After Brief Decline, ‘Exponential Trajectory’ of U.S. Overdose Crisis Resumes

By Pat Anson, PNN Editor

A brief decline in fatal overdoses in 2018 was just a blip in the trajectory of a 40-year pattern of rising drug deaths in the United States, according to a new study published in the journal Addiction.

Researchers at the University of Pittsburgh Graduate School of Public Health analyzed over a million overdose deaths in the U.S. between 1979 and 2019 – and developed a startling chart that shows an exponential curve in overdoses that continues to rise virtually unchecked. The number of deaths has doubled every 10.7 years.   

"The U.S. has not bent the curve on the drug overdose epidemic," said lead author Hawre Jalal, MD, an assistant professor of health policy and management at Pitt Public Health. "We are concerned that policymakers may have interpreted the one-year downturn in 2018 as evidence for an especially effective national response or the start of a long-term trend. Unfortunately, that isn't supported by the data."

PITT PUBLIC HEALTH

Overdose deaths fell about 4% in 2018, which public health officials attributed to a decline in deaths involving prescription opioids and heroin. However, overdoses began rising again in 2019 and preliminary data for 2020 suggests the upward trajectory has resumed.    

Jalal and co-author Donald Burke, MD, say the 2018 decline in overdoses was largely caused by a reduced supply of carfentanil, an illicit drug and potent analogue of fentanyl that is 10,000 times more powerful than morphine.

China added carfentanil to its list of controlled substances in 2017 and began shutting down illicit drug factories that produced it. The U.S. supply of carfentanil soon began to dry up and law enforcement seizures of the drug fell dramatically in five states -- Ohio, Florida, Pennsylvania, Kentucky and Michigan. It was the “sudden rise and then fall of carfentanil availability” that led to the drop in overdoses, researchers found.

"We all celebrated when the overdose death rate dropped, but it was premature," said Burke, former dean of Pitt Public Health and a professor in the Department of Epidemiology. "When policymakers believe a problem is solved, history has shown that funding is reprioritized to other efforts. The drug overdose epidemic is not solved. It continues to track along an ever-rising curve, with deaths doubling nearly every decade. We must address the root causes of this epidemic."

Jalal calls the U.S. overdose crisis an “entangled epidemic” that’s been fueled by multiple drugs, including prescription opioids, but is now largely caused by illicit fentanyl.

“There is a force that keeps overdose deaths on an exponential trajectory. This is in spite of policies that have been trying to bend the curve,” Jalal told PNN. “The main problem is that we don’t know why it keeps tracking an exponential trajectory. I think we should do everything we can to bend the curve, but the policies that we’ve used so far have been more targeted toward drugs that can be modified easily. We can target prescription opioids and we can increase the use of naloxone and methadone, but I think we also have to invest in understanding what’s driving people to use drugs. That’s a major problem that we still don’t have an answer for.”

Jalal says lack of economic opportunity and social isolation — so-called “deaths of despair” — may be partly responsible for the overdose crisis, but more research is needed into the underlying causes. As for possible solutions, he’s as stumped as anyone.

“I wish I knew. I truly wish,” Jalal said. “I think we have to pay attention to what’s driving this whole epidemic. Without understanding it, we are basically targeting our policies toward whatever we think might work or think we have control over. We’re not targeting why people use drugs or what’s causing people to die from drugs.”

A recent study by the CDC found that nearly 85% of overdose deaths in the first six months of 2019 involved illicit fentanyl, often taken in combination with other drugs. About 20% of overdoses were linked to prescription opioids.

The CDC study did not determine whether the opioid medication was obtained legally, or if it was diverted, stolen or bought on the street. Previous research in Massachusetts and British Columbia found that only about 2% of fatal overdoses involved a legitimate prescription for opioids.

A Pained Life: Don’t Throw Out the Bathwater

By Carol Levy, PNN Columnist

In 1976, my trigeminal neuralgia started. In those days, the environment regarding chronic pain was very different. My doctor had only one agenda: He wanted to stop or reduce my constant debilitating and disabling pain.

He couldn’t cure me, so he ordered opioid pain medication. When one opioid didn’t work, he tried another; Darvon, Percocet, Percodan, Demerol. So many I can’t recall them all. When none helped, he prescribed an 8-ounce bottle of opium.

The first pharmacist who saw the opium prescription shook his head. “Sorry. We don't carry it,” he said. The next pharmacy did. “Have a seat. It'll just be a few minutes,” the pharmacist said.

I wasn't looked at askance. No questions were asked about my doctor or diagnosis. I wasn’t warned: “This is a very strong drug. You need to be careful. You could become addicted.”

They trusted that my doctor knew what he was doing. They trusted me to be a responsible patient. I doubt it ever entered the pharmacist’s mind that I might be a drug seeker or abuser.

Now the tables have totally turned. Many of us get questioned by pharmacists. And some of our doctors have stopped writing opioid prescriptions. They should be cautious, right? Because opioids are addictive, you can become dependent or have other bad side effects. And they can be used illegally.

The same is true for steroids. Yet there seem to be no politicians, physicians or groups with an agenda that are working to scare the public about steroids or trying to get doctors to stop “overprescribing” them.  

When steroids first came out there were many, many horror stories about them. The 1956 film Bigger Than Life was about a school teacher (James Mason) taking corticosteroids. They helped his pain from an autoimmune disorder, but he soon became hyper-manic and ultimately psychotic, even trying to murder his son.

His doctor reduced the dosage, but because steroids helped his pain, the teacher continued to take more than prescribed. He even goes to another town, impersonates a doctor, and writes a fake prescription to obtain more of the pills.

Sound familiar?

The movie was a caricature of the potential risks of steroids, which include dependency and addiction. Opioids have the same risks, but most patients with chronic pain take them responsibly, as most on steroids do, and they do not become addicted, try to obtain them fraudulently or go off the deep end.

There will always be bad actors who will be irresponsible, but users of any medication should not be demonized because of a few bad apples. Steroids are easily obtained and the patients who use them are not seen as potential felons. And why would they? For most patients, steroids can be very helpful.

Those who can still get opioids for their pain are often seen as potential miscreants. Yet studies also show that for most patients, opioids do help.

You don’t throw out the baby with the bathwater. You don’t create guidelines scaring doctors into not writing steroid prescriptions because a small percentage of people will misuse or abuse them.

