A community on the front lines of the opioid epidemic
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Like many of the people on this site, I am a software engineer working for a top-tier tech firm in SF. Money isn't a serious problem in our lives.
Total time from "maybe our daughter is doing drugs?" to death was less than three months. We sent her to rehab in that time because she was abusing cocaine and asked to go. I am not some ignorant parent - I've tried plenty of things and k ow the signs well.
Please, if you have kids, tell them about fentanyl. It is SO much more potent than heroin and can kill on the first dose. She went to a party, someone offered her some "coke", she snorted some and she died soon after. Turns out the coke was fentanyl or at least had some in it.
The autopsy of my daughter showed that there were no injection marks. She had a career and in no way fit the stereotype of an addict. One day she existed, the next she did not.
I am neither pro nor ani drug. I don't care about that. All i care about is telling people the story of my daughter. Fentanyl is so much more potent than heroin and it is sweeping the entire nation. If you have kids, please tell them tbat it exists and that people are selling it right now claiming its something different.
Fortunately I knew what to do. We kept him breathing till the ambulance arrived and got him breathing and back to a reasonable level of consciousness again using nasally administered Naloxone (Narcan) solution.
As far as I'm aware Fentanyl overdose can be treated the same way: Give breathes until an ambulance arrives.
What saddens me most about these stories is that no one present had the knowledge necessary to keep someone alive long enough for help to arrive.
Never use along, never dose at the same time as your buddy / buddies. Make sure your buddy / buddies know what to do. If in doubt half the dose.
That's amazing, you're quite literally a hero.
> As far as I'm aware Fentanyl overdose can be treated the same way: Give breathes until an ambulance arrives.
I believe some of the fentanyl analogues going around are more potent than fentanyl itself. Fentanyl overdoses can require multiple doses of Narcan. Fentanyl analogues may require much more than that if it works at all.
> Never use along, never dose at the same time as your buddy / buddies. Make sure your buddy / buddies know what to do. If in doubt half the dose.
Half the dose can be too much. Titrate upwards as if you were just sold pure fentanyl powder by a dealer who doesn't know any better, because that's a thing that happens.
Too many people have died this way (drugged by a nominal friend into an OD or other fatal experience).
[1] https://news.vice.com/article/only-in-the-netherlands-do-add...
Also, morphine was only invented around 1818 and its addictive properties were not understood until much later[2]. For example, "...initially morphine was also marketed as a non-addictive cure for addiction to both alcohol and opium..." That was happening in 1853, nearly 40 years after the invention of morphine.
In the article you linked to, the author states that many of the morphine addicts of the 1900s were people in rural communities who were sold "elixirs" by traveling "doctors" and these potions were often 50% morphine. Which causes the author to state: "...if you look at drug addiction in 1900, what's the number one way in which it is different than drug addiction today? Answer: Almost all addiction at the turn of the century was accidental."
If drugs were legalized, consumers would not be getting accidentally addicted to morphine as they were in the 1900s, because they would be able to know for certain what drugs they were buying and ingesting.
[1] https://mic.com/articles/110344/14-years-after-portugal-decr... [2] http://www.todayifoundout.com/index.php/2014/09/invented-mor...
50% morphine is only about three times opium potency.
I'm talking legalized, not just decriminalized.
I doubt that there are any morphine sodas for sale in Portugal. With viral Facebook promotion featuring tunes from Nirvana and Smashing Pumpkins.
I smoked hand-rolled Sobranie Turkish/Virginia blend when I could afford it, and whatever I could afford, otherwise. For about 20 years.
Nicotine isn't exactly recreational, but it does take the edge off that "too much coffee" feeling. Especially if you've been working more than several hours. And it does sharpen the mind, sort of orthogonal to caffeine. I've had some profound insights after coffee and a cigarette.
On the other hand, there's the fact that quitting is very hard. Harder than opiates. Harder than benzodiazepines. And the long-term health effects, of course, are horrible.
From the article: "You know as late as 1900, ... let's say you would have appendicitis, you would go into the hospital, and you would get morphine as a pain killer during the operation, you would be given morphine further after the operation, and you would come out of the hospital with no appendix but addicted to morphine."
