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The rise of drug overdoses in New Hampshire has created a backlog of autopsies (nytimes.com)
61 points by iamjeff 15 days ago | hide | past | web | 56 comments | favorite

This opioid epidemic has made me question my position on legalization of drugs. I had believed that, in general, legalization of drugs would be a good policy -- it worked fine for marijuana where it has been tried, and I doubted that very many people who don't take hard drugs would start doing so if they were legalized. Now, I'm not so sure.

It seems to be the case that some opioid addicts transition from using prescribed medication to illegally obtained medication, which is sometimes illegally produced and adulterated with other drugs. So, it seems that legalizing the recreational use of opiates would enable people to use the "authentic" version of the drug, which is safer.

On the other hand, there are tons of overdoses from prescribed opiates, which are legally obtained; and the overdoses are increasing. Contra my earlier belief, it seems that as access to opiates became easy and legal (via prescriptions), the number of addicts increased dramatically.

This seems to be a situation in which tens of thousands of people will die every year via ingestion of legal drugs unless some kind of intervention is made to remove their access to those drugs. It's hard to see how legalization or decriminalization would make a big difference.

If you read up on Oxycontin, it was formulated and prescribed in a particular way that created many addicts[1]. In particular it was claimed to work for 12 hours when in some people worked for much less. Being on an opiate for pain and then having it wear off and being forced to wait in pain for sometime before taking it again, is a recipe for creating addiction. Many people also were less wary of taking the opiates when prescribed by their doctors.

I'm not sure if the opiate overdoes epidemic is a clear strike against legalization, but it is surely a cautionary tale about supporting a system of all drugs being open sale of unlimited quantities and unlimited advertising. I support some form of drug legalization but, unlike food that is controlled for content but not much else, legal drugs will need more regulation.

[1] http://www.latimes.com/projects/oxycontin-part1/

I have zero background in chemistry, so this may be a dumb question: but if the issue is it not lasting 12 hours, why can't doctors halve the dose and prescribe it twice as often per day?

Because the 12 hr formula was part of a huge marketing push to reduce doctors' "opiphobia" and get them to prescribe more. Doctors were likely unaware of the roller coaster ride of withdrawal they were sending patients on.

I believe the patent extension to keep it from going generic was predicated on the 12 hour, slow release, dosage.

I think there are a lot of different ways to "legalize", and the particulars of how you do it amplifies the results when it comes to hard drugs, especially highly addictive opiates.

Putting aside the more libertarian approach to legalization where hard drugs are left to the market and profits are made off of their sale, there are other options.

For instance, where drug use is legal, manufacture is illegal, and addicts are able to get free doses while under the supervision of medical staff. The free availability undercuts any potential black market, supervision severely reduces the potential for overdose, and the medical staff is able to have a regular conversation with the patient about options for getting clean.

Moreover, by turning drug use into a medical and welfare issue, it's my belief that it will prevent addiction by removing the "romance" of hard drug use for first time users.

Marijuana is a totally different story, it's benign enough that market legalization works just fine. But for opiates and amphetamines and the like, you need a very different approach.

That said, the opiate epidemic has shown that we have a problem of overprescription that stems from the pharmaceutical industry, and that's something we'd have to address if we were ever to move towards this approach.

I agree with you but consider what capital industry has done to food: the very safest thing people get addicted to.

It has been transmuted into hyper addictive nutritionless junk and it’s marketed with all the strength of humanity’s brightest, with no regard to the legions who now suffer obesity related disability, diabetes, etc.

When that same marketing machine gets its hands on marijuana, I’m sure it’ll make the world suffer.

And if you think to use alcohol as a counter example, think twice because the USA regulates it harder than most. GB is closer to laissez faire, and their alcoholism rates’ increase resembles our obesity.

> On the other hand, there are tons of overdoses from prescribed opiates, which are legally obtained;

So what? Nothing is worse than the prison system. Literally, nothing. Risk of death by overdose does not justify shoveling people into the horrific US correctional system.

