Heroin and Opioid Policy

SUMMARY

Fatal opioid overdoses (and overdoses from other high risk drugs) have reached record highs. Record numbers of Americans are becoming addicted to both heroin and legal opioids. We must combine a number of interventions to prevent opioid addiction, bring more users who use opioids problematically into treatment, and reduce overdose, infection and other harmful consequences of opioid use. We can reduce opioid addiction by changing medical and surgical practice and reducing painkiller prescription for managing acute and chronic pain. To expand treatment, we must increase funding for and acceptance of medication-assisted treatment and reduce barriers to treatment.

To reduce overdose deaths, we need to better educate legal and illegal drug users about the risks of their specific drug use and techniques to reduce that risk We need to maximize the scope of Good Samaritan laws that encourage persons who use drugs to call for EMTs when they suspect an overdose. We need expanded naloxone access programs to put naloxone in the hands of persons using drugs, their family members and friends, and in places where drugs are being used. (Naloxone can wear off more quickly than the opioid drug and a person revived with naloxone should still be transported to a hospital). These programs are short term steps that will reduce deaths, but more profound policy change is needed for the longer term impact. And to reduce disease transmission among persons who inject drugs together, we need to expand needle exchange programs.

We also need to reach the most marginalized individuals — those with insecure housing, who lack health care insurance and regular care, who have given up on treatment, or who show up in emergency rooms for overdose and infection. We can most effectively assist these persons to care for themselves by expanding street outreach, and by establishing overdose prevention sites (also known as safer consumption sites or supervised injection facilities). Such facilities protect those who participate from death and disease while bringing them into contact with medical and treatment professionals. They usually provide access to a range of services from nutrition, wound care to finding housing opportunities.

INTRODUCTION TO OPIOIDS

Opioids are medically highly useful but their use is associated with a noteworthy risk of addiction and overdose. Also referred to as opiates or narcotics, they were originally derived from the resin of the Asian poppy seed pod (known as opium gum). Opium has been used medically for 3500 years or more to treat pain, diarrhea and cough. The non-medical use of opium (for pleasure and socially) can be documented for the past 400 years.

Opium gum yields three psychoactive alkaloids: morphine, codeine, and thebaine, as well as papaverine and noscapine. These compounds can be refined and chemically modified into other pain-killing drugs. Opium is the source of much of the world’s legal and illegal opioid supply. But many opioids are synthesized from chemicals not extracted from opium gum. The opioids include heroin, as well as many common prescription pain-relieving drugs: morphine, OxyContin, Vicodin, codeine and Percocet. These drugs are particularly useful for acute post-trauma or post-surgical pain and chronic pain such as from cancer, but they all produce tolerance and thus can be highly addictive.

There are also important pain relieving drugs that are not opioid-type drugs such as non-steroid anti-inflammatory drugs (NSAIDs). There are some 20 different NSAIDS on the market including the well-known aspirin, ibuprofen (Advil, Motrin), and naproxen (Aleve). NSAIDs can cause stomach bleeding, ulceration or perforation. Acetaminophen (Tylenol), in a third class of drugs called non-narcotic pain relievers, is also highly effective, but can cause liver damage, which is dose related, and for those who consume more than average amounts of alcohol routinely presents a greater risk of liver damage.

While prescription opioids are commonly consumed in pill form, opioids can also be snorted, inhaled or dissolved in a solution and injected. The latter methods release the drug into the bloodstream more rapidly than swallowing pills, and common effects such as euphoria, respiratory depression and nausea can be more intense. If consumed in excess, they can shut down respiration and cause overdose death.

Two common measures of a drug’s effects are its effective dose and its toxic dose. These are the doses that produce the desired therapeutic effect in half the population, and the dose that causes toxicity in half the population. But unlike many drugs, for those who regularly use opioids, the tolerance that quickly develops changes the effective dose and the toxic dose from that of typical first time users. If a dose is too high, it has a toxic effect and can shut down respiration and cause overdose death. After one has been using opioids for a while, it can be challenging to know how tolerant to the drug one has become, or what are one’s effective dose and toxic dose. This is greatly complicated for those who obtain drugs illegally — since packages of heroin are not tested or labeled for contents, and prescription drugs sold illegally may be counterfeit and adulterated — so the opioid users have no accurate idea of the dosages they are using.

Dependent users who stop taking opioids usually suffer a few days of flu-like withdrawal symptoms, and the cramps, sweating and nausea can be extremely unpleasant.  Even after being detoxified (“detoxed”), a former user may often experience cravings to get high — sometimes these cravings can be very intense and recur for many years.