The medical community and the government need to stop throwing out the bathwater. When they refuse to write prescriptions for opioids that have helped patients, the side effect — intentional or not — is to throw us away, too.

Carol Jay Levy has lived with trigeminal neuralgia, a chronic facial pain disorder, for over 30 years. She is the author of “A Pained Life, A Chronic Pain Journey.”  Carol is the moderator of the Facebook support group “Women in Pain Awareness.” Her blog “The Pained Life” can be found here.

Only 2% of British Columbia Overdoses Linked to Prescription Opioids

By Pat Anson, PNN Editor

A new analysis of fatal opioid overdoses in British Columbia found that only about 2% of the deaths were caused by prescription opioids alone. The other overdoses mainly involved illicit fentanyl and other street drugs or a combination of illicit drugs and other medications, which were often not prescribed.

“Our data show a high prevalence of nonprescribed fentanyl and stimulants, and a low prevalence of prescribed opioids detected on toxicology in people who died from illicit drug overdose. These results suggest that strategies to address the current overdose crisis in Canada must do much more than target deprescribing of opioids,” researchers reported in the Canadian Medical Association Journal (CMAJ).

Vancouver, British Columbia was the first major North American city to be hit by a wave of overdoses involving illicit fentanyl, a potent synthetic opioid. A public health emergency was declared in BC in 2016 and strict guidelines were released to limit opioid prescribing. Although prescriptions dropped dramatically, fatal overdoses in BC continued to rise.

Researchers looked at 1,789 fatal overdoses in BC from 2015 to 2017 for which toxicology reports were available and found that 85% of them involved an opioid. Of those, only 2.4% of the deaths were linked to opioid medication alone. Another 7.8% of cases involved a combination of prescribed or non-prescribed opioids.

The findings are similar to a 2019 study of opioid overdoses in Massachusetts, which found that only 1.3% of the people who died had an active prescription for opioid medication.   

“Pain patients and their medications have never been responsible for overdose deaths – not then or now. Will the anti-opiate zealots, with all their data-dredged studies be taken to task for all the unnecessary suffering, disability, and premature deaths they have contributed to within the Canadian pain population?” asked Barry Ulmer, Executive Director of the Chronic Pain Association of Canada, a patient advocacy group.

“The ‘prohibition’ approach that has wrongly been applied for years that focused on reducing access to pharmaceutical products directly contributed to exposure to higher risk illicit substances, which put people at risk of overdose.”

Most Overdoses Linked to Illicit Fentanyl

Researchers say efforts to reduce opioid prescribing in Canada were “insufficient to address the current overdose crisis” because street drugs are involved in the vast majority of deaths. They also warned against the forced tapering of patients on opioid pain medication.

“The risk of harms from these medications must be balanced with the potential harms of nonconsensual discontinuation of opioids for long-term users, including increased pain, risk of suicide and risk of transition to the toxic illicit drug supply,” wrote lead author Alexis Crabtree, MD, resident physician in Public Health at the University of British Columbia.  

Crabtree and her colleagues found that most overdoses involved a street drug, with fentanyl or fentanyl analogues linked to nearly 8 out of 10 overdose deaths. Many of the deaths involved multiple substances, including medications such as stimulants, anti-depressants, benzodiazepines, antipsychotics and gabapentinoids, which were often not prescribed to the victim.   

Over 7% of the overdoses involved methadone or buprenorphine (Suboxone), opioids that are used to treat addiction. About a third of the people who died had a diagnosis of substance use disorder in the year before their overdose.

In a commentary also published in CMAJ, a leading public health expert said it was time to decriminalize drugs and offer a “safe supply” to illicit drug users.

“Unless there is a radical change in our approach to the epidemic, overdose deaths will continue unabated. It is time to scale up safe supply and decriminalize drug use.”

— Dr. Mark Tyndall

“Unless there is a radical change in our approach to the epidemic, overdose deaths will continue unabated. It is time to scale up safe supply and decriminalize drug use,” wrote Mark Tyndall, MD, Executive Director of BC Centre for Disease Control and a professor at the School of Population and Public Health, University of British Columbia.

Tyndall says blaming the opioid crisis on excess prescribing by doctors and the unethical marketing of opioids by pharmaceutical companies fails to address the reasons people abuse drugs in the first place.

“While having a cheap and ready supply of opioid drugs does allow for misuse and addiction, this narrative fails to acknowledge that drug use is largely demand-driven by people seeking to self-medicate to deal with trauma, physical pain, emotional pain, isolation, mental illness and a range of other personal challenges and these are the people overdosing,” Tyndall wrote.

(Update: Canada’s Chief Public Health Officer, Dr. Theresa Tam, issued a statement August 26 saying the COVID-19 pandemic is contributing to an increase in drug overdoses and deaths across Canada.

“There are indications that the street drug supply is growing more unpredictable and toxic in some parts of the country, as previous supply chains have been disrupted by travel restrictions and border measures. Public health measures designed to reduce the impact of COVID-19 may increase isolation, stress and anxiety as well as put a strain on the supports for persons who use drugs,” Tam said.

“For the third consecutive month this year, the number of drug overdose deaths recorded in British Columbia has exceeded 170. These deaths represent a 136% increase over the number of deaths recorded in July 2019. There are news reports of an increase in overdoses in other communities across the country.” )

Study Finds Low Risk of Rx Opioid Abuse Among Young People

By Pat Anson, PNN Editor

The stories are heartbreaking. A young man gets a prescription for opioid pain medication and quickly becomes addicted.

“I lost everything. I had to leave school, and stop playing sports in college. I started to watch my life slip away. These drugs are addictive. One prescription can be all it takes to lose everything,” says Mike.

A mother loses her son to an overdose.

“My son… was 20 years old when he was prescribed opioids,” says Ann Marie. “It took him five days to get addicted.”

These are some of the real-life stories being told in a CDC awareness campaign that warns against the use of prescription opioids. “It only takes a little to lose a lot,” is the theme in a series of CDC videos, billboards and online ads.

The stories are sad, but the widespread belief that adolescents and young adults can quickly become addicted to prescription opioids is not accurate for the vast majority of young people, according to a large new study published in JAMA Pediatrics.

Researchers at Indiana University looked at a database of over 77,000 young people in Sweden between the ages of 13 and 29 who were prescribed opioids for the first time. They were compared to a control group that was given non-steroidal anti-inflammatory drugs (NSAIDs) for pain relief. Both groups had no previous signs of substance abuse.

