Formerly known as the Rx Drug Abuse and Heroin Summit, this year it was located in Nashville. HMP Global, the health care marketing company that created the summit, advertises it as the premiere conference for stakeholders in the overdose crisis—where attendees can “learn about what is working in prevention, treatment and law enforcement.” Some of this year’s speakers are academics and public health researchers who focus their work on harm reduction, but it’s fair to say that’s not where the summit’s priorities lie.

Government agencies and for-profit partners have never exactly been at the forefront of harm reduction, and it’s clear what demographics the summit caters to; the registration fee is over $1,000. It’s always skewed to the right, and it’s not necessarily surprising that HMP Global is now platforming a man who famously wants to build hundreds of “healing farms” into which people facing drug charges can be sent indefinitely to “learn the discipline of hard work,” and who wants us to believe this is an alternative to incarceration. But when RFK Jr. is the overdose-crisis expert addressing an audience filled with many of the nation’s major players in drug policy, that’s still a good indication of a five-alarm fire.

I joined the Rx and Illicit Drug Summit to speak about the opioid crisis plaguing our nation. We are fortunate to have an administration that is tackling this issue head on, and I will continue to work on legislation that will Make America Safe Again. pic.twitter.com/zqucqYnoAY

— Sen. Marsha Blackburn (@MarshaBlackburn) April 23, 2025

Other speakers included United States Attorney General Pam Bondi (R) and Tennessee Senator Marsha Blackburn (R). Several people who attended Blackburn’s panel told Filter that her thoughts on overdose prevention were mostly about the importance of border security, including that “all options are on the table” when it comes to President Donald Trump’s use of the Alien Enemies Act.

Attendees of Bondi’s session told Filter that she appeared to confuse stimulants with benzodiazepines, describing students “using Xanax to study.” And that she repeatedly claimed the majority of the illicit fentanyl in the US is brought in by migrants crossing the southern border. Yet there was still clapping and whooping coming from the audience.

The harm of this type of rhetoric isn’t that it’s partisan, but that it’s rife with misinformation, whether intentionally or out of ignorance. While the summit has had this problem in previous years, this year it’s a frighteningly dystopian indication of what the future may hold as the Substance Abuse and Mental Health Services Administration and other relevant federal agencies are dismantled. Surprise speakers announced at the last minute have not been the norm at past summits. And other than National Institute on Drug Abuse Director Nora Volkow and National Institutes of Health Director Jay Bhattacharya, all of the “featured” speakers highlighted by organizers were elected officials.

RFK Jr., who’s widely known to be in recovery from problematic heroin use in the 1980s and reportedly attends nine AA meetings per week, has spoken publicly about being influenced by the work of psychiatrist and philosopher Carl Jung. Jung wrote of man’s “spiritual thirst of our being for wholeness,” and how drugs and alcohol distract from this quest. Like the Protestant work ethic that teaches us how godliness and salvation are found through hard work and suffering, it all conveniently dovetails with the capitalist need to maintain the supply of human labor.

It’s difficult to guess the likelihood that the new industry he describes will actually be created. Building hundreds of “healing farms” would be expensive, but this has not stopped the US from letting private contractors continuously build new prisons to keep up with the incarcerated labor force. Especially as the Trump administration takes extraordinary measures to remove many of the most underpaid and exploited workers, there’s always a need for more warm bodies.

Image of RFK Jr. via Washington State House Democrats

The post RFK Jr. Is Headlining the Rx and Illicit Drug Summit. This Doesn’t Bode Well. appeared first on Filter.

“It was a very sinister drug,” Quinones told EconTalk of “new meth” when promoting his book, from which the Atlantic article was adapted. “You began to speak babbling, what they call ‘word salad’ in psychology. It began to create mental illness as it marched across the country.”

All meth actually has the same chemical makeup. The only difference is the production method, of which there are several. When the broader public thinks of meth, they’re probably thinking of meth derived from pseudoephedrine (Sudafed). “New meth” refers to meth derived from phenyl-2-propanone, more commonly known as P2P. 

“New meth” is nothing to fear. For starters, it isn’t new at all. It emerged in the 1970s after the rescheduling of amphetamine—from Schedule III, as it orginally was under the Controlled Substances Act, up to the more highly restricted Schedule II category—created a void in the market. Production relied on phenylacetic acid and acetic acid, using a thorium dioxide catalyst. From there, a simple reductive amination reaction produces methamphetamine.  

It’s easier to paint a drug as “sinister” if you don’t mention that there’s an FDA-approved prescription form.

P2P-derived meth was usually assumed to be lower quality than ephedrine-derived meth, meaning less pure. But “purity” means something different for meth than it does for drugs like heroin, cocaine or pressed pills. It doesn’t refer to whether adulterants like fentanyl are present in a sample of meth. Rather, it refers to the molecular structure of the meth itself.

