The Opiate Overdose Crisis: An Experiment in Vancouver Suggests a New Approach

Across North America, first responders and hospitals report a deluge of overdoses among heroin users whose drugs are mixed with fentanyl, a strong synthetic opiate or the even more powerful carfentanil, which is used in veterinary anesthesia. Word from Vancouver is that public health workers have used a reagent test for the presence of fentanyl in other street drugs for the clients that they serve.

In addition to the dangers posed by heroin itself, these additives make street doses unpredictable in strength.  By volume, the synthetics are much more powerful, and street users depend upon illicit manufacturers and distributors to supply semi-predictable products. Although many street users now expect that the heroin they buy (and sometimes, the cocaine) will contain synthetics, they also have little or no way to know how carefully compounded these drugs are. Judging from the rapid rise in overdoses in recent weeks, the answer is that dosage chaos reigns.

Why Vancouver first? First, British Columbia is treating it as the emergency it is. It declared it as such in April 2016, with the CBC reporting that by June, 71 overdose deaths had taken place and 60% involved fentanyl.  But uniquely, the city has a government-funded organization called Insite, a supervised injection site for drug users. Nurses and other clinic workers staff the place, and it is the only program like it right now in North America. Insite also has some health care services, provides clean needles and can respond to overdoses on site.

Drug users bring in their own drugs, and they are free from the risk of arrest while they are there. This also provides an opportunity for drug testing. Consumers of the drugs can learn about the composition of the drugs they are about to inject, while the clinic can gain information about, and report on, trends in purity and composition of street drugs.

Which brings us to the potential of fentanyl test strips. Francine Diep reports in Pacific Standard magazine that fentanyl testing may – emphasis on may – provide some benefit to drug users by detecting its presence. Insite ran a pilot testing program this summer, using the strips for a month on as many samples as they could. 90% of the heroin samples contained fentanyl, and some of the cocaine samples did, as well.

There are two key issues here. First – how accurate the tests are from a strictly scientific viewpoint: what are the rates of type I and II errors, and what is the specificity to the problem of an adulterant like fentanyl as opposed to cross-reactions to other less deadly ingredients? The strips were originally designed to test urine, and in lab settings it has a 6% false positive rate and a 0% false negative rate. Most of the medical consultants on Insite’s project felt that it might do just as well in water-dissolved samples at the clinic. In the abstract, the low false negative rate is good news. The test strip doesn’t react to carfentanil, however.

It should be kept in mind that some users actively seek out synthetic opiate pills, either preferring them to injecting heroin or using them as a bridge at times when heroin is hard to come by.  People who buy hydrocodone illegally may be getting fentanyl instead, or a mixture, and again, the unexpected strength can be deadly. It appears that fentanyl in a hydrocodone preparation is what killed legendary musician Prince at age 57 in Minnesota this past spring.

Also, to what extent does a positive result for fentanyl discourage a user from injecting the drugs? Diep notes that few people at the Vancouver site seem willing to throw away contaminated drugs altogether. But staffers suggest they may be willing to lower their intake if they know the powerful synthetic is present.  The clinic reports that 86% of the drug samples they tested contained some fentanyl, which implies that at least for the population that uses that clinic, it may be hard to avoid.

Fentanyl is now everywhere. It can be purchased on cryptomarkets online, where either tablets or ingredients can be obtained. Making it is not that difficult, and mid-level distributors can move into manufacture. It can also be diverted from legitimate medical use, as it is often prescribed to people with cancer.

Similar ideas for other cities have been stymied by an insistence on abstinence and prohibition-based approaches and legislation which inhibits or quashes altogether such harm-reduction opportunities, in both Canada in the US. The only recent harm-reduction initiative that hasn’t been aggressively and routinely blocked is overdose-reversal medication like naloxone, which many communities distribute to first responders or make available to the public by prescription.

