America’s syringe exchanges kill drug users
economist.com
economist.com
And the correlation can very easily be backwards. In fact, its more likely backwards.
Counties which are facing an increasing barrage of opioids and all the issues related to it, especially spread of disease and an increase in deaths due to unsafe use are almost certainly more likely to create safe needle exchanges.
For the economist to write this article as if causation is established, and further to moralize is insane.
Especially since the Economist famously doesn’t provide bylines so this becomes the official view of the magazine as opposed to a specific editor’s.
And finally, even if the causation is correct, all it indicates is that needle exchange programs need to also provide drug testing capabilities so the presence of fentanyl can easily be identified.
> And finally, even if the causation is correct, all it indicates is that needle exchange programs need to also provide drug testing capabilities so the presence of fentanyl can easily be identified.
This assumes that there are no individuals that are knowingly injecting fentanyl or that a drug user would not take drugs in their possession if they knew it contained fentanyl. Yes, there are individuals that unknowingly take a fentanyl containing substance but I am doubtful that those deepest in opioid addiction avoid it.
https://www.sciencedirect.com/science/article/abs/pii/S09553...
That being said, a needle exchange program could always require the testing of fentanyl and if fentanyl is found decline service.
So the people who apparently want fentanyl and are encouraged by the needle exchange programs would not have them as an incentive anyways.
The Economist predisposes it’s readers to believe that this indicates needle exchange programs are bad, as opposed to leaving open the possibility that due to changing circumstances needle exchange programs which have proven to be extremely successful, also need to adapt, much like every other individual, program, company or non-profit at any time.
I don't understand why doctors are still so quick to prescribe opioids.
In the heavier cases, a flap of gum tissue and covering jaw bone are cut away to expose a submerged tooth that is oriented the wrong way. The tooth is then demolished in place so that the chunks can be lifted out. The patient would be sedated during this procedure, and the wound and recovery period is significantly different.
Went from fine one day with the caveat that one day I'd need oral surgery to have them removed, to burning with a fever while finding an oral surgeon ASAP.
Needed invasive oral surgery. Had to be put under twice-once before operation, and once when bringing me out after, as I had a paradoxical reaction and was thrashing about. Me screaming I didn't know the surgeon and anesthesiologist and thrashing about isn't super good after oral surgery.
Hurt like the dickens afterwards and had to eat soup for a good while.
They gave me ibuprofen and tylenol with codeine afterwards. I only used the ibuprofen and was fine. It only blunted the pain but was definitely manageable after the first day or so.
I've had doctors try and prescribe narcotics for some weird things. I've always denied them as I had a friend who became addicted to heroin after being prescribed oxys for serious 3rd degree burns.
Every time I have to deny narcotics multiple times before they relent and offer something non-narcotic.
Anyways just one person's experience.
Especially not if you haven't first tried if Ibuprofen or Tylenol/Paracetamol or one of a dozen other mostly harmless painkillers do the trick.
So from my perspective, as a very acute surgical drug, it would seem to be a great innovation, but it's probably not something you want to use to relax after a tough day at the office.
Users often have preferences for which is most pleasurable, but nobody would say fentanyl doesn’t get you high.
> the data from the studies included in the aforementioned literature reviews (i.e. General Accounting Office (1993); World Health Organization (2004)) rely on small sample sizes and self-reported data regarding individ- uals’ drug use, and do not typically consider attrition nor spillover effects on those not directly treated. Additionally, many studies use data from Canada, Sweden, or New Zealand to serve as a comparison group for drug rates in the US. Such methods are problematic for addressing causality, given that other developed countries have differing policies on the operations of SEPs and greater access to substance abuse treatment.1 I overcome these existing limitations by cre- ating a novel dataset that combines information on SEP opening dates with restricted administrative county-level data on HIV diagnoses. These data proxy for drug use without relying on self-reporting behavior, and are representative of counties across the US.
It’s using newly-opened SEPs for a discontinuity analysis, which does provide evidence of causation (and furthermore notes that previous studies were correlational).
Your parent comment said they expected counties facing a crisis to open SEPs. That would be a newly opened SEP caused by drug deaths. So how does using newly-opened SEPs for discontinuity analysis make any sense at all?
It was linked elsewhere in the thread, but here it is: https://apackham.github.io/mywebsite/opioidpaper_webcopy.pdf
Emphasis on seemed. I started with "I'm probably missing something" because I haven't studied anything relevant .
https://en.wikipedia.org/wiki/Endorphins
> "Endorphins are released from the pituitary gland, typically in response to pain, and can act in both the central nervous system (CNS) and the peripheral nervous system (PNS). In the PNS, β-endorphin is the primary endorphin released from the pituitary gland. Endorphins inhibit transmission of pain signals by binding μ-receptors of peripheral nerves, which block their release of neurotransmitter substance P. The mechanism in the CNS is similar but works by blocking a different neurotransmitter: gamma-aminobutyric acid (GABA). In turn, inhibition of GABA increases the production and release of dopamine, a neurotransmitter associated with reward learning."