I find that interesting, because as late as 2010 I went to the hospital with severe abdominal pain and received morphine while the cause was being determined. Before I was diagnosed with appendicitis the efficacy of the morphine decreased to the point that I was switched to dilaudid. I was educated briefly on the risk of addiction, had the surgery, left the hospital two days layer, and haven't sought either since.
I don't know if full legalization is the best option, but dismissing it with shaky historical claims is not a great argument.
But there's an additional question for context; would you rather that 10-20% of opiate addicts be contributing members of society, with jobs, and homes, and who simply enjoy some opiates after work, as some enjoy a beer or wine with dinner? Or is it better to force them into the margins of society so they end up robbing convenience stores for drastically marked up and adulterated drugs with an inconsistent supply, so addicts end up alone, jobless, and homeless with little chance of ever recovering? Because we've been trying the second option for decades, and it hasn't made the problem go away. In fact, articles like this say it's worse than it's ever been.
Fun fact; alcohol, being illegal in several Middle Eastern countries, has a similar problem with black market sales leading to death there, as we have with fentanyl mixed with heroin. Bleach gets sold as liquor, victim tries to drink it to get drunk, and they die. Not because alcohol is bad for you, but because they drank fucking bleach, because the black market in the Middle East isn't regulated, just like black market heroin in the US doesn't give a shit about the FDA's regulations.
Sell heroin at Walmart, regulated by the FDA, and at a tenth of the cost, and the problem of accidentally doing life-ending amounts of fentanyl because someone said it was heroin; that problem goes away.
The major problem with black market alcohol is the methanol.
Fentanyl, synthetic opioid, was the cause of most of the ODs in the article, synthetics are a worse problem than the natural versions.
But police suspect the heroin here was mixed with fentanyl, a synthetic opioid that is many times more potent than heroin. A wave of fatal overdoses signaled fentanyl’s arrival in Huntington in early 2015, and now some stashes aren’t heroin laced with fentanyl, but “fentanyl laced with heroin,” said Police Chief Joe Ciccarelli.
[1] https://www.leafly.com/news/politics/fentanyl-maker-insys-gi...
[2] http://www.thecannabist.co/2017/03/23/synthetic-thc-drug-ins...
[3] https://www.statnews.com/2016/09/29/fentanyl-heroin-photo-fa...
When you're choosing between falling another month behind on rent on the apartment you were "so lucky" to get and getting a throbbing cavity filled at the dentist, you might not think too much about it.
There are a lot of business out there which make a lot of their money in some very unethical ways, and people who choose to be part of that... I just don't understand. I couldn't live with myself.
I know several people who have died of overdoses, so I'm probably biased, but I'm truly disgusted by what is going on.
"It is difficult to get a man to understand something, when his salary depends on his not understanding it." — Upton Sinclair
Even professionals want a salary and a job.
False. Syndros is delta-9-THC.
The overdose is similar to too much weed: lethargy, decreased motor coordination, slurred speech, and postural hypotension. Non fatal overdoses have occurred and only one was a death from delta-9 but it was probably related to another condition (in other tests of dronabinol not Syndros specifically -- we'll find out about Syndros soon). Even synthetic THC is safer than opioids, alcohol and many other things. In my opinion natural cannabis is safer than the pharma synthetics.
So why is the natural THC in cannabis Schedule I and this drug Schedule II? Beyond that, the really hypocritical thing about it is that Insys wants to keep legal cannabis away but push their synthetics. That can't be something you agree with unless you are bought in. I don't really care if synthetic THC is out there, but if it is, so should natural THC in cannabis. If both are completely safe, they should at least be same level classified or not on the crooked and legacy DEA controlled substances list at all, especially if they have medical value which they do.
I'm guessing the reason people say you can "overdose" for Syndros is because they're required to specify some arbitrary limit. Just like how storebought honey has an expiration date attached, even though honey never expires.
I suppose it's also easier to take too much, if it comes as a concentrated syrup. But the same thing happens with edibles.
Some questions come to mind:
- Is it the role of the government to keep people safe from themselves? If so, how?
- Would harsher drug laws make things better or worse?
- How big of a role does purported economic opportunity have to do with drug abuse? My theory used to be that structural unemployment was the root of this epidemic; those born into the quickly receding middle class---those who relied on low-knowledge/low-skill jobs for a modest living---are hit the hardest since they did not anticipate such a shortage of low-skill jobs.