> tens of thousands of people will die every year via ingestion of legal drugs unless some kind of intervention is made to remove their access to those drugs.

Thousands of deaths per year? That's your justification for giving the prison system more chum? (500k per year: https://en.wikipedia.org/wiki/United_States_incarceration_ra... )

I don't mean to be emotional, but: I'm curious if you've ever known anyone who spent time in prison, and have heard their candid description of it.

This kind of argument could be used to argue for legalization of absolutely everything.

Not "absolutely everything", but certainly many things.

It's on you to make the case that "saving a drug user's life" is achieved by sending them to the worst place on earth.

Why is it on me? I'm not arguing for any position here, just analyzing your arguments.

(Which ruins their families lives)

Why shouldn't we let them die? One in six base jumpers will die young while jumping. We don't make that illégal.

I mean, everyone knows you can overdose. So that makes it a conscious choice, and we should preserve people's ability to make an informed choice to put themselves in danger.

> Why shouldn't we let them die? One in six base jumpers will die young while jumping. We don't make that illégal.

Well, a base jumper is, well, dead when the parachute fails. You maybe need someone to scrape the remains off the ground, but that's it.

Drug addictions and ODs, as well as the side effects from criminalization (prison/judicial costs, drug related crime) end up costing a boatload of money, plus a highly aggressive user of coke, meth or multiple drugs is often enough a public danger.

Ah, the problem is that they don't, in fact, die. That's fair.

Come on, these are real people. Have some respect.

Addiction changes the brain, there may have been a day when they made a choice but soon it was made for them.

Several of my former classmates have died from heroin/fentanyl. They were looking for help, they were trying to get clean, they were good kids. It destroyed their families and has put enormous strain on our police and ems.

Talk about legalization, fine, but "let them die" is just callous.

Should we then also legalize all forms of suicide, so long as the person has made an informed choice?

Yes. And I think we will, in my lifetime.

>This opioid epidemic has made me question my position on legalization of drugs.

You know what? I am too. If you spoke to me years ago, I'd say much of the danger from opiates comes from not knowing what dose you're taking. Much of the crime comes from the price (due to it being black market). Much of the crime comes from addicts who can't afford their fix (due to the price) or rival dealer (who can't settle disputes in the courts).

Now I think maybe a decriminalization for hard drugs would be better. Purchasing / possessing is not criminalized (or subject to a small fine, like smoking a joint in public is treated in weed-legal states.

(I'm also in support of the states that have ramped up their age to buy tobacco to 21)

Legalization should be accompanied by a comprehensive public health program. The goal should be to eliminate addiction. In particular it should be done like this: When a drug is legalized, it must only be dispensed by licensed health centers / clinics. Anyone can obtain the drug there but must go through public health workers that will help you find treatments. Basically, make addicts come to you so you can keep an eye on their health and help them get better. Fewer addicts also mean greater safety for society due to less criminality.

The problem is not legalization, is the US society that's particularly vulnerable to addiction. Look at EU, the situation is totally different even where drugs are legal (Holland) or addiction is treated like a disease (Portugal)

Everywhere else you don't hear about "opioid epidemic"

If opioids could be sold for recreational use, I think they would be sold with a naloxone in one package, reducing the number of deaths from overdose.

Similarly, regulated drug dens (like regulated brothels) are a perfectly tennable idea. There are middle ground solutions between "ban everything!" and "sell it everywhere!"

It's surprisingly hard to OD with a clean supply, measured dosing, and emergency services on site. I don't think that clean, supervised drug use is actually any more dangerous than say... skydiving or bungee-jumping.

(It's actually hard to fatally OD with just one vaguely sober person an nasal naloxone, but that's more specific to opiates.)

If opioids were sold for recreational purposes, companies would compete to invent an opioid that you simply can't OD on, or it's very difficult to OD on. Maybe, that version could be the legalized version and every other version banned. Other than the risk of overdose, does opioid use generate any more health problems than say alcohol use?

IMO this is a drastic over-simplification of the issue. Legalization is one of many variables here.