All that matters is that the drug molecule binds to the receptor proteins in the brain and peripheral nerves. Studies show that the active dose is directly related to the binding strength of that specific molecule (fentanyl binds more strongly than heroin, so less is needed to get the same effect, oxycontin is about as strong a binder as heroin, about twice as potent as morphine).
Overdose deaths are generally due to (1) unusually high concentrations of active substances or (2) Users who've lost tolerance for some reason taking too much.
Legalization would likely eliminate most accidental overdose deaths as products would be clearly labeled as to contents.
Opioids aren’t pure mu-agonists, they also have sigma agonists effects which produce non-opioid effects and also have off effects (histamine release). Combine that with the onset and duration of action, users can definitely tell if they got fentanyl versus say morphine. But not really between heroin and morphine.
As neuropharmacology and biology remain fields of active investigation, there are several other putative opioid receptors which aren't characterized very well at all but probably have some relevance. Diverse multiple-receptor heteromers are beginning to demonstrate pharmacological relevance (e.g. different binding profiles at mu-delta heteromers) and also at other protein-protein interaction sites (e.g. some drugs inhibit arrestin recruitment and activity dependent receptor internalization).
Also the pharmacokinetics/dynamics matter, things like the central/peripheral availability (e.g. how much constipation) and speed of availability to CNS. Metabolites may be psychoactive or may affect metabolism of the primary drug.
Off-target activity is present in everything and may be meaningful especially in some analogues (e.g. pethidine has significant dopamine transporter inhibiton) or in plant-derived morphine/heroin which comprise a complex mixture of compounds with diverse activities).
All of these things color the subjective experience of a drug. There is not much study made of subjective qualia because the models to describe this sort of thing are not very nuanced or descriptive, but more because it is not very relevant to clinical clinical practice. However, people who use tons of these drugs all the time do report subjective differences along dimensions such as "speediness", sedation, euphoria, "rushiness", malaise, therapeutic index, timecourse, etc. For example a user might report "Compared to heroin, oxycodone feels more energetic, while fentanyl has a nice initial rush but is much more sedating and wears off quicker", stuff like that.
TL;DR in vitro mu-opioid activity is not sufficient to explain objective or subjective variance between opioid drugs, and like much other biology there is much work to be done for all the nuance to be well understood.
Also, the long-term health effects are well understood, and treatments for overdose established. For example, it’s safe to take (pure) heroin regularly (though I wouldn’t personally advocate for this of course).
On the other hand, the new families of synthetic drugs (Cathinones that replaced MDMA, random novel psychedelics, and fentanyl replacing heroin) all have far worse safety profiles.
When you make drugs illegal, the market responds by finding the cheapest illegal substitute, with little concern for safety. On the other hand, if we made heroin legal, then nobody would mess with fentanyl. Ditto with MDMA over m-cat or whatever. And while drug use would increase a bit at the margin, harm to society would dramatically decrease. Most people don’t actually want to be junkies it turns out!
The money saved from not criminalizing drugs could provide extremely good addiction counseling for anyone that wanted it, further reducing the harm.
And lots of crime is just stealing to buy drugs; it’s plausible that overall crime would go down substantially if we gave heroin prescriptions to addicts. I’d rather prescribe heroin (with free access to good addiction counseling) to someone who is addicted than have them breaking into cars stealing stuff to fund their habit.
Finally, another related argument - the geopolitical harm of the drug trade is immense. Drugs flow north to the US, and money and weapons flow south to the cartels. If we legalized cocaine, then we’d stabilize many regimes (eg Mexico, Columbia) that are currently struggling with cartel violence. On net you’d see a massive flourishing of humanity under this policy. A little bit more drug addiction in countries that can afford to treat it, and way less murder and kidnapping in countries that are trying to catch up. (Surprisingly, the Economist recently advocated for legalizing cocaine: https://www.economist.com/leaders/2022/10/12/joe-biden-is-to...)
The issue is that criminalizing drug use costs society far more than encouraging treatment. It doesn't make sense to criminalize obesity, tobacco use, or alcoholism, so why continue to outlaw certain substances other than for historically-racist/-political reasons?
Denver, OTOH, seemed quite cheerful.
Did I get a proper impression of each or anecdotal anecdotes?
Uh, would love to understand their thinking on this. Because you know, addicts are _addicted_. If needle exchanges don't exist, they steal the fit from hospitals. If they are struggling to do that, they re-use, which isn't great for your veins, and if worst comes to worst, they share.
