It was out of my reach. A gram of ketamine, about two months’ worth of therapeutic doses, costs around $100 on the illicit market. But that was out of my comfort zone and purview. Instead, I got prescribed Xanax and made it through.

My moods wax and wane, but the suicidal ideation is a constant. When my mood is low, the siren song is most tempting. When my mood is stable, the intrusive thoughts are little more than illogical annoyances.

Multiple psychiatrists had long encouraged me to try SSRIs. But an experience of being forcibly detoxed from Suboxone after turning myself into jail left me with lingering trauma around medications that require daily dosing.

In summer 2022, a bad breakup combined with a grueling workload pushed me over the edge. I acquiesced to my psychiatrist’s recommendation and started Lexapro. One month later, I nearly jumped off a building. Familiar suicidal ideation morphed into something new and terrifying: impulsive, active suicidality. My psych advised me to immediately discontinue the SSRI. A little while later I tried an SNRI, and cried uncontrollably for days.

“Your insurance may cover it,” were five of the sweetest words I’d ever heard.

That’s when, for the first time, a medical professional directly recommended I try ketamine.

Specifically, she recommended Spravato, which is esketamine, an isomer of ketamine patented and produced by Janssen pharmaceuticals. “Your insurance may cover it,” were five of the sweetest words I’d ever heard.

Ketamine, first formulated in 1970, is a widely used generic medication. With a wide therapeutic index, it’s on the World Health Organization’s list of essential medications for its anesthetic and analgesic properties. Off-label, it’s shown efficacy in treating depression, PTSD and suicidality.

Health insurance will rarely cover ketamine for one of its off-label mental health uses, though. (Yet my insurance covers my propranolol, which is prescribed off-label for anxiety.) But mental health care has long received inferior coverage compared to physical health, even after the passage of a law designed to bring equity.

The scientific literature surrounding ketamine’s efficacy is ample and dates back decades. Esketamine, on the other hand, is expensive, less studied and less efficacious.

Why does my insurance cover esketamine, then? Because Janssen Pharmaceuticals invested millions in double-blind randomized controlled trials (RCT) to get it FDA-approved for treatment-resistant depression. While many studies show ketamine as effective for depression, they are not of the holy-grail, double-blind RCT variety that the FDA demands.

Jacob Sherkow, a professor of law and medicine at the University of Illinois, and an expert on intellectual property and drug regulation, told Filter that insurance reimbursement for off-label uses is complex. “At times contrary to their economic interests, insurers tend to prefer on-label uses.”

Earning FDA approval—to win that golden on-label distinction—is an expensive and onerous process. Janssen did not do this with ketamine, of course. Instead, it isolated the s-isomer of ketamine, and put it inside of an nasal aerosolizer delivery device, creating a patented combination device.

Meanwhile, people who use unregulated forms of ketamine, a Schedule III drug—perhaps because they don’t have insurance coverage—still face arrest and jail. There’s also the familiar issue of drug-supply contamination.

I did my intake at a health clinic that offers intravenous ketamine infusions for cash payments ($495), and Spravato via insurance. Nestled in a nondescript medical plaza in Southeast Portland, the low-slung brick buildings and bubbling fountain gave little indication that behind the glass door, people were tripping balls.

Twice a week for the first month, then once a week as long as my insurance will cover it, up to 18 months.

I was an obvious candidate, being actively suicidal. Ketamine shows remarkable promise at reducing suicidality, with 69 percent of participants in one study showing marked improvement quickly. There was one problem: Spravato is only FDA-approved as a combination therapy, to be taken alongside SSRIs or SNRIs, even though it barely met criteria for producing statistically significant results. Seeing as that class of medication nearly precipitated a suicide attempt, my psych was unwilling to try another one. Thus began a months-long fight with insurance—an ironic protocol for someone who is actively suicidal.

The clinic eventually won a waiver, meaning I could do Spravato as monotherapy. The frequency is standardized: twice a week for the first month, then once a week as long as my insurance will cover it, up to 18 months.

My insurance, which I’m lucky to even have, pays out about $1,200 for Spravato but—typically—wouldn’t cover ketamine off-label, which would be much cheaper, though still require expensive sessions with providers. My total out-of-pocket expenses for this first month will be $280 in copays, plus the Uber rides necessary to get to and from the clinic.

When I finally got approved, the soonest available appointment was five weeks out. Demand for insurance-paid esketamine is high.

While I waited, I posted on Medium about starting Spravato. Janssen Pharmaceuticals emailed me at work, to ask for a correction for referring to it as “ketamine treatment.” Conscious of both its patent and anti-drug rhetoric, the company is devoting significant efforts to making the distinction.

And a hefty PR budget. A big red box showed up on my doorstep, unannounced. It was from Janssen and full of schwag: an intentions journal, Listerine breath strips and a head massager. Clearly, Spravato is not a generic medication with a narrow profit margin.

Day One

I showed up to my first appointment early and was led into a room that looked like a cross between a doctor’s office and therapist’s. A white recliner in the corner with an empty IV-hanger to the left. On the floor, the kind of cloud-and-stars blacklight projector you’d see at the home of the hippie who sells you weed, possibly purchased at Spencer’s.

A psychiatric nurse practitioner went through an excessively long checklist about everything bad that might happen, from high blood pressure to bladder issues to the psychoactive state of “dissociation.” I filled out a depression and anxiety score sheet, as I will do every session.

A technician took my vitals and offered me a quirky array of snacks and beverages. When I declined, they reminded me that Spravato is a nasal spray and tastes bitter. I opted for some Werther’s hard candies and a Kind bar. A tech brought me a heated blanket.

The first day’s dose is 56 mg. As an inveterate drug nerd, I asked about the bioavailability of this route of administration, and they told me 30-40 percent. I was shown the device: a 28 mg nasal spray containing two squirts’ worth, and displaying two green-to-white indicator dots.

The device was trickier than I expected, much more so than Narcan. I practiced the push-once-push-twice maneuver with a tester, alternating nostrils. Finally, I was ready. “Can I dose now?”

They turned on the corny lights-and-stars backlight, which is pleasant even when sober. They reminded me of the stars I saw on night watch during a recent sailing trip in the vast Pacific Ocean, one of the last times I didn’t feel suicidal.

My positioning was off, and the spray leaked out of my nose. They had me sniff and tilt my head back, similar to how I once learned to do cocaine.

I peeled the first device out of its plastic packaging, positioned my thumb over the plunger, and stuck it in my nose as far as its wings would allow. I fumbled trying to administer it, with the device requiring much more force than I’d predicted. I could barely detect the spray going up my nose.

Exactly five minutes after the first dose, the PNP handed me the second 28 mg device and I did each of its two 14 mg squirts in alternating nostrils. My positioning was off, and the spray leaked out of my nose. They had me sniff and tilt my head back, similar to how I once learned to do cocaine. Life always comes full circle.

After the second dose, the provider exited the room, leaving me alone with a security camera to monitor me.

I felt almost no effects. Eventually, I felt very bored. The law mandates they keep us for a full two hours after dosing. At the halfway point, a technician entered to take my blood pressure, which was elevated, as is standard.

How It Affects Me

Having to get a ride to the clinic and carve two hours out of my day, twice a week, is challenging. But so is crippling depression and the constant drumbeat of “kill yourself” dancing through my mind.

The second session that week was my first full dose, at 84 mg—three of the nasal spray devices at five-minute intervals. Unfortunately, the only time they had available was 9 am. It’s weird to trip and then have to return to work. It’s much better suited for an end-of-day activity.

Spravato works more slowly than ketamine infusions, and likely not as well. But patients across the country report: It does work—sometimes, for some people.

To explain how it affects me, I must first articulate how it feels to be bleakly depressed. It’s as if I am living life through a filter, one which dulls not only colors but tastes, sensations, smells and pleasure. Intellectually, I can see myself living a wonderful life, but it’s almost as if I’m watching someone else live it, unable to fully experience the joy I know I should be feeling.

My therapist calls this anhedonia. I do not always notice it in real time, as everything that makes my life worth living slips away into mundanity and tedium. I live muted to life’s pleasures but hyper-sensitized to its pains. I’ve struggled with this since I can remember.

The simplest of tasks feel impossibly behemoth. Dishes pile in the sink, texts and calls go unanswered, and unfinished work begins a guilt-and-shame tailspin that only worsens the procrastination that led to the mounting pile in the first place. Trivial errands fill me with dread and anxiety. God forbid it is trash day and I need to wheel my trash can to the street. It requires so many steps. When my flight is taking off and landing, or hitting turbulence, there’s always a moment I hope I’m crashing. Then I won’t have to have done it myself, but it will be over nonetheless. I immediately regret this when I realize there’s no way I’d be the only casualty.

Perhaps the first sign the fog of depression is lifting is a liked song on Spotify.

What does ketamine feel like? It’s a question that’s been asked countless times on Reddit and Erowid, and never quite answered. It’s an odd drug. Sensory perceptions distort, motor coordination diminishes.

The light machine in the dark room, I find, looks cool. I feel comfortable, like I could melt into the recliner. Music is the most tell-tale sign: it sounds cool. If I go to change the song, my eyes struggle to read against the digital screen. My cognitive function remains fairly intact but shrouded in disorientation. What speech I muster may be slurred, and my responses would be odd anyway.

A true ketamine high—which can be achieved by what is also considered a therapeutic dose, depending on whose protocols you’re reading in PubMed—separates the consciousness from the body.

All my compartmentalized, fractured selves and all my distinct dimensions collapse in on themselves. What exists in my robust virtual world versus my tangible, physical world gets jumbled, disorientingly, with both seeming to exist simultaneously. When my consciousness settles back in, slowly reconnecting its many tendrils to reactivate its integration with my body, it seems to do so having sloughed off much of the detritus that formed in that space between thought and action, the space where my depression lives.

Perhaps the first sign the fog of depression is lifting (a cliché, but they exist for a reason) is a liked song on Spotify.

I’ve always been passionate about music and will often have it playing in the background. I do this out of habit, even when depressed. What I do not do when depressed is really feel the music—think upon hearing a new song, “This is a great song!” before pressing the like button to add it to my library.

I’ll like a few new songs in a day, realizing how previously, I’ve gone weeks without adding anything to the library. If I could crunch the numbers, I guarantee my averaged liked songs on Spotify per week would inversely correlate with my depression.

The same correlation applies to how often I spot a sight worth photographing. I have long been known to stop anywhere to take a picture of something I find intriguing, odd or beautiful. But my ability to perceive beauty is diminished when I can only see the world through a sepia filter.

In our regulatory reality, Spravato is better than no ketamine at all.

I’m now on my third week of treatment. My copays and Uber rides are adding up, not to mention the effect of the multi-hour sessions on my schedule. But after next week, I’ll be dropped down to once-a-week sessions.

Intravenous medical ketamine would work better. I suspect the dosages of Spravato are designed to minimize psychoactivity—dissociation—because God forbid patients get high. (In large-scale clinical trials, too many middle-Americans experiencing dissociation would cause higher rates of unwanted dropouts.)

When I voiced my complaints about Spravato not working as well as ketamine could, the clinic seemed unsurprised. I was told to stick it out, but a few bad days had me considering a $495 ketamine infusion. Or suicide. You know, whichever.

Illicit ketamine would also work better and be cheaper than my copays, even. But because it’s a banned drug, I sit prisoner in a recliner for two hours, twice a week, to pay exponentially more for a less effective treatment for my life-threatening depression.

In our regulatory reality, Spravato—which is, before they email me again, not ketamine!—is better than no ketamine at all.

All photographs by Morgan Godvin

The post The Spravato Diaries: My Ketamine-ish Depression Treatment appeared first on Filter.

Since at least 2020, counterfeit pills have become the dominant illicit opioid in many US cities’ drug markets. They pose heightened risk to people who believe they are consuming genuine pharmaceuticals and don’t have opioid tolerance. As such, they’re a major contributor to surging rates of adolescent overdose.

Medical tourism is meanwhile a burgeoning industry, as the US remains a global outlier in the unaffordability of its health care costs as they continue to rise. Just over the Mexican border, whole neighborhoods service Americans who border-hop in search of medical and dental care, as well as cheaper prescription drugs.

Of the “oxycodone,” 30 percent was counterfeit—of which the majority was fentanyl-based.

Our research team conducted an experiment by entering 40 pharmacies in selected neighborhoods across four tourist-heavy cities in northern Mexico, and asking for oxycodone, Adderall and Xanax. The pharmacies were chosen for being independent, non-corporate establishments that appeared to cater to US tourists, and all the transactions were conducted in English.

Fourier-transform infrared spectroscopy (FTIR) and immunoassay-based testing strips were then utilized to test the purchased pills for benzodiazepines, fentanyl, methamphetamine and amphetamine.