Certain molecules can accommodate slight variations in the ways their atoms and bonds are arranged while still being the same molecule—a feature called isomerism. Methamphetamine, for example, can exist in a D (dextro) form or in a mirror-image L (levo) form. D-methamphetamine is what produces the psychoactive effects; L-methamphetamine is a byproduct. Meth “purity” refers to the proportion of D to L in a sample. 

The ephedrine method of making meth is stereospecific, meaning that it doesn’t make both isomers as a product. That’s its big advantage. P2P does make both, so you have to either separate them later, or sell the racemic product (the mix of the two isomers).

Quinones claimed that separating the two isomers is “tricky, beyond the skills of most clandestine chemists,” but that it seemed “the criminal world” finally figured it out around 2006. Thus, a boom of unprecedentedly pure meth—high D, low L—compared to the so-called less pure P2P meth of 50 years ago. 

Of course, what he’s essentially describing is pharmaceutical-grade meth, the regulated version of which is sold under the brand name Desoxyn. But it’s easier to for an article to paint something as “sinister” if it leaves out that there’s an FDA-approved prescription form that doesn’t cause “cerebral catastrophe” which “always [involves] violent paranoia, hallucinations, conspiracy theories, isolation, massive memory loss, jumbled speech.”

In reality, isomer separation is fairly teachable, and not all that mysterious. The cleanest and most straightforward way to remove the L from the psychoactive D isomer is capillary electrophoresis. This process involves feeding a meth sample into a small capillary tube and exploiting differences between the two isomers that cause one to “stick” to the tube’s coating while the other continues on. Anyone with around $4,000 can do this with via a capillary electrophoresis machine, which automates the process to minimize human error and labor.

Another way of separating the isomers is by making them into diastereomeric salts that can be physically sorted into different layers in a glass container. It’s more time-consuming and less precise, but requires no special equipment.

There’s no evidence that P2P-produced meth is any more or less neurotoxic than ephedrine meth.

In 1980, P2P was federally scheduled, law enforcement having caught on to its role in meth synthesis. This pushed the market into the pseudoephedrine-based production method, originally developed by chemist Nagai Nagayoshi in 1893.

In 2006, the government inevitably cracked down on Sudafed. Buying the medication from a pharmacy now required ID, and sales were tracked to limit the quantities people could buy per month. Mexico followed suit in 2008. Thus, P2P swung back.

The P2P method isn’t slowed by the need to physically go shopping for Sudafed—the tedious process portrayed in early episodes of Breaking Bad—so it makes sense that production and thus availability increased. P2P had just about eclipsed pseudoephedrine-based meth by 2012. Meth prices initially climbed, but dropped back to baseline around 2010-2012.

Other than direct observation, the only way anyone would know which production method was used for a meth sample is to examine leftover solvents which smell awful but aren’t especially dangerous. That requires specialized equipment and knowledge. Anything else is just an assumption based on P2P being the prevailing production method these days, but still not an assumption that means anything either way. 

We have no evidence supporting the idea that the meth currently on the market is meaningfully different at a population level. Or that P2P-produced meth is any more or less neurotoxic than ephedrine meth.

P2P doesn’t even refer to a single method of production anymore. The original method is still popularly referred to, but hasn’t been the norm for years. We now see P2P made using nitrostyrene, or using ethyl phenylacetate. There are still other ways of producing meth that bypass P2P altogether. None of them are a smoking gun to explain rising rates of homelessness. 

“New meth” is a convenient way of ignoring that we have a crisis of affordable housing across the country. That we have stagnant wages, inaccessible mental health care, COVID and escalating climate and drug war emergencies. Mythology has always been a tried-and-tested distraction from harder truths. “New meth” mythology is no different.

Photograph courtesy of Kastalia Medrano

The post “New Meth” Is Nothing to Fear. It Isn’t New. It’s Just Meth. appeared first on Filter.

The effects started wearing off in a matter of hours, and it wasn’t long before the monkey required boosters. If offered a high enough dose of heroin, its interest in using it returned. 

This wasn’t the most sophisticated methodology. But in the decades since, as our technology and grasp of vaccine science advanced, the idea of a vaccine against addiction lingered. Researchers have attempted immunizations for tobacco and cocaine, both of which were tested on humans but failed to receive Food and Drug Administration approval because they were found no more effective than placebo.

Human trials are currently underway for a vaccine against oxycodone, oxymorphone and hydrocodone—better known as OxyContin, Opana and Vicodin. The University of Minnesota Medical School team behind the research sees this as an additional treatment option for addiction to those pharmaceuticals. 

The vaccine is intended for people with opioid use disorder. It would train immune cells to treat opioid molecules like an invading pathogen, and destroy them before they can make it to the brain. It would not reduce cravings, but would block people from feeling any effects of the opioid after they used it. If effective, they would experience no pain relief; no euphoria; no overdose.

The idea is that over time this reduces psychological dependence, too. But this may push people to begin using larger and larger amounts to feel the desired effects—and a large enough dose will overcome the vaccine’s ability to prevent overdose.

The overdose antidote we already have, naloxone, works against all known opioids.