The one thing they _don't_ do is stop getting high. Because they're addicted.
If they were positing that the risk of blood borne disease prevented people who weren't addicts from trying IV drugs, then it's more plausible.
Source: Used to be an IV drug user, and was very glad indeed for needle exchanges. Heroin is a hell of a drug to get off, but at least I don't have HIV or HepC to remember it by.
> Decades of research prove that these programmes curtail disease. Junkies are in fact less prone to sharing needles when they get free ones. That sharply decreases rates of blood-borne illnesses. In 2014 an analysis found that every dollar spent on syringe exchanges spares the government around $7 in HIV-related health-care costs. Needle exchanges opened across America and Europe. For years no one detected the feared rise in substance abuse.
> That was before the opioid crisis plagued America and economists started looking into the trade-offs. A new study by Analisa Packham published in the Journal of Public Economics uncovers an uncomfortable truth: this particular harm-reduction tool does lots of harm. Ms Packham compares how drug users fared in counties that opened syringe exchanges between 2008 and 2016 with those in counties that did not. Before the clinics opened, upticks in HIV diagnoses or overdoses in one set of counties were mirrored in the other. Once a syringe exchange came to town, outcomes diverged. Rates of HIV fell by 15% in counties with the new programme. But deaths soared. On average syringe-exchange programmes led to a 22% spike in opioid-related mortality.
> Simply lowering the risks of getting sick—and the costs of paraphernalia, as Flaco from the Bronx articulated—could also incentivise drug use. Distributing PrEP, an HIV-prevention medication, has been shown to make gay men less inclined to use condoms during sex. So too could harm-reduction tools make addicts use drugs more incautiously. In a study published in 2018 Jennifer Doleac and Anita Mukherjee found that when states legalised naloxone, a medication that reverses overdoses, opioid abuse increased. Though lauded by public-health advocates, naloxone did not save lives as intended. In some regions, fewer addicts died; in others, more did. > These works have been met with anger. Their findings upset harm-reduction defenders who consider their efforts already besieged by critics. The experience was so miserable that Ms Doleac, who studies crime, has decided never to write another health paper.
> Leo Beletsky, a former drug dealer, now at Northeastern University, deems Ms Packham’s findings “nonsensical” and thinks her paper should not have been published. Don Des Jarlais, at New York University, argues that addicts do not respond to incentives like others do, making the moral-hazard effect inconceivable. Susan Sherman of Johns Hopkins University says she doubts that new evidence that harm reduction does more bad than good would convince her to disregard previous research demonstrating otherwise.
> A barrage of complaints led the editors of the International Journal of Drug Policy to retract a meta-analysis that found that safe-injection sites, where users do drugs in supervised settings, did not decrease rates of deadly overdose. “Retractions used to be reserved for fraud,” says Keith Humphreys of Stanford University, a former drug-policy adviser for the Obama administration. No longer, it seems.Science denial has many forms. This appears to be one of the older ones.
In this case, I'd speculate that harm reduction advocates aim is to (tautologically) reduce the (physical/health) harm of drug use so that it's one less problem users face. One aspect of this may be safe consumption, which this article says doesn't work on it's own. Another aspect is overdoses form Fentanyl et al, (which I would argue is largely a byproduct of a drug war that has made heroin too hard to import, and no safe medical supply options for treatment). So the focus could shift to addressing this (which in tandem with safe injection sites could still produce better overall outcomes).
My point is that it's not productive to dispute the studies, better to accept on balance of probabilities and look at how it fits with your overall aim.
(Climate change is very similar. People dispute the studies because they don't like the political rhetoric about how we should react, not because deep down they think all the research is flawed)
Good move on Doleac's part; her naloxone paper was atrocious.
Many of the problems are detailed in "Supervised consumption sites: a nuanced assessment of the causal evidence."
It mentions the reason for retraction, something about "pooling diverse outcomes into a composite measure," anyone have a link to the actual details of the retraction other than that it wasn't for fraud?
"Ahmed Bayoumi and Pamela Leece, who wrote one of two critical reviews that led to the meta-analysis’s retraction, noted that the meta-analysis combined outcomes for mortality, drug-related crimes, sharing of drug equipment, and problematic drug use — even though each of these outcomes could be affected differently by a supervised consumption site.
But I can't find the review itself.
In an era of questionable social science, retracting for bad methods seems defensible, but arguably this should just be not cited on account of being inapplicable. The emotionality of the issue makes that hard--if not retracted, it will go on to be bad evidence for things it doesn't say. People seem to have a pretty low bar for what passes as a judgement on supervised consumption sites.
“Accordingly, that estimate of effect has no practical public health or policy implications,” Bayoumi and Leece concluded.