Only 4.6% of those prescribed an opioid developed a substance use disorder or other substance-related issue, such as an overdose or criminal conviction within five years of being prescribed.  That compared to 2.4% of those in the control group.

"By using several rigorous research designs, we found that there was not a huge difference -- in fact, the difference was smaller than some previous research has found,” said Patrick Quinn, PhD, an assistant professor at the IU School of Public Health-Bloomington. “But the study still shows that even a first opioid prescription may lead to some risk."

Interestingly, young people given oxycodone were at no greater risk of developing a substance abuse problem than those given “weaker” opioids such as codeine or tramadol.

Quinn says further research is needed to determine how much substance abuse risk is caused by opioid medication alone and how much is related to other issues, such as mental health, genetics and environmental factors.

"We need to have a good understanding of what those risks might be in order for patients and doctors to make informed decisions," said Quinn. "Our findings highlight the importance of screening for substance use disorders and other mental health conditions among patients with pain, including those receiving opioid therapy."

A 2018 study of young people given opioids after their wisdom teeth were removed also found the risk of long-term use low. The study of over 70,000 teens and young adults found that only 1.3% were still being prescribed opioids months after their initial prescription by a dentist.  

Forced Opioid Tapering Is Risky and Unethical

By Roger Chriss, PNN Columnist

Prescription opioid use has come way down from its peak in 2012. Fewer people receive an initial opioid prescription, pill counts have been lowered, and more people are being taken off opioids.  The American Medical Association recently reported that there was a 37% decrease in opioid prescribing from 2014 to 2019.

The goal of this was to reduce the harms associated with opioid pain medication amid an ongoing drug overdose crisis. But there is no justification for forced opioid tapers. As PNN reported last year, outcomes for patients taken off opioids are not necessarily good. And despite an ongoing focus on reducing prescription opioid use, there is still no established deprescribing strategy or method.

A new study looked at a dozen randomized controlled trials for deprescribing opioids for chronic non-cancer pain. Researchers found that reducing or discontinuing treatment did not reduce opioid use in the intermediate term. It also didn’t increase the number of patients who stopped taking opioids.

After looking at the evidence, the authors of the systematic review concluded that the were unable to draw “firm conclusions to recommend any one opioid-analgesic-deprescribing strategy in patients with chronic pain."

Ethically Unjustified

But even if we knew how to taper patients on prescription opioids, it would still not be ethical to do so. Forced tapers offer relatively few benefits for the patient and may carry serious harms. Policies promoting opioid tapering have nonetheless proliferated in recent years, including one in Oregon that was tabled after a public outcry.

In a recent paper in The Journal of Law, Medicine & Ethics, physicians Stefan Kertesz, Ajay Manhapra, and Adam Gordon argued against the forced tapering policies being promoted by public agencies.

“Neither the 2016 Guideline issued by the Centers for Disease Control and Prevention nor clinical evidence can justify or promote such policies as safe or effective,” they said.

Specifically, Kertesz and his colleagues said “the provider is trained never to treat a patient as merely a means to an end.” In other words, involuntary tapers with the goal of satisfying prescribing metrics or state-mandated statistics are unethical.

A more detailed analysis of the ethics of deprescribing is taken up by Travis Rieder, PhD, author of the book, “In Pain: A Bioethicist’s Personal Struggle with Opioids.” In a new commentary in the AMA Journal of Ethics, Rieder concludes that nonconsensual tapering is “clinically and ethically wrong” because it exposes so-called legacy patients who are dependent on opioids to uncontrolled pain and withdrawal.

“Forcibly tapering otherwise stable patients off high-dose, chronic opioid therapy reveals that this practice might have an effect that is the opposite of what public health is calling for: it may be a harm expanding intervention, exposing those who have long received opioid medications variously to worsened pain, withdrawal, social instability amidst untreated dependence, or loss of medical care relationships,” Rieder said.

“Taking such risks into account, continuing to prescribe high-dose opioid therapy for a legacy patient does not clearly constitute ethical or legal misprescribing.”

‘Large-Scale Social and Medical Experiment’

There is little doubt that prescription opioids involve serious risks and lead to harm for some patients. In some urgent cases, a forced taper may be justifiable in light of specific risks to an individual. But in general, forced tapers not only introduce new risks and create new harms, but they also damage the doctor-patient relationship and deny the patient’s status as an individual.

Stanford pain psychologist Beth Darnall, PhD, calls forced tapering a “large-scale social and medical experiment” being conducted without sufficient evidence on how to do it the right way.

“You may have a patient that has been on a stable dose of opioids for 10 years, and then you start de-prescribing. We are now exposing them to new risks for opioid overdose, for suicidality, for actual suicide, for withdrawal symptoms, for increased pain,” Darnall told The Guardian.

It's worth noting that both Darnall and Rieder were recently named to a new CDC panel that will advise the agency as it prepares to update its 2016 opioid prescribing guideline.

Physicians already have a wide variety of tools to reduce risk and improve outcomes without resorting to the ethically unjustifiable approach of forced tapers. It’s time to emphasize those tools and underscore the ethical importance of patient outcomes.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research. 

Misleading Data and Bias in Canadian Opioid Reporting

By Marvin Ross, Guest Columnist

It is sometimes said that there are lies, damned lies and statistics. That prophetic statement, often mistakenly attributed to British Prime Minister Benjamin Disraeli, explains the complete confusion in the minds of the public about the use of opioid medication.

By conflating data on prescribed opioids with illicit opioids – an apples to oranges comparison -- the average person has no real understanding of the value of opioid pain relievers. How often do we hear people say they refuse to take pain medication for fear of becoming addicted?

One Canadian agency that confuses, conflates and even admits that its data is misleading is the Canadian Centre on Substance Use and Addiction (CCSA). The reports they publish suggest that prescribed opioids are a major problem to be avoided. They are out of step with some of the provincial coroners and federal agencies such at the Public Health Agency of Canada and Health Canada.

Let's first look at what these other agencies report.

Last month, British Columbia reported its highest number of illicit drug deaths ever, nearly 6 deaths per day, with the vast majority involving fentanyl and its analogues. In neighboring Alberta, 127 of the 142 deaths in the first quarter of 2020 involved fentanyl. Neither province talks about deaths from prescribed opioids, as the main issue is illicit drugs.

While fentanyl is a prescribed drug and has many legitimate uses, only 5% of all opioids prescribed in Canada is fentanyl. Given its frequency in overdoses, it must come from illegal sources.