Prescription opioids like hydrocodone are not a significant driver of overdose. Their mortality impact has been dwarfed by fentanyl and a rising number of synthetic opioids for nearly a decade now. 

The team has received funding to develop a fentanyl vaccine as well. While a once-promising nicotine vaccine meant to aid tobacco cessation ran into issues around dosing, a fentanyl vaccine might be more viable. Most smokers take in large daily quantities of nicotine, and the sheer number of nicotine molecules proved too great for the immune response to fight off. Fentanyl’s higher potency means that people typically consume significantly fewer molecules of it at a given time.

But even if it was developed and worked as intended, it would be years before it was approved and available to patients. We will almost certainly be facing an entirely different drug landscape by then. 

“Given the sheer number of structurally different opioid molecules, I doubt that it would ever be possible to keep up,” Dr. Ryan Marino, an emergency medicine physician and medical toxicologist at Case Western Reserve University, told Filter.

The overdose antidote we already have, naloxone, works against all known opioids.

The federal government funded harm reduction programs for the first time in March 2021, authorizing $30 million to be divided between an unknown number of programs. Applications didn’t open until December, and the funds will be dispensed $10 million at a time over three years. According to the Seattle Times, the UMN team’s fentanyl vaccine research received “about $50 million” just to fund a “future clinical trial,” and “more funding to test vaccines against heroin and other drugs.”

“It is true that more treatment options are generally better,” Marino said. “But what doesn’t make sense to me—as someone who treats both overdose and addiction—is putting so much funding towards this when we already have an antidote for opioids, a long-acting opioid blocker and two other evidence-based treatment options for opioid use disorder that both reduce opioid use and prevent overdose.” 

“With funding, not only could I afford to buy in bulk, I could give participants more supplies to share.”

Jessica Blanchard is the founder of 229 Safer Living Access, a grassroots mobile harm reduction program in Georgia. She receives naloxone and safer sex supplies through other organizations, but buys everything else herself out of pocket. This limits operations to one day a week, during which she can reach about 140 people at most.

“With funding, not only could I afford to buy in bulk, greatly reducing cost, but I could also give participants more supplies to share with those unable to make contact with the program,” Blanchard told Filter. “I would pay program participants to do secondary distribution. [They] are the experts here. They express desire to participate in distributing supplies and educating their peers. But without the ability to compensate them for their time and lived-experiential knowledge, I simply can not ask them to help.”

Vaccines and other shiny new tech may one day have a role to play the overdose crisis and substance use treatment landscape. It’s a core value of harm reduction to be able to offer options, so people can maintain autonomy and access what works best for them as individuals. But the lion’s share of funding should not be going to glossy biotech advancements still in their infancy—and statistically likely to fail—while leaving evidence-based, on-the-ground solutions to compete for scraps.

Photograph via United States Food and Drug Administration

The post An Opioid Vaccine Is Not the Answer appeared first on Filter.

The origin of these rumors was Houston Police Chief Troy Finner, who in a November 6 press conference shared an unconfirmed interpretation of an incident involving an Astroworld private security guard. [Update, November 10: Finner walked back the following claim, stating that the guard himself said he suffered a blow to the head and that no one had injected drug into him.]

“I will tell you, one of the narratives was that some individual was injecting other people with drugs.” 

According to Finner, the guard felt something on his neck. Some unknown length of time later, he fell briefly unconscious and was administered Narcan by onsite medical staff. They observed a mark on the guard’s neck, “similar to a prick that you would get if somebody is trying to inject.”

This narrative was snatched up by TMZ and led to a frenzy of online speculation that soon had “fentanyl” Twitter-trending in Texas.

Finner, in the same press conference, urged the public to “give us time to do a proper investigation”—time he himself had not bothered to take before using his platform to spread a baseless rumor at the expense of people who inject drugs.

It is possible, of course, that someone did sneak around the concert attempting to inject an unknown substance into the necks of strangers. But as an old teacher of mine liked to say, it’s also possible for a rhino to fall through my roof and crush me. 

UPDATE: A source connected to Astroworld tells TMZ, someone in the crowd went crazy and began injecting people with some sort of drug. https://t.co/SdnZeXPleA

— TMZ (@TMZ) November 6, 2021

“The fact that someone was administered Narcan is not evidence that they were experiencing an opioid overdose,” Ryan Marino, an emergency medicine physician and medical toxicologist, told Filter. “I have seen plenty of cases where Narcan has been given to people who have fainted, who are experiencing a panic attack, or even where someone was just drinking alcohol, and while it may appear that they ‘responded,’ that is not always the case.” 

Fentanyl can be fairly easily detected through rapid screens and toxicoligic testing. If there was indeed a shred of evidence that it was present in the security guard’s system, it surely would have been widely publicized by Finner and TMZ and everyone else.

“This would be easy to prove,” Marino said. “I am very skeptical of people blaming drugs without any evidence that drugs were present.”

Fearmongering about people who use drugs has long been driven by myths of needles wielded against innocent bystanders.