- What does religion have to do with this?
- What does culture have to do with this?
- Are members of the military more or less affected by opiod drug abuse?
- Does providing safe places to take drugs alleviate the problem, or does it make it worse?
Here's an article by a psychiatrist about the way Suboxone is regulated now: https://slatestarcodex.com/2015/02/02/practically-a-book-rev...
Religion? Well, addiction is perceived rather like possession by the Devil. Or at least, weakness. Lack of faith. Really, as Bill basically said, those dirty addicts deserve to die.
It's just that Purdue Pharma managed to addict lots of people by rewarding doctors to over-prescribe, and flooding distribution chains in the southeastern US. Maybe economic collapse is part of the problem. But there's a good chance that things will be manageable after the Purdue mess has been handled.
Edit: In a dead comment, revmoo mentioned kratom, a natural opiate analog. The DEA decided last year not to ban it, after massive public comment. Advocates claim that it helps addicts break their addictions.
https://www.theguardian.com/us-news/2016/oct/14/kratom-dea-b...
The root of the problem is doctor prescribed opiates.[2] Prescription pain killers that were marketed as non-addictive turned out to be highly addictive. These are still widely prescribed. For example, oxycontin had revenues of over $2 Billion in 2013.[3]
[1] - https://en.wikipedia.org/wiki/Opioid_overdose
This is an extremely simplistic view that elides...most of what is going on, such as:
1) How poisoning/overdose deaths are reported by medical examiners -- something that varies a lot by region and over time
2) The increased introduction of fentanyl (and fent analogues) into the heroin supply
3) It doesn't factor crackdowns on pill mills and crackdowns (both from DEA and also self-directed) on opioids prescribing in general
Opioid use is not inherently dangerous. Indeed, long-term use of pharmaceutical-grade opioids is remarkably safe (especially compared to other painkillers or other drugs such as alcohol) -- opioids don't tend to cause organ damage.
There are several actual circumstances where opioid use gets dangerous to life and they are:
1) Dosage/concentration uncertainty
2) Contamination of a lower strength opioid (say, morphine or heroin) with a much higher strength one (fentanyl or fentanyl analogues)
3) Poly-drug use: combining opioids with benzos or alcohol to exploit synergistic effects
When it comes to pharmaceutical-grade opioids, the doses are known and measured and there's no risk of contamination with unknown amounts of fentanyl analogues. Indeed, the mechanisms of drug prohibition actually incentivize the use of extremely high potency/volume opioids such as fentanyl.
The third issue, poly-drug use, also is a consequence of prohibition -- the prices of opioids in the black market are artificially inflated (if you don't have the requisite permission slip for the drugs, you need to invest in all sorts of countermeasures to avoid being put in a cage and your product seized), so users need to economize, and this sadly happens by combining benzos with opioids, which can lead to fatal respiratory depression. This is also a symptom of prohibition and is not inherent to opioid use. Indeed, an overwhelming majority of so-called "opioid overdoses" involve other drugs (and most often it's either alcohol or a benzodiazepine).
The DEA (and other flavours of doorkickers) targeting doctors and deputising them as law-enforcement agents who have to decide between the evil undeserving addicts and the deserving patients in pain is what has created this affair.
Blame the prohibitionists, as this is a problem of their own making -- the crackdowns on "pill mills" and "overprescribing doctors" is what denies people a safe and legal source of pharmaceutical-grade opioids and forces them onto the black market of illegal, overpriced, and fentanyl-contaminated opioids (which leads, of course, to the deaths that are used to justify even more crackdowns).
I am not an expert but the overdose problem is not just about purity/concentration. Even ibuprofen has nasty effects over the long term.
"Overdose deaths involving prescription opioids have quadrupled since 1999,1,2 and so have sales of these prescription drugs.3 From 1999 to 2015, more than 183,000 people have died in the U.S. from overdoses related to prescription opioids.[1]
And it isn't like there aren't other models we can learn from. Portugal springs to mind.
https://www.washingtonpost.com/news/wonk/wp/2015/06/05/why-h...