But as synthetic mixes hit the streets, naloxone is less effective. Reports from Indiana suggest that when carfentanil is present, even five or six doses of naloxone may not reverse the effect. Carfentanil is also powdery and light, posing risks to police and EMTs who respond to places where the drug is present just by touching or inhaling it, in a similar way that methamphetamine making can expose others to risk.

So, the way to think of the new synthetic adulterant problem is: a mess we don’t know how to handle, situated on top of a mess that we do know more about than we are willing to do.  You’d think decades of a failed War on Drugs – drugs won, in case you haven’t been keeping up – would demonstrate the need for greater humility and innovation in policy making. The pilot project in Vancouver can save lives and prevent injury, and similar programs could also tell us a great deal about drug adulteration, and how best to protect public health.

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Like Many Things, the Promise of Light and Portable Drug Testing Depends Entirely on Context

images-pills-modern-cover-photo-fbI noted in my last blog entry on the dubious technology “drink spiking detection” devices — such as coasters, test cards, and other reagent-coated bar ware — that both false positives and false negatives are too high to make the technology useful. I also suggested that if such user-end technology — thus far deployed without much real consumer interest — were to become more popular, the imprecision associated with such products could instill a dangerous reassurance to people situationally suspicious enough to test their drinks, while creating undue fear, accusations, and other kinds of serious ramifications in the case of false positives.

But in another realm, there’s already a darker side to false positives in quick field tests. Nationwide concern in the US is beginning to pick up about the sometimes life-altering problems associated with inaccurate or inconclusive field tests used by law enforcement agencies. Field testing technology for drugs on the scene (say, at a vehicle stop) hasn’t developed much since its inception in the 1970s; it appears that what is new is the recognition that cross-reactions with any number of other ordinary chemicals and compounds produce unacceptably high levels of false positives. The New York Times Magazine reported in July that widely deployed reagent field tests have routinely produced false positives for methamphetamine and cocaine. But enter “field drug test” or “drink detector” into a search engine on line, and you’ll find little recognition of the cross-reaction problems that have been known for years.

Furthermore, the necessary visual interpretation of chemical testing results (it turned blue, it turned sort of blue, it turned light blue…) remains a key moment in decision-making in forensic detection and is fraught with the tendency to over-certainty and over-confidence.  This problem has been well-known since the most rudimentary lab techniques were developed in the early 1900s, and remains a problem for cheap, easy field deployables. The cobalt thiocyanate tests used to test for cocaine, for instance, will also turn blue with a number of over-the-counter medicines and cleaning products.

Technically, in order for a positive field test to lead to criminal conviction, it has to be confirmed in a lab by more precise tests. But circumstances rule. Most people arrested for drugs don’t have access to private lawyers or even readily available bail or bond money, and pleas before confirmation are the norm.  Some period of incarceration may ensue anyway, just enough to disrupt the stability of more vulnerable citizens. The Times article chronicles the downfall of a Louisiana woman arrested in Houston and saddled with a felony conviction for crack cocaine, which turned out to be a fragment of the over-the-counter aspirin and caffeine pill that she insisted it was. Having lost her steady home and job as a result, she didn’t even realize that she’d been part of a wave of similar exonerations until the Times informed her, years later.

But on-site drug testing can be used by consumers of drugs, as well. In a different context, the technology, even with its flaws, can prevent harm rather than inflict it. There is a well-functioning model out there – and it comes from the rave scene. In rave and electronic music settings, there’s actually a solid network of nonprofit drug testing that can analyze drugs on the spot. The DanceSafe outfit is probably the best known of these harm reduction groups, but the technology to provide such a service is widespread. MDMA, commonly known as Molly or Ecstasy, is one of the more widely adulterated illicit drugs. On August 3, Lauren Frayer reported on NPR’s All Things Considered radio show that on-site testing had been arranged for a larger music festival in the UK. Due in great part to advocacy on the part of researcher Fiona Measham of Durham University, a legal path has been cleared for the process, to encourage event goers to subject their drugs to testing. In the process, they can discuss the results with a trained counselor. In the US, DanceSafe sells testing kits to consumers, but can’t provide on-site testing and counsel due to risk of attendees’ arrests. (This organization and others are advocating for legal and enforcement-practice reform that would enable this service in the US.)

