FROM AMERICAN LOCALITIES TO GLOBAL SOURCES

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on a particular drug which is part of this epidemic.]

The drug problem has been with this nation for a long time.  If one considers alcohol a drug, its been part of the American story almost from the beginning.  But with the opioid chapter – and especially regarding fentanyl – that story seems to have taken a significant turn.  Here is a thought from Christopher Caldwell of The Weekly Standard:

There have always been drug addicts in need of help, but the scale of the present wave of heroin and opioid abuse is unprecedented.  In Maryland, the first six months of 2015 saw 121 fentenyl deaths.  In the first six months of 2016, the figure rose to 446.[1]

The turn in the nation’s drug story does not promise to have a happy ending; it has already been tragic to too many.

          And the problem seems to be concentrated in certain areas of the country.  This posting looks at some of those areas.  A good place to begin is Ohio.  For example, in 2014, the Center for Disease Control was able to attribute 998 deaths there to fentanyl overdoses and then the same number in only the first five months of the following year, 2015 – a similar rate of increase to that of Maryland.

          Reflecting on this development, a federal official in northern Ohio attempted to underline it by saying:

One of the truly terrifying things is the [fentanyl] pills are pressed and dyed to look like oxycodone. If you are using oxycodone and take fentanyl not knowing it is fentanyl, that is an overdose waiting to happen. Each of those pills is a potential overdose death.[2]

          Another state with a concentration of overdoses is New Hampshire.  There reports indicate that two thirds of deadly overdoses were, at least in part, due to fentanyl consumption.  Again, as indicated in the previous posting, consumers were often unaware they were taking this potent, synthetic opioid.[3]

          Of course, along with its hidden presence, it is sold under various names.  For example, in Florida, fentanyl pills are sold on the street under the name Xanax.[4]   And this aspect leads one to another angle to the story; that of the producers and the suppliers. There the story shifts attention mostly abroad in trying to find out where are the sources of the drug originating and what are the costs in producing and attaining it.

          The Drug Enforcement Administration reports that an interested party can purchase one kilogram of fentanyl for $3,000 to $5,000 in China and smuggling it into the US can be accomplished by merely mailing it there.  That smuggled kilogram can mean a million and half dollars in sales.  This inexpensive drug abroad, in turn, motivates drug dealers to purchase it and then mix the fentanyl in with other drugs they sell without the eventual consumer knowing it.[5]

          According to the medical news outlet online, STAT, Mexican cartels are the main suppliers of heroin, but it is from China that most raw fentanyl originate.  It is also the main source of production machinery.[6]  This machinery opens the potential for many places producing and supplying the drug in pill form.  For example, police in British Columbia found a lab producing 100,000 fentanyl pills every month.  These pills are then sent to Calgary, Alberta, causing a fentanyl problem there, 90 overdoses in 2015.[7]

          And finally, domestic production capabilities have been found.  A drug lab in Southern California was one.  There, pill producing machines were potentially producing thousands of pills per hour.  This facility was discovered by federal agents. [8]  So, as of this writing, while better knowledge has become shared concerning the dangers of the drug, fentanyl, helping to level off consumption rates, the production and distribution seems to be amply in place.  The next posting will address the prevalence of pill mills.

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[1] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction,” First Things, April 2017, accessed June 18, 2018, https://www.firstthings.com/article/2017/04/american-carnage .

[2] David Armstrong, Truly Terrifying:  Chinese Suppliers Flood US and Canada with Deadly Fentanyl,” STAT, April 5, 2016, accessed July 4, 2018, https://www.statnews.com/2016/04/05/fentanyl-traced-to-china/ .

[3] “Addressing America’s Fentanyl Crisis,” National Institute on Drug Abuse/Advancing Addiction Science, April 6, 2017, accessed on July 4, 2018, https://www.drugabuse.gov/about-nida/noras-blog/2017/04/addressing-americas-fentanyl-crisis .

[4] Ibid.

[5] Ibid.

[6] David Armstrong, “’Truly Terrifying’:  Chinese Suppliers Flood US and Canada with Deadly Fentanyl,” April 5, 2016, accessed July 4, 2018, https://www.statnews.com/2016/04/05/fentanyl-traced-to-china/ .

