How America Overdosed on Drug Courts(psmag.com)
psmag.com
How America Overdosed on Drug Courts
http://www.psmag.com/politics-and-law/how-america-overdosed-on-drug-courts
29 comments
It is a generalisation but a good one. "Getting clean" is a loaded term. Most (not all) people who have "drug" problems actually have police problems. The drugs do them very little harm (impurities are a different story, but not as common as people think) but the police and legal systems do them untold damage.
Making the drugs available is by far the best treatment for most forms of drug addiction in the vast majority of cases. The simplest way to do that is to remove criminal sanctions from drugs and make prescription for addiction legal.
Addiction is a complex beast and demanding that people deal with the chemical dependence before dealing with the other problems in an addicts life is usually a cruel approach and ineffective.
This is something a psychiatrist should know.
Making the drugs available is by far the best treatment for most forms of drug addiction in the vast majority of cases. The simplest way to do that is to remove criminal sanctions from drugs and make prescription for addiction legal.
Addiction is a complex beast and demanding that people deal with the chemical dependence before dealing with the other problems in an addicts life is usually a cruel approach and ineffective.
This is something a psychiatrist should know.
I can't really agree with your premise. Our current situation is pretty broken, and our drug laws and enforcement have not achieved their stated aims.
That said, the legality of alcohol hardly keeps it from causing lots of people very serious problems. "Drugs do them very little harm" is fantasy, though you are quite right that a felony history and time behind bars only makes things worse.
That said, the legality of alcohol hardly keeps it from causing lots of people very serious problems. "Drugs do them very little harm" is fantasy, though you are quite right that a felony history and time behind bars only makes things worse.
I'm curious about a couple of your points here.
First, when people involved in addiction treatment say that drugs cause people serious problems aside from legal issues related to the drug itself, I wonder if they are biased by only seeing the users who hooked badly enough to land themselves in various sorts of rehab/therapy programs. Do we know how many people are using these drugs in a more casual way, suffering little to no real harm from them, and never coming to the attention of the legal system?
Second, you say below in reference to heroin being dangerous how many people die of overdoses every year. I was under the impression that the reason overdoses are so common is that, since it is illegal, there is no regulation or easy way to determine the purity of any given batch of it, so it is easy to accidentally overdose if you get a stronger batch than you're used to. If opioids are really that fundamentally dangerous, why is long-term monitored use of methadone etc not considered to be a bad thing, as opposed to going cold-turkey ASAP?
First, when people involved in addiction treatment say that drugs cause people serious problems aside from legal issues related to the drug itself, I wonder if they are biased by only seeing the users who hooked badly enough to land themselves in various sorts of rehab/therapy programs. Do we know how many people are using these drugs in a more casual way, suffering little to no real harm from them, and never coming to the attention of the legal system?
Second, you say below in reference to heroin being dangerous how many people die of overdoses every year. I was under the impression that the reason overdoses are so common is that, since it is illegal, there is no regulation or easy way to determine the purity of any given batch of it, so it is easy to accidentally overdose if you get a stronger batch than you're used to. If opioids are really that fundamentally dangerous, why is long-term monitored use of methadone etc not considered to be a bad thing, as opposed to going cold-turkey ASAP?
1. There is a strong selection bias among the people I see, biased towards people who are much more impaired. That said, many of them had a pattern of spending more time/energy on their addiction causing themselves lots of problems before they sought help. It is true that for some substances there are many people who use recreationally without major problems, and I don't see them (and don't need to see them) for treatment. I have never seen a casual user of intravenous heroin, but perhaps there are some.
2. Difficulty establishing purity is one issue, but the overdoses happen just as often with prescription pain pills with predictable strength. Many people will continue to chase a bigger high and get in trouble that way. Other people (as described in the article) will stop using for a time and lose their tolerance, then assume that a dose that was previously safe is OK. Then they stop breathing.
Methadone clinics generally provide the same steady dose, which avoids this problem.
2. Difficulty establishing purity is one issue, but the overdoses happen just as often with prescription pain pills with predictable strength. Many people will continue to chase a bigger high and get in trouble that way. Other people (as described in the article) will stop using for a time and lose their tolerance, then assume that a dose that was previously safe is OK. Then they stop breathing.