A whopping 82 percent of “Adderall” purchased across the pharmacies (eight out of 11 samples) was actually meth, pressed to look like a 30mg Adderall pill. Of the “oxycodone,” 30 percent (eight of 27 samples) was counterfeit—of which the majority was fentanyl-based. Surprisingly, given heroin’s virtual disappearance from many North American markets, three of the “oxycodone” samples were heroin-based counterfeits that tested negative on fentanyl test strips. All of the pills purchased as Xanax, however, were presumed to be authentic after drug checking.

Altogether, 11 of the 40 pharmacies visited were found to be selling counterfeit pills.

The numbers of drug or medical tourists buying pills from these pharmacies, or when exactly counterfeits became available there, are unknown. But the researchers identified both genuine and counterfeit oxycodone being sold near each other, and utterly indistinguishable from one another except by advanced drug-checking methods.

“For the pills that contain heroin, it’s not even something you could pick up with the standard harm reduction advice to use fentanyl test strips.”

“The alarming thing about these findings is that people probably think they are getting a pill with a known strength, known ingredients, and then it turns out to be something much stronger,” Chelsea Shover, PhD, of UCLA and the senior author of the research, told Filter. “Ultimately this increases risk of overdose.”

The presence of heroin-based counterfeits additionally stretches the typical harm reduction advice of “check your drugs” to its limits. “For the pills that contain heroin, it’s not even something you could pick up with the standard harm reduction advice to use fentanyl test strips,” Shover said. “So that is both alarming and a unique strength of using the FTIR spectrometer alongside test strips.”

But virtually no one who uses drugs has access to this technology. Though heroin is less potent than fentanyl, the unknown dosage in a counterfeit pill can just as easily lead to overdose.

Another alarming finding are lower-miligram counterfeits that are more likely to be consumed by less experienced drug users, or simply a tourist with a toothache: “Percocet” and even “Vicodin” were found to be counterfeit. (While our research team identified counterfeit Vicodin that was simply tramadol, an LA Times investigation, published on February 2, detected fentanyl-based Vicodin counterfeits.)

As for the meth-based counterfeit Adderall, the unknown dosing and lack of quality controls in production are cause for concern. A pill purporting to be 30mg Adderall could contain anywhere between trace amounts and huge doses of methamphetamine. (Meth, it should be noted, is an approved medication for the treatment of ADHD in the form of Desoxyn; principal health risks come from the unregulated supply and unknown dosage.) Clandestine pill presses open up the potential for cross-contamination, especially risky if fentanyl makes its way into a pill bound for a person with no opioid tolerance.

The research team asserts that Mexico does not capture accurate drug-use or overdose data, and that the scope and impact of these phenomena on either domestic or tourist populations are therefore unknown.

Opioid use among the Mexican population remains low, however. Addiction rates (other than alcohol use disorder) are a fraction of those seen in the United States. The few cities that do see high rates of opioid use are along the border, and people who use opioids are predominantly deported from the United States, where they often began their use. According to ethnographic accounts of drug-use patterns in Mexico, people most often consume goma (black tar), china (fentanyl/heroin) or cristal (meth). Mexican citizens are relatively unaccustomed to pharmaceutical opioids, and pain is undertreated in the country.

Our findings should be treated as an artifact of America’s dysfunctional relationship with drugs in general, and pharmaceuticals in particular.

So it seems reasonable to hypothesize that Americans are the main recipients of the counterfeit pills in these pharmacies. Tourists should beware of the likelihood of getting a substance much riskier than what they thought they were buying. Mexican law is clear: You need a prescription for controlled substances, and if you purchase even genuine pharmaceuticals without a prescription, the transaction is illegal. The illegal nature of these transactions leaves them inherently unregulated, increasing the chances of counterfeiting. In all, it is a minefield.

Our research findings should be treated, too, as an artifact of America’s dysfunctional relationship with drugs in general, and pharmaceuticals in particular.

The vacuum left when opioid prescribing plummeted by nearly half in a decade—thanks to unprecedented levels of government meddling in medical practice—was swiftly filled by the illicit market. More recently, Adderall shortages have threatened the prescriptions of millions of Americans accustomed to pharmaceutical amphetamine.

If sanctioned pipelines of pharmaceuticals dry up, it affects not only the people who were prescribed that medication, but also the people who bought those pharmaceuticals “diverted” onto the illicit market. When the opioid-involved overdose crisis was first identified in the mid-2000s, government officials decried 10,000 opioid-related deaths per year. Slashing opioid prescribing—ostensibly an effort to reduce the death count, although some of the policy’s architects were well aware of the potential consequences—saw deaths skyrocket. Both chronic pain patients and people using pharmaceutical opioids without prescriptions were pushed towards illicit opioids—first heroin, and later fentanyl.

The shift to counterfeit pharmaceuticals wasn’t immediate. It took a number of years for the illicit market to accommodate consumer preferences for pharmaceutical-style opioids, but accommodate them it did.

With Adderall, it’s happening faster. As the current scarcity reaches its peak, counterfeits are already in mass production. Journalist Christopher Moraff shared his testing of meth-based “Adderall” in Philadelphia’s drug supply on January 30.  

The adderall shortage is now spreading to methylphenidate drugs like ritilan. Meanwhile counterfeit 30mg pressed adderall are popping up in Philly- this one showing a presumptive positive for meth. pic.twitter.com/0zstOn6r7d

— Christopher Moraff (@moraffreports) January 30, 2023

Without the kind of drug policy changes that the US government refuses to even contemplate, there’s no going back from an environment in which counterfeit pills—not inherently riskier than what’s already on the market, but posing great danger to those who take their branding at face-value—are the norm.

The cornerstone of America’s “partnership” with Mexico against illicit drugs is that the US will work on demand reduction if Mexico tackles supply reduction. Mexico has recently arrested several more bosses of trafficking organizations, each time spawning more spasms of the violence that has raged in the country since 2006, but never reducing supply. The US has utterly failed to reduce demand. The price of both meth and fentanyl continues to fall despite inflationary pressures. Now, America’s voracious drug consumption is finding new ways to encroach onto Mexican soil.

Photograph of counterfeit oxycodone pill via the Drug Enforcement Administration

The post The Counterfeit, Fentanyl-Based Pills Sold at Some Mexican Pharmacies appeared first on Filter.

A mere 20 minutes after the paramedics left, from the comfort of her own living room, she was able to meet virtually with an addiction medicine prescriber, who offered her a prescription for buprenorphine.

“An example like that happens every day,” Dr. Joshua Lynch, founder and medical director of NY MATTERS, told Filter. It was his clinic that was able to see the woman in the minutes after her overdose. Buprenorphine reduces mortality by 37 percent when prescribed to people with opioid use disorder (OUD). And yet this lifesaving intervention is bound by so many regulations that most people who need it still struggle for access.

One of the most pivotal addiction treatment shifts in decades came about almost by accident. The COVID-19 pandemic exposed gaping holes in the US health care system and left people who use drugs, among others, more isolated and vulnerable than ever. However, there was one bright spot in the darkness: Shuttered clinics inspired a herculean effort to move care to telemedicine.

“I needed to get that first step in order to get out of that cycle.”

Telemedicine was initially thought of as a way for people already receiving care to continue receiving it despite shutdowns. But it accomplished something else, too: It brought in people who, for a variety of reasons, were unwilling or unable to receive in-person health care.

“I felt that I needed to get that first step in order to get out of that cycle,” Red, a Portland resident, told Filter. A chef by trade, he lost his job and his housing several years before the pandemic. “Homelessness and addiction make it hard to keep appointments.”

Red received buprenorphine for the first time during the pandemic. Photograph courtesy of Red.

He painted the scenario like this: Without electricity or a phone, he had no alarm clock. Without transportation, he struggled to get anywhere. How was he supposed to show up for in-person appointments?

His lack of access wasn’t for lack of want. “I wasn’t even getting high anymore. I was so sick of everything revolving around drugs. It gets tiring.”

Without the internet, he heard only flickers about the pandemic descending on the globe. It wasn’t until the laundromat near his encampment closed, with huge signs reading, “CLOSED DUE TO COVID-19,” that he realized how big this had become.

The Huge Barriers of US Regulation

When people who use drugs are known to avoid health care settings due to stigma, why wasn’t telehealth buprenorphine prescribing available long ago? It’s a question many in the harm reduction field have been asking.

The direct answer, dispiritingly, is a byzantine US regulatory structure—in which compliance and control, not access or efficiency, have been the goals.

In 2002, right after the FDA approved buprenorphine for the treatment of OUD, the DEA rescheduled it into a more restrictive category

The Controlled Substance Act of 1970 placed all regulated substances into one of five schedules, with Schedule I the most highly restricted (considered to have no accepted medical use and high potential for “abuse”). Both the Drug Enforcement Agency and the Food and Drug Administration play roles in categorization and enforcement. Buprenorphine was originally in the restricted Schedule II (“high potential for abuse”). However, after an injectable formulation was approved for pain treatment in the 1980s, it was moved to the least restricted Schedule V (“low potential for abuse”).

Most tellingly, it was in 2002—right after the FDA approved buprenorphine (Suboxone and Subutex) for the treatment of OUD—that the DEA rescheduled it into a more restrictive category, Schedule III.

By then, the opioid-involved overdose crisis was already headline news. A singular focus on prescription opioids led to broad crackdowns on prescribing; a shift to unregulated opioids would follow, culminating in the unprecedented deaths, mostly involving illicit fentanyl, that we see today. Lawsuits against opioid manufacturers, pharmacies and distributors have meanwhile led to settlements totalling in the billions.

Policies misguidedly designed to reduce harm by making opioids hard to access are increasing harm, paradoxically restricting OUD treatment. Though any DEA-registered physician can prescribe opioids for pain, buprenorphine to treat OUD requires a special “X-waiver” and additional training.

Buprenorphine is a partial opioid agonist and a partial antagonist, acting differently in the brain to full opioid agonists like heroin, oxycodone or methadone. Bupe has a very high affinity to mu opioid receptors—but low intrinsic activity at the site, hence the “partial” agonist. This means it will displace other opioids in the receptors.

Its antagonist properties mean it has a very low risk of respiratory depression, the most commonly fatal symptom of opioid overdose. Its effects do not increase linearly with increased dosage, making it less desirable (a mere 4 percent of respondents in one study reported it as their drug of choice). For some, this means it can also be less effective in treating OUD, with methadone showing higher reduction in mortality and higher patient retention. But unlike methadone, buprenorphine prescriptions can be obtained via a regular provider, picked up from the pharmacy and dosed daily from home.

The specter of “diversion,” in a political landscape bent on restricting all opioids, has consistently been used to hold buprenorphine access back.

In August, on a panicked Dept. of Health and Human Services (HHS) and DEA call about reduced buprenorphine access at pharmacies nationwide, a DEA officer referred to the sharing or selling of bupe among people who use opioids as “righteous diversion.”

Yet the specter of “diversion,” in a political landscape bent on restricting all opioids, has consistently been used to hold buprenorphine access back. In reality, diverted buprenorphine is most often used in ways aligned with its clinical indications. Diverted bupe can decrease the risk of fatal overdose and improve treatment outcomes.

The X-waiver, created by Congress in 2000, is the most salient example of the addiction treatment paradox. It meant that buprenorphine, uniquely, could only be prescribed by “X-waivered” prescribers, whose special registration with the DEA required eight hours (for physicians) or 24 hours (for all other providers) of additional training.

Last year, the federal government finally recognized these requirements as a “perceived barrier” to buprenorphine prescribing. It eliminated them—but only for providers who wish to be capped at 30 buprenorphine patients. For those seeking the standard cap of 100 patients the first year, 275 patients all subsequent years, the requirements around training, counseling and psychosocial services remain. A true X-waiver fix would require legislative action.

Technology has developed much faster than our laws. The Ryan Haight Consumer Protection Act of 2008 was a response to online pharmacies occasionally prescribing in an unscrupulous manner, pumping out opioids with little oversight, which did result in some fatal overdoses. In keeping with anti-opioid sentiment, the sweeping law covered not only full agonist opioids but all controlled substances, including buprenorphine. It mandated an in-person evaluation to first begin medication, and then an in-person follow up every 24 months, at a minimum. The law severely hindered the ability to prescribe any controlled substance, no matter its schedule, via telehealth.

Access to buprenorphine was better than for methadone, which in the United States is administered under a shockingly high-barrier and quasi-carceral system of clinics—but that’s a very low bar. 

The COVID Emergency

The public health response to the COVID emergency brought more than mask mandates and testing regimens. It also supplied the political momentum to enable broad but temporary suspensions of certain regulations as enforced by the DEA.