[7] Ibid.

[8] Ibid.

BIGGEST KILLER

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on a particular drug which is part of this epidemic.]

Of late, there is a newer, scarier form of the opioid drug.  It is a synthetic form; it’s fentanyl.  The numbers concerning fentanyl are “jaw-dropping.”  There is not much of a history here, the dangers associated with fentanyl seem to have mushroomed since 2014.  What can be said is that the drug is mostly smuggled into the country although there some production facilities in the US.

          Here are some of the reported facts concerning fentanyl.  First, fentanyl is a synthetic opioid; as such, it is a painkiller.  That function should not hide its hideous qualities.  It is enormously more potent than morphine – 50 to 100 times – and more potent than heroin – 30 to 50 times.[1]  A mere 2 milligrams (or just under two ounces) is enough to kill a person.  Looking at, smelling, or tasting it is misleading and dangerous; it is white, odorless, and flavorless.

          To underline these characteristics, first-responders who have been called to help overdose victims have suffered overdose symptoms themselves by either touching or smelling residue amounts.[2]  These accidental incidences has changed protocols by which authorities handle on-site drug samples.  Now, applying DEA recommendations, officers or medics do not field test suspected fentanyl samples.  Instead they send collected material to laboratories for analysis.[3]

          With these factors, one can imagine the costs regarding the effects of this drug on users.  Several sources have reported the resultant death rates associated with fentanyl.  Allison Bond,[4] who illustrates the comparative danger of fentanyl by showing the lethal amounts of the drug next to lethal amounts of heroin (the former consists of a few grains, while the latter fills about one-eighth of a two-inch vile), reports on these death rates. 

Highlighting the state of New Hampshire, Bond reports deaths rates in the US skyrocketed from 2015 to 2016, a 540% jump.  A study appearing in the Journal of American Medical Association (JAMA) further supports this finding by stating that the massive increase in opioid-induced deaths are almost totally due to fentanyl consumption.[5]  And, of course, when one considers drug use, mixing becomes a factor.

Big urban areas, such as Philadelphia, Detroit, and Chicago, have seen fentanyl-laced heroin become a major problem.  These substances are easily hidden, and victims report that they were surprised to learn their heroin intake was so doctored; in some cases, what they consumed was pure fentanyl.[6]  And the extent of the “fentanyl problem” might be undercounted. 

According to the Center for Disease Control, reported figures of opioid overdoses omit synthetic opioids, but the agency believes that a significant portion of that count is due to illicit fentanyl.  Therefore, the total effect of this synthetic drug is not known.[7]  Its surreptitious quality relating to its use and even to its generally known dangers – many Americans first became knowledgeable of its dangers with the death of the rock star, Prince – has added to its lethal effect.

So, what one can surmise is that the dangers of fentanyl have to do with its undistinguishable characteristics in granulated form and the lack of knowledge (most victims in hospitals, from overdoses, are surprised that they are there due to their heroin being laced with fentanyl).[8] 

The next posting will report on some of the facts concerning the production of fentanyl, on the effects the drug has on various states or regions around the country, and on some of the supplying areas around the world.

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[1] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction,” First Things, April 2017, accessed June 18, 2018, https://www.firstthings.com/article/2017/04/american-carnage .

[2] Catherine S Hwang; Hsien-Yen Chang; Caleb G Alexander, "Impact of Abuse-Deterrent OxyContin on Prescription Opioid Utilization," Pharmacoepidemiology and Drug Safety, 24, no. 2, 2015, 197–204 AND Kristen A. Morin, Joseph K. Eibl, Alexandra M. Franklyn, and David C. Marsh, “The Opioid Crisis:  Past, Present and Future Policy Climate in Ontario, Canada,” Substance Abuse Treatment, Prevention, and Policy, vol. 12, no. 1 (2017), 45 AND “FDA Requests Removal of Opana ER for Risks Related to Abuse,” U.S. Food and Drug Administration, Office of the Commissioner, June 8, 2017, accessed July 2, 2018, https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm562401.htm .