Online drug commerce has advanced the prospect of user-initiated testing, as well. A firm called Energy Control in Barcelona tests any drug sent to it and provides a report. It now receives government support in the interest of harm reduction, although it started out with a single doctor, Fernando Caudevilla, who posted to the now-defunct Silk Road darknet platform, offering testing and advice. The testing is highly precise but not immediate – with at least a few days’ turnaround time. The company takes Bitcoin payments to enhance anonymity.

A number of drug cryptomarkets have emerged in the wake of Silk Road’s closure in 2013, when it was seized by the FBI as part of the indictment of its founder, Ross Ulbricht. The market for online illicit drug transactions is growing rapidly, according to a newly-released RAND report.

So you can assume that there is a latent demand for user-end testing products, for people that use drugs voluntarily, and have the resources to buy them discreetly. People who purchase drugs in hand-to-hand transactions aren’t the same as those who buy on line. It’s unclear whether this sort of simple re-agent technology would be used widely by those who purchase street drugs.  Energy Control reported that cocaine was much purer in online samples than street ones, suggesting that a bifurcated market remains — starkly by economic resources — and perhaps also the interest in drug content verification. In any case, having users make contact with neutral testers and advice-givers seems all to the good, in terms of enhancing public health and at the same time adding to the research body of knowledge about illicit drug trends. Increasing awareness of the fallibility of light-and-portable tests — and resisting the “gee whiz” style of reporting on technology — also seems useful to everyone.

The Promise and Pitfalls of Consumer Drug Detectors. Okay, Mostly Pitfalls. (Part 2 of 2)

What’s in Your Drugs? Summer Drug Testing Roundup, part 2 of 2:

Read Part 1 here

On the heels of a bar drugging scare this past summer in Seattle, some local bars in the Capitol Hill section of that city are supplying test strips for bar patrons. These easy-to-use reagent strips can typically test for GHB, and in some cases Ketamine. The problems, though, with such devices are legion. Where to begin? I’ll get there in a roundabout way by first talking about the state of easily deployed drug identification technology.

Given the recent attention to contamination and tampering of both street and prescribed drugs, along with the drug counterfeiting problem, there’s clearly a general demand for light, reasonably precise, and portable field and home test technology for consumers to use. For reasons of legal sanction, privacy, expense, and convenience, commercial lab testing on-demand still leaves behind a big unmet need.

After-ingestion drug kits already exist – worried parents can get their kid to pee in a cup and test for any number of illicit substances, which they can then mail into a lab for confirmation. But the unmet need – or perceived need – is for before-you-consume products.  For instance, while the press loves entrepreneurs who come up with yet another “revolutionary” spiked drink detector (test cards, straws, cups, coasters, even a nail polish that you can stick in your drink) – funders … not so much. Though things may change, press fanfare is usually followed by failure on the venture capital and the crowdsourced funding circuit.

People seem to feel ambivalent, at best, about using these items anyway. I’d love to think this had something to do with clarity about the real nature of a variety of inter-related problems – drug use, alcohol use, and sexual assault – but I suspect there’s more to it.

In studying the date rape drugs scare, I noticed that the uptake for these detection items is low.  Campus public safety departments and bars, for a while in the 2000s, bought bulk lots to hand out only to find enthusiasm for the products’ use to be weak. The industry also lacks success testimonials – the natural one being “I foiled a spiker!” – for two reasons: one, the testing products aren’t used much, and two: because spiking in public venues, among strangers, is much lower than the hype would suggest. Once a particular scare dies down, demand from the nightlife industry tends to wane, suggesting that patrons aren’t particularly clamoring for even more reactive coasters or drink sealers.