The Public Health Agency divides their overdose statistics into those involving patients with prescribed opioids and those with substance abuse problems.  Prescribed opioids accounted for 0.02% of total hospitalizations, while for the substance abuse population it was 0.04% of hospitalizations.

There are distinct differences in age between the two groups. People in the prescribed group were usually men and women aged 60 and older. For those with substance abuse problems, the most prevalent age group is 20 to 39 years of age. It is well known that illicit drug use is more prevalent in younger people, as this data demonstrates.

Health Canada tracks reported adverse drug reactions for prescriptions and finds that analgesics are the least likely drugs to result in an adverse event. Only 1.8% of all adverse reactions involve pain medications.

Confusing Illicit Opioids with Legitimate Opioids

These statistics all demonstrate that the problem is illicit drug use and not valid prescribed opioids given to patients in pain. In contrast, the CCSA conflates legitimate and illicit opioids, and provides a totally biased picture of what is happening.

Their July 20 report is entitled “Prescription Opiods” with no mention of illicit opioids. But then they provide data that really pertains to the illicit kind.

In 2017, 11.8% of Canadians were prescribed opioids, down from 13% in 2015. Little changed was the proportion of patients who used their prescriptions for non medical uses, which is 3 percent. So, 97% of patients prescribed opioids used them properly.

Despite that, Canada, like the United States, introduced draconian prescribing guidelines to control the 3% and, of course, that negatively impacted the 97%.

There were nearly 16,000 overdose deaths in Canada between 2016 and 2019, according to the CCSA report, with emergency room visits for opioid poisoning doubling for the 25-44 age group. Given this is a report about prescription opioids, the impression the naive reader would get is that deaths and hospital visits all pertain to legally prescribed opioids.

Next, the CCSA points out that, while the number of opioid prescriptions in Canada has fallen, 5.5% of those taking them can still become addicted. That estimate for addiction is low, but there is other research suggesting that it is even lower. In keeping with their anti-opioid bias, they state that prescription “opioids can also produce a feeling of well-being, relaxation or euphoria (“high”).”

What people who take opioids for pain experience is a decrease in pain or no pain at all, if they are lucky. That's it – there’s usually no high and no euphoria. Addicts take these drugs for its high.

They then move on to talk about the healthcare costs associated with the use of opioids, but again do not differentiate between prescribed and illicit. This leaves the reader with the impression that anyone who takes opioids for any reason is costing the health system extra for adverse events, hospitalizations, overdoses and deaths.

In fact, they are mostly talking about illicit uses as the data they provide is not dissimilar to the data provided by the Public Health Agency or Health Canada. To hammer home the CCSA’s deception, the very next section deals with driving under the influence of prescription drugs.

In 2018, two prominent health experts completed a review of all the independent health agencies funded by Health Canada and recommended that three of them had outlived their usefulness. One of those was the Canadian Centre on Substance Use and Addiction, which they recommended be abolished. For some reason, it still exists.

I asked CCSA to explain their misleading statistics and it took them almost three weeks to respond. Research and policy analyst Samantha King, PhD, admitted the data is misleading unless readers take a deep dive into the footnotes.

“We are aware that for some of the data captured in the summary, including hospitalizations due to opioid poisonings and opioid-related deaths, there is no ability to differentiate between legal or illegal sources of opioids that are causing these harms. For this reason, these sections only refer to opioids in general and contain footnotes where appropriate, highlighting the limitations of the data,” King wrote to me in an email.

So, why call the report “Prescription Opioids” when, unlike coroners and other federal agencies in Canada, you cannot differentiate between illicit opioids and legitimate ones? All I can say is that it is fortunate that Canada's handling of the Covid-19 Pandemic is being handled by the Public Health Agency and not CCSA.

Marvin Ross is a medical writer and publisher in Dundas, Ontario. He is a regular contributor to the Huffington Post.

The CDC, Opioids and Cancer Pain

By Roger Chriss, PNN Columnist

In 2016, the Centers for Disease Control and Prevention issued its controversial opioid prescribing guideline. Insurers, states and other federal agencies soon followed with mandatory policies and regulations to reduce the use of opioid pain medication. All this was supposed to exclude cancer-related pain care, but in practice that’s not what happened.

Dr. Judith Paice, director of the Cancer Pain Program at Northwestern University’s Feinberg School of Medicine, told the National Cancer Institute in 2018 that the opioid crisis “has enhanced fear — fear of addiction in particular” among both patients and doctors.

“Many primary care doctors no longer prescribe opioids. Oncologists are still prescribing these medications, but in many cases they’re somewhat anxious about doing so. That has led some patients to have trouble even obtaining a prescription for pain medication,” Paice said.

In 2019, the Cancer Action Network said there has been “a significant increase in cancer patients and survivors being unable to access their opioid prescriptions.” One out of four said a pharmacy had refused to fill their opioid prescription and nearly a third reported their insurance refused to pay for their opioid medication.

That same year, CDC issued a long-awaited clarification noting the “misapplication” of the guideline to patients it was never intended for, including “patients with pain associated with cancer.”  

Long Term Use of Opioids Uncommon

Cancer pain management in the U.S. has been severely impacted by the CDC guideline, even though rates of long-term or “persistent” opioid use are relatively low and stable:

• A major review of over 100,000 military veterans who survived cancer found that only 8.3% were persistent opioid users. Less than 3% showed signs of opioid abuse or dependence.

• A study of older women with breast cancer who were prescribed opioids found that only 2.8% were persistent opioid users.  

• A study of 276 patients with head or neck cancer found that only 20 used opioids long-term – a rate of 7.2 percent.

• And a study of nearly 23,500 women with early-stage breast cancer who had a mastectomy or mastectomy found that 18% of them were using opioids 90 to 180 days after surgery, while 9% were still filling opioid prescriptions 181 to 365 days later.

While any sign of opioid abuse or addiction is concerning, these studies show that long-term use of opioid medication is relatively uncommon among cancer survivors. The American Cancer Society says opioids are “often a necessary part of a pain relief plan for cancer patients” and “can be safely prescribed and used” for cancer pain.

Cancer patients and their doctors have been successfully managing opioid risks long before the CDC guideline or associated state laws and regulations. Perhaps it is time for lawmakers, regulators, insurers and pharmacies to learn from the cancer community rather than getting in the way of clinical best practices.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research. 

