and also what time of day they use it."
Are Teenagers Replacing Drugs With Smartphones? (Matt Richtel, NY Times, 3-13-17) Amid an opioid epidemic, the rise of deadly synthetic drugs and the widening legalization of marijuana, a curious bright spot has emerged in the youth drug culture: American teenagers are growing less likely to try or regularly use drugs, including alcohol. Use of smartphones and tablets has exploded over the same period that drug use has declined. Are teenagers using drugs less in part because they are constantly stimulated and entertained by their computers and phones? “Playing video games, using social media, that fulfills the necessity of sensation seeking, their need to seek novel activity,” Dr. Silvia Martins said, but added of the theory: “It still needs to be proved.”
What is video game addiction? (Illinois Institute for Addiction Recovery) Video game addiction is described as an impulse control disorder, which does not involve use of an intoxicating drug and is very similar to pathological gambling. Video game addiction has also been referred to as video game overuse, pathological or compulsive/excessive use of computer games and/or video games." A page about what the known facts are.
Frequently asked questions about Internet addiction (The Center for Internet and Technology Addiction)
The 6 Most Common Types of Technology Addiction (Family Addiction Specialist) Gaming, social media, online gambling, pornography (online sexual addiction), online shopping, and work-related digital addiction.
Are You Addicted to Technology? Patti Verbanas, Technology Today, 10-7-21) A Rutgers expert discusses signs of and treatments for technology addiction.
HouseSmarts KidSmarts Tech Addiction, Episode 170 (Dr. David Greenfield). It's a process addiction, as opposed to a substance addiction. It's a mood-altering behavior. "All of us are unable to keep track of time or space while we are on it." It gives us the illusion of being more efficient, but it actually makes us more distracted. We experience withdrawal when it is taken away from us. It will usually affect social, family, and personal relations. Setting limits on use is important. (Along the right side are links to Dr. G speaking about other aspects of technology addiction.
Are Your Kids Addicted To Their Phones? 'Screenagers' Wants to Help (Keith Wagstaff, Forbes, 2-28-16)
Screenagers: Growing Up in the Digital Age. The movie.
Screenagers (posts on Tech Talk Tuesdays blog)
Screentime, teenagers, and digital media (Common Sense Media)
Internet Sex Addiction: Case Studies and Treatment (Dan Pollets, Psychology Today, 8-6-08)
Are we addicted to technology? (Zoe Kleinman, BBC News, 8-31-15) Symptoms and suggestions for change.
Teens say they’re addicted to technology. Here’s how parents can help. (Amy Joyce, Washington Post, 5-3-16)
Technology Addiction: Concern, Controversy, and Finding Balance Common Sense Media polled over 1,200 parents and teens to find out how the saturation of mobile devices in family life is playing out in homes and child-parent relationships. See the infographic Dealing with Devices: The Parent-Teen Dynamic
We Spend More Time Watching Netflix Than With Our Friends (Lindsay Holmes, HuffPost, 5-17-16)
American Time Use Survey: Leisure time on an average day (Bureau of Labor Statistics) Watching TV takes up far and away the most time.
Smartphone dependency: a growing obsession with gadgets (Ellen Gibson, Associated Press, USA Today, 7-27-11) More Americans are ditching their iPods, cameras, maps and address books in favor of the myriad capabilities of a smartphone.

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Eating disorders

How to Tell if You Have Food Addiction (Recovery Village)
What to know about food addiction (Medical News Today) Some foods with high sugar, fat, or starch content may have close associations with food addiction. These are known as hyperpalatable foods – while they are not inherently addictive, their flavour makes them easy to compulsively eat. Examples of possible trigger foods include chips, fries, candy, chocolate, cookies, white bread, pasta, ice cream.