[3] “Briefing Guide for First Responders,” U. S. Department of Justice/Drug Enforcement Administration, accessed July 2, 2018, https://www.dea.gov/druginfo/Fentanyl_BriefingGuideforFirstResponders_June2017.pdf .

[4] Allison Bond, “Why Fentanyl Is Deadlier Than Heroin, in a Single Photo,” STAT, September 29, 2016, accessed July 2, 2018, https://www.statnews.com/2016/09/29/why-fentanyl-is-deadlier-than-heroin/ .

[5] Peter D. Scott, Peter Dale and Jonathan Marshall, “Cocaine Politics:  Drugs, Armies, and the CIA in Central America (Berkeley, CA:  University of California Press, 1991), 2. 

[6] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction.”

[7] Josh Katz, “The First Count of Fentanyl Deaths in 2016:  Up 540% in Three Years,”  The New York Times, September 2, 2017, accessed July 2, 2018, https://www.nytimes.com/interactive/2017/09/02/upshot/fentanyl-drug-overdose-deaths.html .

[8] Adrienne Cutway, “Orlando Man Pleads Guilty to Selling Heroin Mixed with Fentanyl,” Orlando.com, March 20, 2017, accessed July 2, 2018, https://www.clickorlando.com/news/orlando-man-pleads-guilty-to-selling-heroin-mixed-with-fentanyl AND Jacqueline Howard, “Why Opioid Overdose Deaths Seem to Happen in Spurts,” CNN, February 8, 2017, accessed July 2, 2018, https://www.cnn.com/2017/02/08/health/opioids-overdose-deaths-epidemic-explainer/ AND “Opioid Data Analysis,” Centers for Disease Control and Prevention, no date, accessed July 2, 2018, https://www.cdc.gov/drugoverdose/data/analysis.html .

BIGGEST SELLER

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on a particular drug which is part of this epidemic.]

The next class of opioids this development will address is Oxycodone, including a derivative of this drug, OxyContin.  When it comes to recreational use of opioids among Americans, these two forms constitute the most used.  According to the US Department of Health and Human Services report, circa 11 million Americans consume an oxycodone drug for recreational or non-medical reasons.  As such, Oxycodone accounts for a large portion of this epidemic.[1]

          Oxycodone has its own history in the US.  It starts in 1939 when it was first made available on these shores.  But it took until 1970s before US authorities, in the Food and Drug Administration, to deem this drug as having a high probability of being abused and potentially causing addiction.  This government agency did this by classifying it as a Schedule II drug.  As the short history – provided in previous postings – indicates, the drug company, Purdue Pharma, began an active campaign to popularize a form of the drug in 1996.  To get around the addictive quality of the drug, this company introduced OxyContin. 

This “controlled release” formulation of the drug was meant to make the resulting product less apt to be addictive and the FDA approved it.  Unfortunately, it did not take a long time before consumers learned how to derive a purer oxycodone drug by simply crushing the controlled release tablets.  They then could consume the derived drug by various ways:  swallowing, inhaling, or injecting it.  Any of these modes renders a very powerful opioid.[2]

The derived drug, when consumed, results in an upgraded “high” that is described as being “morphine-like.”  Purdue’s eventual testing in 1995 demonstrated how users, by crushing their product, could extract a 68% oxycodone.[3]  All these developments cost Purdue dearly.  Eventually, in 2007, the company paid a $600 million fine for making false claims about their product specifically regarding its risks.[4]  Then, in 2010, the company issued a newer version.

In that year, Purdue introduced a reformulated OxyContin.  By using a polymer, they made their pills very difficult to crush or dissolve.  In turn, this made the product significantly less apt of being abused.  Predictably, documented use of the drug declined slightly.[5]

Despite this development, in 2012, Canada’s government decided to strip OxyContin from its approved drug list.  In 2017, the FDA requested the producers of oxymorphone, an injectable form of the opioid, to remove it from the domestic market.  The agency determined that the risk of the drug is greater than its benefits.  This marked a turning point for the FDA since it was the first time it issued such a request due to fears of abuse.