Study: Using Cannabis for Pain Relief Reduces Risk of Opioid Overdose

By Pat Anson, PNN Editor

Illicit drug users who use cannabis for pain relief are less likely to experience an opioid overdose or use heroin, according to a Canadian study recently published in the online journal PLOS ONE.

Researchers at the University of British Columbia (UBC) the BC Centre on Substance Use (BCCSU) interviewed nearly 900 illicit drug users in Vancouver who reported using cannabis between 2016 and 2018. Participants were asked whether they used cannabis to relieve pain, improve sleep, address nausea or for recreation. Most said they used cannabis for a medically therapeutic reason.

"We're seeing more and more in our research that people are using cannabis for therapeutic reasons," says lead author Stephanie Lake, a doctoral candidate at UBC's School of Population and Public Health. "We're also seeing that, for some individuals in our study, this therapeutic use corresponds with either less use of illicit opioids or a reduced risk of overdose."

Participants who used cannabis for pain relief had lower odds of a non-fatal opioid overdose and for injecting heroin daily. Previous research from the BCCSU found that many people at risk of overdose, particularly those living with pain, may be using cannabis to reduce their reliance on illicit opioids.

Another key finding of the study was that therapeutic cannabis users relied on illicit sources for their cannabis supply – even though medical marijuana was fully legalized in Canada in 2013. About half of study participants said that illegal dispensaries were their most important source of cannabis.

"The mounting evidence related to the motivations behind people's cannabis use strongly suggests that improving access to cannabis for therapeutic purposes could help reduce overdose risk associated with illicit opioid use," says M.J. Milloy, PhD, a research scientist at BCCSU who was senior author of the study.

"Authorities should pause their efforts to close unregulated sources of cannabis and eliminate the illicit market until barriers to legal cannabis are addressed, especially during the overdose crisis."

Vancouver was the first major North American city to be hit by a wave of overdoses involving illicit fentanyl, heroin and other street drugs. A public health emergency was declared in British Columbia in 2016. Since then, Vancouver has become a laboratory of sorts for novel ways at addressing addiction, such as providing a “safe supply” of prescription opioids and prescription heroin to illicit drug users.

“Our community and many others across Canada and the United States are experiencing an opioid overdose crisis rooted, in part, in inadequately or inappropriately-managed chronic pain and sparked by widespread exposure to an unregulated illicit opioid supply contaminated with potent opioid analogues,” researchers concluded. “Our finding may also reflect an opioid-sparing effect of cannabis, whereby opioids are not replaced, but the dosage or frequency of opioid required for analgesia is reduced with the use of cannabis.”

Other studies have debunked the idea that medical cannabis reduces opioid use. Two large studies published last year found no evidence that legalizing cannabis reduces prescription opioid use, overdose or mortality.

“We tested this relationship and found no evidence that the passage of medical marijuana laws — even in states with dispensaries — was associated with a decrease in individual opioid use of prescription opioids for nonmedical purposes," researchers found.

A 2018 study suggested that cannabis legalization could actually make the opioid crisis worse, concluding that “cannabis use appears to increase rather than decrease the risk of developing nonmedical prescription opioid use and opioid use disorder.”

The Other Side of Cannabis

By Madora Pennington, PNN Columnist

I knew from my friend Nick’s Facebook feed that he was a cannabis enthusiast. His posts preached how it cures pretty much everything and will lead us to world peace.

Nick never tired of encouraging me to try it for my pain from Ehlers-Danlos Syndrome, even as I explained repeatedly that since my mother was psychotic, I avoid all drugs which may cause psychosis. Theoretically, I am at higher risk for that adverse reaction.

Psychosis is a disconnection from reality. A person may have delusions, hallucinations, talk incoherently and experience agitation. Since the 1970s, researchers have been investigating whether cannabis can trigger a psychotic break or full-blown schizophrenia. Daily users of highly potent cannabis are five times more likely to develop psychosis. The risk comes not only from genetic factors, but also from early-life neglect or abuse and even being born in the winter.

Having a rare and complicated medical condition, I get a lot of advice. I took Nick’s insistence I go on cannabis as kindness, as I take all unsolicited health tips. Our social media friendship grew. When my husband and I took a trip to his part of the world, he invited us to stay with him.

Nick picked us up at the train station in the English countryside looking like a dashing movie star. Slim and trim in a crisp Oxford shirt and Ray Bans, spryly maneuvering our luggage, he was still attractive in his 70s. Speaking English like Prince Charles, he confessed, “I am actually a cannabis farmer. I expect no trouble from the local police, but would you prefer to get a hotel room in town?”

My husband and I once risked our lives in the back alleys of Hong Kong to get me a fake Hermes bag. We did not need to consult with each other. We opt for adventure. I would not miss my chance to live a Jane Austen fantasy.

We ate off Nick’s three centuries-old family silver, the forks worn down from hundreds of years of scooting food across the plate. We sat beneath the Regency era portraits of his ancestors. Nick had a room devoted to his cannabis crop, growing fast underneath sun simulating lamps. The odor from the plants permeated his entire country home.

In real life, just as on Facebook, Nick’s favorite subject was the virtues of cannabis. He had been using it since he was a young man. Decades ago, he had spent a couple of years in prison for distribution. Recently his wife had left him over his devotion to marijuana. It was clear from Nick’s stories and life choices that cannabis had created tremendous tension with his family.

We talked of him coming to stay with us in Los Angeles, how we could all go to San Francisco to visit the Haight, as Nick was a genuine 1960s hippie. But leaving home to travel was a problem for him. When he does, he has to ask a friend to tend to his plants, which also means asking the friend to break the law.

Our days with Nick at his charming cottage were governed by his need to partake. Our visits to local sites were cut short, so he could be done driving and functioning for the day, and get home to get high. He did not seem to enjoy the excursions and seemed overwhelmed by being out and about, his anxiety growing, urging us to wrap up and get back home.

Cannabis Side Effects

Like Nick, many people are certain that marijuana helps them get by. On it, life is tolerable and pleasant. Anxiety is calmed. They are out of pain and able to sleep. But are they really benefiting?

At first, marijuana has a calming effect, but over time it negatively changes the way the brain works, causing anxiety, depression and impaired social functioning. With regular use, memory, learning, attention, decision-making, coordination, emotions, and reaction time are impaired. Heavy cannabis use lowers IQ. 