On January 31, 2020, the federal government officially declared a public health emergency (PHE). On March 16 that year, the DEA sent out a letter to registered prescribers of controlled substances, activating the PHE exemption to the Ryan Haight Act and permitting the prescription of controlled substances without first conducting an in-person visit. On March 25, the DEA suspended its requirement that prescribers be registered with the agency in each individual state, allowing for nationwide prescribing. (The DEA cannot affect state regulations, but independently many states also loosened their requirements on where prescribers must be located and registered.)

On March 30, the DEA expanded this guidance so that a regular phone call could satisfy the requirements to receive a controlled substance prescription, eliminating the barrier of requiring a smart phone and high-speed internet. Though the Ryan Haight Act technically remained in effect, the PHE ushered in broad exemptions.

Addiction medicine providers immediately saw an opportunity to improve access to buprenorphine, and telehealth clinics sprouted coast-to-coast. Providers who were already X-waivered were largely allowed to prescribe into other states, as long as their or their patient’s state didn’t prohibit it. Access was later expanded by the 2021 loosening of X-waiver requirements, making “getting X-waivered” for up to 30 patients as simple as filling out an online form.

“Having a 30-minute video conference and then picking up the script is far easier than chasing the bag all day or hustling to get money.”

In Portland, Red was an early beneficiary of the changing regulations. Of course, he had no phone. But he learned about the opportunity by word-of-mouth. A friend would bike to meet him at his encampment so that he could connect for virtual visits with the Portland-based HRBR clinic, using her smart phone. He was able to pick up his buprenorphine prescription at the nearest pharmacy.

Photograph courtesy of Red.

It gave him just the “first step” he needed to get his life in order. “I could try and start making it to appointments, start looking for a job, cleaning up, instead of just worrying about the addiction part,” he said.

Within a few months of being on the medication, he moved into a city-sanctioned camp with services, and was hired on as staff. With his own phone, he could reliably track and attend his scheduled virtual appointments. Two years later, he recognizes that low-barrier buprenorphine access is what enabled him to break the “vicious cycle” of addiction.

“It turned a negative into a positive,” he said of how the pandemic increased OUD treatment access. Red switched to methadone maintenance after moving to a place with a clinic nearby, but it was low-barrier buprenorphine access that first brought him towards stability.

As many people have pointed out, the overdose crisis is unlikely to abate until treatment—whether it’s medications, safe supply or other evidence-based strategies—is easier to access than the adulterated street supply.

“Having a 30-minute video conference and then picking up the script is far easier than chasing the bag all day or hustling to get money,” Red said of the calculus. If it had required hours on public transit, the potential for missed appointments, urine screenings or other barriers, it’s unlikely he would have reached the same conclusion.

Telehealth is more than just addiction medicine, though. Long before the pandemic, Red began having other health problems but struggled to access care. Now, he has hip surgery scheduled and regularly receives general health care in addition to his medication maintenance. 

Access for People Who Never Had It

Dr. Joshua Lynch, on the opposite coast, had mirror-image experiences from the provider end of telehealth. In late March, 2020, his initial push was simply to open a virtual emergency department. But the project rapidly evolved based on demand for services.

“We realized that patients with substance use disorder, primarily opioid use disorder, were the ones using the telemedicine platform that we put out there,” he said.

Digging into the data, he realized his new platform had attracted not people whose care had been disrupted by the pandemic, but people who had not yet been receiving care anywhere.

That realization refutes a concern that’s sometimes aired: that telemedicine could result in lower levels of care compared to in-person visits. This operates on the assumption that you’re comparing people receiving care in person with people receiving care virtually. That, as both Red and Dr. Lynch suggest, simply isn’t how it played out for people with substance use disorder. (In fact, research confirms that telehealth outcomes and perceived patient experience are on par with in-person care.)

Telehealth increased buprenorphine access for rural and various underserved populations, including many people who previously had no access. Yet severely diminished in-person and inpatient care offset this, meaning there was no significant whole-population increase in bupe uptake.

A great paradox of American medicine has long been that the people most in need of care are the least likely to receive it.

The pandemic initially decreased the amount of people starting new prescriptions, though numbers then rebounded. Racial and ethnic minorities experienced greater decreases in buprenorphine uptake than white people, showing the unequal burden and systemic racism of the system. Despite increases over time, buprenorphine is still utilized less frequently in neighborhoods where more people are Black, Brown, Indigenous or poor. One study estimated that 87 percent of people who need medications for OUD are not receiving them.

A great paradox of American medicine has long been that the people most in need of care are the least likely to receive it. Many people—people who are likely to be poorer, and therefore likelier to suffer poor health—don’t have insurance. Among those who do (for example, in states with expanded Medicaid coverage), the system can be so complex that severe barriers remain.

For people who use drugs, poor health care access and quality are artifacts of de jure and de facto systems of stigmatization. Health care professionals are known to perpetuate stigma, and many people who inject drugs, especially, report negative, even traumatizing, experiences in medical settings.

For those on the margins, obstacles can be insurmountable. Imagine if Red had been asked to get his past medical records faxed from various clinics, or if he needed a pre-authorization from a primary care physician that he did not have. Any one of those commonplace barriers would have derailed his attempt at treatment.

Uncertainty and Impending Threats

As patients and providers look to the future, everyone is wary. The temporary exemptions to the Ryan Haight Act and other requirements are set to expire when the public health emergency does. Without further intervention, the system will revert to its February 2020 state, decimating buprenorphine access and leading to yet more unnecessary deaths as the overdose crisis only grows.

Rapidly shifting regulations have the potential to leave patients stranded.

The onerous and uncertain federal regulatory structure is further compounded by individual states whose legislatures have made even more restrictive guidelines, and may not stick to the pandemic-era loosening.

Rapidly shifting regulations, whether from the government or pharmacies, have the potential to leave patients stranded without access to their medications. In Ohio, for example, patients at Boulder Care, a telehealth provider, are routinely denied the ability to fill their legitimate prescriptions. This has led to documented cases of patients returning to the street supply.

According to Ben McClean, Boulder Care’s general counsel, Ohio is the most prescriptive state when it comes to rules that further complicates buprenorphine prescribing. The state’s medical board has determined what an evaluation should look like, what types of screenings are required, visit cadence, maximum days’-worth of medication, and myriad other requirements not seen for any other type of medical treatment. If a patient refuses a referral to mental health counseling, the law says they must be mandated to a 12-step program—an abstinence-based modality with far lower chances of keeping someone alive.

Nationwide, Walmart pharmacies are becoming notorious for refusing to fill buprenorphine prescriptions, and/or for simply running out of the medication. This is not merely another tale of a mega-corporation acting from malice, but rather reflects the interplay between corporations and government bureaucracy within a disjointed system.

Having been subjected to multi-million-dollar lawsuits for filling legitimate opioid prescriptions, large chain pharmacies have adopted risk-averse policies, fearing further backlash. The distributors have initiated quotas for buprenorphine, again in response to DEA-initiated policy that arbitrarily quantified what was and was not an appropriate amount of opioids.

“It smells of legal protectionism, at the expense of people who need care the most.”

The DEA has several more unwritten policies that evoke fear among pharmacies, such as the dreaded “red flag” system. Unofficially, it is well known that a person filling a prescription hours away from their doctor’s office is a “red flag,” indicative of “doctor shopping” or otherwise frowned-upon behavior, and likely to draw DEA scrutiny.

Yet having providers who are physically located hundreds of miles from the filling pharmacy is par-for-the-course in telemedicine. Some Walmarts seem to be imposing the Ryan Haight Act requirement and refusing to fill prescriptions if that patient has not seen that provider in person within the past 24 months, perhaps in preparation for the impending expiration of the PHE. The DEA has refused to make a clarifying statement.

“It smells of legal protectionism, at the expense of people who need care the most,” Dr. Liz Ryan, Boulder Care’s medical director, told Filter. That some of the most acute access issues are coming not directly from government policy but from corporate policy shaped by fear of government intervention makes for a complicated situation.

Health care professionals asked the DEA to publicly announce a moratorium on enforcing buprenorphine-related restrictions, such as going after prescribers or pharmacies for “overprescribing”—or even to implement measures as simple as putting its guidelines in writing to mitigate the nebulous fears of corporations. So far, nothing.

The DEA is notoriously unresponsive. But the call it convened in August between HHS (whose public health emergency declaration enabled the increased access) and impacted providers might indicate a shift in tact.

“There is general agreement among pharmacist societies, drug wholesalers, and telehealth SUD clinicians that buprenorphine needs to be viewed differently than other controlled substances,” University of Austin Professor Lucas Hill, a pharmacist, told Filter. He insists there is a simple solution to what’s sometimes framed as an intractable problem. “The most efficient way to achieve that would be to deschedule buprenorphine. This would immediately exempt orders and prescriptions for buprenorphine from the increased scrutiny that is being applied to controlled substances as a result of federal and local opioid-related lawsuits.”

Don’t count on it, however. The DEA, it should be noted, was supposed to create special rules for telemedicine registration per the Ryan Haight Act a decade ago. The 2012 deadline came and went. The DEA was again instructed to create the rules by fall of 2019, following passage of the SUPPORT Act of 2017. The deadline came and went and the rules—the only way to create a framework for legal telehealth prescribing of controlled substances—never came. Nobody knows for sure if DEA will finally do what Congress has repeatedly mandated it to do, or if Congress will make the DEA’s role irrelevant by superseding the Ryan Haight Act.

The public health emergency proved to be a unique, instructive example of deregulation. But how much will regulators learn?

The current public health emergency is set to expire in January of 2023. On October 13, HHS Director Xavier Becerra extended it yet again, having previously reaffirmed providers will be given 60 days’ notice ahead of its final expiration. But Donald Trump declared the “opioid crisis” a public health emergency in 2017, and it has been extended ever since. It is theoretically possible that the pandemic-related prescribing guidelines could simply be ported over to the other public health emergency declaration.

The rules could be made permanent, which would quell the uncertainty currently gripping providers. As for the attorney whose job it is to understand the nuts and bolts of this complex issue, Ben McClean reports being “personally optimistic.” There are numerous, tiered solutions at the disposal of regulators, he said, from temporary public health emergency extensions to permanent rule changes to the de-scheduling of buprenorphine.

Amid corrosive uncertainty, there is one thing everyone knows for sure: telehealth prescribing of buprenorphine was a game-changer. People who had long been excluded from care found access.

The public health emergency proved to be a unique, instructive example of deregulation. But how much will regulators learn? If rules ostensibly designed to “reduce harm” exponentially increase it, why are they so hard to get rid of? 

On October 19, when Filter asked the DEA about the future of buprenorphine regulations, a spokesperson said they “have nothing further to announce at this time.” That same day, based on CDC rolling averages, it is likely that nearly 300 Americans died of overdose.

Top photograph by US Department of Agriculture via Flickr/Public Domain

R Street Institute supported the production of this article through a restricted grant to The Influence Foundation, which operates Filter. Filter‘s Editorial Independence Policy applies.

The post Buprenorphine Access: Telehealth Revolution Faces Uncertain Future appeared first on Filter.

It’s a question that really matters when youth overdose, in particular, has skyrocketed mostly due to counterfeit pills. While people who use powder opioids understand there is some level of risk, pills stamped with whatever it might be can lull someone into a false sense of security. Much of the pill market is people who knowingly and intentionally buy fentanyl pressed to look like 30 mg oxycodone. But when those same counterfeit pills trickle out into the hands of the unsuspecting, tragedy strikes.

The false reassurance of a negative could be worse than no test at all.

Some of those people intend to just swallow their pills (which is never advised when dealing with fentanyl) and may not wish to grind them into powder. Preferably, an entire pill will be ground up to be tested. For various reasons, not everyone is likely to do that. Yet the advice to “test a part of the pill,” even if more likely to be followed, seems potentially dangerous: If that segment of the pill does not contain fentanyl when it is present in the rest of the pill, the false reassurance of a negative could be worse than no test at all.

So what’s the right advice? I’ve often heard the chocolate chip theory repeated as a reason to be reluctant to use fentanyl test strips—inexpensive tools for getting a crude yes-or-not answer—for pills. On the other hand, people who are addicted to “Blues”—the pressed pills, ostensibly oxycodone but ubiquitously fentanyl, that have soared in popularity on the West Coast—will sometimes “go up” on a pill 50:50, splitting it in half. Drug users tend to know best: If there were a chance that a half-pill contained no fentanyl, I doubt that would be an acceptable practice.

My instinct was that fentanyl test strips should still hold value for anyone looking to use a pressed pill, but (obviously) above all for those who don’t intend to consume fentanyl. Familiarity with a supply doesn’t equal certainty. And it’s always better to have more information—even if important caveats should be emphasized and applied to the strips’ results.

I did a tiny and unscientific experiment: testing two different Blues that were different shades of blue.

I also understood that expecting someone to grind up their entire pill and add water to it might not always be realistic. That led me to wonder what happens when you test only a portion of a fentanyl pill.