There's a lot of interesting detail to be learned from studying their system, but the tl;dr is that after decriminalization, deaths in Portugal due to overdose plummeted.
See, before opioid prohibition, deaths from opioid use were quite rare. You ever heard a pothead drone on about "it's nearly impossible to overdose from smoking marijuana"? The same thing applies to smoking opium. It's nearly impossible to overdose on that. But prohibition (which optimises for potency/volume, in order to reduce the risks of ending up in a concrete box) has pushed us from opium smoking and oral laudanum to injectable heroin to fentanyl and now (in the late 2010s) we're at fucking carfentanil (which is so potent it's been used as a chemical weapon).
This is the "iron law of prohibition" at work: https://en.wikipedia.org/wiki/Iron_law_of_prohibition
The current USian "opioid crisis" is another manifestation of opioid prohibition pushing people from safer, cheaper, less disruptive and deadly drugs to more deadlier ones. Two decades ago some USian opioid users could go to pill mills and get prescriptions for pharmaceutical grade opioids but the DEA kicked down doctor's doors a bunch and that ended up pushing people to the illicit market. Maybe next time you see those scary increasing graphs of opioid deaths vs time, give that a thought? Sum up all those deaths (compared to the baseline, prior to the increased LEA focus on "pill mills) and ask yourself: are all those needless deaths worth it?
The DEA cracking skulls over opioids and investigating doctors is literally the only reason illicit fentanyl (and fent analogues) even is a thing. I am so very doubtful that skull-cracking and door-kicking will miraculously work after decades of it not working. The only way out of this hell is a total unconditional surrender in this "war on drugs".
I'm not an expert. Can you please link to studies to verify this?
We're talking about overdosing and I don't think marijuana falls into that category.
Can you imagine a THC analog that's 10^4 times more potent? Is overdose really impossible? I suspect that we'll find out, in a few years :(
Now, if it was legal people wouldn't have to resort getting that crap as a replacement.
Ironically, the obverse task -- trying to create a molecule that acts on similar neurobiological targets as an illegal drug but doesnt get people high or look like a molecule from an illegal drug -- is similarly fraught. A flagrant example is BIA 10-2474, an experimental drug meant to target the endocannabinoid system in a roundabout way -- not by directly activating receptors, but by inhibiting an enzyme that degrades endogenous chemicals that activate endocannabinoid receptors -- which would have similar effects as directly activating those receptors. A trial of it killed one person and irreversibly neurologically damaged a few others.
We criminalise drugs at deep costs to research and medecine (I haven't even gotten into the use of MDMA in psychotherapy or ketamine for depression), and regardless on what side of the law they work on, it is a very difficult task for chemists to try to imitate drugs that have been with humanity for millenia when they aren't allowed to make molecules that look like blacklisted ones.
I mentioned the (commonly known) lack of marijuana overdoses to analogise it with the (lesser known) utter rarity of overdoses with smoked opium: low potency mixed with a route of administration that acts as a dead man's switch (if you nod out, you'll likely drop the opium pipe) makes for safe drug use.
Rehabilitate at least enough users that you can darn well ask them what's driving this. They know; it's their lives. Ask people, and then find ways to address the problems in their lives that they point out.
Stop treating this as alien! It's all around us, every day, every city, every year. We have no right to ignore this kind of mass suffering as if we can do nothing!
You may be conflating the medical consequences of addiction with the decision to start using.
There is usually very little to the "choice" that addicts once made. My girlfriend was injected with meth amphetamine when she was 11 (by an "angry" 14 year old). That experience solidly messed up her brain chemistry, and no one knew how to help her.
Her doctor used Depot Provera to chemically castrate her at around age 19-20. This likely made her suicidal, as is frequently the case [1].
Should my girlfriend be punished for her doctors inability to help her?
[1] http://www.sciencefriday.com/segments/looking-beyond-condoms... - caller at 8min30sec was similarly made "manic and suicidal" with Depot Provera.
She overdosed on me a year ago, likely because of the benzodiazepines that the mental hospital got her hooked on (she thought heroin would get her through benzo withdrawal, but really each amplifies the other's effect). I called 911, they did their job, and the police decided they didn't need to make the situation worse.