Saying that a certain population should die because of their criminal nature and high "cost to society" is straight up nazi shit. What's the policy implementation of that opinion just curious? It really doesn't get more clear than this.
This is such a ridiculous viewpoint on a hacker forum. There are no intrinsic resources - iron ore is just a bunch of rocks, crude oil is a toxic sludge, Uranium is a bunch of radioactive ore.
Economy is not a zero sum game, it's about allocating current resources to expand future ones (AKA growth)
They already implicitly did. Turns out the dysfunctional criminal justice and medical system the praise affect more than just addicts. Who would have thought.
I think that people are more concerned with opioid death statistics than opioid addiction itself. And there is a shattering sense of defeat, which is normal, that is associated with realizing that you cannot help anyone who doesn’t want to help themselves. And if they don’t want to help themselves, then they may go down a collision course that will be their undoing. In this case that often means death.
I feel strongly this way, or maybe I'm missing your point. Addiction is terrible, but death is clearly worse than addiction. Addiction is survivable.
My point is that the “preventive maintenance” approach to opioid addiction is more about death statistics than it is about death itself. It’s a numbers game. A nation’s response to situations such as this will largely be determined by how many people don’t die, because people have a distaste toward death and the general public is subservient to what data suggests irrespective of its practical and tangible representations.
No offense, but your view here seems insane to me.
I don't follow your point about death statistics vs death itself.
"Helping them stay on drugs" is very much the wrong way to look at it. How about "reducing the harm they do to others"?
“Helping them stay on drugs” is the practical way of looking at it, because in practice that’s what’s happening. “Reducing harm” in this context sounds like some sort of neo-Hippocratic Orwellian spin on the fact that the alternative is to address the greater issues that lead to and foster drug addiction that are beyond the scope of this tiny box that I’m typing into and do not involve more needles.
Before reading that I thought that maybe the SEP groups were wrong to call the publishing of the paper a mistake, but now having read it and seeing that it presents correlational data as causational data I understand why those groups were criticizing the research itself.
I’m not an expert in this field so I would appreciate if others can also read the actual paper and explain to me why the author is correct to claim causation instead of correlation.
Proving causation is the cherry on the top of research.
Most of the time correlation and mechanism is all that can be found in a timely manner. This data is really quite good.
Correlation between smoking and poor health was shown decades before causation was considered proven.
It'd be ridiculous to tell someone don't worry keep smoking, all the data we have this far shows only correlation! Right up until the 50s, when in the 20s it became apparent smokers died young.
What we see here is people moving thresholds depending on their bias. This is the root cause of confirmation bias.
The only way needle exchange fits into civilized life is as one aspect of a shelter-first treatment scheme that gets these people to a place where they can vomit in their own rooms for a change.
- smoking has long-term negative health outcomes
- drug abuse also has long-term negative health outcomes
Short term:
- I can’t even really think of a dirty-needle equivalent for smoking
- using a dirty needle has a large number of short-term/acute/immediate outcomes: infection, incurable disease (Hepatitis, HIV, etc) and spreads between users
It’s not as if we’re taxing cigarettes and giving away fentanyl for free to everyone. Yes, we even do give some drugs out for free (e.g., methadone and suboxone), but only to people who have already ruined their reward systems and become addicted. I couldn’t go to a doctor or a clinic and say “the last time I consumed an opiate was 12 years ago after my knee surgery but please sign me up for free methadone!”
There are definitely no drug users who are regular people who don't commit any non-possession related crimes!!
Fox news told me drug users are the cause of all crime so it must be true.
"Simply lowering the risks of getting sick—and the costs of paraphernalia, as Flaco from the Bronx articulated—could also incentivise drug use."
It's at the point that if you're not aware of and advocating for obvious solutions like this, the blood is on your hands.
If you need data, look at Portugal.
2. Even if it were true, nations get to dictate their policies and it is perfectly understandable for them to not want to subsidize drug abuse.
How does legalizing manufacturing of a killer substance stop ODs?
It’s not legalizing it that could potentially help with ODs but regulating it. It’s the difference between injecting a random-assumed-to-be-heroin substance dissolved in tap water on a heated spoon and injecting a known 10mg/mL vial of heroin.
Legal weed in Canada has THC % numbers on it and it makes dosing so much simpler. While the impact of too much THC is nowhere near as bad as opiates, it’s quite nice being able to look at a bag and pretty accurately predict how much to have to get a desired effect.
Edit: same with alcohol. It’s really nice to be able to look at a 355mL can of beer and know that drinking it isn’t going to have the same effect as a 355mL bottle of vodka.
https://www.statista.com/statistics/911927/drug-overdose-dea...
Just because they say something you dislike doesn't make them "right wing".