So I did a tiny and unscientific experiment: testing two different Blues that were different shades of blue. (I’m unsure if that means they were from different suppliers, different batches, or simply ended up different hues.) An acquaintance made a donation to science, and our experiment was conducted at a syringe service program.

My first observation was that the Blues looked alarmingly like the oxycodone M30s they were alleged to be. They were very small, almost too small to get a good photograph. They were pressed densely, with clean lines and no obvious indication of their counterfeit status.

My next observation was that they were almost impossible to break. Later, I learned that people who regularly use them (again, the real experts) have figured out that you can set them on a Bic lighter and use its convex shape to then break them in half by pressing with your thumbs.

For the experiment, the harm reduction specialist I was working with brought out a mortar and pestle. We bashed the pill once, trying to split it without it pulverizing. My initial idea was to break the pill into quarters and test each quarter. Instead, it fractured into small bits.

We then picked up some of the tiny slivers we produced—four fragments from each pill, with a lot left behind that was never tested—and placed them into sterile cookers. We added some water, stirred them around, and then tested each sample using BTNX fentanyl test strips.

Of the eight fragments from two different pills we tested, every single one showed an obviously positive result. It did not seem to matter how little we mixed the samples—even the fragments that had dropped in like tiny rocks and were wholly undissolved produced glaring positives.

In these pills, it seemed that the fentanyl was distributed enough that testing any small sample would allow you to identify its presence. (This is not to say the chocolate chip cookie theory is incorrect. Due to the nature of clandestine pill press operations, it is unlikely the mixture of inert filler and fentanyl is ever homogenous. But even trace amounts of fentanyl in the tested portion result in a positive.)

For what it was worth, it strengthened my belief that fentanyl test strips could have value.

Needless to say, the findings of our mini-experiment are limited in all kinds of ways and should not be applied to any pills other than the two we tested. But for what it was worth, it strengthened my belief that fentanyl test strips could have value, even if caveats must apply to any negatives.

Oh and by the way, I conducted this experiment with my bare hands because I knew that fentanyl cannot practically be absorbed through skin contact. Just for the sake of it, I used a fentanyl test strip to test my urine (technically what they’re made for) that night and the next day. As expected, it was negative both times.

Counterfeit pills are a very American phenomenon. They cropped up to fill the void left after medical prescribing of opioids plummeted—it didn’t fall, it was pushed—though demand stayed the same. Ten times as many annual deaths are now linked to illicit opioids as were ever linked to prescription drugs. The danger pills pose to less experienced and knowledgeable people—who may not have opioid tolerance, might not recognize the signs of an overdose and are less likely to have naloxone—is acute.

Passing out fentanyl test strips does more than give people a drug testing tool. It serves as a tangible, physical reminder for why drugs need to be tested. They function as a conversation-starting, memory-jogging prop as well as a testing device. If you get someone to test their “oxy,” you’ve already won more than half the battle. You’ve moved risk from an unknown unknown into a known unknown, establishing in somebody’s mind the wildly uncertain risk level of what they purchased.

We have shifted risk to a known unknown. Once it enters that category, all harm reduction practices are on the table.

If someone intending to swallow their “oxy” orally struggles to break it in pieces and therefore opts to not test it all, that’s a big issue. But again, if you have the person thinking about the presence of fentanyl, via the physical embodiment of fentanyl test strips, I believe we are winning.

The test strip represents their knowledge that risk exists. Other precautions may occur to people who use the strips, or curiosity may lead them to look them up. They may be more likely to have naloxone on hand and to not use alone. We have shifted risk to a known unknown. Once it enters that category, all harm reduction practices are on the table.  

Photographs by Morgan Godvin

The post Are Fentanyl Test Strips Helpful for Counterfeit Pharmaceutical Pills?  appeared first on Filter.

I didn’t need the Steps to quit heroin. And my recent experience of quitting kratom after nine months of daily use has only cemented my suspicion: We are not powerless over the drugs we use.

Type “kratom withdrawal” into Google and you will see a series of addiction treatment centers and SAMHSA warnings. Where there is money to be made, there is pristine search engine optimization. Surprise, you can go to an expensive inpatient detox and rehab for this plant.

Spend any time on the r/quittingkratom subreddit, and you’ll be left with an even more dire impression of the drug. People lament the green sludge that has robbed them of their lives, turned them into recluses only focused on their next dose, driven them into poverty, all the while beleaguered by withdrawals comparable to heroin.

When I made the conscious decision to take kratom daily, deciding that the benefits outweighed the cost, I knew the day would come that I would need to taper off of it entirely. Thanks to my raging PTSD from being force-detoxed into withdrawal at the county jail, I always held a healthy skepticism of any substance that required daily dosing. For this reason, and the fact that there is scant research about long-term or heavy kratom use, I always kept my dose low. When tolerance left it creeping upward, I would dramatically reduce for a week to “reset.” But I never completely stopped.

Thanks, once again, to criminal-justice system traumas, however, I’m now massively wary of breaking laws. I regret that that sentence could be read by some as a justification of punitive policies; it should not be. Nonetheless, it’s true for me. So when my best friend suggested that we visit the UK this summer, I knew what it meant. Kratom is a banned substance there. I would have to taper all the way off.

Because of my felonies, I had to apply for a tourist visa even though most Americans don’t need one. While I waited, I read up what the tapering journey would be like. It filled me with fear. Dozens of people reported horrific opioid-like withdrawals, mental cravings and an inability to cease using. People described 100 gram per day habits—meaning you’d consume an entire kilo in a 10-day span. (That’s still only $200 a month—an expense, certainly, but I feel like the “kratom impoverished me” complaint should be taken in the context of the overpriced, adulterated illicit opioids that some of us kratom users were previously paying for.) It all felt unbelievable to me, as I’d hovered between 4 and 12 grams a day and preferred the low end of that range.

Such absolutist portrayals on both ends of the spectrum frustrate me.

I became increasingly trepidatious about the task. In r/quittingkratom, most people go cold turkey, or “CT” in the lingo. Despite the fact that slow tapers, in my experience, almost entirely mitigate withdrawal symptoms, the people in the subreddit described finding it too challenging to resist temptation and stick to a taper schedule. Others said they found dose-reduction withdrawals to be so similar to CT that it didn’t matter.

In r/kratom, on the other hand, it’s almost entirely rainbows and sunshine. Miracle drug! Lifesaving! Despite the benefits I found in kratom, such absolutist portrayals on both ends of the spectrum frustrate me—which is why I made sure to acknowledge my physical dependency when I outed myself as a kratom user some months ago.

I ended up buying the supplements random strangers on the internet recommended, some of which have an evidence base and some of which don’t. I liked the black seed oil, which I’d previously used to potentiate my dose. I megadosed vitamin C, and took more things that I won’t go into because of the haywire nature of the unregulated US supplement market. I threw everything at the wall to see what stuck. (Something was working, because I would feel worse when I forget to take my meal-sized handful of “supplements.”)

I was enthralled by all the r/quittingkratom accounts of true addiction, in which people’s desire to live their life, have sex, have fun or do anything else was completely supplanted by their kratom use. Were we using the same substance?

I started by cutting out my occasional midday doses, then began lowering my morning and evening doses. I got down to 2 grams per day within a couple of weeks. I had little trace of opioid withdrawal, with which I am intimately familiar. Sleep became more challenging, and the mental health symptoms that made me take kratom in the first place felt more intense, but quickly everything regulated. (Not that my baseline is all that great.)

But I did have an unexpected symptom: brain zaps, which sometimes radiated throughout my body, resulting in panicked consultations with friends of mine who “get it”—read: a medical student and a generous psychiatry resident. I had felt “shocks” once before, after tapering off of prescription Xanax more quickly than my psychiatrist advised. (My need to prove I have power over drugs seems ingrained.) Concerned that it was GABA withdrawal like from the benzos, which does pose a seizure risk, I took a low dose of a leftover prescription benzodiazepine. It didn’t abate the shocks; this was my very ad hoc diagnostic tool to confirm that the shocks were instead related to the neurotransmitter serotonin. A flurry of Reddit searches confirmed it’s a semi-common symptom. I wish there were more peer-reviewed literature; I researched heroin exhaustively back in the days of Bluelight, but find kratom to be mostly a black hole.

To my best guess, kratom functions as an SSRI. This is suggested by research on its hypothetical mechanism of action. My taper was slow enough to avoid opioid-like withdrawal symptoms but too fast to avoid SSRI-style withdrawal. I sat at 2 grams daily for two more weeks, but struggled to get below that amount. Less than that felt exactly the same as none at all. It was time to jump off.

Drugs are not good or bad. It is our relationships to them, influenced by many outside variables, that form the crux of our subjective experiences.

I took my last dose Saturday morning. I didn’t experience so much as any discomfort. On Sunday, I went hiking. On Monday, I went to a Pride Gay Skate event at the roller rink. And it struck me anew how little drug addiction has to do with the drug itself.

There are some important caveats to my personal experience. I may be formerly incarcerated with mental health challenges, but I am not subjected to extreme poverty, racism or any number of other stressors that heavily impact people’s management of their relationships with drugs. Yet none of these very real societal factors are inherent to any drug—and that’s the point.

Drugs are inanimate substances. They are not good or bad. It is our relationships to them, influenced by many outside variables, that form the crux of our subjective experiences. Human beings are so desperate to externalize our internal emotions, to find something else to obsess over beyond our existential dread. I realized this once, fresh out of inpatient treatment, pulled over on the side of the road with the Domino’s Pizza sign alit on top of my car midway through my shift, gasping for air as I descended into a panic attack.

It’s because I need heroin, I told myself. That’s not true but it will become a self-fulfilling prophecy if you believe it, some wiser part of myself responded. We want a way to make the incomprehensible digestible. Identifying an external, concrete source of our troubles—rather than the complex interplay of psychological and societal circumstances—is relatively reassuring.

This anxiety is because I need heroin. Believe in your inherent need, and you have a clear remedy. And heroin will help, at least initially. But if instead you tell yourself a different story—like, this is anxiety that reflects aspects of my life, but experience tells me it will subside—that might become true, too. There’s a venerable study, led by William R. Miller, co-creator of motivational interviewing, that reflects these ideas. For people with alcohol addiction, it found, two factors were “optimally predictive of resumed drinking.” Those were: “lack of coping skills and belief in the disease model of alcoholism.”

It is never really about the drug. The vast majority of people who try any drug never become addicted, contrary to popular lore. It’s about the relationship, and as with other relationships, we sometimes adopt toxic dynamics.

I do not doubt that people struggling with kratom addiction are, in fact, struggling. To those who went to inpatient only to resume addictive use, my heart goes out to you. I know that pain. But I also know that addictive relationships with non-drug behaviors can be just as painful. And I know that kratom is a relatively mild substance that can be successfully tapered with few ill effects—if other variables allow it.

Funnily enough, the UK ended up denying my visa. But I wanted to prove to myself that I could endure the withdrawals, taper and quit anyway. And I did.

Telling people they’re powerless over a drug carries the severe risk of making them believe it.

Though I’d rather not test it, I do believe that my life is purposeful enough today that even taking heroin wouldn’t lure me back into compulsive, uncontrolled use. My relationship to that substance has changed because my relationship to myself has changed.

Most critically, my social context has changed. I am not, as I once was, an impoverished adolescent with no hope for my future, living an unequivocally miserable life. While I still struggle with suicidal ideation, unlike before I went to prison, it no longer feels like the most rational choice. (Its profound irrationality bothers me most, in fact.) After military benefits supported me through a bachelor’s degree, I have found work that supports me financially and that I find meaningful.

Many people do not share these privileges, and the unequal toll of addiction damningly reflects the injustices of our society. At the same time, knowing what addiction is not can be empowering to anyone. It isn’t the drug. And telling people they’re powerless over a drug carries the severe risk of making them believe it.

Photograph by Morgan Godvin

The post Quitting Kratom Reminded Me How Little Drugs Have to Do With Addiction appeared first on Filter.

Those funds were not to be issued piecemeal to a variety of siloed and disconnected providers, but rather to new, unified Behavioral Health Resource Networks (BHRN) in each county. The BHRNs would be comprised of individual organizations, each providing one, some, or all of the services.

However, an early allocation by the legislature meant that the first round of grants went out ahead of schedule and were not mandated to go to BHRNs. These “Access to Care” grants were issued in summer 2021. The request for BHRN grant applications was released that fall, with funding initially slated to go out by the end of 2021.

The process was unique from the start, and painful at times.

For a variety of reasons, that didn’t happen. Wanting to break from the status quo of government divestment and inequities, Measure 110 intentionally gave the power of grant review and distribution to the newly-formed Measure 110 Oversight and Accountability Council. This was to comprise 21 directly impacted Oregonians and experts in the field, including harm reduction.