There’s also a third problem: many of these reagent testing devices manage to lack both specificity and sensitivity – enough so that both false positives and false negatives are fairly common in lab settings. The test cards and strips for GHB, for instance, are based on a simple Ph test. Pour some mineral water on it – or any number of other liquids that are common in drinks and in bars – and you can get a positive result. (Fun bonus error: some wines have GHB in them.) Yet, as a 2010 article in Maclean’s suggests, in addition to missing about a third of tampered samples (that is, producing false negatives), the most widely distributed products “would still finger 12 innocents as toxic creeps for every 1 guilty man it identified.” A great deal of mayhem could ensue in the wake of a false positive before the 12 inculpated spikers (at a sensitivity level of 88%, according to the UK lab study by Caryl Beynon and associates of some similar spike-detecting products) could be cleared of wrongdoing. (Here are some other studies that examine the problems with this technology.)

Newly deployed handheld mass spectrometers are much more precise, but they still aren’t the kind of thing that a layperson interested in their personal safety will be able to use and understand well. Technicians and scientists have to be trained to interpret (and not over-interpret) results; the rest of us might well end up in the same guessing-game position both before and after the field test.

Yet, to be fair, while the date rape drug detection industry lacks testimonials of success, false positive scandals seem to be lacking as well.  I haven’t read of any calamities associated with the big error rates of these products. The Maclean’s article came out after a spate of new products hit the market, but the lackluster interest and scientific problems with the devices were reported on in the press as early as 2002, in an article by Margie Mason via the Associated Press. This is another indirect – though fairly convincing — indication that such devices, which are still employing the same technology, are celebrated without being actually used much. They’re neither foiling drink spikers nor falsely implicating our bar mates. In all likelihood, they get ordered, deployed near the lemons and swizzle sticks, and then get mothballed.

Next up in this blog: a third entry in the Summer Drug Testing Roundup. More pitfalls of light and portable drug testing, but I promise a bit more promise also.

What’s in Your Drugs? And Does it Matter if it isn’t what you think? (Part 1 of 2)

Summer Drug Testing Roundup, part 1 of 2: 

In mid-July in Yorkshire, England, ITV and other news sources reported that purchasers of “street Valium” got more than they bargained for and a number of them had sought medical attention. The first odd thing was that the drug had turned their tongues blue, and the second was that the drugs’ effects were much heavier than expected. Within weeks, police made an arrest and recovered about 40 more of the suspect tablets.

It appears that the underground compounder making the drugs mixed diazepam (known by one of its commercial names, Valium) with flunitrazepam (known as Rohypnol) or “roofies.” Swiss pharmaceutical giant Roche began blue-dye tagging Rohypnol tabs in response to spiked-drink reports in the United States in the late 1990s. Both Valium and Rohypnol are benzodiazepines, but Rohypnol is stronger. Roche makes both of the name brands, but generic versions are around, as well. Valium is mostly used as an anti-anxiety drug, whereas Rohypnol treats insomnia. (Roche was never all that aggressive in seeking to swim upstream against the negative publicity as it marketed the drug in the US. Rohypnol was too similar to other insomnia drugs anyway, and Roche focused mainly on countering the negative publicity.)

No doubt the purchasers of the illicit drug had expected a Valium-high, but experienced something more anvil-like and presumably suffered some of Rohypnol’s known side effects, such as amnesia.

The recent incident in Yorkshire points up the strangeness of continuing to use the term “date rape drugs” in any meaningful way. References to Rohypnol assume, often without sources or reference, that it is widely implicated in drugging and drink-spiking cases. In fact, Rohypnol is available by prescription in Europe and elsewhere, and it is rarely implicated in predatory drugging incidents. In the handful of cases where anything other than high blood-alcohol levels has been found, none of the commonly labeled “date rape drugs” are among the top substances. Instead, the usual street substances are found, including stimulants. But the moniker “roofie” leapt clear of its origins and took on a meaning of its own.