This damage can persist, even after use stops. Teenage users are more likely to experience anxiety, depression and suicidality in young adulthood. According to the CDC, about 1 in 10 marijuana users will become addicted. For people who begin using younger than age 18, 1 in 6 become addicted.

As is the case with other mood-altering substances, cannabis withdrawal symptoms — which include irritability, nervousness, anxiety, depression, insomnia, loss of appetite, abdominal pain, shakiness, sweating, fever, chills and headache — provokes the desire to use.

If someone is using cannabis to escape emotional distress, they never get the chance to deal with underlying problems. Psychiatrist Dr. David Puder recommends to his patients on cannabis that they stop in order to benefit from therapy.

“When they are off of marijuana, they have the ability to be present and really process what they will need to process in therapy in order to get over anxiety and depression,” Puder says, noting that users will often experience a flood of emotions and memories once they stop.

Medical marijuana has been approved for chronic pain and over 50 other health conditions by various states. Whether it actually helps with pain is uncertain. The U.S. Surgeon General warns the potency of marijuana has changed over time and what is available today is much stronger than previous versions. Higher doses of THC (the psychoactive chemical in cannabis) are more likely to produce anxiety, agitation, paranoia and psychosis. Consumers are not adequately warned about these potential harms.

House Guests

Our friend Nick was sure his marijuana use was his choice and that he was not addicted. He insisted my husband and I get high with him.

What is a polite house guest to do? Go along, of course, although we prefer whiskey and a steak. Nick promised we would love it, and that we were free to go upstairs and have sex and open up about anything. We giggled awkwardly. I ingested the smallest possible dose.

Nick then got higher than we had seen him during our entire visit, wolfing down his dinner in minutes. Then, after promising we’d have a tremendous evening of emotional openness and transcendent sharing, he burst into tears recounting how he was the victim of violence in his youth.

I felt for him, it was a horrifying event. Was this unresolved trauma the cause of a lifetime of drug use, denial and self-isolation? We had to wonder. It was truly awkward and uncomfortable, but Nick didn’t seem to remember his outburst. When we returned home, he continued to hound me to take up cannabis.

Madora Pennington writes about Ehlers-Danlos Syndrome and life after disability at LessFlexible.com. Her work has also been featured in the Los Angeles Times.

The opinions expressed in this column are those of the author alone and do not inherently reflect the views, opinions and/or positions of Pain News Network.

Coronavirus Is Now More Deadly Than Opioid Crisis

By Roger Chriss, PNN Columnist

The coronavirus pandemic is claiming lives daily. The number of confirmed infections worldwide passed one million today, with over 51,000 deaths.

Case counts in the United States are rising fast, with nearly a quarter of a million people infected and over 5,600 deaths. Over a thousand Americans are now dying every day from COVID-19.

This means that the pandemic is causing more deaths in the U.S. per day than the opioid crisis did in 2017, its worst year. Over 47,000 people died of opioid-related overdoses that year, according to the CDC, or about 128 people a day.

The worst is still ahead of us. The White House coronavirus task force projects that between 100,000 and 240,000 Americans will die from COVID-19.  

Other estimates are higher and some lower. Researchers at the University of Washington project that over the next four months approximately 81,000 people will die from the virus. In other words, the pandemic will kill more Americans in 2020 than opioids did in any year.

If things get worse, because the virus turns more virulent, medical resources dwindle or the public health response weakens, then the estimated death toll may rise into the millions.

Most of us couldn't do anything about the overdose crisis, because it was not an infectious disease epidemic. Practices like social distancing, scrupulous hygiene and self-isolating do not matter in a drug overdose crisis. But for a pandemic viral illness, they are vital.

The importance of distancing cannot be understated. As the University of Oxford Mathematical Institute explains, without distancing an infected person may pass the virus to three people in a week, which in six weeks leads to 1,093 new cases. However, if everyone reduces their contacts by a third, then each infected individual will only infect two others.

Hygiene is similarly important. Regular scrubbing of hands with soap and water, sneezing or coughing safely into an elbow, and strict avoidance of hand-to-face contact can help break the chains of transmission, reduce infection and prevent deaths.  

White House coronavirus response coordinator Dr. Deborah Birx told NBC News that keeping the number of deaths below 200,000 will require that “we do things almost perfectly.”

Early evidence suggests that social distancing and other public health measures are already helping in the San Francisco Bay area and the Seattle-Puget Sound area. But continued vigilance is needed.

“Our model looks at the data to determine if social distancing measures are slowing the spread of COVID-19,” said Dr. Daniel Klein, computational research team leader at the Institute for Disease Modeling. “While the results indicate an improvement, the epidemic was still growing in King County as of March 18th. The main takeaway here is though we’ve made some great headway, our progress is precarious and insufficient.”

Opioid overdoses led to far too many deaths. The pandemic stands to kill far more and lead to vastly more illness. There is a lot we can each do to avoid becoming sick ourselves and protect our families, friends and communities.  

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

What If the Opioid Crisis Is Worse Than We Think?

By Roger Chriss, PNN Columnist

A recent study in the journal Addiction reports that the opioid crisis in the U.S. may be worse than we’ve been led to believe. The number of overdose deaths linked to legal and illicit opioids over the past two decades could be about 28 percent higher than reported.

Economists Andrew Boslett, Alina Denham and Elaine Hill looked at drug overdose deaths between 1999 and 2016 in the National Center for Health Statistics. Of 632,331 deaths, over one in five had no information on the drugs involved. The researchers estimated that as many as 72% percent of those deaths likely involved opioids. This yields an additional 99,160 deaths involving prescription opioids, heroin, fentanyl and other street drugs that were not counted.

This estimate may or may not be right, but it is definitely not new. Claims like this have been around for years.

In 2017, Business Insider reported on an investigation by CDC field officer Dr. Victoria Hall, who looked at the Minnesota Department of Health's Unexplained Death (UNEX) system. She found that 1,676 deaths in the state had “some complications due to opioid use,” but were not reported as opioid-related deaths.

A 2018 study at the University of Pittsburgh found that as many as 70,000 overdose deaths were missed because of incomplete reporting.

‘Cooking the Data’

It has long been suspected that the CDC’s opioid overdose death toll is faulty – either too high or too low, depending on your point of view. Public health data in the U.S. is shoddy, the result of a fractured and fragmented system that has little central guidance or administrative oversight. The overdose numbers aren’t as reliable as they should be, which raises suspicion they are being manipulated.