‘You Don’t Look Anorexic’ (Kate Siber, NY Times Magazine, 10-18-22) New research shows that our assumptions about eating disorders are often wrong — and that many larger-bodied people are starving themselves. Across the board, the pandemic exacerbated eating disorders, including typical and atypical anorexia, through increased isolation, heightened anxiety and disrupted routines. Despite its prevalence, atypical anorexia is still considered widely underdiagnosed and under-researched, and many primary-care doctors have never heard of it. An excellent piece on the topic.
As Eating Disorders Spike During Pandemic, Rural Treatment Options Lag (Carly Graf, KHN, 4-19-22) Eating disorders, including anorexia, bulimia, and binge-eating disorder, are some of the most fatal mental illnesses. Yet treatment options are sparse, particularly in rural states such as Montana. A third of people with eating disorders are men, a group that is underdiagnosed and undertreated. Although Black, Indigenous, and other people of color are no less likely to develop an eating disorder, they are half as likely to be diagnosed or receive treatment.
National Eating Disorders Association. NEDA's provider database
Stuck at Home, She Feared More Than the Virus (Amanda Long, Washington Post Magazine, 4-26-2020) She'd spent her whole adult life struggling with an eating disorder. After recovery, a week of self-isolation felt like the ultimate test. Then a book she'd ordered came with the author's inscription: "What would you do if you trusted yourself?"
National Eating Disorders Association (NEDA) (forums and other forms of support)
A Very Good Liar (Erin Branning, Hippocampus, 7-7-21) A daughter's memories of her mother: "One afternoon, while sitting at the nurse’s station, she sees her chart and the words Anorexia Nervosa written under Diagnosis. She doesn’t know what this means, and no one has ever used those words with her....I used to think my mother was a very good liar, but really we were all pretending not to see what was right in front of us."
Eating Recovery Center
***Patient Voices: Eating Disorders (NY Times Health Guide) How does an eating disorder take over someone’s life? Is it a matter of losing control or trying to seize it? Eight men, women and children tell of their struggles with anorexia, bulimia and other forms of eating disorders. Join the discussion.
Cravings: How I Conquered Food by Judy Collins. Bulimic for 11 years, she now adheres to a program she swears by called GreySheeters Anonymous. See David Bruce Smith's review.
Eating Disorders News (blog of Psychology Today)
Unhealthy Weight Loss or Gain from Eating Disorders (Pritikin Wellness Resources)
Critical Points for Early Recognition and Medical Risk Management in the Care of Individuals with Eating Disorders (10 pages, free download from Academy for Eating Disorders (AED) .
Videos about eating disorders (Academy for Eating Disorders)
Anorexia (NY Times fact sheet)
Eating disorder not otherwise specified (EDNOS), Wikipedia entry\
Something Fishy (website on eating disorders)
Eating Disorders (free detailed booklet describes the symptoms, causes, and treatments of eating disorders, National Institutes of Mental Health)
National Eating Disorder Information Centre's blog
My name is Ron, and I am a food addict (Ron Cothran, CNN, 3-28-14 ) He writes that after gastric bypass surgery, "I no longer could eat to feel better; I needed to find a healthier way to deal with life." One reader comments: "You know what's worst of all? The treatment for chronic overeating is to think about every food choice you make for the rest of your life."
A Small Loss (Mary W's blog about her struggle with weight loss-gain-loss).
Eating disorders 'prevalent among fitness professionals' (Rhiannon Beacham, BBC News, 12-31-12)
YMCA patrons stage intervention for anorexic woman (Steve Hartman, CBS News, 5-2-14)
Mirror, Mirror Off the Wall: How I Learned to Love My Body by Not Looking at It for a Year by Kjerstin Gruys
Diabulimia (National Eating Disorders Association, NEDA), a non-clinical, media-coined term used to describe an eating disorder that affects some individuals with type 1 diabetes, who purposely restrict insulin in order to lose weight. Also referred to as the Dual Diagnosis of Eating Disorder and Diabetes Mellitus Type 1 (ED-DMT1).
Diabulimia: All in Our Heads? (Amy T, DiabetesMine, 10-28-10). In 2007, journalists began writing about diabulimia (women with type 1 diabetes, who were shunning their medication for fear of getting fat-- or restricting or stopping taking their insulin to lose weight). See articles by expert Ann Goebel-Fabbri, at the Joslin Diabetes Center. There is a new book by Maryjeanne Hunt about battling this eating disorder: Eating to Lose: Healing from a Life of Diabulimia, which is reviewed here.
Binge Eating in Men: Understanding a Widely Misunderstood Eating Disorder (Carolyn C. Ross, Psychology Today, 10-2-12)
Narrowing an Eating Disorder (Eating Disorder Not Otherwise Specified, or EDNOS, by Abby Ellin (NYTimes, 1-18-10)
Shattered Image: My Triumph Over Body Dysmorphic Disorder by Bryan Cuban
Obesity (Making Evidence Matter links to useful evidence-based articles about obesity.)


Memoirs about Food Addiction and Eating Disorders

Brave Girl Eating: A Family's Struggle with Anorexia by Harriet Brown. “One of the most up to date, relevant and honest accounts of one family’s battle with the life threatening challenges of anorexia."
Curbing It by Jeff Garlin
The Elephant in the Room: One Fat Man's Quest to Get Smaller in a Growing America by Tommy Tomlinson (coming in January 2019). Read about it in A conversation with Tommy Tomlinson: Getting naked in print and public (in which Chip Scanlon interviews Tomlinson for a piece in Nieman Storyboard, 10-9-18) "A writer who tells intimate stories of others turns his notebook on himself in a searing memoir that undresses his own and America's obesity."
Gaining: The Truth About Life After Eating Disorders by Aimee Liu, whose memoir of life with anorexia, Solitaire, came out when she was 25.
Heavy: An American Memoir by Kiese Laymon (in which he explores "what the weight of a lifetime of secrets, lies, and deception does to a black body, a black family, and a nation teetering on the brink of moral collapse."
Hunger: A Memoir of (My) Body by Roxane Gay (a searingly honest memoir of food, weight, self-image, and learning how to feed your hunger while taking care of yourself).
Hungry Heart: Adventures in Life, Love, and Writing by Jennifer Weiner
Purge: Rehab Diaries by Nicole Johns (a raw and engaging account of her months in rehab, in a residential treatment facility for eating disorders.
703: How I Lost More Than a Quarter Ton and Gained a Life by Nancy Makin ("A moving, funny, tongue-in-cheek, and deadly serious story about how one woman lost and found herself by going online").
Wasted: A Memoir of Anorexia and Bulimia by Marya Hornbacher. Written at 23 for young adults, this brutally candid memoir may "trigger" those still in grips or early stages of disease, say some readers, serving as a how-to guide for eating disorders. Good insight for families of those with ED.

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Helpful organizations and publications

Self-help groups
Alcoholics Anonymous (AA) Very popular, but does not work for everyone.
Families Against Narcotics (FAN)
Narcotics Anonymous (NA)
SMART Recovery (Smart Management and Recovery Training)
Dual Recovery Anonymous (men & women who meet to support each other in our common recovery from two No-Fault illnesses: an emotional or psychiatric illness and chemical dependency)
Co-Dependents Anonymous (CoDA) We found in each of our lives that codependence is a deeply rooted compulsive behavior born out of our dysfunctional family systems.
Al-Anon Family Groups (strength and hope for friends and families of problem drinkers)
Nar-Anon Family Groups (a 12-step program for families & friends of addicts)
Self-Help Groups for Drug Addiction (with descriptions)
Women for Sobriety (WFS) and WFS Message Forum and Chat
Secular Organizations for Sobriety (SOS), a nonprofit network of autonomous, non-professional local groups, dedicated to helping individuals achieve and maintain sobriety/abstinence from alcohol and drug addiction, food addiction and more.