Heroin (diamorphine) is chemically similar to other opioids. It is produced from morphine, the principal naturally occurring alkaloid of opium. It was invented in 1874 by an English chemist who combined morphine with acetic anhydride to produce diacetylmorphine (called diamorphine in the UK and Europe). In 1898 a paper was published in Germany noting that diacetylmorphine was “invented” by a German chemist working for Friedrich Bayer and Co. which gave diamorphine the  brand name “Heroin.” It was produced as a medicine for cough and pain in the chest and lungs, and sold “over the counter” in the United States. As early as 1903, a medical article noted that patients were becoming addicted to heroin in Alabama.

In 1914, heroin and the opiates became subject to federal regulation and taxation pursuant to enactment of the Harrison Narcotics Act. Early in the administration of the law by the Treasury Department, physicians and pharmacists who prescribed and dispensed opioid drugs were targeted for prosecution even though the regulations were highly ambiguous. By 1924, Congress made it illegal to import opium to produce heroin, and thus all heroin being sold and consumed in the U.S. was illegally imported.

In 1970, in the Comprehensive Drug Abuse Prevention and Control Act, Congress placed heroin in a schedule of the most dangerous drugs and that have no accepted medical uses, i.e. Schedule I. (However, in the United Kingdom, the status of heroin (known as diamorphine) as a legal drug was affirmed in 1926 and is still legally used to treat pain). In the U.S., the manufacture, distribution or possession of heroin for any purpose is a serious crime. In federal law, manufacturing (such a packaging) or distribution of 100 grams of a substance containing a “detectable amount of heroin” is subject to a mandatory minimum sentence of 5 years up to 40 years. (21 U.S.C. 841(b)(1)(B)(i)). For 1000 grams, the minimum is 10 years, up to life imprisonment. (21 U.S.C. 841(b)(1)(A)(i)). There is no parole in federal law. Many states have mandatory minimum laws as well that may be triggered by different quantities. Many other opioid drugs are in schedule I. (21 CFR 1308.11(b) and (c)).

A great many opioids are manufactured by pharmaceutical companies and their production is supposed to be carefully monitored by the government (21 U.S.C. 827) and subject to production quotas (21 U.S.C 826). These drugs are listed on Schedules II, III, IV and V (21 CFR 1308.12 to 1308.1). Heroin is currently illegal in the U.S. As a result, the government cannot control the quality of heroin and protect the users of heroin in the ways it tries to protect consumers of legal drugs. Over the past half century, heroin has been produced for the illegal U.S. market in Southeast Asia (such as Myanmar, Thailand and Laos), Southwest Asia (such as Afghanistan and Turkey) and in the Western Hemisphere in Guatemala and Colombia. By 2018, most heroin supplied to the U.S. was produced in Mexico by Mexican criminal organizations, and there is almost no production in Guatemala or Colombia.

THE OPIOID EPIDEMIC

America has had a number of opioid epidemics. Post World War II, there was an increase in heroin use and addiction which generated harsh crackdowns and new laws such as the Boggs Act of 1951 with mandatory minimum sentences. Heroin use increased again in the mid-1960s, notably in New York City. During the Vietnam War, many American servicemen used heroin in Southeast Asia. While many continued to use heroin upon their return to the U.S., probably a majority discontinued use, often without any formal treatment. Draftees who did not want to go to war and could not obtain a deferment, who felt that the war and violence were pointless, and experienced the trauma of the horror of buddies being badly injured or killed randomly had a mindset and were in an environment (“set” and “setting”) that might have made heroin use numbing. But upon return to the U.S. and the resumption of civilian life, in a very different set and setting heroin use made no sense, and formerly “addicted” military personnel were able to quit, according to Norman Zinberg, M.D., a Harvard Medical School professor and clinician.

The current opioid epidemic began in the late 1990s, with an expansion in prescribing legal opioids that generated a rise in opioid overdose deaths. It is important to note that like most U.S. drug use phenomena, there were very distinct regional variations. What was being experienced in Appalachia was not being experienced in New York City. One response to the epidemic was to reformulate one of the most commonly misused drugs, Oxycontin, in 2010. The RAND Corporation points out that consequently, that year, the number of opioid deaths from heroin began to increase dramatically, and in 2013, fentanyl began to contribute a dramatically larger fraction of opioid overdose deaths.