The Yorkshire Street Valium incident points to a more common problem — adulterated drugs in the illicit market. Up until recently, consumers of illegal or restricted substances had no way to verify that what they were buying was what they thought they were buying. Underground mid-level distributors and wholesalers sometimes employed chemists for verification of samples from larger lots they were negotiating to buy, but the street user was more or less on his or her own. In the US, there have been a number of cases in which seekers of heroin were sold heroin-fentanyl combinations, with sometimes fatal results. Fentanyl is a powerful synthetic opiate, and by weight or volume tends to be considerably stronger than heroin. Also this July, law enforcement in Long Island, NY arrested 24 people in connection with heroin and fentanyl distribution. At least one of the combinations they were distributing seems to have provoked an uptick in overdoses.

But in describing a street preparation as a deadly dose, you have to consider not only the objective effects of a particular dose, but the expectations that the buyer and user bring to the anticipated high. Fentanyl itself is now sought out, on its own or in combinations, by illicit users. Heroin users often expect their purchases to be cut with other things; toxicologists note that most of the time, the adulterants buffer rather than strengthen the effects of the drug. But the haphazard and after-the-fact investigation of the content of illicit substances, as well as a non-transparent supply chain, means that it is difficult to separate effects of the drugs themselves and the drugs’ potential substitutions and additives.

In my book on drugs associated with the “date rape drugs” scare, I noted that there was really no factual basis to label certain popular club drugs like GHB as the preferred weapons of predators. GHB, Ketamine, and Rohypnol – like many central nervous system depressants – have been implicated in specific cases, but any CNS depressant can work, and the labeled drugs are found less often than other widely available drugs (and, of course, alcohol). GHB also presents an interesting conundrum in that it is often not clear whether people who had some in their system were dosed by someone else with ill intent, or whether the GHB was a part of a popular mix of MDMA and GHB sometimes sought out in club settings.

Just to add to the confusion, GHB’s street names are myriad, including Liquid Ecstasy and Cherry Meth. and its effects are seemingly subjective enough to be mistaken for any number of knowingly ingested substances.  The underground compounder often finds that GHB is a cheap substitute for other drugs. GHB is also sought out by recreational users for its reputation as a calorie-free buzz mimicking moderate alcohol ingestion. It can be very dangerous, however, in combination with alcohol.

Voluntary drug users clearly might benefit by being able to quickly and easily test the content and potency of their drugs, but for many reasons the market hasn’t reached this potential public yet.  In my next blog, I discuss the problems with validity and reliability of home and field drug test kits, and the products that come to market to purportedly fix this problem. Depending on context, testing technology can either aid well-being and safety or undermine it.

The book is out (July 2016)

Book Title is Drink Spking and Predatory Drugging: A Modern History
http://www.palgrave.com/us/book/9781137575166

It’s a wide-ranging look at the spectre of the compromised drink, amidst the shifting cultural and gender politics of psycho-chemical treachery. A preview chapter is available at Google Books, and you can also “Look Inside” at Amazon. If your public, institutional, school, or university library hasn’t ordered it, you can make a request.

If you’d like to review the book for a news source or journal, contact reviews@palgrave.com