Organizations focused on understanding and dealing with substance abuse and misuse
Action on Smoking and Health (ASH, building a world with ZERO deaths from tobacco)
Addiction and Suicide (Ocean Recovery)
Addiction Journal
Addiction Treatment Events (event announcements from national organizations, AddictionResource)
Alcoholism & Drug Abuse Weekly
American Society of Addiction Medicine (ASAM) (The Voice of Addiction Medicine -- professional society representing over 4,200 physicians, clinicians and associated professionals ) Connect. Advocate. Educate. Treat.
College Drinking: Changing the Culture. Planning alcohol interventions using NIAAA's College AIM, Interactive Body (how every organ is affected by alcohol), College alcohol policies, etc.
Drug Abuse (NIDA, links to many resources, including NIH clinical trials locator)
Drug Facts: Understanding Drug Abuse and Addiction (NIDA)
Foundation for Advancing Alcohol Responsibility
Harm Reduction Coalition Founded in 1993 and incorporated in 1994 by a working group of needle exchange providers, advocates and drug users--today, strengthened by a network of allies who challenge the persistent stigma faced by people who use drugs and advocate for policy and public health reform. See The Controversial Answer To America’s Heroin Surge (John Knefel, Buzzfeed, 5-16-14) With heroin use at epidemic levels, harm reduction — a bold, long-contested approach to treating addicts — is gaining political traction. But are we ready to make it easier to shoot heroin even if it means fewer deaths?
An Interactive Lesson Guide for Parents and Teachers to Teach Kids About Drugs and Alcohol (White Sands Treatment)
Legal Action Center. Nonprofit U.S. law and policy organization that fights discrimination against people with histories of addiction, HIV/AIDS, or criminal records, and advocates for sound public policies in these areas. Staff members serve as legal advocates for drug and alcohol abuse treatment centers and their patients.
MedHelp articles on substance abuse
Memoirs and fiction about addiction and alcoholism
National Institute on Drug Abuse (NIDA)
National Institute on Alcohol Abuse and Alcoholism (NIAAA)
National Registry of Evidence-based Programs and Practices (NREPP) (SAMHSA)
• Online MSW Programs: 60 Digital Resources for Addressing Substance Use Disorders, Addiction and Recovery
Partnership for Drug-Free Kids (Helpline: 1-855-DRUGFREE)
Physicians to Prevent Opioid Abuse (Facebook page)
Prevention Coalition (founded by a group of retired school counselors and therapists to provide an accessible drug use and abuse prevention resource for parents, teachers, counselors and other concerned adults)
Rehab.com (listings for individuals and families seeking treatment: 15,936 alcohol treatment centers, 14,732 drug treatment centers, and 16,946 mental health centers in U.S. and Canada) For 24/7 Treatment Help Call: (888) 352-9771
Substance Abuse and Mental Health Services Administration (SAMHSA)
SAMHSA's behavioral treatment services locator
Women for Sobriety "Happiness is a habit I am developing. Happiness is created, not waited for." ~Acceptance Statement 3.