Tiny injection marks, like what the medical staff may have thought they saw on the guard’s neck, don’t look much different than small scratches or even an irritated hair follicle. And injecting a drug into someone takes more than a fraction of a second, and can’t really be done from arm’s length while running through a crowd. The plunger must be depressed, pressure applied, the distance between the two parties maintained.

Imagine when you last got a vaccination—it’s not a glancing “prick” that a nurse could have run past you and administered drive-by style without stopping.

Fearmongering about people who use drugs has long been driven by myths featuring needles wielded against innocent bystanders. In the 1980s and 1990s, early confusion about the infectiousness of HIV combined with rampant homophobia led to widespread rumors that people living with HIV were intentionally planting HIV-tainted needles in movie theater seats, gas station pump handles and vending machine coin returns. 

Crowd crush, the phenomenon which is much more likely a factor in the concert deaths, is not always an intuitive one to grasp. When I was a new paramedic student, it had baffled me. How could someone be suffocated by simply having lots of people pressed against them? 

I think we need some education on crowd crush!

I get it – I had a hard time understanding how this could be deadly when I began paramedic school.

This is an accessible primer on the issue, and explains how 8 people lost their lives on Friday. (It wasn’t The Mystery Stabber.) pic.twitter.com/x4l1Z1DjGG

— Claire Zagorski, MSc, LP (@clairezagorski) November 7, 2021

When experiencing crowd crush, our rib cage is so severely and consistently compressed that we become unable to take a breath, resulting in what’s called compressive asphyxia. Further compression also cracks bones, and those unable to stay on their feet find themselves trampled under wave after wave of panicked people.

There are a few things you can do if you find yourself caught in a gathering where crowd crush might develop. Pay attention to when groups of densely packed people start forming, and get away from these clusters as soon as you can. Avoid barriers like fences or walls, and do whatever you can to stay on your feet. You can buy a bit of room for your ribcage to expand by keeping your arms bent and tucked at your sides; like a boxer’s stance.

TMZ stated that its source was someone connected to the Astroworld festival, the producers of which are already facing civil litigation (and perhaps even criminal prosecution) from these tragic deaths. The concert production company LiveNation, which among many tasks was responsible for show security and safety infrastructure, was revealed to have a litany of previous Occupational Safety and Health Administration violations.

Crowd crush deaths are tragic, but ultimately this is a tangible, well-described medical phenomenon, the conditions for which seem to have been created by event organizers who didn’t follow safety regulations. We don’t need a syringe-wielding boogeyman to blame for the deaths. 

“The widespread chaos that ensued in this tragedy is not consistent with drug exposure or effect,” Marino said. “Crowd crush is more than plausible; drugs are pretty implausible.”

Photograph via United States Fire Administration

The post Let’s Examine the Astroworld Syringe-Wielding Assailant Rumor appeared first on Filter.

The composition of K2 seemed to be in constant flux. One week would bring patients in the grip of frightening hallucinations; the next, severe low blood pressure that sent some of them to intensive care. Other weeks we might see mania, or hives or elevated acid levels in the blood. We were concerned. We still are.

The past few years have seen a precipitous fall in the availability of unadulterated heroin in North America, increasingly mixed with, or outright replaced by, an ever more diverse array of molecules. These include not only a dozen variants of fentanyl, but benzimidazole-based drugs like isotonitazene and etonitazene; benzodiazepines like etizolam; and odd ducks like the veterinary sedative xylazine. Prohibition breeds innovation.

Law enforcement and legislators play Whac-a-Mole with each new substance as it emerges. The chemicals, supplies and physical space needed to manufacture synthetic drugs become carefully watched as well. Ingredients of choice get noticed, their purchase regulated and tracked. And their manufacturers get pushed further into the margins, forced to use less desirable and more dangerous options.

This is how people end up producing drugs under tarps in the woods instead of in a clean lab space. Using processes that create hazardous by-products. Handling chemicals that are carcinogenic or toxic. Safety measures enjoyed by above-ground chemists, like emergency showers and ventilated hoods that protect from splatters and explosions, are a luxury. And as profits take a hit and labor becomes more risky, people increasingly turn to a logical way to stretch the product: cutting it, with a substance that is cheaper, more potent or both than the substance it will later be marketed as.

We are seeing the supply chain not just change, but splinter.

The number of banned but still readily available drugs in the United States used to be finite. The handful we did have (heroin, for instance) were fairly well understood, their effects familiar. The medical guidebook for treating someone who overdosed on heroin or overamped with meth is well known. But now, patients are arriving with unfamiliar and dramatic presentations that aren’t readily found in textbooks.

We are seeing the supply chain not just change, but splinter, in ways that go beyond even the novel synthetic opioids linked to rise in overdose. COVID-stretched health care workers’ ongoing ignorance of the current supply is a recipe for disastrous misdiagnosis. 

Levamisole, a veterinary deworming medicine, is widely used as a cutting agent for cocaine because it’s inexpensive and easily sourced. With repeated use, levamisole chokes the human body’s ability to make the white blood cells that protect us from infection. The early symptoms of this condition are vague enough—aches, fever, chills, malaise—that clinicians often mistake it for the flu. If it worsens, patients can present with rapid breathing and heart rate, become disoriented and even die without treatment.