Here's the link to my comment from 13 days ago: https://news.ycombinator.com/item?id=13846763
In case I wasn't clear about it, I think that the production, distribution and consumption of drugs should be legal. Not only is it none of anyone else's business, there's solid evidence that legalisation helps efforts to minimise harm.
But in the case of people who make an informed, consensual decision to take drugs (and again, to be clear, it sounds like neither was the case for your girlfriend) there is clearly a moral dimension to the decision.
Perhaps you're confusing with my claim that choosing to use drugs has a moral element, with some sort of moral censure on my part?
I'm with Scott Adams on this: you should be free to kill yourself at any rate of your own choosing, provided your cold dead body isn't blocking my driveway in the morning.
People should be perfectly free to act immorally, provided they're not violating the rights of others.
Are you claiming that tens of millions of people got a pop-up box asking them, "Are you sure you want to abandon your children, alienate your family, and ruin your life? This operation is irreversible!"? Remember, one of the major ways in which the opioid epidemic has spread was medical doctors, of all people, prescribing heavy opioids for pain management.
How do you think these things happen?
How do you think the other cases should be judged, though? Say the case of someone who starts using heroin as an adult, without first being prescribed opioids.
Would you not treat that as a moral failure on his or her part?
I mean, restricting availability of Oxycontin etc clearly hasn't worked.
Edit: My point is that the Drug War is immoral.
1. We need more radical ideas like distributing heroin.
2. I'm not by any means convinced that distributing heroin will actually solve the problem. Clearly, nothing we've done so far has worked. Perhaps this will work.
3. There is some good sentiment behind the drug war. Still, there are a lot of evil pharmaceutical companies which have no good intentions.
4. Pharma firms inherently gravitate towards evil because more money lies there. Perhaps there are a few truly evil execs at these companies, but I think the sith-like aura comes from the sum of many only slightly evil actions. If we remove the money, we remove the problem. But how?
If people had unstigmatized access to heavy depressants, like heroin (as opposed to "light" marijuana), would that really have a better net than if they weren't available at all?
What comes to mind in this situation is reminiscent of dystopian neo-Tokyo in movies, where everything is grim and the people have reclused from life in their cramped cities, into daily drug escapes.
Genuinely curious as to what the end-game is for legalization of controlled substances. Perhaps there's a middle ground (a moderate position if you will) that could be more efficient?
ETA: I think it could work well if it was paired with something, say an educational program and increased mental help resources (two places in which the U.S is lacking and thus a poor place to pioneer open-drug policies) so it doesn't divulge into a free-for-all after drugs flood the market.
Right now we have a dystopia where everything is grim and people continually drop dead from needlessly toxic drugs which is frankly more horrid than one when people frequent opium dens or whatever. Drug use is not worse than death.
>*Cost Issues: 48 dollars/day: Patient costs are covered by national health insurance agency. Patients pay 700 dollars/year for the compulsory insurance. Note: The Swiss save about 38 dollars per day per patient mostly in lowered costs for court and police time, due to less crime committed by the patients.
[0] http://www.citizensopposingprohibition.org/resources/swiss-h...
Quick rundown: The poppy plant has two main alkaloids that make up the majority of its analgesic activity: codeine and morphine. Codeine works following being broken down by the liver into morphine. It's essentially the same drug but requires larger doses due to the inefficient pathway.
I have had a chronic pain condition for many years now and take 30mg morphine sulfate tablets twice daily. Instant release taken often works far better than extended release drugs because the total dose is much less, which keeps tolerance levels low, thereby lower dependence.
Oxycodone is 1.5 to 2x as strong as morphine. [1]
Oxymorphone is 7-8x times as strong as morphine. [1]
Fentanyl is 50-100x times as strong as morphine. [1]
Of course this is referring to gram for gram, and these substances do have different molecular weights. But even so, the potency has much to do with bonding length between the drug and the body's receptors. Bonding length is correlated with bonding strength, also correlated with addictive qualities.
For low to moderate pain, Tramadol[2] is the best analgestic. For moderate to severe pain, Tapentadol[3] (Nucynta) is by far, the most therapeutic and least addictive. I used to take it until I lost my insurance. Unfortunately it costs $1500 a bottle. It's a newer drug. The same company Depomed that created Tramadol kept going and made a better and stronger version. Having tried gabapentin, muscle relaxers, all kinds of stuff, pretty much everything out there, I will say, Tapentadol is really an amazing drug. It's unfortunate its so expensive and not covered by many insurances though.