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The war on drugs

‘We feel like our system was hijacked’: DEA agents say a huge opioid case ended in a whimper (Lenny Bernstein and Scott Higham, WashPost, 12-17-17) "After two years of painstaking investigation, David Schiller and the rest of the Drug Enforcement Administration team he supervised were ready to move on the biggest opioid distribution case in U.S. history. The team, based out of the DEA’s Denver field division, had been examining the operations of the nation’s largest drug company, McKesson Corp. By 2014, investigators said they could show that the company had failed to report suspicious orders involving millions of highly addictive painkillers sent to drugstores from Sacramento, Calif., to Lakeland, Fla. Some of those went to corrupt pharmacies that supplied drug rings. The investigators were ready to come down hard on the fifth-largest public corporation in America, according to a joint investigation by The Washington Post and “60 Minutes.”...Instead, top attorneys at the DEA and the Justice Department struck a deal earlier this year with the corporation and its powerful lawyers, an agreement that was far more lenient than the field division wanted, according to interviews and internal government documents. Although the agents and investigators said they had plenty of evidence and wanted criminal charges, they were unable to convince the U.S. attorney in Denver that they had enough to bring a case."
Prosecutors Treat Opioid Overdoses as Homicides, Snagging Friends, Relatives (Joseph Walker, WSJ, 12-17-17) As U.S. drug deaths hit record levels, prosecutors and police are trying a tactic that echoes tough-on-crime theories of the 1990s
This company’s drugs helped fuel Florida’s opioid crisis. But the government struggled to hold it accountable. (Lenny Bernstein and Scott Higham, WaPo, 4-2-17) "To combat an escalating opioid epidemic, the Drug Enforcement Administration trained its sights in 2011 on Mallinckrodt Pharmaceuticals, one of the nation’s largest manufacturers of the highly addictive generic painkiller oxycodone....the DEA and federal prosecutors would contend that the company ignored its responsibility to report suspicious orders as 500 million of its pills ended up in Florida between 2008 and 2012 — 66 percent of all oxycodone sold in the state....Florida’s lax laws, dishonest doctors and unscrupulous pharmacists had turned the state into ground zero for the nation’s prescription opioid crisis....Prosecutors noted that the DEA had twice placed the industry on notice about its responsibility to report suspicious orders. They also said Mallinckrodt was aware of enforcement actions the agency had taken against distributors for failing to report the inordinate amounts of painkillers they were shipping to retail customers in states such as Florida." Significant cash sales are an indication of diversion (to illegal sales of drugs). Look for patterns of pharmaceutical firms illegally promoting off-label drug use and paying kickbacks to doctors. Sources close to the negotiations said that the two sides had recently reached a tentative agreement to settle the case for $35 million. Mallinckrodt told its shareholders the investigation “will not have a material adverse effect on its financial condition” because it has set aside the money."For a company the size of Mallinckrodt, a $35 million fine is “chump change,” one government official said.
"Drug manufacturers have paid much larger fines for other misdeeds. Glaxo­SmithKline was fined $3 billion, and Pfizer was fined $2.3 billion for illegally promoting off-label drug use and paying kickbacks to doctors. Purdue Pharma paid a $600 million fine, and three of its executives pleaded guilty to charges that they misled regulators, doctors and patients about the risks of the painkiller that is widely blamed for setting off the nation’s opioid crisis: OxyContin. All of those cases were initiated by the Food and Drug Administration. The largest fine the DEA has levied against a drug distributor was the $150 million that McKesson, the nation’s largest drug wholesaler, recently agreed to pay following allegations that it failed to report suspicious orders of painkillers."
Investigation: The DEA slowed enforcement while the opioid epidemic grew out of control (Lenny Bernstein and Scott Higham, Washington Post, 10-22-16) "he epidemic began in the late 1990s after the introduction of the powerful, long-acting opioid OxyContin and an aggressive marketing campaign by the drug’s manufacturer, Purdue Pharma, to persuade doctors to prescribe it for all kinds of pain. A new philosophy of pain management resulted in a surge in demand and the U.S. addiction rate. From 2000 to 2014, 165,000 people died of overdoses of prescription painkillers nationwide. The crisis has also fostered follow-on epidemics of heroin, which caused nearly 55,000 overdose deaths in the same period, and fentanyl, which has killed thousands more. The number of U.S. opioid prescriptions has risen from 112 million in 1992 to 249 million in 2015." The Justice Department "issued a statement saying that the drop in diversion cases reflects a shift from crackdowns on “ubiquitous pill mills” toward a “small group” of doctors, pharmacists and companies that continues to violate the law."
"In the summer of 2014, Rannazzisi said that he received an unusual request. To foster better relations with industry, the Justice Department wanted to meet with senior representatives of drug distributors and pharmacy chains. Rannazzisi said he was appalled. Some of the companies were either under investigation or in the midst of settlement negotiations with the DEA diversion office, he said....That summer, lobbying by the pharmaceutical industry intensified on Capitol Hill. Several members of Congress, led by Reps. Tom Marino (R-Pa.) and Marsha Blackburn (R-Tenn.), were proposing a measure that critics said would undercut the DEA’s ability to hold drug distributors accountable. Four major players lobbied heavily in favor of the legislation, called the Ensuring Patient Access and Effective Drug Enforcement Act. Together, McKesson, AmerisourceBergen, Cardinal and the distributors’ association, the Healthcare Distribution Alliance, spent $13 million lobbying House and Senate members and their staffs on the legislation and other issues between 2014 and 2016, according a Post analysis of lobbying records."
The Likely Cause of Addiction Has Been Discovered, and It Is Not What You Think (Johann Hari, author of Chasing the Scream: The First and Last Days of the War on Drugs, Huffington Post, 1-20-15)
Should Even Heroin Be Legal? (Andrew Sullivan, The Dish, part 1 of book club discussion of Johann Hari's book Chasing the Scream: The First and Last Days of the War on Drugs. See also part 2. "In Chasing the Scream, Hari reveals his startling discoveries entirely through the true and shocking stories of people across the world whose lives have been transformed by this war. They range from a transsexual crack dealer in Brooklyn searching for her mother, to a teenage hit-man in Mexico searching for a way out. It begins with Hari’s discovery that at the birth of the drug war, Billie Holiday was stalked and killed by the man who launched this crusade – while it ends with the story of a brave doctor [in Portugal] who has led his country to decriminalize every drug, from cannabis to crack, with remarkable results." Listen to Hari's TED talk Everything you think you know about addiction is wrong (June 2015) or read the transcript (TED talk, June 2015). "For 100 years now, we've been singing war songs about addicts. I think all along we should have been singing love songs to them, because the opposite of addiction is not sobriety. The opposite of addiction is connection."
‘Pimping out’ drug addicts for cash (Alfred Lubrano, Philadelphia Inquirer, 6-1-17) In Philadelphia, addicts have become a cash crop, used by some treatment centers and recovery houses to create a perpetual money churn. On the street, it's called "pimping out." Stripped of basic rights, addicts are told by the people who run their boarding houses — called recovery houses — what facility to attend, when to go, and for how long. If addicts don’t take the van rides, house operators threaten them with eviction...In exchange for herding people into centers, recovery house operators pocket illegal, under-the-table payments – ranging from $100 to $400 per person monthly – that keep them in business. The centers, in turn, bill the government for a piece of the $680 million in Medicaid and state money disbursed in 2016 by a nonprofit contracted by the city to combat addiction and mental health issues.
A tool to protect police dogs in drug raids from overdosing (Associated Press, 6-1-17) Police dogs simply follow their noses to sniff out narcotics. But inhaling powerful opioids can be deadly, so officers have a new tool to protect their four-legged partners: naloxone, a drug that has already been used for years to reverse overdoses in humans.
Overcoming Opioids: The Quest for Less Addictive Drugs (AP, NY Times, 4-17-17) "Tummy tucks really hurt. Doctors carve from hip to hip, slicing off skin, tightening muscles, tugging at innards. Patients often need strong painkillers for days or even weeks, but Mary Hernandez went home on just over-the-counter ibuprofen. The reason may be the yellowish goo smeared on her 18-inch wound as she lay on the operating table. The Houston woman was helping test a novel medicine aimed at avoiding opioids, potent pain relievers fueling an epidemic of overuse and addiction." (KHN)
Locating blame in the opioid epidemic (Washington Post editorial, 10-30-16) "Destructive and persistent, the epidemic of opioid addiction is also deeply ironic: Unlike previous drug scourges in U.S. history, this one spread via perfectly legal channels. Millions of people were introduced to addictive pain-killing medications by doctors’ prescriptions, filled at pharmacies, ultimately supplied by pharmaceutical manufacturers. All of this went on in one of the most heavily regulated sectors of the U.S. economy — health care — which is supervised by a veritable army of officials working for dozens of agencies, state and federal.
Controversies involving Corizon Health (Wikipedia). "CMS became Corizon Health, Inc., in 2011, after essentially merging its operations with PHS Correctional Healthcare (previously known as Prison Health Services, Inc.), its largest competitor in the correctional health care industry. Corizon Health, like its predecessors CMS and PHS, and its competitors, along with self-operated correctional health programs, has faced criticism from government officials, public-health advocates and experts for being more concerned with maintaining lucrative government contracts than effectively treating sick inmates, who are considered the most chronically and profoundly physically and mentally ill members of any society." It keeps changing its name.
Medicaid Coverage Inconsistent for Addiction Tx (Neel A. Duggal, MedPage Today, 12-22-16) Some states skimp, others generous. "Overdose deaths are robustly correlated with lack of treatment access." -- David Kan, MD, of the University of California San Francisco, on the wide variation among states in their Medicaid coverage of substance abuse treatments.
How drugs intended for patients ended up in the hands of illegal users: ‘No one was doing their job’ (Lenny Bernstein, David S. Fallis and Scott Higham, WaPo, 10-22-16) "For 10 years, the government waged a behind-the-scenes war against pharmaceutical companies that hardly anyone knows: wholesale distributors of prescription narcotics that ship drugs from manufacturers to consumers....Many companies held back drugs and alerted the DEA to signs of illegal activity, as required by law. But others did not. Collectively, 13 companies identified by The Washington Post knew or should have known that hundreds of millions of pills were ending up on the black market, according to court records, DEA documents and legal settlements in administrative ­cases, many of which are being reported here for the first time.
"A review of the DEA’s campaign against distributors reveals the extent of the companies’ role in the diversion of opioids. It shows how drugs intended for millions of legitimate pain patients ended up feeding illegal users’ appetites for prescription narcotics. And it helps explain why there has been little progress in the U.S. opioid epidemic, despite the efforts of public-health and enforcement agencies to stop it. A Post investigation published Saturday revealed that beginning in 2013, some officials at DEA headquarters began to block and delay enforcement actions against wholesale drug distributors and others, frustrating investigators in the field.
"The 13 companies include Fortune 25 giants McKesson, Cardinal Health and Amerisource­Bergen, which together control about 85 percent of all pharmaceutical distribution in the United States. They also include regional wholesalers such as Miami-Luken and KeySource Medical, both based in Ohio, as well as Walgreens, the nation’s largest retail drugstore chain. Many of the distributors are tiny operations with just a few employees."
Where the most prescriptions are prescribed, the most overdoses happen. Counties with high rates of prescription and overdose include Appalachia, the California-Oregon border, Pennsylvania, Oklahoma, and Arizona.