In January 2021, I was appointed to the council—checking the boxes of harm reductionist, drug policy researcher, and formerly addicted and incarcerated person. With unprecedented racial and ethnic diversity for an Oregon statewide governmental body, and several of us formerly incarcerated, the council was handed the reins to determine funding priorities and oversee implementation of the law.

The process was unique from the start, and painful at times. The size of the group and the open-ended nature of the task produced occasional conflict and frequent delays. Yet progress was made, steadily. Instead of using previous government boilerplate requests for grant applications, we drafted one from scratch, with most councilmembers contributing. The Oregon Health Authority (OHA) provided us with very little guidance or feedback, however, despite the fact very few of us had grant experience. We created something of a Frankenstein’s monster, with disparate parts cobbled together as many people penned in their two cents.

The council also made the scoring rubric to gauge grant eligibility from scratch, without OHA advice. The result was a 300-cell spreadsheet with questions that did not always closely align with the applications.

Well over 300 entities applied, and they received sometimes conflicting advice on how to construct their applications. Dozens of harm reduction providers, grassroots organizations, and culturally specific organizations applied, which is of itself a win. Harm reduction was weighted equally to other services, a rarity in such a process. As councilmembers began evaluating requests, trouble soon arose.

The sheer labor of the task was monumental; as a volunteer, I was expected to spend a total of approximately 60 hours reading grant applications and filling out their rubrics. The spreadsheet was unwieldy and had many inapplicable cells; I ended up leaving much of it blank and filling out what I felt were the most salient points. The state considered it to be incomplete, even after I went back through multiple revisions, in a process that ended up taking well over 100 hours of my time.

It was unsustainable. So eventually, OHA staffers were tasked with reading each grant application and filling out its accompanying rubric. Each application was reviewed by two people. But the unwieldy nature of the rubrics’ spreadsheet as well as the nontraditional (and also unwieldy) grant applications led to further delays. Soon, Access to Care grantees were running out of money, forcing the OHA to offer them extensions out of other funding pots just to ensure continuity of care.

Evaluations finished months behind schedule. Still, for a first-of-its-kind process, it is remarkable that we have now allocated $270 million.

Finally, our council split into two grant review subcommittees in order to expedite the evaluations, meeting twice a week for four hours each time, in addition to the regular council meetings. The reviews are now complete—this dashboard provides an overview—and the grant recipients have been mailed “letters of intent to award.” The process now moves into government contracting, which can itself be onerous.

The evaluations finished several months behind schedule. Still, for a first-of-its-kind process, it is remarkable that we have now allocated $270 million (the available cannabis tax revenue for the current two-year budget) to substance use services.

The current funding cycle spans through December 31, 2023. The application process will resume in 2023 for the next cycle, but will likely be substantially revised and refined. The first time, with no precedents to lean on, is always the hardest.

Each county must have all services present—again: harm reduction, peer services, housing, low-barrier SUD treatment and supported employment—to be considered a full BHRN. The OHA will conduct outreach and direct awards to fill any service gaps across the state.

Outreach, in terms of providing information on services available through Measure 110, is a mandated component of all BHRNs. But currently this task is most often falling to police, which will widely be viewed as problematic, due to a lack of other resources.

Unlike the form of decriminalization just announced for British Columbia, drug possession in Oregon sees police officers still writing citations, with the power to confiscate someone’s drugs. And thresholds are regrettably set low, with anything over 1 gram of heroin being an arrestable quantity.

In practice, very few Oregon jurisdictions are seeing many citations for amounts below the thresholds. To waive the $100 fine for a citation, a person must call a phone number and undergo a behavioral health assessment, which offers connection to services but does not mandate it. Once BHRNs are fully established, this hotline will be joined by brick-and-mortar services, and the decision whether or not to continue the phone line beyond its current contract will be brought to the council. One critique of Measure 110’s implementation is that most eligible people are not calling the hotline; people who have just been cited by police are wary of calling any number they provided.

Another issue is that fentanyl was not originally scheduled in Oregon’s Revised Statutes to reflect Measure 110—meaning that when misdemeanor quantities were reduced to civil violations, fentanyl was not included. This omission was rapidly rectified with the passage of Senate Bill 755 in summer 2021, but rumors on the ground abound that you can still be arrested for small-quantity fentanyl possession, even though this is not so.

Law enforcement regularly lament the lack of punitive and coercive options, and cite it in their ongoing opposition to Measure 110.

Police mostly can’t be bothered with writing a citation when little will come of it; beyond a citation and request to call the hotline, there are no further coercive measures built into the law. A failure to pay the $100 fine does not result in an arrest warrant, license suspension or other punitive consequence. Law enforcement regularly lament the lack of punitive and coercive options, and cite it in their ongoing opposition to Measure 110.

After years of ranking last, or next to last, in access to substance use disorder treatment services, Oregon has a long way to go to even be brought up to average. This biennium’s $270 million is a great start; the next biennium’s allotment will be bigger. Outreach into communities of people who use drugs, as mandated by the BHRN grant funding, will disseminate information about which new services become available—and when this information is delivered by credible messengers, as opposed to police, uptake in services should increase.

For the majority of Measure 110 services, abstinence is not a requirement—though it can be, and often is, the self-chosen goal of the participant. We did fund a substantial amount of recovery housing, where drug use is prohibited, but tried to ensure that people who resume using drugs will not face sudden homelessness. While some frontier counties (a designation that means population density is well below standard “rural”) simply cannot sustain the same level of services, in most counties Housing First options will be present.

If a person chooses recovery housing that requires abstinence (medications for opioid use disorder are universally permitted without exception) but then starts using drugs again, they will not be immediately evicted. If they continue to use and no longer qualify for recovery housing, the memoranda of understanding with other organizations that provide Housing First models or shelters should ensure a ready alternative. In practice, there may be kinks, but the goal to have roofs over heads no matter what is central to Measure 110 values.

Another critique within the Portland metro area has been people’s objections to public drug use. This was never particularly rare before Measure 110, although the pandemic accelerated houselessness and severely impacted the economic core of the downtown area, with up to 100,000 office workers no longer commuting in. With a reduction in city sweeps of encampments, homelessness became more visible, much to the ire of many housed Portlanders. Drug use in some public spaces is inevitable when so many people don’t have private spaces. Safe consumption sites would be a sensible and lifesaving response, but opposition and legal challenges remain before these can be opened in the state.

With dedication and the right support and coordination, things will improve from here.

Unlike the vast majority of medical care in the United States, the BHRNs will truly be a coherent network, with each entity having memoranda of understanding with all other funded entities in that county that form the BHRN. All services are free-of-charge, though Medicaid must be billed whenever possible so that funds stretch further. Innovative interventions such as peer mentoring, contingency management, housing stipends for peer workers, drop-in and recovery centers, and more are all being supported with Measure 110 funds, which are relatively unrestricted.

The goal is to increase capacity by funding infrastructure projects as well as direct services. There is a nationwide behavioral health workforce shortage, but Measure 110 funding requires that staff are paid living wages. With a living wage comes higher levels of retention. As housing costs spiral, other innovations, such as housing stipends, become more and more important to the future of the workforce.

So yes, implementation of Measure 110 has been bogged down and beset by challenges. But thousands of people have already accessed services that weren’t previously available, and with dedication and the right support and coordination, things will improve from here. Thousands of Oregonians have avoided drug arrests and subsequent criminal records since the passage of the law, an obvious success. First rule, do no harm. Secondly, begin the healing process. That process will take years, but it has now begun to reach full swing.

Photograph by Ian L via PublicDomainPictures.net 

The post Oregon’s Decrim Funding Has Been a Trial to Implement. Better Is to Come. appeared first on Filter.

A cousin of the coffee plant, kratom is a tree native to Southeast Asia. Its leaves are shredded into a bitter green powder and sold across the world. I order mine online, avoiding the low-grade product sold at gas stations and headshops.

Over the six months since I began using kratom, I haven’t been mentioning my use to many people, and certainly not in addiction-recovery circles. Decades of drug-war rhetoric baked irrational fears into the American psyche. If the drug isn’t alcohol or caffeine, it is insidious. Except anyone who has taken kratom realizes how bogus this is.

Kratom makes my days livable, manageable.

I take the herbal supplement two or three times daily, which ends up costing me about $1 per day. It would be cheaper (and faster-acting) if I only used the powdered form, which I sometimes do by making a sealed “taco” of Japanese potato starch disks called oblate papers. With a preference for speed and convenience, I usually take pre-filled capsules.

Its effects are mild, don’t impair me in any way, and have a natural ceiling—a consequence of kratom having both agonist and antagonist opioid-like properties. When I found a dose that worked for me, I stayed there, raising only incrementally to combat inevitable tolerance before going on “tolerance breaks.” Kratom makes my days livable, manageable.

The herb is not on our banned drugs list more by chance—including its former obscurity in the United States—than design. But there are periodic threats to this status. When there was talk of an international ban, which for now has not materialized, I felt the vice grip of the drug war once again.

I was addicted to heroin for years and, as a direct result, was in prison for years after that. Then came the random urinalyses and the perpetual fear. Once, the day after a doctor’s visit where my physician told me to drink more water because my blood pressure was low, my urinalysis sample came up “dilute” at the federal probation office, a punishable offense. I had long since quit opioids, but trace amounts of THC (whether from CBD or unwittingly consuming even the residue of edibles) could have sent me back to prison. I avoided all supplements, however natural, for fear of contamination.

My mental health suffered. If suicidality is a scale, I never get below a four out of 10. Some days are worse than others, with shocking amounts of my mental energy consumed by batting back thoughts of suicide. On the outside, this can look like laziness or paralysis. But merely existing in that moment, without taking a gun to my head, is the best I can do. The pandemic first triggered my jail-learned fear of infectious disease, thanks to being confined in overcrowded spaces with lice and tuberculosis for four years. Later, the pandemic restrictions caused another trigger for my PTSD as I felt trapped and confined.

The solution? Xanax. I was mostly living abroad during that time, where Big Pharma panic never took hold because opioid prescribing never took off. A psychiatrist prescribed me Xanax and encouraged me to try SSRIs, which I wouldn’t do (I have since softened). I had once binged benzos and feared that if I took one pill, I would end up with a needle in my arm the next day. But it didn’t happen. I used the medication when I needed it, never escalated my dose or frequency, and tapered off easily once my panic subsided. I learned then that addiction is not a fixed mental state, but rather a consequence of circumstance.

Back in the United States, my distant addiction history disqualified me for prescription benzodiazepines.

Back in the United States, my distant addiction history disqualified me for prescription benzodiazepines, despite my having used them without problems for an entire year. Left without pharmaceutical support, I began looking into alternatives for my anxiety, depression and chronic suicidal ideation.

Mostly, I fantasized about doing heroin. Being appointed to the Measure 110 Oversight and Accountability Council to oversee Oregon’s drug decriminalization has been one of the most challenging experiences of my professional career. However rewarding it may be, we find ourselves under constant, public pressure. I had never gotten so close to returning to heroin.

That’s when I found kratom. I’m a researcher, so naturally, I researched it exhaustively. Various subreddits provided ample material. With a sample size of thousands upon thousands of posts, I could glean clear patterns.

People use kratom for opioid replacement theory, opioid withdrawal management, chronic pain, anxiety, depression and other mental health woes. Others use it as a pre-workout supplement, for mild euphoria, or to make shift work more bearable. (Traditionally, it was used by Southeast Asian laborers working long hours in the sun.)

Few of these thousands of accounts of benefits are reflected in academic research. With few exceptions, kratom studies are retrospective, which introduces inherent negative bias. No one walks into the emergency department to tell you that kratom cut their pain in half; people walk in because something negative has occurred.

Of the few documented cases of kratom-involved death, virtually all had other substances present. It does not cause respiratory depression, unlike opioids. As buprenorphine induction for people using fentanyl becomes increasingly difficult, could kratom be used as withdrawal relief? I think so, but without legal standing I cannot do a randomized control trial and have it be ethical. It’s a catch-22.

Kratom does cause physical dependency, and that can be downplayed by its advocates. It has effects on the kappa opioid receptors, among other mechanisms. It has both mildly sedating and stimulant effects, a unique mix for a molecule. Now, when I go more than 14 hours without kratom, I have mild temperature dysregulation. I feel hot or cold, sweat. Anyone who has experienced opioid withdrawal is familiar with this symptom.

But critically, it stops there. My nose might run, my eyes water, but I feel fine. I’ll have trouble falling asleep, the most annoying symptom. But the very mild withdrawals can be averted by even rapid tapers, which I sometimes do for my tolerance breaks. When I stopped taking Xanax, I wrote out a schedule and stuck to it, and the same can be done with kratom.