Fentanyl had been a problem in the 1980s, and illegal importation, manufacture and distribution became subject to the mandatory minimum sentences of the 1986 Anti-Drug Abuse Act (21 U.S.C. 841(b)(1)(A)(vi); 21 U.S.C. 841(b)(1(B)(vi); 21 USC 960((b)(1)(F); and 21 U.S.C. 960(b)(2)(F)). For much of the 21st century, fentanl was relatively uncommon in the illegal drug supply until the second decade, and then became much more available in 2012. By 2018, it was being added to most of the heroin being sold at retail, as the ingredient in counterfeit prescription opioids, and added to cocaine. “New” drugs are especially frightening to law enforcement and the public, and a myth was generated that a person can get high or suffer from an overdose simply from touching fentanyl or being in the same room as fentanyl. First responders are not in danger being in rooms where drug users possess fentanyl. This fear should not be used to prevent rapid response to persons suffering from a suspected opioid overdose.

Americans are becoming addicted to both heroin and legal opioids in increasing numbers. Today, an estimated 2.1 million people struggle with opioid addiction, and an estimated 467,000 are addicted to heroin. From 2002 to 2013, heroin use increased 63 percent.[2] In 2010, 16,235 Americans died of prescription opioid overdose, and in 2013, heroin overdose killed another 8,257.[3] Between 2002 and 2013, the rate of heroin overdose deaths has nearly quadrupled.[4]

The increase stems from doctors overprescribing prescription opioids. Due to a new medical focus on treating pain in the 1990s as well as false advertising by pharmaceutical companies, opioid painkiller prescriptions exploded from 76 million in 1991 to 219 million in 2011, almost one for every American adult.[5] Around 2007, authorities began responding to growing addiction and overdose by cracking down on prescription excess and fraudulent "pill mills." Many patients, upon finding themselves addicted when their prescriptions ran out, began buying their pills on the street. Since the government crackdown reduced the supply of pills, the street price skyrocketed. Dealers convinced many patients to switch from $50 Oxycontin pills to the cheaper, more accessible alternative—$10 doses of heroin. An estimated 80% of new heroin users began using the drug after becoming addicted to prescription opioids.[6]

POLICY SOLUTIONS

As we reduce painkiller prescriptions, we can expect the increase in illegal pill and heroin use to continue. Despite the government crackdown, painkiller prescriptions did not decline much by 2014 from their peak in 2011. That year, doctors still wrote almost one prescription for every adult in America.[7] While the crackdown ostensibly targeted “pill mills” (physicians consciously over-prescribing painkillers for profit), the more significant phenomenon for increasing addiction has been over-prescription by well-intentioned doctors.[8] The small decline in prescriptions has already pushed hundreds of thousands of patients to buy opioids on the street. As more doctors cut off their patients from legal opioid prescriptions, more patients will turn to the street market, and many of them to heroin.

We can reduce the transition of opioid users from prescription opioids to heroin by changing how physicians respond to patients they suspect may be dependent on opioids. Currently, when a doctor suspects a patient has become dependent, the doctor is inclined to treat the patient as a threat to their license and freedom. It is against the law to maintain patients on opioids, unless in the context of treatment for addiction using a medication such as methadone, buprenorphine, suboxone or naltrexone. A patient who provides information to their physician that demonstrates or even creates an inference that the patient may be dependent could be cooperating with narcotics detectives to prepare a case against their doctor in to “work off” a criminal charge they may be facing. The prudent physician is likely to immediately cut off the patient from further opioid prescriptions. The doctor may even be reluctant to make any kind of referral to a treatment program: that would be an acknowledgement that the patient is dependent — leading potentially to criminal liability or to civil liability for a claim that the doctor engaged in malpractice leading the patient into addiction. The consequence of this is that, instead of providing help, doctors are incentivized to force the patient to quit a notoriously addictive drug, without any medical guidance. Many patients, cut off from the legal supply of a pharmacy, begin to buy pills on the street, where dealers introduce them to heroin. To stop this transition of patients from doctors and pharmacies to patrons of the criminal market, the law must enable doctors to continue to approach their patients as patients, and not suddenly treat them as threats to their livelihood and freedom. Addiction experts recognize that dependent users need to transition off of opioids gradually, instead of trying to quit “cold turkey.” In many cases, a great obstacle to connecting a patient to treatment may be the patient’s doctor, if they consider resisting addiction as a simple matter of willpower. To minimize the conversion of patients to “illegal drug users,” the law must be changed to ensure that doctors can treat patients’ addictions responsibly without fearing prosecution. If DEA is committed to minimizing the size of illegal drug markets and the power of international drug trafficking organizations, they would endorse this reform.

For the millions of people who have become addicted to opioids, we need to expand a number of underused interventions proven to avoid overdose, stop dependency, and prevent the most damaging consequences of opioid abuse. These include: (1) Naloxone Access and Good Samaritan Laws, (2) Medication-Assisted Treatment, and (3) Safe-Injection Facilities.