Drug industry hired dozens of officials from the DEA as the agency tried to curb opioid abuse (Scott Higham, Lenny Bernstein, Steven Rich and Alice Crites, WaPo, 12-22-16) Critics say the revolving door undercuts the agency’s ability to curb the rising opioid epidemic. Since 2004, "the pharmaceutical companies and law firms that represent them have hired at least 42 officials from the DEA — 31 of them directly from the division responsible for regulating the industry, according to work histories compiled by The Post and interviews with current and former agency officials."
An opioid epidemic is what happens when pain is treated only with pills (Joel Achenbach, WaPo, 12-23-16)Yet the crisis masks a "pain gap" for many people.
One-third of long-term users say they’re hooked on prescription opioids (Scott Clement and Lenny Bernstein, WaPo, 12-9-16) And 6 in 10 day say doctors aren’t helping them figure out how to quit.
The Controversial Answer To America’s Heroin Surge (John Knefel, Buzzfeed, 5-16-14) With heroin use at epidemic levels, harm reduction — a bold, long-contested approach to treating addicts — is gaining political traction. But are we ready to make it easier to shoot heroin even if it means fewer deaths? "There’s the just-passed plan to have New York City police officers carry a heroin “antidote” to reverse overdoses, part of a $5 million program; the state legislature passed a Good Samaritan law to protect users who call 911 if they witness an overdose and another law that decriminalizes heroin residue in used needles. At the federal level, Attorney General Eric Holder has endorsed first responders carrying similar kits, and a spokesperson for the Drug Enforcement Administration echoed support for the programs. But a significant reason for the shift in lawmakers’ attitudes is the advocacy work done on the national level by groups like the New York City-based Harm Reduction Coalition, and the local organizing that groups like Brooklyn’s VOCAL-NY are doing on the city and state level."
Opioid Crisis: Can recent reforms curb the epidemic? (Peter Katel, CQ Researcher, 10-7-16) "Overdoses of opioid drugs, including powerful prescription painkillers and heroin, have killed almost 250,000 Americans since 2000, leading many experts to compare the crisis to the HIV and AIDS epidemics. Opioid addiction, once largely an urban minority affliction, has spread to every corner of the United States, hitting young adults and white people especially hard. One study has found that more adults use prescription painkillers than cigarettes, smokeless tobacco and cigars combined. As opioid abuse grows, propelled in part by a flood of cheap heroin from Mexico, alarmed authorities are trying to figure out how to fight back. In July, President Obama signed a bill encouraging the expansion of treatment programs and the development of alternatives to opioid painkillers. But many experts are divided over how best to help opioid addicts. Some advocate providing them with limited doses to control their addiction, while others say that such an approach would make the crisis worse."

Why I stopped prescribing narcotics, and never looked back (Alan A. Berg, Kevin MD, 4-10-16) "After 30 years, I have learned that I can’t recognize who has a drug problem and I don’t want to play the game any longer."

Political Gridlock Blocks Missouri Database For Fighting Drug Abuse (Bram Sable-Smith, Side Effects Public Media, 4-14-16) In the battle against America’s surging opioid drug addiction, 49 states, the District of Columbia and even Guam have all implemented some kind of prescription drug monitoring program (PDMP). Missouri is the sole holdout. State Sen. Rob Schaaf blocks it in the state senate, saying the bill interferes with the right to medical privacy, fearing hackers.

Legalize It All: How to win the war on drugs (Dan Baum, Harper's, April 2016) "Nixon’s invention of the war on drugs as a political tool was cynical, but every president since — Democrat and Republican alike — has found it equally useful for one reason or another. Meanwhile, the growing cost of the drug war is now impossible to ignore: billions of dollars wasted, bloodshed in Latin America and on the streets of our own cities, and millions of lives destroyed by draconian punishment that doesn’t end at the prison gate; one of every eight black men has been disenfranchised because of a felony conviction." Nixon's top aide John Ehrlichman revealed to Baum that the invented "war" targeted Vietnam war protesters and Black Americans: "We knew we couldn't make it illegal to be either against the war or Black, but by getting the public to associate the Hippies with marijuana and Blacks with heroin, then criminalizing both heavily, we could disrupt those communities. We could arrest their leaders, raid their homes, break up meetings, and vilify them night after night on the evening news. Did we know we were lying about drugs? Of course we did."
Baum reports, "I must have looked shocked. Ehrlichman just shrugged."