Upon stopping, I do feel depressed and suicidal. But is that from withdrawal, or simply a return to baseline? Kratom is not a magic bullet. I still struggle with mental health most days. But at least I have something reliable to lean on that is unlikely to harm me.

For me, as for many others, kratom is the epitome of harm reduction when used as a replacement for far riskier alternatives.

Problems might arise only when use is stopped suddenly, as often happens with unregulated drugs whose supply is unreliable. There have certainly been issues with the kratom supply chain. Like all things billed “supplements” in the United States, it has almost no government regulations. It has been found adulterated with everything from bacteria to actual drugs. (I highly recommend Amanda Mull’s feature Everything is a Multivitamin about the deregulated chaos of the industry.)

These incidents have been used in calls to ban the substance but they’re evidence that more consumer protections are needed, not prohibitions. Kratom regulation bills, to enhance such protections, have passed in several states, Oregon included.

If kratom were banned tomorrow, or the supply failed completely, I would probably end up on Blues. Without something, however mild, to tickle my opioid receptors, I am a hulking mass of raw nerves, existential dread and anxiety. For me, as for many others, kratom is the epitome of harm reduction when used as a replacement for far riskier alternatives.

Why are a few non-prescribed drugs legal, and the rest banned? A mix of chance, racism, oppression and evidence-averse legislators. And yet for six months, I hesitated to share publicly that I use the substance. It doesn’t cause me intoxication and it helps, rather than hinders, me in getting through daily life. But in most recovery circles, it jeopardizes my status as a person in long-term recovery. It can also jeopardize my access to high-quality healthcare, as providers are wont to blame any symptom on this herb they do not understand. The internalized shame and stigma persist.

The days of demonizing drugs can and must be over. Kratom provides myriad benefits to people who use it, and could have substantial applications in addiction medicine and chronic pain treatment. But no form of drug use is cause for shame. I refuse to hide in the shadows any longer. 

Photograph by drogen.bz via Wikimedia Commons/Creative Commons 3.0

The post Kratom Helps Me Cope With Life, So What’s the Problem?  appeared first on Filter.

“I’m a bit surprised that I’m even still alive,” rapped Mac Miller in 2014, “mixing uppers and downers, practically suicide.” It proved a premonition when the ultra-successful rapper died in 2018 after taking counterfeit pills that contained fentanyl.

As the moral panic of the War on Drugs peaked in the 1990s, most Americans swallowed the rhetoric and enthusiastically supported punitive policies. Hip hop stood in stark defiance. Its open discussion of drugs, among other taboos, riled mainstream (read: white) America.

That makes hip hop and harm reduction natural bedfellows. Because it is much easier to discuss safer use in forums where use itself is already out in the open. Critics have long accused the genre of “glamorizing” drug use. But while hip hop lyrics encompass the allure and pleasures of drugs, they also include desperate insights into racist criminalization, addiction, hopelessness and suicidal ideation.

A tenet of harm reduction is not judging substance use, but trying to reduce the harms associated with it. Hip hop has a decades-long tradition of not judging, but also of experiencing the related harms.

Hip hop duo Atmosphere co-headlined a tour with Cypress Hill—and brought harm reduction along with them.

Despite this, rap concerts have often lacked the kind of harm reduction services one might typically find at raves and days-long music festivals. That’s all changing.

This August, hip hop duo Atmosphere co-headlined a tour with Cypress Hill—and brought harm reduction along with them. The tour spanned the American West, playing 17 shows across 11 states. At 14 of the shows, local harm reductionists staffed a booth to pass out naloxone and fentanyl test strips, and share overdose prevention information.

The program, Beats Overdose Prevention, was designed and implemented by a long-time fan turned harm-reduction-on-tour-coordinator (it’s me, I’m the fan), and supported by the Levenson Foundation and Health in Justice Action Lab. It was first championed by Slug, Atmosphere’s rapper. It was then endorsed by Cypress Hill, who—with the help of trademark songs like “Hits From the Bong”—have been advocating for cannabis destigmatization and reform for nearly 30 years. Beats Overdose Prevention hopes to encourage a broader trend in hip hop and music to include harm reduction messages in lyrics, videos, and at events.

Slug is leading the way. During his set each night, just before playing the cult classic “God’s Bathroom Floor,” he delivered a speech to the audience. In typically lyrical fashion, he subtly and poetically shared harm reduction messages—about looking out for one another, and about the unending tendency for humans to numb their pain. Tens of thousands of people have now heard this live.

Slug with the author in Rad Health Resources shirts at the August 7 show in Houston, Texas

Slug first entered the harm reduction scene in May, with an Instagram post. In the first photo, he is seen wearing a Rad Health Resources T-shirt emblazoned with “Dead People Can’t Recover.” Next, he can be seen holding Narcan, IM naloxone and fentanyl test strips.

The post was met with tens of thousands of likes and a slew of heart-wrenching comments, about everything from loved ones lost to overdose to lives saved by harm reduction. The message resonated with an audience well outside of the bubble that the movement typically inhabits.

This increasing resonance could reflect increasing empathy. Last year was the worst in history for drug overdose in the United States, with over 93,000 people dying. As the magnitude of our overdose crisis swells, so does the number of people directly impacted by loss. What was once dismissively referred to as a plight of “addicts” is now impacting most Americans on a personal level. Tactics of othering and dehumanization flounder when tragedy strikes close to home. The nation is being forced to reconsider its preconceptions.

Overdoses have disproportionately skyrocketed among Black Americans—who also faced many drug-related deaths, and grossly disproportionate criminalization, long before the overdose crisis began dominating headlines.

Illicit fentanyl is ubiquitous in today’s drug supply, a convergence of prohibition and unregulated market forces. Counterfeit pharmaceuticals have stepped in to meet demand after prescribing was rapidly and unscientifically reduced. While heroin itself presents a risk for overdose, above all when combined with substances like alcohol or benzos—and many a musician has succumbed—the risk is exacerbated with fentanyl.

Mac Miller, Prince and Lil Peep all died from what were likely counterfeit pharmaceuticals that contained the highly potent synthetic opioid; fentanyl test strips could have given them lifesaving knowledge of what they were about to take.

In light of this threat, it’s notable how many references to “percs” and “xans” are found in trap music. Trap—in this context I’m referring to the present-day iteration of the hip hop subgenre that favors repetitive vocals and synthesized rhythmic beats—is particularly apt to discuss “pill popping.”

Trap artist Lil Xan, whose stage name literally refers to Xanax, is these days an advocate for benzodiazepine addiction recovery and awareness. While he and other artists advocate for recovery, as Slug’s T-shirt reads, dead people can’t recover. And most drug use does not involve addiction. So there’s a vital role for harm reduction, for artists and fans alike, in keeping people alive during what many are describing as a slaughter—engendered by punitive policies and the prejudices that caused them.

“Many tragedies are avoidable. No one is expendable.”

Along with key resources like fentanyl test strips and naloxone, hip hop’s cultural acceptance of pill usage may itself be protective. While “never use alone” may seem patronizingly out of reach to highly stigmatized injection drug users, consumers of pharmaceuticals (including counterfeit ones) may feel more comfortable abiding by that harm reduction mantra.

The movement that was born as a response to HIV in the 1980s has, understandably, remained significantly focused on injection drug use. Harm reduction organizations are often syringe service programs. While those who inject remain at an elevated risk of overdose and other harms, people who prefer other routes of administration are dying, too. People who do not inject may be less likely to seek out traditional services; some have never even heard of harm reduction.

Polysubstance use, which is commonly mentioned in trap lyrics, is a major driving factor of overdose. Less common—dare I say, absent—are lyrical mentions of safer use strategies. Such references would have the potential to reach millions.

Hip hop, just like harm reduction itself, has a legacy of defiance. The openness with which it discusses drug use is rare in American culture, and the perfect jumping-off point for messaging that could save countless lives. If hip hop can be at the forefront of destigmatizing drug use, it can be at the forefront of safer use and harm reduction, too.

“Harm reduction matters to me because I don’t believe we can afford to lose hungry bright young minds. Many tragedies are avoidable,” Slug stated. “No one is expendable.”

Top photograph of Cypress Hill performing in Montana on August 25: Neubauer Media   

Beats Overdose Prevention logo designed by Allison McBride.

The post Hip Hop and Harm Reduction on Tour appeared first on Filter.

The drab Pfizer website lists the availability of its injectable naloxone formulation as “depleted.” In a perfect world, Pfizer’s listing would be banal. A shortage of one generic WHO-declared essential medication for one manufacturer (among several in the US) doesn’t sound like a crisis scenario. Yet Pfizer’s supply disruptions are causing the worst naloxone shortage the country has faced since at least 2012, when overdose levels were less than half of what they are now.

Insiders confirm that the shortage has devastated community-based naloxone distribution.

The Opioid Safety and Supply Network (OSSN) Buyer’s Club is the largest source of naloxone distributed to directly to affected communities—accounting for 1.3 million doses in 2020 alone. And the Buyer’s Club has relied solely on naloxone from Pfizer at a specially negotiated price.

In late April, Pfizer quietly communicated that naloxone supply would be interrupted, toppling what was already a precarious distribution network. Insiders confirm that the shortage has devastated community-based naloxone distribution, as the Buyer’s Club is the single largest distributor in most states.

Pfizer did not respond to Filter’s request for comment.

“I would guess that the naloxone shortage is related to redeployment of pharmaceutical production resources to COVID-related work, as well as the general chaos in manufacturing and transport,” Leo Beletsky, professor of law and health sciences at Northeastern University, told Filter. “Pharmaceutical supply chains have been in total disarray.”

Fewer than half of harm reduction organizations in an OSNN member survey provided to Filter report receiving any federal funds (including federal funds routed through state agencies) to purchase naloxone. Some innovative purchasing mechanisms have been created and painstakingly maintained in the face of perpetual budget scarcity.

The OSNN Buyer’s Club collectively purchases large volumes of naloxone as an informal network of 108 harm reduction programs sprawled across 39 states and DC. Much like how the Veterans Administration is legally able to negotiate prices directly with pharmaceutical companies (unlike Medicare) and therefore has some of the lowest drug prices, the OSNN negotiated a lower purchase price directly with Pfizer.

Harm reduction organizations have now been relegated to purchasing their naloxone at prices orders of magnitude higher than before, greatly reducing the amount they can afford.

The Affordability Problem

Recently, the federal government approved the largest-ever appropriation for harm reduction at $30 million, and an even larger appropriation that also removes the long-standing ban of federal dollars being used to purchase syringes is set to pass. It should be a time of hope in the harm reduction world, after decades of being underfunded and dismissed by the federal government.

Instead, organizations across the country are scrambling to provide their communities with the life-saving medication central to overdose prevention. As naloxone grows more scarce, people are reverting back to materials not needed in nearly a decade, posting resources on social media about what to do in an overdose when there is no naloxone.

Community-based naloxone programs have found that people who use opioids themselves are most likely to use naloxone to reverse an overdose, making them the priority population for naloxone distribution. Highly marginalized people are also most susceptible to barriers such as cost. Naloxone is not free, though people who use drugs typically acquire it at no-cost from harm reduction programs. The cost barrier, previously detailed in Filter, is the chief reason access is still limited.

Syringe service programs (SSPs) depend on injectable naloxone because it is most affordable. They distribute high volumes into their communities, primarily among people who use drugs and are most likely to be present during an overdose.

A July 8 NASTAD (National Alliance of State and Territorial AIDS Directors) memo states that between 2017 and 2020, SSPs distributed 3.7 million doses of generic injectable naloxone purchased through the OSNN Buyer’s Club. At that volume, cost savings immediately translate into more doses that can be purchased—and more overdoses that can be reversed. The memo goes on to list potential supply shortage mitigation strategies for SSPs, striking a hopeful chord in an attempt to ward off the panic that is brewing in the field.

Without access to affordable injectable naloxone, there is renewed interest in why Narcan is so prohibitively expensive.

Purchasing naloxone directly from pharmacies is possible, whether for harm reduction organizations or individuals. One dose of the injectable version of naloxone is listed on GoodRx and CMS at just below $15, though it is unclear how that price will fluctuate as the market shifts. Overdose reversal kits as compiled by harm reduction organizations include either two or three vials of injectable naloxone, reflecting that some overdoses require more than one dose. So if organizations were forced to purchase their naloxone at market rate, it would cost over $30 per person, multiplied by the thousands of people they may serve.

The nasal spray formulation Narcan, meanwhile, is listed on both GoodRx and CMS at around $128. (Note: CMS lists it per dose but it is sold per two-dose package.) Even people who aren’t purchasing high volumes suffer sticker shock at that price and hesitate. It makes scaling up Narcan distribution to a level required for saturation unfeasible.

Yet as things currently stand, harm reduction organizations scrambling to acquire any naloxone at all may end up purchasing Narcan to exhaust their time-limited grants before the end of the cycle; Emergent Biosolutions, its manufacturer, is poised to see its profits surge right along with overdoses.