The Atlantic makes a similar point about the coronavirus outbreak.

"Everyone is cooking the data, one way or another. And yet, even though these inconsistencies are public and plain, people continue to rely on charts showing different numbers, with no indication that they are not all produced with the same rigor or vigor," wrote Alexis Madrigal. “This is bad. It encourages dangerous behavior such as cutting back testing to bring a country’s numbers down or slow-walking testing to keep a country’s numbers low.”

The implications of under-counting deaths in the overdose crisis require careful consideration. Political campaigns, public policy, state laws and regulations, and clinical practice are built on these numbers. For instance, the Trump administration was recently touting a 4% decline in overdose deaths, but that reduction may not exist.

Similarly, cannabis advocacy groups argue that state legalization has reduced overdose deaths. But again, that reduction may evaporate with better data. State laws and regulations are built on the assumption that trend lines were going in a particular direction. But maybe they aren’t.

Most important, policy groups have argued strenuously that reducing prescription opioid utilization would alleviate the overdose crisis. But if there are vastly more deaths than recognized, where does that leave these groups?

Of course, determining cause of death is a process fraught with difficulties. The New York Times reports that morgues are overburdened and understaffed, many suspected overdose deaths are not fully evaluated, and reporting on the cause of death is not standardized.

Making a probabilistic assessment is even more fraught. For instance, a recent attempt to use stool samples to measure how many rodents, birds and other wildlife are eaten by domestic cats was undone by the discovery that cat food manufacturers regularly change their ingredients.

In other words, there are many known problems and occasional surprises in public health data, so any estimate has to be treated with caution. But if opioid overdoses are vastly undercounted, then we should reassess the policies and politics of the crisis.

Roger Chriss lives with Ehlers Danlos syndrome and is a proud member of the Ehlers-Danlos Society. Roger is a technical consultant in Washington state, where he specializes in mathematics and research.

Overdose Deaths Fell by 4.1% in 2018

By Pat Anson, PNN Editor

A new analysis by the CDC has confirmed earlier estimates that drug overdose deaths in the U.S. decreased by 4.1% in 2018, the first decline in the nation’s overdose rate in nearly three decades.

The decline was led by a drop in overdoses involving prescription opioids (-13.5%) and heroin (-4.1%). Much of that progress was offset by a 10% increase in deaths involving synthetic opioids, a category that includes illicit fentanyl and fentanyl analogs.

Fentanyl and other synthetic opioids were involved in 31,335 overdose deaths -- nearly half of the 70,237 drug deaths in 2018 and over two-thirds of the 46,802 opioid deaths.

The 14,975 deaths linked to prescription opioids represent about 22% of the total number of fatal overdoses.

“Decreases in overdose deaths involving prescription opioids and heroin reflect the effectiveness of public health efforts to protect Americans and their families,” CDC Director Robert Redfield, MD, said in a statement. “While we continue work to improve those outcomes, we are also addressing the increase in overdose deaths involving synthetic opioids. We must bring this epidemic to an end.”

U.S. DRUG OVERDOSE DEATHS IN 2018

SOURCE: CDC

Synthetic opioid deaths in 2018 increased in the Northeast, South and West and remained stable in the Midwest. The highest synthetic opioid death rate (34 deaths for every 100,000 people) occurred in West Virginia, which also has the highest death rate involving prescription opioids (13.1 deaths per 100,000 people).

Seventeen states experienced declines in prescription opioid deaths in 2018, with no states experiencing significant increases.

While opioid prescribing has been declining since 2012, much of the CDC’s public messaging remains focused on reducing the use of opioid pain medication.

“Because of the reductions observed in deaths involving prescription opioids, continued efforts to encourage safe prescribing practices, such as following the CDC Guideline for Prescribing Opioids for Chronic Pain might be enhanced by increased use of nonopioid and nonpharmacologic treatments for pain,” wrote Nana Wilson, PhD, a CDC epidemiologist and lead author of the study.

“Additional public health efforts to reduce opioid-involved overdose deaths include expanding the distribution of naloxone, addressing polysubstance use, and increasing the provision of medication-assisted treatment.”

Wilson and her colleagues noted that an increase in overdose deaths among African-American and Hispanics showed a need for “culturally tailored interventions” to address health and other societal factors.   

While the decline in overdose deaths in 2018 is encouraging, preliminary CDC data indicates the trend is not continuing into 2019. Deaths are increasing from synthetic opioids, cocaine, methamphetamine and psychostimulants such as attention deficit disorder drugs.

Overdose deaths often involve multiple drugs, so a single death might be included in more than one category and be counted multiple times. The quality of the data also varies widely from state to state. Only 39 states have good to excellent overdose data, according to the CDC.

Tweet Led to Dr. Kline Losing His DEA License

By Pat Anson, PNN Editor

A complaint from a woman in upstate New York launched the investigation that recently led to a North Carolina doctor losing his DEA license. Julie Roy doesn’t know Dr. Thomas Kline or any of his patients, but claimed he was dangerous and that “someone can die” because Kline believes opioids are rarely addictive.

Kline surrendered his DEA license to investigators with the North Carolina Medical Board last month.  He is still able to practice medicine but can no longer prescribe opioids and other controlled substances, leaving his 34 patients in medical limbo. All of them suffer from chronic pain and rare diseases that other doctors are increasingly unwilling to treat because they fear coming under scrutiny for opioid prescribing

“I do feel bad for the patients that were affected,” Roy told North Carolina Health News, which first reported on her role in the Kline investigation.

Roy became upset with Kline because he has been an outspoken advocate for pain patients online. Roy’s 26-year old son died from a heroin overdose and she took offense when Kline posted a Tweet last year stating that “opiates work fine without addiction potential” in 99.5% of people.    

She tweeted the North Carolina Medical Board on May 15, saying “this is a doctor that you allow to have an active license. He would love to prescribe every person on earth an opioid.”

NORTH CAROLINA HEALTH NEWS

That same day, Roy made a formal complaint with the medical board against Kline, making a series of unsubstantiated claims about the doctor.

“He is giving out information regarding opioids that is not correct and could cause harm,” she wrote. “I am very concerned as pain patients believe what he says. He says opioids are only addictive to someone who is genetically prone plus a ton of other misinformation.”

Roy even claimed that Kline might be “suffering from substance use disorder himself.”

