PowerPoint. Controversial responses to opioid addiction. An essay on multiple aspects of the issue: 1. medication-assisted treatment (MAT), 2. the criminal justice system, 3. harm reduction and 4. marijuana. See also an updated essay called "opioids".

1. Controversial Responses to Opioid
Addiction
Sarasota, FL, Jan., 2019
1.Medication-assisted treatment
(MAT)
2.The criminal justice system
3.Harm reduction
4.Marijuana

2. Polarized views
• Opioid addiction is a crime and a
moral failing and should be
treated as such, as by
incarceration without treatment.
• Opioid addiction is a disease,
deserving of compassion even as
far as the radical idea of
prescribing heroin to addicts who
are resistant to more standard
treatment.

3. Opioids
• Pain relievers: hydrocodone, codeine,
morphine, notorious OxyContin®
• Heroin: Illegal, a major cause of
addiction
• Fentanyl: Legal, sold illegally,
powerful, a major cause of overdose
death

4. • Opioid receptors (green)
• Dopamine, pain relief, euphoria
• Respiratory depression, overdose,
death
• Endorphins—runner’s high
• Cravings, dependence, addiction

5. Addiction: A chronic relapsing disorder
characterized by the compulsive desire
to seek and use drugs, with impaired
control over substance use despite
negative consequences
Diagnostic and Statistical Manual 5
(DSM5): Levels of severity
There is a spectrum of opioid misuse.

6. Medication-assisted treatment (MAT)
• Methadone
• Buprenorphine (e.g. Suboxone)
• Naltrexone (Vivitrol)
• Psychosocial support

7. Polarization
• Detoxification followed by abstinence
plus 12-step programs (AA, NA)
• MAT, including the opioid medications
• Hazelden-Betty Ford Center

9. • The agonists suppress cravings
without normally inducing euphoria.
Transition without full withdrawal.
Can become dependent.
• Methadone: cumbersome legal
constraints.
• Buprenorphine: 8-hour course,
limitations on number of patients
• 50% or better success rate, much
better than psychosocial support
alone. Patient can be cautiously
weaned. Can lead a normal life.

10. Dark side of agonists (buprenorphine)
• Diversion, minors, black market,
prisons—but usually for self-
treatment.
• Neonatal abstinence syndrome
• Advantages outweigh disadvantages.

11. Naltrexone—antagonist
• Blocks effect of e.g. heroin
• Relieves cravings
• No restrictions on prescribing
• No risk of diversion. No black market.
Safe
• Requires unpleasant full detoxification
• Oral form unsuccessful, long-acting
Vivitrol successful
• Success rate about the same as
buprenorphine—but!
• Blocks endorphins
• Expensive

12. Agonists stigmatized
• Tom Price: “If we’re just substituting
one opioid for another , we’re not
moving the dial much.”
• Alkermes aggressive, including
criminal justice system.

13. 60% received MAT in 2 states that
expanded Medicaid: MA, VT
30% received MAT in 3 states that did
not: GA, TX, FL
79% overdose death decrease in France
after buprenorphine

14. 12- step programs
• Narcotics Anonymous literature: “By
definition, medically assisted therapy
indicates that medication is being
given to people to treat addiction. In
NA, addiction is treated by abstinence
and through application of the
spiritual principles contained in the
Twelve Steps.”
• Medically Assisted Recovery
Anonymous (MARA).

15. • Bipartisan opioid bill
• Gateways to treatment
 ER’s
 Harm reduction facilities
 Criminal justice system

16. Criminal justice system
Joaquín Guzmán (El Chapo)

17. Criminal justice system
• Low end offenses
• Drawbacks of a criminal record
• Drug courts
• Portuguese plan
• Law Enforcement Assisted Diversion
(LEAD)

18. Criminal justice system
• Incarceration, detoxification, paucity
of medical treatment
• Rhode Island plan
• Sarasota jail recovery pod
• Vivitrol just before release
• Ethics and legality of withholding
agonists/Massachusetts case

19. Harm reduction: Minimize the harms of
illicit drug use
• Naloxone (Narcan)
• Clean needle and syringe exchange
programs
• Safe injection sites (SIS’s)
• Prescription heroin

20. Comments on the Web
• “Darwin’s Theory says ‘survival of the
fittest.’ Let these lost souls pay the
price of their criminal choices and
criminal actions. Society does not owe
them multiple medical resuscitations
from their own bad judgment, criminal
activity, and self-inflicted wounds.”

21. Harm reduction
• Naloxone (Narcan), opioid antagonist,
antidote for opioid overdose.
 Availability: EMT’s, police, family and
friends—librarians!
• Clean needle and syringe exchange
programs to combat HIV, hepatitis, etc..
• Status in FL
 Margaret Good: “HB 171 will be a step in
reducing intravenous diseases…and…death
attributable to dirty needles. This bill is
needed in all parts of Florida including
District 72.”