Legalization doesn't just enable people to "do the drugs". It also lowers the barrier the government has in obtaining data about the phenomenon.

With additional data, government can be more proactive in preventing addiction in the first place.

If Russia wants to hurt the U.S., why bother with so nebulous a tool as election tampering? Why should North Korea bother with expensive nuclear weapons to harm the U.S., not that the strategies are exclusive?

Just produce cheap opioids and dump them in our borders, we'll take care of the rest.

Or maybe they're already doing it.

Doesn't even need to - we took care of invading Afghanistan and quadrupling the worlds supply of opium a couple decades ago.


Mods: typo in title - 'overdoes' instead of 'overdose(s)'

When no other action has driven change, financial factors seem to often spur movement. Autopsies in NH are paid for by the state, so a surge will surely trigger a deeper awareness in the legislature. There have also been a number of stories recently about workforce capacity losses and hiring challenges; this places the problem more squarely in the domain of businesses which may have deeper pockets than the government. It is my prediction that before long we'll see lawmakers announcing new public-private initiatives sponsored by large companies to combat the opioid crisis at a community level. I think we're on the leading side of this trend, as government initiatives on the health industry level are just getting rolling, https://www.nih.gov/opioid-crisis

The numbers just seemed incredibly high to me. I looked for similar data for the EU, and I found one report for 2015 (http://www.emcdda.europa.eu/system/files/publications/4541/T...).

The number of overdose deaths in the EU is ~7500 there, and there is no similar large increase since 2006 (the data in that report doesn't go as far back as the NY Times article data for the US). The report cautions that there is underreporting in some countries, but even then the number seems to be much lower than in the US.

"With the nation snared in what the government says is the worst drug epidemic in its history..."

When have I heard that before?

Maybe during the crack epidemic. Or the meth epidemic. Now it's the opioids' turn.

"But this time it's different," I'm sure.

Wait, is your contention that the US can't have a series of worsening problems with drugs over the last 40-50 years as wages have stalled and the economy rotted?

That seems... Unreasonable.

If a problem is growing, every iteration should be the worst in history.

Except that we are pushing for the same old "solution" and apparently the problem is getting worse. That should be enough reason to do a u-turn on the war on drugs.

I am not so worried about drugs as I am about false advertising and lack of awareness. I agree with the main point though. We need to treat this as a health and wellness issue, not as a crime. At the very least, possession itself (yes I'm making a whole sale statement) should not be a crime. Now if folks start selling poorly labeled drugs, the seller I'm ok vilifying.

Discount the rhetoric, count the bodies

Agreed. See for instance https://www.nytimes.com/interactive/2017/06/05/upshot/opioid... with a graph showing US drug overdose deaths are far higher now (well, as of 2016 estimated data) than ever before.

There are indeed many drug panics. This one is the real thing.

I had no idea that drug overdoses are the number 1 cause of mortaliy for people under 50 in the US. Ok I don't live there, and I know from the web and talking to US citizens it's not all as sunny&happy as some media wants the outside world to believe, but this sounds pretty bad. The NYT article wisely doesn't try to point to an underlying cause, anyone? Is it e.g. a worsening of socio-economic factors or is there more to it?

This isn't exclusive to the U.S. of course, but there's the pernicious view that they're "bad people", they make bad choices etc.

To this view I would reply with the idea, attributed to Socrates, that there is no such thing as "moral weakness", or that doing good and bad amounts to knowledge of what is good or bad or a lack of it (keeping in mind knowledge could be more than merely mental abstractions).

Now unless this idea can be disproven, how can "moral weakness" be used as a justification to ignore the plight of these people?

There's definitely more to it. This problem will continue regardless of the number of jobs available.

“ ... as long as American life was something to be escaped from, the cartel would always be assured a bottomless pool of new customers.” -Pynchon

Kids want to get high and they’re cheap?

Yes, this time is different -- since white people are dying, we suddenly feel sympathy. When blacks OD from crack, they were thrown into jail and treated like morally failed individuals. When whites die from heroin, we feel sympathy and want to treat them.