Without access to affordable injectable naloxone, there is renewed interest in why Narcan—generally preferred for its ease of administration—is so prohibitively expensive. Under FDA patent law, Narcan is a “combination device”—both a drug and device packaged together. The cheap cost and multiple generic offerings of the actual compound within, the naloxone, become irrelevant in the face of this designation.

Recently, a second company, Hikma Pharmaceuticals, has patented Kloxxado, an ethically questionable higher-dose nasal spray formulation, indicating that equivalent technology is not prohibitively difficult to replicate. Competitors offering similar nasal naloxone combination devices could enter the market which would, in theory, bring down the price.

Potential Interventions

The “free market” isn’t the only potential solution to the crisis, however. In 2017, former President Donald Trump declared the ”opioid crisis” a public health emergency. It was more than political theater: The declaration of a public health emergency is a legitimate legal framework that expands government options to act and opens up funding streams. HHS Secretary Xavier Becerra extended the declaration in July 2021.

“A ton of these public health powers that we have seen used in COVID can be used here,” Jennifer Oliva, public health law scholar at Seton University School of Law, told Filter. “All of this federal stuff on the federal level is triggered by a declaration of emergency. The federal government can use its public health emergency powers under a number of different statutes and extend liability waiver, bulk purchase, stockpile, do all kinds of stuff.”

“In a more functional society, you would think, ‘These are essential medications, we need some sort of biosecurity structure.'”

Beletsky noted that such critical supply problems are neither new nor limited to naloxone. “Currently, we offload the production of essential medications onto the private sector, supported by taxpayer funds,” he explained. “We get very poor results in terms of supply and competitive pricing.”

“A big structural intervention could be getting the federal government actually involved in the production of essential medications, especially those in shortage,” he continued. “In a more functional society, you would think, ‘These are essential medications, we need some sort of biosecurity structure to ensure these are being produced at adequate quantities and getting where they need to go.’”

Even without such federal intervention, more could be done. A naloxone distribution problem has long been recognized. Some agencies, such as law enforcement, get more than they need, while others struggle to get any at all. Transporting naloxone from an area of surplus to an area of shortage is complicated by wildly varying state laws that require a complex chart to interpret. So the drug does not always get into the hands of the people most likely to use it, instead expiring on the shelves of clinics and police departments.

“We can’t just freely offer our extra [doses] to somebody else,” lamented Ella Bannister, founder of the Alabama Harm Reduction Coalition, “because it was technically bought through a specific grant with specific deliverables through federal funding. I find that that’s a big barrier as we move through this shortage.”

Many federal grants are routed through state agencies. While grantees have myriad requirements to fulfill, the state agencies are provided little oversight.

“There are all kinds of regulations for us when we receive grants, so why aren’t there stricter regulations for the federal government?” Bannister asked. “They could put in a percentage of how much needs to go to smaller nonprofits, places that actually serve individuals who use, rather than just allowing [the state] to decide what they want to do with it.”

“It is really going to take every organization across the US coming together.”

Extreme fragility in the US naloxone distribution network—caused by chronic underfunding, and compounded by egregious and unregulated drug prices—left it susceptible to minor fluctuations. Then a global pandemic brought major disruption. At a time of unprecedented overdose deaths, it will be harder than ever to get naloxone into the hands of people who need it until at least this fall.

“This is a crucial time to be able to have [injectable] naloxone because we have such [overdose] surges,” Bannister said. “And it just doesn’t seem possible.” As for a solution, “It is really going to take every organization across the US coming together.”

Harm reduction—a field and a movement that’s used to operating in precarious conditions with resourcefulness and tenacity—will surely find ways through the current shortage. Many people who need naloxone will not.

Photograph by Morgan Godvin

Jacob Sherkow, professor of law at the College of Law, University of Illinois, provided background information to Filter on FDA and patent law.

The post The US Faces a Naloxone Shortage at the Worst Possible Time appeared first on Filter.

“I used to joke that county jail was school for the ‘hood,” says DeMacon, an African American woman from East Portland, Oregon. “I just started meeting more and more people who were into more and more things. Honestly, it taught me how to do more criminal activity.”

Like so many, her constant encounters with the system went hand in hand with her heroin addiction. She recounts having overdosed five times, resuscitated each time by police or EMTs with naloxone. Once it was a grocery store bathroom, another time a 24-hour diner. Somehow, she was always found.

Now 30, DeMacon has grieved for more of her friends than most people twice her age. At least 10 people she knows have fatally overdosed. She fears more deaths are on the horizon.

“I was on probation. I could never pass a drug test. It’s stressful being in that situation because you’re always possibly going to go to jail.”

“In jail, they don’t care about you,” she says, her voice tinged with cynicism and sadness. “You’re just another number. They don’t even treat us like humans. I’ve literally been called ‘animal’ by a CO.”

She sought substance use disorder treatment many times, only managing to “graduate” once at a center that emphasized healing from past traumas. She used heroin again an hour later. On her other eight attempts, she didn’t last more than four days before leaving.

Now, she says, she “fell in love” with life. She left her addiction behind and is starting school in the fall, though she worries that her criminal record could limit her options. She has decided to major in political science, since it was politics—of which the criminal justice system is a direct outcropping—that wreaked so much havoc on her young life.

“I was on probation. I could never pass a drug test,” she says. “It’s stressful being in that situation because you’re always possibly going to go to jail. You have to check in with your PO, but if you do that, you’re probably going to jail as well [because of the urine test].”

“So, do you just not check in and take the warrant?”

Tanesia DeMacon

For decades, that was the paradox faced by Oregonians with substance use disorders (SUD) who had been arrested. You were jailed, put on my probation, and if you provided a positive urine screen, or transgressed on one of countless other technicalities, you were violated and sent right back to jail.

Although the drug war is global, the United States remains an outlier among wealthy nations for the punitive harshness of its drug policy. Out of more than 1.5 million drug arrests made in 2019, the vast majority—86.7 percent—were for simple possession. Despite a growing recognition of its racist origins and implementation, two decades into the 21st century, the War on Drugs rages on.

But in November, Oregon became the first US state to try a different approach than the one that has harmed DeMacon and countless others—including many people who do not have SUD—when voters passed Measure 110, decriminalizing small-scale possession of all drugs.

Measure 110 also diverts a portion of tax revenue from the cannabis industry, which Oregon legalized back in 2014, to SUD treatment.

The passage of the measure made history. It also brought controversy close on its heels, as lawmakers and wider society grapple with interpretations, funding and challenging timelines.

Decriminalization in Practice

The decriminalization element of Measure 110 went into effect on February 1.

Haven Wheelock, a chief petitioner of the measure, is already seeing the impact. As a harm reductionist who administers a syringe service program at OutsideIn in downtown Portland, she is on the frontlines, and has seen the suffering caused by the drug war. It’s one of the main reasons she became so passionate about decriminalization and funding evidence-based treatment.

Her clients, she said, often tell her that they “walk through the world always scared.” The constant fear of arrest for drug possession takes a psychological toll on people who use drugs. Measure 110 has assuaged some of that fear.

“People are finally breathing just a little bit easier.”

A limitation of decriminalization—as opposed to legalization—is that it does not make the drug supply safer. Fentanyl has contaminated a large swath of the market, from heroin and pills purporting to be opioids or benzodiazepines to cocaine and other stimulants. This volatile and unreliable supply, exacerbated by the COVID-19 pandemic, is linked with unprecedented death rates, even higher than those reported by media.

Wheelock believes Measure 110 brings hope in this regard, however. “One of the benefits … is we’re going to be able to do effective drug checking and safe consumption spaces within the next three years.”

She is working on messaging, so people know just how much of a drug they can possess.

Both of these interventions save lives. Safe consumption is currently banned nationwide and drug checking is nearly absent in Oregon. But reforms tend to pave the way for more reforms. And for now, harm reductionists can become involved—in drug checking, for example, which may require taking brief possession of residue amounts of controlled substances—with less fear of legal retribution.

While much confusion around this rapid policy shift remains, Wheelock sees the positives. She is working on messaging, so people know just how much of a drug they can possess before it becomes an arrestable offense. For heroin, it’s one gram—less than many people use in one day or buy at a time. For other substances, the quantities are less strict.

When a law enforcement officer finds someone in possession of drugs, they are now written a Class E violation. They will either face a $100 fine, or undergo an assessment within 45 days. If the assessment is not completed, the fine will be imposed. People caught with drugs who do not have a SUD still must still complete the assessment—but if the assessment tools work as intended they won’t be recommended to treatment. For people diagnosed with SUD and recommended treatment, completing treatment is not mandatory. Once an assessment is completed, the violation is dismissed.

People can alternatively show up to court to contest the ticket and a judge is authorized to reduce the fine to the minimum of $45. If the judge determines the ticket to have been given improperly, it could also be dismissed.

Importantly, unpaid fines will never trigger incarceration and missed court dates will never trigger a warrant for failure to appear. The Oregon Judicial Department is developing an e-filing system with Lines of Life so that when people complete their assessments, that information is automatically given to the courts.

The legislature is in the home stretch of finalizing SB755—the bill to make Measure 110 become law. Dozens of amendments have been compiled from their respective work groups and weaved into one single bill.

Questions not addressed in the text of the ballot measure had to be answered by the legislature—such as which category of court would attend to the newly-created Class E violations (the answer: circuit courts) or which professionals should conduct the screenings (likely to be certified drug and alcohol counselors and peers).

There were some quirky legal issues. For example, the measure only modified Oregon’s pre-existing drug codes, from which fentanyl and hydrocodone were omitted. (Instead they defaulted to the federal Schedule II statute.). But that was perceived as an accidental oversight and “user amounts” for both fentanyl and hydrocodone have now been defined—and therefore decriminalized.

The Measure’s Health Care Arm

Other questions surround Measure 110’s treatment funding arm. A temporary phone line, administered by the nonprofit Lines for Life, has been set up to provide the assessments and referrals to services demanded by small-scale possession cases in the new era.

The measure emphasizes harm reduction, supportive housing, peers to mitigate retention and navigation barriers, and the full spectrum of treatment services, including medications for opioid use disorder. The funding for all this is not supposed to be restricted to people who receive citations for drug possession—any Oregonian who requests services will be eligible. It is a truly fundamental shift in how the state deals with substance use, recognizing the importance of services for people who actively use drugs as well the importance of being securely housed. Some say there isn’t enough money to meet the need, but it is a start.

Intended as a stop-gap until what the measure called “Addiction Recovery Centers” can be set up statewide, the phone line could yet become a permanent fixture. Like so much else, that remains to be seen.

Oregon’s budget biennium ends on June 30. The cannabis tax revenue earned in the first quarter of 2021, stipulated by Measure 110 to go to the Drug Treatment and Recovery Services Fund, was already slated to go elsewhere.

This conflict between the measure, voter intent and Oregon’s budget cycles has been somewhat mitigated by the legislature: On March 16, the Oregon House of Representatives announced an allocation of $20.2 million for immediate disbursement into the fund—a rare instance of legislators moving faster than expected.

The foundational shift can be felt in the council meetings.

Implementation of Measure 110’s health care aspects has many more moving parts—not least the Oversight and Accountability Council (OAC), which was mandated to be formed by the date decriminalization took effect. The Oregon Health Authority voluntarily raised the number of council members to 21, above the minimum of 16 set out in the measure.

I was appointed by the Oregon Health Authority to the Council because of my lived experience with repeated incarceration for heroin possession, my less-than-pleasant experiences in drug court, and my current public health expertise and my drug policy research position at the Health in Justice Action Lab.

The foundational shift can be felt in the council meetings. Many of the councilmembers have been directly impacted by incarceration or addiction; others are leaders in the treatment and recovery services field. In a state that is 85 percent white (though Census Bureau race statistics obfuscate Latinx heritage), the majority of members are people of color—a damning recognition of the drug war’s disproportionate impacts.

Black and Indigenous Oregonians are grossly overrepresented in the criminal-legal system and in drug arrests specifically. Black Oregonians are convicted of drug possession at a rate two-to-three times that of whites, while Indigenous Oregonians are convicted at a rate five times higher. Upholding values of racial justice is a defining aim of the landmark bill.

While Measure 110 modified pre-existing segments of the Oregon Revised Statutes around drug possession, it also added entirely new language. Senate Bill 755 is taking all of the pieces and “plugging them in” to state law. This process has been far more arduous than it sounds, requiring three separate Senate work groups involving an extraordinary range of stakeholders and hundreds upon hundreds hours of work.

There have been major changes to the treatment section of the bill, but with near-unanimous support from stakeholders. Language has been one area of heated discussion. The name “Addiction Recovery Center” was deemed problematic because of the implication it must be a “center”—a brick-and-mortar location—which may not be necessary, or even possible, in all areas of the state. While Oregon’s population is heavily concentrated in the Willamette Valley, containing the Portland Metro and Eugene, the vast majority of the state is rural.