Republicans — Then And Now — Talking About Drug Addiction (Eyder Peralta, The Big Listen, 2-8-16). "This talk of redemption and second chances fits right in with conservative narratives of sin and redemption.'...This suggests a conservative model of treatment couched in terms of sin and salvation rather [than] diseases and cures--which is in keeping with certain conservative ideas about religion and individual responsibility. From that perspective, drug abuse remains a moral failing but one that can be better addressed in treatment than in prison. But again the key point is that so far, such a model of drug treatment has been more inclined to find possibilities for redemption among white drug users than among drug users of color."
The Use of Confrontation in Addiction Treatment: History, Science, and Time for Change (William L. White and William R. Miller, Counselor, 2007) "It is time to declare a final moratorium on the use of harsh, humiliating confrontational techniques in addiction treatment. It is time to lay to rest once and:for all the arrogant notion that we should or even can dismantle other human beings and then put them back together in better and wiser form. With impressive consistency, research tells us that authoritarian confrontation is highly unlikely to heal and may well do harm, particularly to the more vulnerable among those we serve. Within this context, such confrontational treatment is professionally unethical, and is doubly problematic when used with coerced populations such as court-ordered or employer-mandated populations." (p. 24)

War on Drugs (Wikipedia's helpful overview. which places the drug war in political and military context)

Impact of the War on Drugs on Incarceration (Human Rights Watch on racially disproportionate drug arrests). See Summary and Recommendations.
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Memoirs and fiction about drug abuse, addiction, and alcoholism