Mostly it's poor rural whites, most of whom arent all that deserving of much sympathy for other reasons, so most people even in New Hampshire aren't all that cranked up about it. What's mildly concerning to me is why so many have switched from the time-honored traditions of drinking and smoking away the depression of sad, broken hillbilly life and started bumping fentanyl.

I'm guessing opiates are more deadly than crack.

I’ve heard this argument many times now and I still fail to see how we’re feeling sympathy for these people. Every time this conversation is brought up I see 0 solutions and people that very low-key suggest these people have to die because coal must disappear, because outsourcing to China is good because we’re living in a global economy, because they vote Trump and they don’t share our liberal view of society and they might not like black people or feminists, etc.

I think the overall tone today is much more sympathetic than that surrounding the crack panic of the 90s, especially when the legal and political environments are compared (3 strike laws v complaints about Narcan expense seem to constitute the political extremes). However, I agree that the disturbing undercurrent of contempt for certain demographics is certainly quite prominent in the public discussion.

Those are some... pretty strange views. Where do you see them expressed?

One from this thread is fairly close to what they described.


The not deserving of much sympathy really brings it home. After all, rural white hillbillies don't deserve sympathy, I guess? I'd say that's rather prejudiced and, no, I'm not white.

I think you might be... extrapolating a lot from this.

So what effect would drug decriminalization have on this situation?

A large portion of the deaths are from prescription drugs:


> Opioids (including prescription opioids, heroin, and fentanyl) killed more than 33,000 people in 2015, more than any year on record. Nearly half of all opioid overdose deaths involve a prescription opioid.

Open supervised drug injection in clinics would be an excellent mitigation scheme if it were legal. Canada has been demoing such clinics with a lot of success.

Here's how to "fix" the opioid crisis, through healthcare and rehabilitation not criminalization.

When a person gets hooked on opioids, never cut them off cold turkey. At the end of a surgery/injury/treatment with prescribed opioids for pain, our current system makes users go from regularly used/available to not at all, or once addiction is noticed then access ended immediately. This is the root cause of the problem, from there people go out and get street opioids, sometimes heroin and sometimes it is cheapened by fentanyl where you get a few specs of it and you OD. Basically, the cutting off of the user access to the drug from regularly available to none is the MAJOR problem here.

What we need to do is this, taper people off if possible, if not then why not let them continue to get them until they can ween themselves off through rehab. Basically all opioid patients can get them as long as they need but it switches from the doctor to a healthcare specialist in controlling addictions at the end of every opioid prescribed treatment. Some will not need this but for the ones that have been on them for a while due to pain/rehab, there would be no cold turkey stopping. At least if people are hooked, this prevents them from going out and getting heroin laced with fentanyl that could be deadly. We are basically setting people up to die this way in our current system.

Every solution I have seen is to be harsher on doctors expecting them to control it, or harsher on the amounts they give, all that is strong arm tactics and pushing liability on people that don't want it making the problem intensely worse. Instead we should put the liability of addiction on the patient themselves and give them options to help themselves with education and rehab, don't just cut them off and leave them on their own.

We need a health layer in our system that helps people with addictions and getting quality drugs that aren't going to kill them as some people will just do that and some need help, we can pay for it by ending the War on Drugs. Pharmaceuticals will go along with this plan because it allows people to keep getting pharma drugs as long as they need to get off of them, but users won't be doing it alone, nor trying to stop cold turkey. This type of policy will help a large portion of at least the opioid addicts that get hooked through regular medical channels.

Ending the War on Drugs while using that money for healthcare/rehab instead of incarceration, allowing other low level substances like cannabis, and providing people a path to take when they finish with their medical treatment if they find they have an addiction is better. Once the US stops treating drug usage and addictions as a crime and start viewing them as health issues or manageable issues with lower level substances, this will all be much, much better.

@dang I flagged this because there’s a typo: overdoes should be overdose

(My brain read it as “overlords” and I was trying to understand why I made that mistake.)

Edit: thanks

Drug problems get worse with higher unemployment


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