Xylazine, a non-opioid veterinary sedative, has been increasingly devastating communities of opioid users by turning the supply into “tranq dope.” It can also open up painful skin ulcers and cause perplexing effects like severe anemia. 

Codeine, being one of the less-hawkishly regulated opioids, is sometimes found in what’s sold as heroin. But codeine, as I learned after caring for a patient who’d used what he thought was heroin, often causes a reaction similar to a severe allergy when injected—which is why in clinical settings it’s not administered through an IV. But nothing’s protecting injection drug users who don’t realize codeine is in their supply.

And of course there’s fentanyl. Largely confined to heroin for most of the 2010s, it has over the past few years begun surfacing in cocaine and counterfeit pressed pills (like fake Xanax) and just about every prohibited substance that is not marijuana. The rules have changed.

Excited to share that the labor of love that is our textbook "Treating opioid use disorder in general medical settings" is officially published. Thanks to the incredible scholarship of the all-star author line-up, it was a joy to edit their work https://t.co/qFUGsZpvH1

— Sarah Wakeman (@DrSarahWakeman) September 14, 2021

Of course, the best way to keep people who use drugs safe is to simply legalize all drugs, regulating their production the same way as the drugs you get from a pharmacy. When you buy ibuprofen, you’re buying something that’s been subject to federal manufacturing standards to ensure it contains no contaminants—reaction by-products, dirt, bacteria and of course other drugs. Prohibition denies people that protection.

This idea is not an appealing one for many people who hold positions of power, including those who dictate how and where overdose response funding gets allocated. But as health care workers—as people who hold positions of power within spaces that are notoriously hostile toward drug users—we can learn to protect more patients from more harms.

We must decide that building up our knowledge is a priority.

Harm reductionists have created a number of educational resources that can help improve care of people who use drugs—on synthetic opioids; on reducing health care stigma; on common misconceptions; on accessing and administering naloxone, which is still effective against novel synthetic opioids whether or not we recognize their names.

To enact real progress, we much face our implicit (or explicit) biases against people who use drugs and ensure that when they access the health care spaces we work in, they are treated humanely. We must acknowledge that prohibition is filling our exam rooms with more people sick in more ways we weren’t expecting—and decide that building up our knowledge is a priority.

Photograph via National Institute on Drug Abuse

The post Health Care Workers Need to Be Watching the Splintering Drug Supply appeared first on Filter.

The patient got a laugh out of this, as did my trainers. This wasn’t cruel of them; I was fine. I didn’t feel any effects at all. 

This makes sense, because fentanyl can’t absorb through the skin very well. (There are fentanyl skin patches prescribed for pain, especially among cancer patients, which work very slowly and use additives to help the fentanyl absorb, but they’re in no way analogous to either liquid injectable fentanyl or powdered illicit fentanyl.) But month after month, we see headlines recounting police encounters with fentanyl that lead to—as the police tell it—sudden, dramatic, near-fatal overdose, often requiring multiple doses of naloxone. 

Deputy David Faiivae of the San Diego County Sheriff’s Department recently had one such experience, according to a widely circulated video put out by the department. Faiivae had no direct contact with the powder; he was simply standing in its vicinity. Shortly after being warned by his field training officer to stay back from the suspected fentanyl—“Hey dude, too close. You can’t get too close to it”—Faiivae fell to the ground. He was given four doses of naloxone, after which he returned to his normal self. 

Law enforcement accounts of passive fentanyl “overdoses” have abounded for years. Perhaps the most well-known is that of former East Liverpool, Ohio, patrolman Chris Green, who in 2017 used his bare hand to dust a small amount of powdered fentanyl off his uniform. Somewhere between a few minutes to nearly an hour later (reports vary), he felt that his head was “in a vice grip,” his heart as if he’d been “kicked in the chest” and his stomach as if he’d come down with the flu. After being administered a staggering four doses of the nasal spray Narcan—one is almost always enough, and more than two is highly unusual—he was feeling more like himself. Green was terminated from the East Liverpool Police Department earlier this year over numerous complaints of misconduct, including “dishonesty,” but none related to the fentanyl incident. 

False police reports of secondhand fentanyl overdose are remarkably consistent.

False police reports of secondhand fentanyl overdose are remarkably consistent: After alleged contact through the skin or in the air, an officer feels lightheaded, dizzy, and then faints. Their heart races, they feel sweaty, their chest tightens and their breathing becomes rapid. 

These are certainly frightening symptoms. They are not, however, the symptoms of an opioid overdose.

Overdose from an opioid like fentanyl would take the form of loss of consciousness and slow, shallow breathing that eventually stops. There would be tiny pupils, and dusky or bluish skin around the lips and fingernails, depending on the person’s skin tone. These were not the symptoms Faiivae displayed. So what exactly is going on here? 