The Basketball Diaries by Jim Carroll (about his teen years, growing up hip, with drugs and sex, on New York"s mean streets)
Beautiful Boy: A Father's Journey Through His Son's Addiction (David Scheff chronicling a precocious teenager's spiral downward from abuse of mind- and mood-altering drugs to meth addiction)
Chancers: Addiction, Prison, Recovery, Love: One Couple's Memoir by Susan Stellin and Graham MacIndoe. In this powerful memoir of addiction, prison, and recovery, a reporter and a photographer tell their gripping story of falling in love, the heroin habit that drove them apart, and the unlikely way a criminal conviction brought them back together. Read more about it.
Dead, Insane, or in Jail: A CEDU Memoir by Zack Bonnie. "Dead, insane, or in jail" were the options open to 14-year-old Zack B "if he ran away from the cult his parents inadvertently inducted him into....Too many people can relate to this account, unfortunately. Although Rocky Mountain Academy has closed its doors, several hundred residential teen-treatment programs, religious reeducation camps, and places that commit spiritual assassination still operate without oversight in the United States." For more about these "therapeutic boarding schools," check out
---Goodreads comments on Dead, Insane, or in Jail.
---The Cedu Program Resurfaces in Mount Bachelor Academy, Oregon (Liam Scheff) and Escape by Paul Morantz on the Surviving CEDU blog.
---State suspends license from central Oregon school for troubled teens (Michele Cole, The Oregonian, 11-3-09)
--- Bye Bye Mount Bachelor Academy (scroll down the page for comments, from former participants and their parents, etc.)
The Dead Inside: A True Story by Cyndy Etler. Goodreads: 'Cyndy Etler's gripping memoir gives readers a glimpse into the harrowing reality of her sixteen months in the notorious "tough love" program the ACLU called "a concentration camp for throwaway kids."...To the public, Straight Inc. was a place of recovery. But behind closed doors, the program used bizarre and intimidating methods to "treat" its patients. In her raw and fearless memoir, Cyndy Etler recounts her sixteen months in the living nightmare that Straight Inc. considered "healing."' And the companion book: We Can't Be Friends: A True Story . "This is a gritty, hard-hitting, and, for many readers, unfortunately necessary exploration of what's really behind the lures of self-destructive behaviors, and what real recovery is and isn't." - Bulletin of the Center for Children's Books
Double Double: A Dual Memoir of Alcoholism, mystery novelist Martha Grimes and her son Ken Grimes' memoir about alcoholism, creeping up on them until in 1990 they faced the problem and dealt with it, she at a rehab clinic, he through a 12-step program.
Drinking: A Love Story by Caroline Knapp. "Freelance journalist Knapp began drinking in her early teens and continued unabatedly until she "hit bottom" in 1995 and checked herself into a rehab at the age of 36....a confession utterly devoid of self-pity, an extraordinarily lucid and very well-written personal account of a common addiction that is filled with insights as well as a comprehensive treatment of the subject." --Publishers Weekly
A Drinking Life: A Memoir by Pete Hamill. As a child during the Depression and World War II he learned that drinking was to be an essential part of being a man, it was only later he discovered its ability to destroy lives.
Drugged as Children, Foster-Care Alumni Speak Out (Lucette Lagnado) The past decade and a half has seen an upsurge in strong antipsychotic drugs prescribed for children in Medicaid and foster care. The inspector general of Health and Human Services, the federal agency that oversees Medicaid payments, has launched an inquiry into such prescriptions. Now, with roughly 20,000 young people being emancipated from foster care each year, many are anxious to speak out. Overseen by state and local governments, foster care provides temporary placement for minors unable to remain in their own homes. Antipsychotics, drugs dispensed for a broad array of diagnoses, have ignited a wave of debate—most recently over their use in poor children and the billions that they cost the Medicaid and Medicare systems annually. Most scrutiny centers on a new class of antipsychotics sold under such brand names as Abilify, Seroquel, Risperdal and Zyprexa. Stephen Crystal, a professor of health-services research at Rutgers University, estimates that 12% to 13% of kids in foster care take these medicines....According to Prof. Crystal's research, the largest diagnostic groups receiving the drugs in foster-care in 2009 were those with disruptive-behavioral disorders and attention-deficit/hyperactive disorders. "These diagnoses involve difficulty focusing attention or controlling behavior—but that is different from not being in touch with reality," a key element of psychosis, he says.
Dry: A Memoir by Augusten Burroughs. "Imagine coming home to find hundreds of empty scotch bottles and 1,452 empty beer bottles in your apartment. This is what Burroughs (Running with Scissors) encountered upon returning from Minnesota's Proud Institute (supposedly the gay alcohol rehab choice). "--Publishers Weekly
Friends, Lovers, and the Big Terrible Thing: A Memoir by Matthew Perry. The beloved star of Friends takes us behind the scenes of the hit sitcom and his struggles with addiction in candid, funny, and revelatory memoir. By the time he was 49, he had spent more than half his life in treatment centers or sober living facilities,
How to Stop Time: Heroin from A to Z by Ann Marlowe. "Part memoir, part cultural criticism and part junkie riff, journalist Marlowe's fragmented reflections on her seven years as a heroin addict....She also proves to be an excellent cultural commentator, presenting insights into why people start using drugs, how society glamorizes heroin whereas actual users do not and how men and women take drugs differently."~Publishers Weekly. “Addiction is a mourning for the irrecoverable glories of the first time"
I’m Dancing as Fast as I Can (Barbara Gordon on her addiction to prescription drugs)
Junky by William S. Burroughs. "Burroughs fictionalized his experiences using and peddling heroin and other drugs in the 1950s into a work that reads like a field report from the underworld of post-war America. The Burroughs-like protagonist of the novel, Bill Lee, see-saws between periods of addiction and rehab, using a panoply of substances including heroin, cocaine, marijuana, paregoric (a weak tincture of opium) and goof balls (barbiturate), amongst others."
Lit by Mary Karr (her memoir about alcoholism, getting sober, and getting God, by the author of The Liars' Club (in which the addiction is her mother's).
The Long Run by Mishka Shubaly. After nearly twenty years of chasing oblivion, a fight in a bar reveals to a newly sober Mishka Shubaly that he is able to run long distances. Despite his best attempts to dodge enlightenment and personal growth, the irreverent young drunk and drug abuser learns to tame his self-destructive tendencies through ultrarunning.
The Los Angeles Diaries: A Memoir by James Brown. Brown details in vignettes how, after growing up with an emotionally disturbed mother and drifting with his brother and sister into addiction, "he screwed over his first wife, children, sister, writing students, and agent--all while feeding addictions to booze, crank, and novels by hustling hollow teaching and scriptwriting gigs....Brown says meeting his second wife changed his life and then keeps the process to himself, omitting the third act. Even though his is a story of selfishness selfishly told, Brown's blackout days make for a darkly alluring read. This is the kind of book that becomes an underground classic for all the wrong reasons." ~Booklist
Mother Daughter Me: A Memoir by Katie Hafner. "“Weaving past with present, anecdote with analysis, [Katie] Hafner’s riveting account of multigenerational living and mother-daughter frictions, of love and forgiveness, is devoid of self-pity and unafraid of self-blame."~Cathi Hanauer, Elle
The Night of the Gun: A reporter investigates the darkest story of his life. His own. by David Carr. Built on sixty videotaped interviews, legal and medical records, and three years of reporting, The Night of the Gun is a ferocious tale that uses the tools of journalism to fact-check the past. Carr’s investigation of his own history reveals that his odyssey through addiction, recovery, cancer, and life as a single parent was far more harrowing—and, in the end, more miraculous—than he allowed himself to remember.
Parched: A Memoir by Heather King. "It’s a story about a good girl gone bad - gone good. "Parched,"…lays naked her 18 years wrapped in drugs and alcohol: sweet memories, toilet rims and all." - Jeanné McCartin, Portsmouth Herald
Permanent Midnight by Jerry Stahl. “Permanent Midnight is one of the most harrowing and toughest accounts ever written in this century about what it means to be a junkie in America, making Burroughs look dated and Kerouac appear as the nose-thumbing adolescent he was.”~Booklist
Portrait of an Addict as a Young Man: A Memoir by Bill Clegg. A charismatic, high-profile literary agent with an inferiority complex binges on crack cocaine. The Globe and Mail called Clegg's unflinching, intelligent, and grim account "a skillfully conjured, slow-motion train wreck from which it's impossible to look away."
Smacked: A Story of White-Collar Ambition, Addiction, and Tragedy by Eilene Zimmerman. Listen to her story on "Fresh Air". Zimmerman didn't learn of her ex-husband's addiction to cocaine and opioids until after his drug-related death. Her memoir, Smacked, explores how her former spouse, a wealthy, high-powered attorney, hid his addiction and depression from her and their two children. The book grew out of this article: The Lawyer, the Addict ("A high-powered Silicon Valley attorney dies. His ex-wife investigates, and finds a web of drug abuse in his profession.")
Tweak: Growing Up on Methamphetamines by Nic Sheff (the story that inspired the movie "Beautiful Boy"--"Difficult to read and impossible to put down." (Chicago Tribune)

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The problems with drug courts

Methadone, Suboxone, abstinence, treatment facilities, clinics, drug courts, and other options