Naloxone Access and Good Samaritan Laws

We need to make sure that patients survive their opioid addictions. Many are surprised to learn that heroin overdose deaths are entirely preventable. Naloxone (brand name Narcan), which is administered by injection or nasal spray, reverses overdose within seconds by dislodging the drug from the brain's opioid receptor sites.[9]

Naloxone is available in hospitals and carried by paramedics and some police officers. In many cities and states, community-based overdose programs are now training ordinary citizens to administer naloxone, and providing them with naloxone. States are suspending the requirement that naloxone be issued only be prescription to a named individual (However, without a prescription to the purchaser many insurance carriers are not covering naloxone purchases. An individual may not want a record of a naloxone purchase because the stigma of the inference that they need it for themselves and are using opioids regularly. A remedy is to distribute naloxone routinely when an opioid prescription is picked up at a pharmacy.)

Because of stigma and shame, many users of illicitly purchased opioids use alone and in hiding, where they are unlikely to be discovered if they suffer an overdose, and thus will die. Of course, at the current time, any person who injects opioids who might attempt to minimize their by injecting at a hospital or near a medical establishment or fire house would be arrested. Even when persons who use drugs use opiods with others who use drugs, in the event of a suspected overdose the other users frequently hesitate to call 9-1-1 because the police will respond in addition to medical personnel. However, 40 states, as of June 2017, had enacted some form of a 9-1-1- Good Samaritan law that bars or limits the prosecution of the person who makes a call for charges of illegal drug possession. The provisions of the first 19 such states (as of 2014) are summarized here.

If we can stop opioid overdoses, why did they still claim the lives of 130 Americans a day in 2017 (47,600, Figure 3)? From 1996 through June 2014, these laws have empowered Americans to reverse an estimated 26,000 overdoses.[13] We could save thousands of lives every year by expanding these laws to all 50 states.

Medication-Assisted Treatment

Opioid addiction cannot be cured, but it can be managed. Successful treatment programs help individuals get through withdrawal, cope with cravings, and manage personal issues that lead to addictive behaviors through both pharmacological and behavioral interventions.

The most effective treatment method, Medication-Assisted Treatment (MAT), lacks availability and funding. MAT patients receive regular oral doses of opioids, usually methadone or buprenorphine (brand name Suboxone). When properly dosed, these opioids stop cravings without causing a “high,” allowing patients to function normally. Patients continue to take these opioids for months or years, until they are ready to quit. Traditional abstinence-only treatment advocates criticize MAT for “simply replacing one opioid with another.” However, anyone familiar with MAT knows the difference between “nodding” on illegal, uncontrolled heroin and using Suboxone to banish cravings while functioning normally. These replacement opioids allow MAT patients to take safe, controlled levels of medication, rebuild their lives, and fully quit when they are ready.[14] As a result, MAT programs have far lower relapse rates than abstinence-based programs, which force users to quit immediately. Still, these criticisms have limited MAT funding.[15] 

In addition to being underfunded, MAT is blocked by our medical and criminal justice systems. Concerned about doctors dealing drugs, the federal government requires doctors to get specially certified for MAT and caps their allowed number of Suboxone patients.[16] In rural areas, many patients cannot find an open MAT slot.[17] MAT patients also suffer in the criminal justice system. If arrested, most jails refuse to allow patients to continue their Suboxone treatment, sending them into withdrawal. Many drug courts, which are designed to divert drug users out of the criminal justice system, require patients to quit MAT. Fortunately, the Obama administration has threatened to cut off funding for drug courts hostile to MAT. Access to MAT programs needs to be expanded, particularly in rural areas and within the criminal justice system.

Supervised Injection Facilities

What can be done to help the most marginalized and depressed heroin users, who are not seeking treatment? Many of these people are homeless, unemployed, suffering from disease and chronic skin infections, cut off from family and friends, and branded with a criminal record. Heroin is their solution to this situation.[18] They need a place where they can avoid overdose and disease. In order to successfully quit their painkiller, they need comprehensive support to tackle their housing, employment, medical, criminal and personal problems.