Drugs are not decriminalized on tribal land, which is subject to federal law.

There was also conversation around the term “addiction” since the medical terminology is substance use disorder—and even then, not everyone accessing services will meet the diagnostic criteria. “Behavioral Health Resource Network” is the frontrunner. The term “assessment” has been changed to “screening.” It was mandated in the ballot measure as being performed by a “licensed treatment provider,” meaning Lines for Life could only hire people with CADC certification and not peer mentors—another hiccup that is being rectified by the bill.

Meanwhile, the OAC is busily determining how it will distribute grants from the Drug Treatment and Recovery Fund. It has $20 million to dole out by June 30, and then each quarter thereafter, depending on cannabis tax revenue. Current revenue projections from the Legislative Fiscal Office amount to $318 million for the 2021-23 cycle, of which $228 million would be routed into the fund for disbursement, broken down into eight quarters over the two years.

The Oregon Health Authority is also negotiating with the state’s nine federally recognized tribes to ensure they receive adequate funding. It is important to note that drugs are not decriminalized on tribal land, which is subject to federal law.

Some Severe Challenges

Aaron Knott, policy director at the Multnomah County District Attorney’s Office,  which ceased prosecuting drug possession earlier than the rest of the state at the behest of DA Mike Schmidt, called Measure 110’s timelines “the most aggressive I have ever seen in a ballot measure.”

He has a point. From distributing grant funding to fundamentally altering policing and the courts, things are required to move remarkably fast.

However, despite some pushback from community advocates fearing unnecessary bureaucratic footdragging, the timelines have now been somewhat extended by Senate Bill 846—a companion bill to SB755 that also codified into law, in alignment with Measure 110, the changes to how cannabis tax revenue will be distributed.

The deadline to establish the Addiction Recovery Centers, to use their original name, has been extended three months and is now January 1, 2022. The Oversight and Accountability Council now has until September 1, 2021 to establish its rules—a two-month extension. The temporary phone line will no longer be terminated in October, but will rather be extended into at least next year.

Concerns about the measure go beyond its technical workings and logistics. While law enforcement was predictably against it, opposition also came from more unexpected corners—including the recovery community.

“Nonprofits and other people are all advocating for their own things … There’s redundancy all over the place.”

“What we have is a system that is fractured and incomplete,” said Tony Vezina. He’s the executive director of 4th Dimension Recovery Center, a nonprofit youth service with multiple locations in the Portland metro area. A person in long-term recovery and a leader in the recovery community, Vezina advocated against Measure 110, even though he doesn’t disagree with decriminalization in principle. He sees the current system as utterly lacking in cohesion, compounded by inadequate resources.

“It’s also fractured from a governance policy perspective,” he said. “I hate to use the word but there should be some type of authority. No one is steering the ship. The system is just this free-market thing where nonprofits and other people are all advocating for their own things … There’s redundancy all over the place.”

Even Measure 110’s strongest proponents would agree that we need to get organized to implement it well. And a good starting point in determining where the state needs to go would be knowing where it is today. Included in the $20.2 million Oversight and Accountability Council allocation, the legislature earmarked $200,000 to go directly to the Oregon Health Sciences University to complete an inventory—determining just what the state does and does not have in terms of a SUD treatment ecosystem.

That’s something the state’s Alcohol and Drug Policy Commission (on which both Vezina and I serve) has been asking for for at least two years, but it was never funded.

“What Measure 110 did was accelerate the decriminalization part, put some money into the system, but then also exacerbated the disorganization,” said Vezina.

Tony Vezina

He also cited well-founded concerns about the preparedness of our health care system, where providers receive little-to-no training in addiction and are known to stigmatize people who use drugs.

Unlike health care, our criminal justice system has always been active, seeking people out and bringing them in. Vezina hopes that the expansion of Oregon’s treatment ecosystem will include more points-of-engagement, actively connecting with people with services. Passively sitting by and waiting for someone to call a number is not sufficient, he believes.

Even having one number to call is progress from where the state was before. Oregon consistently ranks bottom of the pack for treatment access—though defining “treatment” is tricky, as Senate workgroups can confirm. There is no unified system to triage or direct people who need services—or even to identify who needs them. Parents watching their children struggle with SUD have no idea where to go for help, what to do.

The Lines for Life line may be able to refer someone to services, but inadequate supply of those services can result in long wait lists. There may be nowhere for people to go. Further grant allocations from the OAC should improve this situation in time; some providers envision a number like 211—something easy to remember and centralized.

“If it were me, and I was either mandated to an assessment or desperate for help, or had a kiddo I was desperate to get help for, I would want one phone number,” said Jessica Gregg, chief medical officer at DePaul Treatment Centers. “I would want someone to answer it. I would want, ‘This is the next step … if it doesn’t happen, call me back. Here’s my name.’”

A key to improving health outcomes is improving integration within and across the service delivery system.

Systems integration will remain a barrier to care. Because the US service provision is dependent on grant-funding to thousands of for-profit and nonprofit organizations—and because of our unfathomably complex insurance structure that excludes millions—the burden of navigating this byzntine system falls onto the patient. With no robust public health infrastructure or centralized provider, we have a hodgepodge where everyone works mostly independently. Not coincidentally, despite spending more on health care per capita than any other rich country, the United States reports alarmingly poor health outcomes.

Privileged people in ideal circumstances are often incapable of navigating our systems. For marginalized people who use drugs, with numerous other barriers, it becomes an impossibility.

Dane Zahner, the prevention and harm reduction manager for HIV Alliance, highlighted the myriad obstacles facing the people he serves. “About 50 to 60 percent are homeless,” he said. “They also have transportation needs here in rural Oregon. There are barriers to food and barriers to housing.” The list goes on.

People who are handed a list of phone numbers and sent back to the streets inevitably fall through the cracks. So a key to improving health outcomes is improving integration within and across the service delivery system. Oregon is not Portugal, that famous international example of successful decriminalization coupled with service provisions. The state does have expanded Medicaid, but only 23 percent of the state’s residents are on it. Most of the rest are divided between any number of private insurers. Almost 250,000 are uninsured.

To Gregg, one way to help people navigate these labyrinthine systems is simple: “Peers, peers, peers.”

Measure 110 and SB755 repeatedly emphasize the importance of peers, echoing decades of evidence that shows how they increase engagement and retention in SUD treatment. Hopefully the infusion of funds into the system will enable more peer hires—though there are whispers of a looming behavioral health shortage due to low wages, a situation that could, in theory, be mitigated by the extra funds.

COVID has disrupted service provision and fueled surges in both drug use and overdoses. Extricating COVID—the confounding factor—from the data around decriminalization and treatment will be a challenge for researchers studying the outcomes of Measure 110 in years to come. We know that 2020, before decriminalization, was the worst year in history for overdose deaths. 2021 is currently on a similar trajectory.

Problems With Policing, High Hopes

A mere fraction of the people cited for drug possession since February 1 have called Lines for Life, the only currently authorized provider of screenings to avoid that ticket. Some advocates have suggested that law enforcement officers hostile to decriminalization are not communicating the procedure clearly to people cited, or failing to provide the phone number to Lines for Life. They also suggest that people are simply so afraid of police that they are choosing not to engage with the system.

Oregon first fundamentally changed drug policing in 2017, when the legislature reduced possession from a felony to a misdemeanor. Arrests plummeted afterwards, despite drug use likely remaining constant. Whether police changed their tactics or simply didn’t want to bother with a misdemeanor is unknown.

Measure 110 is an even bigger shift. Columbia County Sheriff Brian Pixley recognizes that it will reduce barriers for some people struggling with addiction and could increase the likelihood that someone seeks help, without fear of going to jail. He noted that drugs are not legalized, and will still be confiscated by law enforcement as evidence for what’s now a Class E violation.

He nonetheless has strong reservations about the measure. “Frontline deputies are having to shift their mindset and rethink things like search and seizure, subject stops, detention, and DUIs,” he said.

Some would argue that is the point. The War on Drugs has been used to dramatically expand police powers when it comes to search, seizure and detention, greatly diminishing Fourth Amendment rights. Police interactions, which Measure 110 is intended to reduce, also carry far greater risks for people of color. Portland, for example, has the fifth worst arrest disparities in the nation, with Black people being killed by police at a rate 3.9 times that of white people.

The reality is that the burden of substance use disorder and mental health “care” has largely fallen onto the criminal justice system.

Sheriff Pixley also expressed concerns that there will be an increase in crime rates, addiction, and overdose if people no longer fear jail or severe legal repercussions. What evidence we have points the opposite way, however. Oregon, again, is not Portugal. But Portugal saw better outcomes across the board after implementing its own decriminalization model back in 2001.

Pixley hopes to be able to get the funding to provide medications for opioid use disorder in jail and naloxone to people upon their release—funding that could potentially come from the cannabis tax revenue.

The reality of the last several decades is that the burden of substance use disorder and mental health “care” has largely fallen onto the criminal justice system, which—besides the inherent ethical problems—is unequipped and unwilling to handle it. No government alternative was provided.

Tera Hurst is familiar with this reality. She’s the executive director of the Health Justice Recovery Alliance (HJRA), described as the implementation arm of what was the Yes on 110 campaign. Initially supported by the Drug Policy Alliance, HJRA’s fiscal sponsor is now Partnership for Safety and Justice, an Oregon reform organization. They are advocating for funding from the legislature, suitable amendments in SB755, consistent support of the OAC, and overall excellence in implementation.

“Most law enforcement, they have just never had a system that isn’t starved,” Hurst said. “They’ve always had to constantly arrest folks. They watch them cycle through, they watch them on waiting lists. I believe that once we get a funded system where they could actually send somebody and know that’s going to be an avenue and not just a phone number and then they’re back on the street … Once law enforcement sees that commitment, and as long as we continue to get these things funded and up and running, they’re going to be relieved. They will be able to say ‘Hey, call this number. It worked for so-and-so. It works.’”

Seeing, as they say, will be believing. Though some people with SUD who come in contact with the criminal justice system and its programs do find recovery that way, most arrests are destabilizing at best and often traumatizing—or ultimately, deadly. One study showed the risk of overdose being 129 times greater in the two weeks after release from incarceration.

Reducing arrests will mean that fewer people who use drugs will be saddled with criminal records. The collateral, lifelong consequences of criminal convictions are numerous, ranging from housing, to employment, to government benefits, to professional licensure, to immigration.

Jack, a Chinese American man who asked that only his first name be used, got a possession conviction before the 2017 defelonization.

“Being labeled a felon,” he said, “I sometimes feel like a second-class citizen.”

A recognized shortcoming of many decriminalization measures—and of Measure 110 in particular—is the failure to expunge past convictions for things that are no longer criminalized. Jack still has a felony.

Jack, who unequivocally supported Measure 110, reflected on how different his life might be had it been in effect before his conviction.

Senate Bill 397, currently before congress, makes expungement more accessible by eliminating fees and shortening wait times. But advocates like Tera Hurst and Haven Wheelock want to see it become automatic and sweeping. That is proving to be a heavier bureaucratic lift than it would seem (many records are not digitized), but the wheels are turning for future legislative sessions.

There is also ongoing conversation between lawmakers and immigration experts about how to avoid triggering future deportations—and whether there is any potential for relief for people already removed from the country. (Though that looks bleak.)

Jack, who unequivocally supported Measure 110, reflected on how different his life might be had it been in effect before his conviction—now a common refrain of impacted Oregonians.

“Maybe there would’ve been better resources to guide me to the right treatment center instead of me hopping around, for years on end, in and out of different treatment centers before I found a program that worked for me,” he said. “Possibly could’ve saved years of my life I can never get back.”

“Punitive measures aren’t effective in addressing this issue,” he continued. “Jail does nothing but worsen the problem… I didn’t learn anything of any value during my tenures in jail. I learned nothing but to perfect the crimes I already did and I learned more crimes to feed my addiction.”

As of February 1, the state of Oregon stopped inflicting some of its worst harms on people who use drugs. Now comes the healing phase—if it is handled right.

There are many moving parts, and in the short-term, there will be hard work and growing pains. In the long-term, experts are hopeful. People who use drugs are already breathing a sigh of relief. But it remains to be seen whether Measure 110 turns out to be the domino that brings the entire drug war crashing down.

Top photograph courtesy of the Yes on 110 campaign. Other photographs courtesy of Tanesia DeMacon and Tony Vezina.

R Street Institute supported the production of this piece through a restricted grant to The Influence Foundation, which operates Filter.

The Drug Policy Alliance previously provided a restricted grant to The Influence Foundation to support a Drug War Journalism Diversity Fellowship.

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