Dying To Be Free (Jason Cherkis, Huffington Post, 1-28-15) This investigation into how the drug treatment system was failing heroin addicts spotlighted Kentucky’s drug courts and their failure to embrace medical treatment options for opiate addicts. (Powerful story supplemented by video.) A powerful piece of reporting. Twelve-step programs treat alcohol and drugs according to the same principles. But heroin changes the way the brain works. There is a treatment for heroin addiction that actually works. Why isn't it being used? One point among many: There is a "newer maintenance medication on the market sold under the brand name Suboxone. Like methadone, Suboxone blocks both the effects of heroin withdrawal and an addict’s craving and, if used properly, does it without causing intoxication. Unlike methadone, it can be prescribed by a certified family physician and taken at home, meaning a recovering addict can lead a normal life, without a daily early-morning commute to a clinic. The medical establishment had come to view Suboxone as the best hope for addicts like Patrick. Yet of the dozens of publicly funded treatment facilities throughout Kentucky, only a couple offer Suboxone, with most others driven instead by a philosophy of abstinence that condemns medical assistance as not true recovery. Even at clinics that offer the medication, the upfront costs and budget limitations render it out of reach for the vast majority who come through their doors." But read the whole story of how the criminal justice approach to the "war on drugs" is failing Kentucky.
"There’s no single explanation for why addiction treatment is mired in a kind of scientific dark age, why addicts are denied the help that modern medicine can offer. Family doctors tend to see addicts as a nuisance or a liability and don’t want them crowding their waiting rooms. In American culture, self-help runs deep. Heroin addiction isn’t only a disease – it’s a crime. Addicts are lucky to get what they get."
Calls to Overhaul Methadone Distribution Intensify, but Clinics Resist (Markian Hawryluk, KHN, 3-3-22) Patients who take methadone, a synthetic narcotic used to treat opioid addiction, must jump through more hoops than perhaps any other patient group in the U.S. due to rules dating back five decades. Proponents for easing the rules say the pandemic has shown certain constraints serve more as barriers to care than protections. And consensus is growing among clinicians, patients, and regulators that it’s time for change.
New Meds Block Heroin Craving, But Reporter Finds Treatment Centers Don't Use Them (Terry Gross, Fresh Air, NPR, 2-4-15). Listen to the story or read the text. The Huffington Post's Jason Cherkis investigated the heroin epidemic in Kentucky, and found that the abstinence-based approach used in most treatment centers was leading to many fatal relapses. If you relapse on alcohol, the chances of dying are slim. When you relapse on heroin, especially after a period of abstinence, there's a much greater chance of dying. A 30-day drug treatment program is common, partly because that's what insurance will cover, but that's not long enough to deal with the changed brain. Methadone was use to help addicts get off heroin as far back as the '70s, but you have to go to a clinic to get methadone, which is regulated. Now there are new drugs, buprenorphine and Suboxone, which doctors can prescribe and which block the craving for heroin, makes addicts feel normal, calms them down, and cuts down on the painful withdrawal. They can begin to rebuild their life. A combination of such "medication and counseling is sort of the accepted standard of care among medical authorities in the United States but is not largely practiced."

Kentucky Considers Changes To Drug Courts For Heroin Addicts (Jason Cherkis, Huffington Post, 2-25-15)

How America Overdosed on Drug Courts (Maia Szalavitz, Pacific Standard, 5-18-15) Hailed as the most compassionate way for the criminal justice system to deal with addicts, drug courts were designed to balance punishment with rehabilitation. But after 25 years, the verdict is in: Drug courts embolden judges to practice medicine without a license—and they put lives in danger....When people who are addicted refrain from using heroin for over a week, they lose their built-up tolerance to opioids. A dose that a week ago barely produced a high might now be fatal." Within hours of getting out of jail, an addict can overdose on what was the habitual amount used. "Any addiction doctor—or anybody who simply follows evidence-based treatment guidelines—would know exactly what to prescribe for [an addict at high risk of returning to addiction]: opioid maintenance, by far the most effective treatment, known to lower the death rate of opioid addiction by between 66 and 75 percent. Maintenance is the indefinite use of an opioid medication such as methadone or buprenorphine, typically combined with counseling. The World Health Organization has called it “essential medicine,” and the National Institutes of Health, the Institute of Medicine, and the White House Office of National Drug Control Policy have all endorsed it in various consensus statements....But many drug court judges vociferously oppose the practice and require patients to become completely abstinent as a condition of participation or graduation. They believe that maintenance simply amounts to swapping one drug addiction for another. This critique betrays a fundamental misunderstanding of opioid pharmacology and addictive behavior."
Should We Have a Bailiff and a Judge at Weight Watchers? (Clovis Thorn, Managing Director of Development, Drug Policy Alliance, Huffington Post, 5-3-13) "I hope we never mandate that someone has to lose weight or face the criminal justice system, or has to stop smoking cigarettes, or has to stop cheerleading. (Have you seen the statistics for cheerleading injuries?!) If our government was to criminalize any of these things, we'd cry totalitarianism, gulags and Big Brother. Yet we criminalize people who use drugs. We call it the drug war. We dress it up as drug courts. Drug courts are part of a kinder, gentler drug war. Mind your manners, pass clean urine screenings, and everyone wins. The reality is much different."

Drug Courts Are Not the Answer: Toward a Health-Centered Approach to Drug Use (Drug Policy Alliance, 3-22-11) This report finds that "drug courts are an ineffective and inappropriate response to drug law violations. Many, all the way up to the Obama administration, consider the continued proliferation of drug courts to be a viable solution to the problem of mass arrests and incarceration of people who use drugs. Yet this report finds that drug courts may not reduce incarceration, improve public safety, or save money when compared to the wholly punitive model they seek to replace. The report calls for reducing the role of the criminal justice system in responding to drug use by expanding demonstrated health approaches, including harm reduction and drug treatment, and by working toward the removal of criminal penalties for drug use."

Every Drug Court Should Allow Methadone Treatment (Maia Szalavitz, Op Ed, NY Times, 7-20-15) Complete abstinence programs are the only treatments some courts allow. Among those who administer drug courts, which are aimed at helping defendants get treatment and avoid prison, "only a third allow maintenance use of methadone or a newer medication called buprenorphine (Suboxone) and 50 percent ban maintenance outright. But they are ignoring medical evidence showing that maintenance is the best approach to opioid use disorders, which involve drugs in the same class as heroin, like OxyContin and Vicodin." "In the scientific literature..., there’s no question that maintenance works. Every expert group that has ever studied it — from the Centers for Disease Control to the Institute on Medicine and the World Health Organization — has determined that, for opioids, ongoing maintenance is superior to abstinence." "Drug courts were first offered as an alternative to punishment at the height of the war on drugs in Florida in 1989. Today, they serve around 120,000 defendants. If their goal is actually to treat addiction, they need to offer individualized treatment that meets a higher standard of care and gives participants the best odds of survival and recovery."

Google "Drug Court" and you will find many interesting (and disturbing) stories.

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