TAKE 3 W/ SLP, February 2022
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[An edited version of the Big 3 segment read on the Recovery in the Middle Ages podcast episode #76, March 4, 2022]
The Big 3 is Recovery in the Middle Ages podcast’s end-of-the month look at stories we’ve been following as we compile the Wednesday Weekly news clips.
In this segment, we take a slightly deeper dive into three stories. Not just the big headlines, but also the stories that shed light on innovations in treatment and public policy, and on diverse experiences with addiction and recovery.
What 3 items are on tap for this installment?
· One. The “other” dark side of fentanyl
· Two. Some inconvenient and uncomfortable truths about nicotine and recovery
· Three. A “novel” approach to harm reduction in Portland, Oregon
One. The “other” dark side of fentanyl
Most of us are acutely aware of the role fentanyl has played in driving overdose deaths in the U.S. to record heights in recent years. The highly potent opioid has found its way into all manner of powders and pressed pills. Drug users (and probably many illicit drug sellers) are often unaware of the presence of fentanyl in their supplies.
Given the danger, a healthy fear of fentanyl makes sense. But is confusion and/or misinformation in the media coverage fueling fear beyond what is warranted? And could fear of fentanyl swing the pendulum toward more punitive approaches to drug policy?
“The cops who touched fentanyl” and other sources of confusing information
Last fall, two San Diego police officers claimed to have suffered overdoses from skin contact with fentanyl. Experts later opined that panic attacks were the more likely explanation, and that skin contact with fentanyl is unlikely to cause harm (see, for example, “How misinformation about fentanyl can be deadly,” Los Angeles Times, Aug. 15, 2021). Much has been written about this and similar episodes. For more information, I recommend the New Republic podcast from September titled “The Cops Who Touched Fentanyl.”
Even though the risk of physical contact with fentanyl has largely been debunked, its persistence could make bystanders and first responders hesitant to render aid to overdose victims and could further stigmatize drugs users.
Another source of confusion is reporting on the subject of fentanyl-tainted marijuana. Several months ago, Forbes reported that fentanyl in marijuana supplies is largely a myth (“Fentanyl-tainted marijuana is a myth that refuses to go away,” Forbes July 31, 2021). A February 2022 article in The Hill, however, provides a credible account of a Connecticut teen whose death appears to the result of an overdose attributed to fentanyl-laced marijuana.
A recent article in The Atlantic highlighted yet another source of confusion about fentanyl. While some claim higher doses of Narcan are required to reverse overdoses caused by fentanyl, the story in The Atlantic cites experts who raise questions about the practice, and suggest higher doses of Narcan can actually be more dangerous (see “An Anti-overdose Drug is Getting Stronger, Maybe That’s a Bad Thing?” The Atlantic, Jan. 14, 2022).
With the possible exception of the skin contact myth, I don’t feel like I have sufficient information to speak with confidence on any of these. My concern is that the uncertainty and confusion these stories create could serve to heighten the fear of fentanyl.
Will fear of fentanyl shift the narrative about people who suffer from substance use disorders?
As we edge closer to the beginning of the fourth decade of the opioid epidemic, a case could be made that a more sympathetic addiction narrative has emerged. Stories of suburban kids who gets hooked on prescription opioids after an illness or injury - and who then turn to heroin when pharmaceutical opioids become too inaccessible or costly - have helped to frame opioid addiction as a “suburban” (often a euphemism for “white”) problem. This re-framing has arguably helped reduce the stigma of addiction, increase support for therapeutic solutions ,and turned some of the anger toward pharmaceutical manufacturers.
The push for more punitive approaches to fentanyl
“Fear, moral panic, penalization of drug use – all lead to stigma and marginalization of the affected population. And this is counter to the goals of public health which wants folks not to run and hide but to come forth for prevention and treatment services...Overdose deaths due to illicit fentanyl represent a historic crisis; one full of challenges. But, this era is also one of historic opportunity: to rebalance our drug policies more in favor of demand reduction, including treatment, and away from failed prohibitionist policies; and
to reorient to a healthier society resilient to problematic drug use.
”
Lawmakers and prosecutors in several states have seized the moment as an opportunity to push for more punitive laws aimed at people who sell fentanyl. In California, lawmakers recently voted against a bill that would allow voluntary manslaughter or murder charges for drug dealers and manufacturers in cases of drug-related deaths (“Effort to bring harsher punishments to fentanyl dealers shot down by California lawmakers,” KCRA, Jan. 12, 2022). Supporters say they will try to gather the signatures necessary to put the measure on the ballot in the fall.
Even though support for increased penalties to address the fentanyl problem is understandable, public policy borne from fear and misinformation is rarely sound.
Evidence from the War on Drugs should make us second guess the notion that punishment effectively curbs drug supply or demand. We should also be concerned that more serious charges and more stringent sentencing will disproportionately impact black and brown folks as is so often the case.
In his January 2020 testimony to Congress titled, “No Moral Panic: Public Health Responses to Illicit Fentanyls,” University of California at San Francisco professor, Dr. Daniel Ciccarone, M.D. calls the fentanyl crisis an historic opportunity to rebalance drug policies more in favor of treatment and away from “failed prohibitionist policies.”