The next posting will look at fentanyl.

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[1] “Opioid Crisis Fast Facts,” CNN Library, June 16, 2018, accessed June 25, 2018, https://www.cnn.com/2017/09/18/health/opioid-crisis-fast-facts/index.html .

[2] Art Van Zee, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” American Journal of Public Health, vol. 99, no. 2, (February 2009), 221-2273.

[3] Ibid.

[4] Barry Meier, “In Guilty Plea, OxyContin Maker to Pay $600 Million,” The New York Times, May 10, 2007, accessed June 29, 2018, https://www.nytimes.com/2007/05/10/business/11drug-web.html?mtrref=www.google.com&gwh=5EB54309CD06FBA620248E850CC5CC0B&gwt=pay .

[5] Catherine S Hwang; Hsien-Yen Chang; Caleb G Alexander, "Impact of Abuse-Deterrent OxyContin on Prescription Opioid Utilization," Pharmacoepidemiology and Drug Safety, 24, no. 2, 2015, 197–204.

AN OLD ENEMY

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reporting a set of factoids on a particular drug as a part of this epidemic.]

The class of drugs considered to be opioids include various drugs.  They include prescription pain relievers, heroin, and synthetic opioids.  Of special concern, fentanyl has caused heightened effect on the health of tens of thousands of Americans.  This effect can be measured in terms of deaths and economic costs.  Generally, the economic cost of misused prescription opioids is estimated to be $78.5 billion a year.  That includes healthcare, lower productivity, treatment, and criminal activity.[1]

          The last posting shared a set of statistics that gives one a sense of how extensive the problem of opioids is in the nation.  Here is another that reflects how centered the problem is in certain areas of the nation:  in 2016, West Virginia, the most affected state, had an overdose death rate of 52 per 100,000 population.  West Virginia was followed by New Hampshire and Ohio with each reporting 39 deaths per 100,000.[2]

          This posting begins the next phase of developing a unit of study suitable for an American government course.  That phase, after providing a short history over the last several postings, provides a set of factoids that can function to develop individual lessons.  These factoids will be organized around the various drugs that make up this crisis.  This posting will highlight heroin.

          Heroin is chosen as the first drug to be looked at because in the minds of most Americans, heroin has the longest history.  As the short history in the previous postings indicates, awareness by many Americans stretches back to the 1950s when it was known that there were groups of Americans addicted to this drug.  Those groups were inhabiting large urban centers.  As such, the problem for most Americans was troubling, but not imminent.

          While heroin has this longer history, in terms of understanding the opioids problem, it is more a result than a cause of the problem.  Two facts reflect this relation to opioids:  of those who misuse prescribed opioids, 4 to 6 percent “graduate” to heroin and 80 percent of those, who use heroin, previously misused prescription opioids.[3]  This latter development is because heroin is cheaper then prescribed opioids and can be readily obtained through black market outlets – without a prescription.[4]

          Other facts regarding heroin are: 

·        men are significantly more likely to use heroin;[5]

·        between 2012 and 2015, deaths due to heroin-use were more numerous than deaths due to other opioids even though among women, deaths were higher due to opioid medications;[6]

·        while the problem of cocaine deaths is a greater problem among black population, all types of opioids (including heroin) are responsible for more deaths among all races;[7]

·        an overlooked fact, due to the concern over opioids, there has been a shift of attention from other drug addiction problems to the opioid problem.  For example, attention to cocaine-use has suffered from this shift – along with a lack of effective medication to treat cocaine addiction.[8]

·        The last decade or so has seen significant increases in heroin use.  Those numbers include an increase from an estimated 374,000 Americans using heroin in the years 2002-2005 to 607,000 in the years 2009-2011.[9]  By 2014, as a reflection of a leveling-off progression, the number was estimated to still be over half a million.[10]

The next posting will highlight Oxycodone.

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[1] “Opioid Overdose Crisis,” National Institute on Drug Abuse, March 2018, accessed June 25, 2018, https://www.drugabuse.gov/drugs-abuse/opioids/opioid-overdose-crisis .