22. Safe injection sites (SIS’s)
Vancouver, Montreal & Ottawa. U.S.: Only
secret sites

23. Benefits of safe injection sites
• Cost-effective
• Increase uptake into drug treatment
programs & lead to drug use cessation
• Reduce public drug use, discarded
syringes & related litter
• Prevent HIV, hepatitis, etc.
• Eliminate drug overdose death
• Don’t lead to increased injection drug use
• Don’t lead to increased crime
• Engage users in medical, mental health
and other social services
• Not everyone agrees with all of that

24. Safe injection sites
• San Francisco plan passed by
California legislature
• Rod Rosenstein: “swift and
aggressive action by the Dept. of
Justice.” (Crack House Statute)
• “A war zone” in Vancouver
• Governor Brown vetoed the bill
• Confrontation with the federal
government?
• The American Medical Association
supports both needle exchange
programs and SIS’s.

25. Prescribing heroin
• Denmark, Germany, the
Netherlands, the UK, Switzerland,
Vancouver
• Requirements for enrollment
• Avoid stealing, black market
• Assures pure heroin
• Somewhat normal life

26. Legalization of marijuana
• Decreases in use, abuse, overdoses and
deaths from opioids
• Interpretion: Marijuana was
substituted for opioids
• Increased marijuana-related
emergency room visits by children
• Increased marijuana-related
automobile accidents.
• How to exploit its advantages while
minimizing its harms.

27. Marijuana (cannabis) plant
• ~100 cannabinoids
• Tetrahydrocannabinol (THC),
psychoactive
• Cannabidiol (CBD), not psychoactive
• Taking marijuana: Smoke, inhale vapor,
or ingest whole plant; or use isolated
chemical components

29. • Cannabis an effective
treatment for chronic pain
• More research is needed on the
various forms, routes of
administration, and
combinations of cannabinoids
• (What exactly are we talking
about?)
• Marijuana for treatment of
addiction—CBD!

30. DEA Schedule I
• No currently accepted medical use and a
high potential for abuse
• Marijuana, heroin, LSD, ecstasy
• Not alcohol
• Not cigarettes (the leading cause of
preventable death in the United States)
• CBD from hemp is now legal!
• Catch-22: roadblock to research
• THC is an FDA-approved medication
(Marinol , Syndros)
• So is CBD (Epidiolex)

31. • Medical marijuana largely decided at the
ballot box!
• Keith Roach, M.D.:“My ideal future
regarding medical marijuana is one
where it is studied openly and subjected
to the same scrutiny as other medicines,
where both the purified extracts are
studied as well as the whole plant.
Marijuana needs to be compared against
the best treatments we have…Only this
way can we confirm or refute the
benefits and risks of this drug.”

32. • Remove marijuana from Schedule I!
• Legalization by states becomes
unambiguous
• Free up prison resources
• Allow regulation
• Reduce black market, violence (iffy)

33. Marijuana problems-1
• Will use increase with legalization?
Alcohol prohibition example
• Impairs driving (not as bad as alcohol)
• Can precipitate psychosis
• Respiratory symptoms, bronchitis
(when smoked)
• Amotivational syndrome

34. Marijuana problems-2
• Gateway drug? David Sheff
(“Beautiful Boy”):“Pot was...a
gateway drug for me…I became less
fearful of other drugs.”
• Dependence and addiction (not as
bad as alcohol or opioids).
• Marijuana Anonymous: "Ours is a
progressive illness often leading us to
addictions to other drugs. Our lives,
our thinking, and our desires center
around marijuana—scoring it, dealing
it, and finding ways to stay high.”

35. Marijuana in pregnancy
• Linked to low birth rates, still births,
intensive care, behavioral/learning
problems
• Interference with development of the
nervous system
• American College of Obstetrics and
Gynecology and the American
Academy of Pediatrics recommend
against it

36. On the rise

37. • Mystery caller with “morning sickness”:
69% of Colorado dispensaries
recommended cannabis
• Budtenders provide medical advice
with no licensing or training
• Medical schools teach very little about
marijuana
• “This course, presented by Florida
Medical Association and Florida
Osteopathic Medical Association,
addresses the relevant laws and rules
that govern physicians who intend to
certify patient eligibility for medical
marijuana in Florida.”

38. Marijuana in adolescence
• Brains still developing
• Linked to
 Impaired brain development
 poor educational achievement
 Drop in IQ
 lower employment and income
 Impaired social relationships
 Worse risk of psychosis
 Greater (17% vs 9%) chance of
addiction

44. E-cigarettes (“vaping”)
• 12th grade students vaping nicotine in
past 30 days: 2017-11%, 2018-21%
• Adverse effects on developing brain
 Nicotine dependence, addiction
 Subsequent use of tobacco cigarettes
and even marijuana
• Use in pregnancy may be harmful to
fetus
• Jerome Adams, Surgeon General, has
declared this to be an epidemic.

45. • A possible solution: state-run
monopoly—no profit motive, as in
Uruguay
• Monopoly for alcohol reduced access to
youth
• Right way to legalize:
 Regulation
 Warning labels
 Restrictions on advertising
 Education of clinicians and the public
 Ban on edibles that are attractive to
minors
 Possible government-run monopoly