Will we answer Dr. Ciccarone’s call? If the negative reaction to the Biden administration’s recently announced federal harm reduction grant program is any indication, it could be an uphill battle (see, for example, “Opinion: The ‘crack pipe’ outcry was a huge missed opportunity,” Washington Post - Feb. 18, 2022).
Two. Some inconvenient and uncomfortable truths about nicotine and recovery
In the January 26, 2022 edition of The Oregonian’s “Dear Doctor” advice column, a reader asks why there aren’t rehabs for people addicted to cigarettes which “is much harder and more difficult [to quit] than heroin.”
The doctor responds by explaining in-patient rehab is expensive, time-consuming and disruptive for the patient, and used primarily when the threat of physical harm from drugs and alcohol is extremely high.
On its face, the question about residential rehab for nicotine sounds absurd. Could anyone really expect their spouse or employer to give them blessings and well wishes for deciding to take a month away from their responsibilities to quit smoking or vaping?
But let’s not dismiss the significant issues the question raises too quickly. In our myopic focus on acute care, particularly when it comes to treating addiction, we tend to discount the importance of addressing chronic long-term issues.
Here are some important facts – some uncomfortable truths – to consider about nicotine and recovery. People with substance use disorders are much more likely to smoke or use nicotine of any form. They are also more likely to die from a smoking-related illness than from the addiction that brought them to treatment in the first place.
In a 2015 talk posted on YouTube, Ohio doctor and addiction specialist Todd Carran notes that only about 17.5% of adults in the U.S. smoke compared to about 80% (or higher according to some studies) of people recovering from substance use disorders. That’s more than four times as many! Smoking-wise, it’s like the recovery community is stuck in the 1970s.
Dr. Todd Carran - Nicotine and Recovery
So why is it that the vast majority of treatment programs allow patients to smoke freely (even though they commonly prohibit or severely limit coffee and other forms of caffeine)? The answer, according to Dr. Carran, is that giving up nicotine is viewed as “too much” to ask of someone who is already working to give up another addictive substance. There’s a fear that the stress of quitting nicotine could harm recovery or lead to relapse.
What does the research show? Just the opposite. According to Dr. Carran, two reputable large-scale studies show people who quit smoking or using any form of nicotine while being treated for another addiction are less likely to relapse back to their primary mood-altering substance, and also more likely to remain abstinent from nicotine.
“I was surprised to learn that people with substance use disorders are more likely to die from tobacco-related illness than from the addiction that brings them to treatment in the first place. When patients enter drug treatment, they should be provided with the tools to quit all substances, not become addicted to a new one.”
A new law (AB 541 - Berman, 2021) took effect in California this year. It requires mental health and substance use disorder treatment programs to assess patients and clients for nicotine use disorder and to provide treatment for people who request it.
Based on the prevalence of nicotine use among people in recovery, and the evidence of successful outcomes related to quitting nicotine while in recovery, the new law certainly seems like a step in the right direction.
Now, if they could only get the coffee to flow more freely in rehab! Perhaps that’s an amendment to consider for the rehab patient/client bill of rights proposal being considered by the California Legislature this year.
Three. A “novel” approach to harm reduction in Portland, Oregon.
Cities in the U.S. hit hardest by the impacts of the opioid crisis have become incubators for innovative harm reduction efforts such as safe syringe exchanges, multi-disciplinary outreach and overdose response teams. and efforts to establish safe injection sites. Portland, Oregon is a prime example. For my latest SLP Insights interview, I spoke to author Jordan Barnes whose new book, Bridgetown: A Harm Reduction Novel (available March 6, 2022) focuses on a syringe exchange in Portland.
Jordan grew up in Hawaii. He moved to Portland for college where he received an education in shooting heroin and cocaine. His first book, One Hit Away, is a memoir about his recovery journey.
Jordan says he found his way to detox by way of compassionate staff at a syringe exchange program. That’s an important point. Critics often fault harm reduction services for enabling addicts but overlook the fact that harm reduction programs can - in addition to saving lives and preventing the spread of transmissible diseases - serve as conduits to steer drug users to treatment.
Jordan eventually made his way back to Hawaii where he spent more than a year in a residential treatment program before writing his memoir. Jordan’s new book is fiction, but it draws on his experiences as a client of harm reduction services in Portland.
During our conversation, Jordan shared his perspective on Oregon’s Measure 110, which recently decriminalized possession of small amounts of almost all drugs. Critics of the law raise concerns that Oregon doesn’t have the necessary support infrastructure in place to help people who would have otherwise wound up in the criminal justice system.
Jordan’s research for Bridgetown provided him with an “on the ground” perspective. What he learned from speaking to harm reduction staff and advocates in Portland left him with a more optimistic view. If you are interested, read the SLP Insights interview. Or better yet, look for Bridgetown wherever you buy books.
And that, my friends, is the Big 3 for February 2022. I’ll be back next month so stay tuned!
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