In 92 locations across Europe, Canada, and Australia, injection drug users bring their own drugs into supervised injection facilities (SIFs) and inject in the presence of medical staff. SIF staff provide sterile injection equipment, medical advice and treatment referrals, and they intervene in case of overdose. All 92 SIFs have demonstrated a track record of success—millions of injections and tens of thousands of overdoses have not killed a single person.[19] The difference is stark. A year ago in Pittsburgh, a batch of heroin mixed with fentanyl killed 22 people.[20] Nine months later in Vancouver, a similar batch caused 32 people to overdose. Thirty-one of them overdosed at Insite, the city's SIF, where the medical staff saved their lives. The 32nd, a woman in her 20s, was found dead in a downtown hostel.[21]

SIFs also save millions of dollars by reducing disease transmission. Since users can be arrested for possessing needles, many share syringes with other drug users, spreading blood-borne diseases. As a result, when compared to the general U.S. population, people who inject drugs are 35 times more likely to have Hepatitis C and 23 times more likely to be HIV positive.[22] A single new infection carries lifetime costs of $68,000 for Hepatitis C and $408,000 for HIV/AIDS.[23] Researchers estimate that over the past decade alone, the Vancouver SIF has saved millions of dollars and dozens of lives for the local population.[24]

SIFs have a number of other benefits. Medical staff spot skin infections early on and intervene before they develop into expensive, life-threatening conditions.[25] Studies show that SIFs also reduce syringe littering and the frequency of drug use in public places.[26]

Critics warn that SIFs will encourage more heroin use, but in fact they reduce use. SIF medical staff build relationships with depressed, outcast users and help them turn their lives around. Studies show that SIFs increase the percentage of users entering treatment.[27] They also show that SIFs do not attract new users, which makes sense--who takes up an activity because a medical facility treats it as a disease?[28]

Given that SIFs have been so effective against heroin overdose crises in other countries, why don't we embrace them here? Public officials are reluctant to support SIFs because they fear their constituents' reactions: "Why spend taxpayer money to enable drug use?" The answer: SIFs save taxpayer money by preventing death and disease. They don't enable drug use, they support drug users in seeking medical help and bring more drug users into treatment.

OPIOIDS and CJPF

We must treat individuals suffering from opioid addiction with dignity and respect during all stages of their drug use and recovery.  We must admit that threatening and punishing drug users has failed to stop drug use, while ruining millions of lives. Over 80 percent of Americans agree that the war on drugs has failed.[29] Around the nation, policy makers are adopting elements of an effective opioid policy, starting with smarter prescription drug controls, Naloxone Access and Good Samaritan Laws, increased funding for and access to Medication-Assisted Treatment. Another intervention, supervised injection facilities, has been called for by the Mayor of Ithaca, NY.

CJPF has long advocated for the safe and humane treatment of all individuals who struggle with addiction. Recently, in 2015, Executive Director Eric E. Sterling testified before the Maryland Heroin and Opioid Emergency Task Force. Chief of Staff Amos Irwin wrote an article on heroin overdose and supervised injection facilities for the Huffington Post.[30] Amos Irwin for CJPF has prepared cost-benefit analyses to estimate how much money would be saved by establishing SIFs in specific American cities (In press).

SOURCES

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[3] Davidson, Peter; Gilbert, Michael; Jones, Stephen; Wheeler, Eliza. (2015). “Opioid Overdose Prevention Programs Providing Naloxone to Laypersons—United States, 2014.” Center for Disease Control and Prevention Morbidity and Mortality Weekly Report (MMWR). Jun 19. Accessed 15 Dec 2015 at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6423a2.htm

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[4] Bernstein, Lenny. (2015). “Heroin Deaths Have Quadrupled in the Past Decade.” The Washington Post, Jul 7. Accessed 15 Dec 2015 at https://www.washingtonpost.com/news/to-your-health/wp/2015/07/07/heroin-deaths-have-quadrupled-in-the-past-decade/

[5] Meier, Barry. (2007). “In Guilty Plea, OxyContin Maker to Pay $600 Million.” New York Times, May 10. Accessed 23 Dec 2015 at http://www.nytimes.com/2007/05/10/business/11drug-web.html?_r=0

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[6] Kuehn, Bridget. (2013). “SAMHSA: Pain Medication Abuse a Common Path to Heroin Experts Say This Pattern Likely Driving Heroin Resurgence.” Journal of the American Medical Association, Oct 9. Accessed 10 Dec 2015 at http://jama.jamanetwork.com/article.aspx?articleID=1750124

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[10] Davis, Corey. (2015). “Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws.” The Network for Public Health Law. Accessed on 15 Dec 2015 at https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf

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[29] Rasmussen Reports (2013). “82% Say U.S. Not Winning War on Drugs.” Rasmussen Reports, Aug 18. Accessed 15 Dec 2015 at http://www.rasmussenreports.com/public_content/politics/general_politics/august_2013/82_say_u_s_not_winning_war_on_drugs

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[30] Irwin, Amos. (2015). “Why Heroin Overdoses Are Rising and How We Can Prevent Them.” Huffington Post, Mar 10. Accessed 10 Dec 2015 at http://www.huffingtonpost.com/amos-irwin/why-heroin-overdoses-are-_b_6831632.html