So in summary, if a person has the insurance, the doctor should prescribe them Tapentadol or Tramadol. As a last resort, prescribe Codeine and/or Morphine. Not these crazy synthetics with ridiculous addiction profiles and bonding strengths.
Hope this helps anyone who ever has a pain condition.
[1] https://en.wikipedia.org/wiki/Equianalgesic
I am an addict. I have been all of my life, and will be until the day I die (hopefully at an old age and happy).
I'm also business owner, young and I would say very successful compared to others in my age group.
Ironically, I actually credit Oxy for getting sober from alcohol (coming on 3 years), and I've been sober from cocaine for probably around 3.5 years (don't remember, very blurry).
However I'm currently dependent on opiate pills and I feel very lucky that I can afford my addiction, at least for now.
I'm afraid to get sober. I'm afraid to tell the truth to the ones I love who supported and congratulated me on getting sober from alcohol and cocaine.
Instead of telly a long story, I wanted to offer some ideas to this community, from the perspective of an addict and entrepreneur, a few of these could even be successful startups that save lives:
1) doctors need to stop prescribing. I am very open with my Doctor, it is written on the front page of the screen that shows my health record: previously cocaine dependent, alcoholic. Yet when I went in for a bad burn, they prescribed Percocet. I went to the doctors seeking some numbing cream and to ensure I didn't get an infection. But I got pills, and I'm an addict. I KNEW 100% I would become addicted. It didn't happen over night of course, but here I am. Replacement therapy is called liquid handcuffs for a reason: methadone is dangerous and deadly, Sub withdrawal I hear is worse than oxy/heroin withdrawal. I would love to see an experiment long term between traditional replacement therapy, compared to actually supplying addicts with pure drugs.
2) make a reliable and widely available and free test kit to detect Fent and other deadly synthetic and powerful opiates.
3) make a cheap wearable fitbit like device. It will detect slowed/stopped breathing and alert either authorities or maybe an app that has listed contacts who are trained and have access to naloxone, like a rape or danger alert sent to your designated contacts and if no response 911. It would have to have little monetary value so it's not sold, but maybe could help save some lives.
4) make an implant that can detect slow breathing/overdose and administer naloxone during an overdose internally. Like a diabetes monitor/pump.
5) sue Purdue and change our countries addiction to prescription pain killers. To me this is the big tobacco of our time. They spent millions and millions advertising and buying doctors telling them this is a non-addictive 12 hour pain reliever. Pain in the past was rarely medicated. Purdue changed this and made billions. The truth is Percocet/Oxy usually lasts only 6-8 hours, maybe 10 if you're lucky. Each individual is unique. Purdue advertised 12 hours non-addictive and that's how doctors prescribed. so when the pain comes back before 12 hours or you start getting sick you take the next pill. And you use your entire script before the next refill. They MUST have known this. Profiting on addiction is shameful. Marketing a product to purposefully create addicts to sell more pills is criminal an I hope that somebody can leak or a prosecutor can make this case and bring some justice, and badly needed funding to aid in recovery, research, and alternative replacement options.
I'm also not sure that Fent/synthetic opiates would go away if everyone could grow opium. It depends on cost and scale. Fent is cheap as shit for how powerful it is. I'm not sure mass cultivation (time + resources) would be cheaper. IDK maybe I have no idea I have never grown poppies and don't know the cost.
But I do know the price for 100 grams of fent and it's insanely cheap.
If opium/naturally derived opiates were available for cheaper/free from governments than sure it would probably reduce dramatically the amount of fent produced.
I'm not sure how I feel about your characterization of poison/medicine.
I don't want to argue about it either.
But I guess I'm genuinely curious as to where you're coming from with that statement and your experience. Are you an opiate user? alcoholic/recovering alcoholic or addict? mental health? everyone's experience is different so who am I to judge or critique.
edit again don't want to argue, but I guess I would offer a simple question about the 'most beneficial plant known to man'. How would you compare say, antibiotics derived from plants to poppies in terms of benefit to man?