“The man should not have an active license with his pro opioid perception. The information he puts out alone could cause harm. I would like you to verify (t)hat he is not writing opioid prescription,” Roy wrote.  

Kline Caught Off Guard

Kline responded in writing to Roy’s complaint in July, telling the medical board the information he shared about opioids was accurate and backed up by research. He also denied taking opioids or having a substance use disorder.

“Ms. Roy has lost a son to opiate addiction. Losing a child is the worst of all tragedies. This tragedy could have been avoided with the new knowledge I am presenting in my published research and public talks urging for early identification and treatment of opiate addiction to stop deaths in people like Ms. Roy’s son,” Kline said.

Because none of his patients were harmed by his prescribing and no other complaints were filed against him, Kline thought that would be the end of the matter – even when the medical board asked to review the records of nine of his patients.

Kline was caught off guard when investigators made a surprise visit to his office in Raleigh on February 17 and told him to surrender his DEA license. He did so voluntarily, not realizing at the time that it was unlikely he’d ever get the license back.  

No formal charges have been made against Kline and the medical board won’t comment on the status of the investigation — which could drag on for several more months.

Kline says he’s been able to find new doctors for a handful of his patients, but others are suffering due to untreated pain or running low on their prescriptions.

Ironically, Roy was once a pain patient herself and was on long-term opioid therapy after a failed back surgery. She told NC Health News that her pain medication stopped working, so she switched to buprenorphine (Suboxone), another opioid that’s usually prescribed to treat addiction.

Should Gabapentin Be Used to Treat Alcohol Abuse?

By Pat Anson, PNN Editor

Gabapentin (Neurontin) is so widely prescribed for so many different conditions that a Pfizer executive infamously compared it to “snake oil” in a 1999 email.

“Gabapentin is the snake oil of the twentieth century. It has been successful in just about everything they have studied,” said Christopher Wohlberg, who was a Pfizer Medical Director at the time.

Although only approved by the FDA to treat epilepsy and neuropathic pain caused by shingles, gabapentin is widely prescribed off-label to treat fibromyalgia, anxiety, depression, ADHD, migraine, bipolar disorder, restless leg syndrome and a growing number of other conditions.  

Already the 6th most widely prescribed drug in the United States, gabapentin is also being touted as a treatment for alcohol abuse.

In a small study published in JAMA Internal Medicine, researchers found that gabapentin was effective in treating patients with alcohol use disorder (AUD) – problem drinking that has become severe. Compared to a placebo, gabapentin significantly increased abstinence and reduced heavy drinking days, especially for those who suffer from symptoms of alcohol withdrawal.

“The weight of the evidence now suggests that gabapentin might be most efficacious after the initiation of abstinence to sustain it and that it might work best in those with a history of more severe alcohol withdrawal symptoms,” concluded lead author Raymond Anton, MD, an addiction psychiatrist and professor at the Medical University of South Carolina.

“Armed with this knowledge, clinicians may have another alternative when choosing a medication to treat AUD and thereby encourage more patient participation in treatment with enhanced expectation of success.”

As many as 30 million Americans have AUD, but only about a million are taking a medication to help them reduce drinking or maintain abstinence. The FDA has approved three drugs (naltrexone, disulfiram and acamprosate) for the treatment of alcohol abuse.

Side Effects and Abuse

The suggestion that gabapentin should also be prescribed for AUD comes at a time when the drug is already under scrutiny for its abuse and side effects, including an association with a growing number of suicide attempts. Patients prescribed gabapentin often complain of mood swings, depression, dizziness, fatigue and drowsiness.    

Although the CDC’s controversial 2016 opioid guideline calls gabapentin and its chemical cousin pregabalin “first-line drugs” for neuropathic pain, a recent clinical review found little evidence that either drug should be used off-label to treat pain.

Gabapentin does not carry the same risk of addiction and overdose as opioid pain relievers, but illicit drug users have discovered that gabapentin can heighten euphoria caused by heroin and other illicit opioids. Should a drug like that be used to treat addiction?

Hundreds of clinical studies are underway to find new uses for gabapentin, not only for alcohol abuse, but for a cornucopia of conditions such as obesity, insomnia, breast cancer, asthma, menopause and overactive bladder. One recent study even found that gabapentin improves sexual desire in women with vulvodynia.

Instead of finding new uses for an old medication, maybe it’s time to come up with a new drug.

Dangerous New Street Drug Found in Counterfeit Painkillers

By Pat Anson, PNN Editor

A dangerous new street drug that’s even stronger than fentanyl has been found in counterfeit opioid painkillers seized during a police raid on Canada’s eastern seaboard.

Like fentanyl, isotonitazene is a potent synthetic opioid that is many times stronger than heroin or morphine. In recent months, isotonitazene was detected in over a dozen overdose deaths in Illinois and Indiana, where it was mixed with cocaine. The drug has also recently been found in New Brunswick and Alberta, and has been connected to at least two overdose deaths in Calgary.

Now it is being used to make counterfeit pain medication.

Police in Halifax, Nova Scotia seized 1,900 white tablets from a Halifax home last month while conducting a drug investigation. The pills were sent to Health Canada for a laboratory analysis, which confirmed the tablets were made with isotonitazene.

The pills have an “M” on one side and the number “8” on the other side – making them virtually identical to an 8mg Dilaudid (hydromorphone) tablet.

SOURCE: HALIFAX POLICE

“The appearance of the pill may lead people to believe they are consuming a different drug. Given the potency of the drug, a person may need several doses of naloxone to counter an overdose caused by isotonitazene,” Halifax police said in a statement.

No overdoses have been linked to isotonitazene in Halifax, but police are urging anyone who consumes the pills to seek immediate medical attention.

The Center for Forensic Science Research and Education released a public safety alert last November, when isotonitazene was first linked to overdoses deaths in the Midwest.

“Pharmacological data suggest that this group of synthetic opioids have potency similar to or greater than fentanyl based on their structural modifications,” the alert warns. “The toxicity of isotonitazene has not been extensively studied but recent association with drug user death leads professionals to believe this new synthetic opioid retains the potential to cause widespread harm and is of public health concern.”

Although law enforcement and public health officials have only recently become aware of the threat posed by isotonitazene, illicit drug users have been warning each other about isotonitazene for several months in online message boards.

“I wanted to let the community know that the potency is far above the 60x morphine that's listed online. Everyone should be VERY careful when handling this compound,” one poster warned on Reddit.