Forget the Screaming Headlines about Drink Spiking on Campus

The news and screaming headlines surrounding the release of a new research study on drink spiking focused on what was hailed as a surprising new discovery about the problem. Women’s Health noted that the percentage of people victimized was appalling, and Cosmopolitan seemed both horrified and somehow relieved that it wasn’t just “an urban myth.” I wonder what number of drink spikings might be taken in stride – I do hope the answer to that remains ‘none’ despite all the misleading fanfare. But you can’t blame the press entirely here. As a social science researcher and writer, I know that it’s very hard to control the media spin on your research, but a press release about the study issued by the American Psychological Association (APA) dodges the study’s limitations and also, oddly enough, its strengths.
“Just a Dare or Unaware?” by Suzanne Swan and associates is being published in the research journal Psychology of Violence. The featured findings do sound pretty dire. But taking a more granular look at the research — and giving better attention to the toxicology and other public health literature, should temper the creepy press enthusiasm a little here.
The researchers developed a pretty interesting survey data set on drink spiking, which suggests that about 7.8% of the college student respondents believed they’d been given drug-spiked drinks. It was an impressively large, multi-campus survey in the US (just over 6,000 respondents.) More than 1% said they’d spiked other people’s drinks. Swan and her associates carefully note that there’s no way to know whether the respondents were really drugged, or whether they mistook their symptoms of excess alcohol for something more sinister. As we can see, the press doesn’t seem to see that as much of a problem, and assumes that suspicion of drugging is indicative of it. It isn’t.
Most toxicology studies — including all of the ones briefly cited in “Just a Dare” — strongly indicate that most people who believe they’ve been drugged and seek help at emergency rooms have not been. Most commonly, they present with extremely high blood-alcohol levels, and sometimes common street drugs. If you want to read a good summary of this research, David Grimes article in The Guardian explains much of the consensus in the field, and reiterates scientists’ plea to pay greater attention to alcohol itself. (And here is a starter bibliography I put together for my recently published book on the topic, Drink Spiking and Predatory Drugging: A Modern History, from Palgrave Macmillan.)
That aside, it seems to me that the press, and to some extent the researchers, have kind of buried the real striking findings here. First, the new study sheds fascinating light on the myriad reasons for drink spiking — both the reasons as interpreted by people who suspect it was done to them and those that say they drugged others. It doesn’t actually refute the urban myth analysis; indeed, it largely supports it. The researchers unfortunately insist on using Weiss and Colyer’s 2010 article in Deviant Behavior and the article I co-authored in 2009 with Adam Burgess and Sarah E.H. Moore in the British Journal of Criminology as a kind of fake touchstone for an “it’s all an urban legend” trope, against which they present what they claim is their own “no, it’s not” data. But both of these articles were about the date rape drugging scare, and in particular the scenario by which a stranger slips a drug into a drink at a bar or party and then hauls off the compromised victim to a private place to sexually assault them. Other social scientists (Valverde and Moore; Berrington and Jones) have pointed out problematic aspects of this scaremongering, early on, from a gendered violence standpoint.
Also buried in Swan’s study is the finding that in a sample of 6,064 students, 67 report being drugged and then subject to unwanted sex (acceding to verbal coercion or hectoring, such as the threat to end a relationship), or actual forced sex. That’s 1.1% of the total sample, and 14.5% of the students who report a suspected drugging experience. (It looks like an additional 13 students suspect sexual victimization, but weren’t sure.) In other words, most people attribute drugging incidents to motives other than the chemically-facilitated rape that the press has touted as an omnipresent danger for more than 20 years. The “date rape drugs” scare has contributed to attempts to breathe new life into the War on Drugs and has people focused on so-called “predator drugs” that are mostly consumed voluntarily, for pleasure or to manage other drugs’ let-down symptoms. According to the respondents in Swan’s study who suspect they were drugged — about a third of whom were male — the some commonly surmised reasons were variations on intended fun and recreation (such as “to loosen me up” and “to have more fun.”) Some said it might have been for malicious reasons, or a mistake. A surprising number (47 respondents) said they just didn’t know.
As for the study’s claim that 7.8% is “higher than expected” — I suppose it all depends on how you see it: That’s honestly lower than even I would have expected, given the hype of the last two decades. I certainly can concur with Swan et al.’s conclusion that public health and public safety interests need to focus on developing interventions that “move beyond the exclusive focus on sexual assault and should address the varied motives of those who drug others.”

[15 scientific studies on drink spiking]   [a summary of scientific consensus on spiking]