Illicit fentanyl cited by police comes from a different source than the fentanyl I accidentally sprayed on myself in the ambulance, but it is still the same molecule. Fentanyl was first used medically in 1968, developed by then-nascent Janssen Pharmaceuticals. Unlike morphine or opium, it is a synthetic opioid, meaning it comes from a laboratory and not from nature. As such, fentanyl is thoroughly studied and well understood, its chemical and physical properties extensively documented for decades.

We know that its chemical properties and arrangement of atoms mean it doesn’t pass through our skin without additives to help it along, and even then it takes hours (as anyone who uses fentanyl skin patches can attest). We also know that it’s a heavy molecule that doesn’t linger in the air and thus does not pose an accidental inhalation risk. Secondhand fentanyl overdose is not a real concern.

The experiences of officers like Faiivae are often most reasonably explained by anxiety, ironically brought on by the panic stoked around illicit fentanyl by police departments themselves. Police-targeted outlets publish guides on how to safely handle fentanyl that include recommendations for respirators and HAZMAT gear. Fentanyl-resistant gloves are now commonplace and actively marketed to first responders. As officers work in an environment where they’re inundated with horror stories of fentanyl taking down colleagues through mere incidental exposure, fear and anxiety build to a fever pitch. 

Textbook mass hysteria right here. Research shows that surging attention paid to cases (like the video from San Diego last week!) triggers more cases. This is particularly true if victims are part of somewhat closed tight-knit communities (ie, California cops!) https://t.co/BnxAXkQQ60

— Natalie Shure (@nataliesurely) August 10, 2021

Police culture widely rejects the appearance of weakness and vulnerability, such that responding to anxiety in a constructive way—perhaps by talking to a mental health professional—is widely underutilized and viewed as unacceptable. In a culture that fetishizes mental and physical toughness and abhors vulnerability, fentanyl makes a handy scapegoat for covering anxiety attacks.

This idea that certain bodies are fundamentally tainted was coined the “poisoned-body myth” by sociologist Liz Chiarello. Many of us remember the early days of the HIV epidemic, when panic fomented by lack of information but plentiful homophobia led to rumors that the virus could be spread on public toilet seats, or by hugging. I distinctly remember an elementary school gym teacher, clad in ’80s tube socks and short shorts, warning us to never put our fingers in the coin returns of vending machines because people hid HIV-tainted needles in them.

Of course, none of this was true. But those rumors discouraged people from touching or even associating with people living with HIV. Health care professionals routinely refused to care for HIV-diagnosed patients. Bystanders balked at performing CPR when needed, despite the infinitesimal risk of HIV transmission through mouth-to-mouth contact. HIV transmission can still bring felony charges in some US states today. 

We repeat that history by spreading false information about fentanyl. We paint drug users as literally, physically toxic to be close to—dangerous to approach or touch, even if they’re experiencing an overdose.

In response to the San Diego Sheriff’s Department video and its claims, hundreds of health care professionals, first responders, journalists, people who use drugs and public health researchers (including me) signed an open retraction request. It’s aimed at news outlets that publish, unchallenged, police accounts of passive fentanyl overdose. 

“By speaking with one voice through this letter, we seek to hold reporters, media outlets and law enforcement organizations accountable for spreading dangerous misinformation,” University of Texas at Austin Professor Dr. Lucas Hill, one of the letter’s authors, told Filter. “Passive fentanyl exposure is not a health risk for overdose responders. It’s time to kill this myth for good.”

Photograph via United States Military Health System

The post A Guide to Fentanyl Touch Overdoses, Which Do Not Exist appeared first on Filter.

Almost certainly not. The concern that cannabis flower is being dusted with fentanyl is not new, either. Back in 2017, Hamilton County, Ohio coroner Dr. Lakshmi Sammarco was quoted at a press conference saying that “we have seen fentanyl mixed with cocaine, we have also seen fentanyl mixed with marijuana.” In a follow-up piece in Vice, Sammarco clarified that she had, in fact, not seen evidence of fentanyl-contaminated cannabis, but was instead repeating something that her co-presenter, US Senator Rob Portman, had told her before that presser—and she didn’t know where he sourced his information. Further reporting found no good evidence of fentanyl-laced bud, and instead only speculation, the suspicions of anxious parents and social media hearsay.

Despite no verified, reliable reports of fentanyl-laced cannabis out there, the rumor remains.

I focus here on cannabis flower—not resins, oils, vape cartridges or other processed forms of cannabis. However, while these forms’ added steps of handling and processing make them less clear-cut than simple bud, and contamination has at times occurred—as with the role of vitamin E acetate in unregulated THC products in lung injuries that were wrongly attributed at first to e-cigarettes—there is still no evidence of any widespread fentanyl contamination in such products.

Even in cases where someone dies of fentanyl poisoning and postmortem drug tests are positive for THC, chances are high that these drugs were used separately. THC famously lingers in the body’s fat for days or weeks, resulting in positive THC tests well after the last use of the substance.