[2] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction,” First Things, April 2017, accessed June 18, 2018, https://www.firstthings.com/article/2017/04/american-carnage .

[3] Deborah Dowell, Rita K. Noonan, and Debra Houry, “Underlying Factors in Drug Overdose Deaths,” JAMA, vol. 318, no. 23, 2295-2296. 

[4] Andrew Kolodny, David T. Courtwright, Catherine S. Hwang, Peter Kreiner, John L. Eadie, Thomas W. Clark, and G. Caleb Alexander, "The Prescription Opioid and Heroin Crisis: A Public Health Approach to an Epidemic of Addiction," Annual Review of Public Health, vol. 36, 2015, 559–574.  Accessed June 25, 2018, see https://www.annualreviews.org/doi/abs/10.1146/annurev-publhealth-031914-122957 .

[5] Austin Frakt, “Overshadowed by the Opioid Crisis:  A Comeback by Cocaine,” The New York Times, March 5, 2018, accessed June 25, 2018, https://www.nytimes.com/2018/03/05/upshot/overshadowed-by-the-opioid-crisis-a-comeback-by-cocaine.html .

[6] Ibid.

[7] Ibid.

[8] Ibid.

[9] Leigh Anderson, “Heroin,” Drugs.com, May 18,2014, accessed June 25, 2018, https://www.drugs.com/illicit/heroin.html .

[10] "What Science Tells Us about Opioid Abuse and Addiction," Abuse, National Institute on Drug, January 27, 2016, Drugabuse.gov. This site no longer posted.  See “Opioid Epidemic,” Wikipedia, https://en.wikipedia.org/wiki/Opioid_epidemic#cite_note-38 , footnote #43.

OPIOID CRISIS GRADUATES

[Note:  This posting is a continuation of a report on the development of a civics unit of study.  This unit is directing students to formulate informed positions on the opioid epidemic.  Presently, this development, in real time, is reviewing the history of this epidemic.]

As the twentieth century reached its latter years, there was an increasing demand for what is now called opioids.  In the 1970s two drugs particularly, and their names, started to become common and known by many if not most Americans.  Despite initial apprehension over prescribing Vicodin and Percocet, doctors began to regularly prescribe these drugs in the 1980s.  This despite the fact that there were warnings against readily prescribing these addictive drugs.[1] 

Unfortunately, in January 1980, a short letter appearing in the New England Journal of Medicine had a bit of influence and helped change the thinking regarding these opioids.  Apparently, the letter issued by a group of Canadian researchers indicated that these drugs were not as dangerous as initially thought.  Their findings determined that only a handful of people who took one of several opioids became addicted.[2]

Years later, a follow-up comment by this journal further explained that the Canadians were only reporting on research regarding hospitalized patients and not people out in the general public after hospital visits – an observation that seems obvious upon reading the letter.  An author of the initial letter claims that his intent was not to give a green light to prescribing these drugs.[3]

          As the 1980s progressed another drug took center stage.  Crystalized cocaine, a drug that became popular during the 1970s, has a history stretching back 3500 years in South America.  There the coca plant, from which cocaine is derived, has been grown over all those years and has been used for a variety of purposes such as fatigue, depression, and sexual dysfunction.

Eventually, a German chemist, Friedrich Gaedcke isolated and purified the drug from the plant back in 1855.  Further “improvements” found a way to better extract the drug and this was accomplished by a German grad student, Albert Niemann, who first used the name, cocaine, for this product.  His work was done in 1859.[4]

This cocaine chapter in the drug story is important because of the crack epidemic in the 1980s led to government policies that were in place to meet the opioid epidemic.  Crack consumption resulted in an almost 2 per 100,000 population death rate and, under the leadership of Vice President George H. W. Bush, led to CIA and US military interdiction policies.  This initiative was given the name, War on Drugs.[5]

Under that general governmental posture, the opioid crisis grew some years later and became central in the nation’s consciousness as it resulted in vast devastation to numerous American communities.  This development began to take hold in the late 1990s.  And central to that growth was a well-thought out marketing strategy (1996-2001) for the opioid, OxyContin.  That strategy was aimed at alleviating concerns over the addictive qualities of that drug.[6]