Despite no verified, reliable reports of fentanyl-laced cannabis out there, the rumor remains. When awareness of a new drug permates a community, panic and rumor reliably follow. And while the potential harms of fentanyl are very real, their context is critical.

Fentanyl is a good and important medication, used around the world in hospitals and ambulances to ease suffering. It has played a key role for COVID-19 patients in critical condition. But that hasn’t stopped personal protective equipment manufacturers from advertising their products as “fentanyl resistant” and recommending full-body suits with a respirator for being near the drug, none of which is necessary.

As past unfounded and harmful fears around “reefer madness,” “crack babies” and MDMA being dropped into trick-or-treat buckets illustrate, drug panic and rumors are constant—and reliably more histrionic than the actual potential harms of a given substance.

We can also consider what kind of actual risk there would be if someone did get fentanyl on their cannabis flower.

A good start to combating ignorance-based panic is knowledge. Just as we should know about the absence of evidence for fentanyl contamination, we can also consider what kind of actual risk there would be if someone did get fentanyl on their cannabis flower.

There are, of course, a few different ways to consume cannabis. The method most of us probably think of is smoking. In the case of cannabis flower, smoking involves loading the material into a pipe or roll paper, lighting it on fire, and inhaling the smoke. Burning fentanyl with flame destroys it, so even if someone smoked cannabis contaminated with fentanyl, the fentanyl would not be active in the smoke. In fact, burning drugs in an incinerator is a common way to dispose of them, both for prescription medications and for illegal drugs seized by law enforcement.

Edibles are another point to consider. What if fentanyl were baked into a pot brownie or gummies? The first thing to point out is that swallowing fentanyl and absorbing it through the gut is a very different experience from injecting it without knowing that it’s present in the shot—the circumstance that’s driving overdose rates. Just as taking hydrocodone tablets produces a more gradual and controlled high than injecting a comparable amount of heroin or morphine into a vein, the effects of oral medications are more controlled and less risky just based on this route of administration.

Fentanyl in particular is low-risk if eaten because it doesn’t work well when given orally. While there are formulations of fentanyl that are absorbed through the inside of the cheek or under the tongue, when swallowed it’s heavily broken down by our liver before the drug has a chance to get to the brain. As such, fentanyl isn’t manufactured as a pill or liquid to swallow.

But another layer of safety here is that fentanyl is unstable in heat. In the process of decarbing cannabis and baking, or applying heat to extract cannabinoids into an oil, the drug would be partially degraded. Fentanyl has a few different points of vulnerability—heat, ultraviolet light and even hydrogen peroxide. Even if fentanyl made it into a batch of brownies, oil or other edible medium, the heat used for baking, decarbing or extracting would erode the fentanyl steadily and surely.

Vaping cannabis, and the potential risk of vaping fentanyl in the process, is a more nuanced discussion. Fentanyl definitely can be vaped, although the process of heating it on a piece of foil and inhaling the wispy vapor that rises from it is usually called “smoking.” (I only point this out to make the distinction between this method and “smoking” by lighting a substance aflame.)

But whether fentanyl could reasonably be vaped accidentally with bud is another issue. When we vape anything, we inhale the vapor coming off of a substance that’s been heated to its boiling point. This is true even for solids, and is the science behind “smoking” crystalline solids like meth and crack. If you never heat a substance to its boiling point, it won’t produce vapor—just like if your stove never gets hot enough, a pot of water won’t boil.

It’s much easier to imagine this molecule as a grinning boogeyman than it is to confront the grisly consequences of the War on Drugs and our own role in perpetuating them.

Fentanyl’s boiling point is 466℃, or about 871℉. For comparison, I consulted the sites for two popular brands of vape used for cannabis: Pax and Grenco. Pax states that the hottest temperature reached by its products is 210℃. Grenco, maker of the G Pen, states that the highest setting of this device gets to 220℃.

This makes sense, as the boiling points for the desirable compounds in cannabis, like THC, CBD and the many terpenes, don’t exceed this temperature. An excessively hot device could potentially release harmful compounds, but would also be less pleasant for the user and run down the battery more quickly. So while fentanyl can be vaped, it needs high heat to get there, and the devices used to vape cannabis simply don’t get that hot.

The panic around fentanyl is not only a distraction but a missed opportunity. It’s much easier to imagine this molecule as a grinning boogeyman coming to snatch our children than it is to confront the grisly consequences of the War on Drugs and our own role in perpetuating them. You can stop worrying about fentanyl in the weed. Let’s worry about building a safe supply, opening safe consumption sites, and promoting harm reduction programming. There are plenty of real boogeymen out there.

Photo by Cambridge Jenkins IV on Unsplash

The post The Pernicious Myth of Fentanyl-Laced Cannabis appeared first on Filter.

Our math teacher’s approach is an example of the operant conditioning modality of positive punishment. It discourages a behavior by adding (hence the “positive”) a noxious stimulus, and the subject of that stimulus then learns to avoid it by changing the behavior in question. This cycle is familiar to many survivors of abuse, relationship violence and bullying. It’s recognizable in even society’s most mundane forms of positive punishment, like parking tickets. 

In April, the Food and Drug Administration approved Kloxxado, an 8 mg naloxone nasal spray. Kloxxado is similar to the much more recognizable Narcan, which is a 4 mg nasal spray. Both are single-dose products of the same silhouette and general size. But while opioid users are widely familiar with Narcan’s standard 4 mg, Kloxxado’s double-strength dose is unprecedented.

By contrast, single-dose vials of intramuscular naloxone found in ambulances or on pharmacy shelves are 0.4 mg. Just one or two doses injected into a muscle have remained consistently effective even in our increasingly fentanyl-saturated market. Kloxxado produces a maximum blood plasma concentration more than 11 times what’s usually sufficient. 

Even with the proliferation of novel opioids, there is no compelling evidence for an 8 mg sledgehammer.

The rollout of an 8 mg naloxone product was probably inevitable. Rates of fatal overdose have increased exponentially over the past decade, and reached a catastrophic zenith under the pandemic as people who use drugs were forced to isolate, source their supply from unfamiliar sellers and adjust to dramatically reduced hours and services among syringe service programs (SSP). 

Even before the pandemic, aggressive prohibition was relentlessly splintering the composition of the state-banned drug supply. What’s sold as heroin these days is likely to contain any number of names in a long list of unfamiliar, polysyllabic molecules—flualprazolam, furanylfentanyl, isotonitazene. These names are unfamiliar to most of us, and unfamiliarity breeds fear. 

But even with the proliferation of novel opioids, there is no compelling evidence that supports a need for an 8 mg sledgehammer. The 4 mg Narcan already achieves a high plasma concentration and comes in a standard two-pack; in the event that the second dose is needed, it can be administered a few minutes after the first. But this hasn’t slowed the flood of misguided news stories of naloxone-resistant opioids that can take a cop down with mere incidental exposure. Panic builds, marketing opportunity arises and now we have Kloxxado. And on the horizon, another product that’s more potent still.

Currently under development for commercial rollout as a nasal spray, nalmefene is an opioid antagonist that works similarly to naloxone but clings to opioid receptors more tightly, for much longer. It was relatively unheard of before Opiant Pharmaceuticals pitched it as the answer to a 2017 National Institutes of Health call for “stronger, longer-acting formulations of antagonists” to combat the rise in fatal overdose. The resulting product will be around five times more potent than Narcan.

Naloxone revival can be a brutal experience. It throws the recipient into an abrupt whiplash from being high to being in withdrawal—bringing nausea, vomiting, pain, chills, sweats and diarrhea. In the hands of a skilled administrator, intramuscular naloxone can minimize this suffering because it can be dosed slowly and conservatively.

But gradual titration isn’t possible with nasal sprays—like Narcan, Kloxxado and the forthcoming nalmefene product—because the plunger delivers the entire dose in one push. This can make it easier for people without medical training to administer, and an easily taught intervention is usually for good public health. Except when outsized dosing comes into play. 

It’s not just that naloxone doses of 8 mg or higher are unnecessary—they may be actively harmful.

It’s not just that naloxone doses of 8 mg or higher are unnecessary—they may be actively harmful. For opioid-tolerant users, waking up to agonizing pain can prompt the understandable desire to make it stop. The quickest way to do this would logically seem to be consuming an opioid.

Often what’s at hand will be the same batch that led to overdose only moments before. And because the naloxone will still be active in the brain for several hours, any opioids used in that time won’t bring the expected relief—pushing some people to use even greater amounts, out of desperation. So on top of the positive punishment effect training people to associate naloxone with misery, ultra-potent opioid antagonists could be poised to increase fatal overdose.

There are ways we can reduce this harm; take the handful of EMS programs that offer post-naloxone buprenorphine to ease withdrawal. But it’s much more common for health care providers to treat people who use state-banned drugs with hostility, contempt and lack of empathy. If we embrace ultra-potent opioid antagonists, we send yet another signal to drug users that their suffering is incidental, as is whatever happens to them after we pack up and leave. 

It’s not hard to imagine Kloxxado and the nalmefene product enjoying a warm welcome from law enforcement. Bureaucrats, too, may appreciate these products as an easy out when speaking about the overdose crisis; they can assure the public that they’re funding the strongest possible interventions. But comfort of police officers and public officials is immaterial to this crisis. We must consider the risk of ultra-potent opioid antagonists functioning as positive punishment—teaching the people at highest risk of overdose that overdose antidotes are simply not worth the misery. 

Before reaching over Narcan for Kloxxado, or Kloxxado for nalmefene, talk to the populations who are going to be on the receiving end. They can tell you that in most cases, no good will come from use of these products. Tread cautiously. 

Photograph via Flickr/Creative Commons 2.0

The author would like to thank Dr. Lucas Hill at The University of Texas at Austin College of Pharmacy for his feedback and guidance in developing this piece. 

The post The Naloxone Arms Race Is Headed Nowhere Good appeared first on Filter.