A private pharmaceutical company, Purdue Pharma, organized more than forty promotional meetings at three locations in both the southeast and southwest US.  They coined the term, “Partners Against Pain.”  This was a marketing strategy that offered bonus system to incentivize sales of OxyContin.  Part of the strategy was to downgrade beliefs in the addictive danger of the drug.  They claimed that addiction affected less than 1 percent of users.  Along with incentives, this claim encouraged doctors to liberalize prescribing the drug.[7]

Nationally, the uptake in prescribing and subsequent consumption led to the death of 10.3 per 100,000 population and, in New Hampshire death rate of 30 per 100,000 and West Virginia, a rate of 40 per 100,000.[8]  In a 2016 national survey, conducted by Substance Abuse and Mental Health Services Administration, it was reported that more than 11 million people in the US misused prescribed opioids.  In addition, one million used heroin and 2.1 million fell into addiction of either prescribed opioids or heroin.[9]

One final statistic to end this short history is the following:  from the year, 2010 to the present, overdoses of illicit opiates have tripled.  There are signs, as the dangers of this type of drugs have become more readily known, that upsurge has leveled off.[10]  This writer is beginning to see public service announcements informing viewers of the dangers involved.  This development of the unit of study will continue in the next posting with reports on the usage of various opioids.

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[1] Clare Waismann, “The Devastating Effect of Opioids on Our Society,” The Hill, August 26, 2016, accessed June 18, 2018, http://thehill.com/blogs/pundits-blog/healthcare/293473-the-devastating-effect-of-opioids-on-our-society .

[2] “Opioid Crisis:  The Letter That Started It All,” BBC, June 3, 2017, accessed June 21, 2018, https://www.bbc.com/news/world-us-canada-40136881 AND Jane Porter and Hershel Jick, M.D., “Addiction Rare in Patients Treated with Narcotics,” The New England Journal of Medicine, January 10, 1980, accessed June 21, 2018, https://www.nejm.org/doi/full/10.1056/NEJM198001103020221 .

[3] Pamela T. M. Leung, Erin M. MacDonald, Matthew B. Stanbrook, Irfan A. Dhalla, and David N. Juurlink, “A 1980 Letter on the Risk of Opioid Addiction,” New England Journal of Medicine, vol. 376, no. 22, 2194-2195, accessed June 21, 2018, https://www.nejm.org/doi/full/10.1056/NEJMc1700150 AND “Opioid Crisis:  The Letter That Started It All,” BBC.

[4] Erik MacLaren, “Cocaine History and Statistics,” DrugAbuse.com, no date (some of the statistics reported through the year 2014), accessed June 21, 2018, https://drugabuse.com/library/cocaine-history-and-statistics/ .

[5] Peter Dale Scott and Jonathan, Cocaine Politics: Drugs, Armies, and the CIA in Central America (Berkeley, CA: University of California Press, 1991.).

[6] Art Van Zee, “The Promotion and Marketing of OxyContin: Commercial Triumph, Public Health Tragedy,” American Journal of Public Health, vol. 99, no. 2, (Februray 2009), 221-2273.

[7] Ibid.

[8] Christopher Caldwell, “American Carnage:  The Landscape of Opioid Addiction,” First Things, April 2017, accessed June 18, 2018, https://www.firstthings.com/article/2017/04/american-carnage .

[9] Neil Doherty, Scott Gottlieb, Elinore McCane-Katz, Anne Schuchat, and Nora Volkow, “Federal Efforts to Combat the Opioid Crisis:  A Status Update on CARA and Other Initiatives,” National Institute on Drug Abuse, October 25, 2017, accessed June 21, 2018, https://www.drugabuse.gov/about-nida/legislative-activities/testimony-to-congress/2017/federal-efforts-to-combat-opioid-crisis-status-update-cara-other-initiatives .

[10] Deborah Dowell, Rita K. Noonan, Debra Houry, “Underlying Factors in Drug Overdose Deaths,” JAMA, vol. 318, no. 23 (December 19, 2017), 2295-2296.