Methadone clinics generally provide the same steady dose, which avoids this problem.
"There is a strong selection bias among the people I see" This is a real problem in drug policy. The majority of drug users stay well clear of medical professionals. They learn quickly not to discuss their habits with doctors or nurses as it leads all sorts of problems.
Prescription pain pills are not heroin. They are dangerous in overdoes because of the effect they have on the breathing reflex. It is a common practice among the drug addicts I knew to never let a fellow user 'nod off', that is loose consciousness as it leads to death when they stop breathing.
This is not a problem for heroin addicts using heroin. But (in the world I inhabited 15 years ago) heroin was very rare.
Prescription pain pills are not heroin. They are dangerous in overdoes because of the effect they have on the breathing reflex. It is a common practice among the drug addicts I knew to never let a fellow user 'nod off', that is loose consciousness as it leads to death when they stop breathing.
This is not a problem for heroin addicts using heroin. But (in the world I inhabited 15 years ago) heroin was very rare.
I'm a former drug abuser. I'm white, so I got away with too much I shouldn't have by the legal system.
1. Absent a legal system, a person still has to live in society. To be healthy a person must maintain themselves and their place in society.
Drugs perturb the systems in your brain that give you that ability and awareness. Many drug users already have history with mental illness and make that awareness aspect worse.
2. It is a powerful respiratory depressant. There is a fine line between pleasure and not breathing. It's very easy to tip the scale, especially if you're injecting it directly without an 'undo' switch (vomitting). You lose the ability to care because you're chasing a fleeting feeling.
Tolerance plays a huge part. Someone taking a 10mg hydrocodone pill for the first time might end up higher than the guy who just slammed 5 grams of heroin just to be well for the next few hours. If the first guy did 1/100th of that he might be dead.
Time, purity, dosage and most of all the unknowable limit your body has play the biggest role here.
Opiates combined with other respiratory depressants = death. Alcohol, cough medicines, anxiolytics and sleep aids can kill you if combined with opioids.
Methadone is a wager an addict makes with a professional. It's dangerous (it's a r. depressant), it's addictive and it fucking sucks. But for some people it beats living like trash to find the next high.
For most non-hardcore addicts, methadone would be a terrible thing.
1. Absent a legal system, a person still has to live in society. To be healthy a person must maintain themselves and their place in society.
Drugs perturb the systems in your brain that give you that ability and awareness. Many drug users already have history with mental illness and make that awareness aspect worse.
2. It is a powerful respiratory depressant. There is a fine line between pleasure and not breathing. It's very easy to tip the scale, especially if you're injecting it directly without an 'undo' switch (vomitting). You lose the ability to care because you're chasing a fleeting feeling.
Tolerance plays a huge part. Someone taking a 10mg hydrocodone pill for the first time might end up higher than the guy who just slammed 5 grams of heroin just to be well for the next few hours. If the first guy did 1/100th of that he might be dead.
Time, purity, dosage and most of all the unknowable limit your body has play the biggest role here.
Opiates combined with other respiratory depressants = death. Alcohol, cough medicines, anxiolytics and sleep aids can kill you if combined with opioids.
Methadone is a wager an addict makes with a professional. It's dangerous (it's a r. depressant), it's addictive and it fucking sucks. But for some people it beats living like trash to find the next high.
For most non-hardcore addicts, methadone would be a terrible thing.
What harm does heroin do a person? Pharmacologically it does very little. Addiction is the main harm.
The vast majority of drug users do not have problems (almost every adult uses drugs) except problems with the legal systems.
This is well known and extensively documented. I would encourage you to study what has happened in Portugal over the last decade.
Different drugs have different effects. Alcohol is one of the more dangerous yet is legal and a huge business. More dangerous than cocaine, heroin, ecstasy.
See David Nutt's research from the UK.
http://www.businessinsider.com.au/alcohol-more-harmful-heroi...
http://www.sciencemediacentre.co.nz/2010/08/06/professor-dav...
The vast majority of drug users do not have problems (almost every adult uses drugs) except problems with the legal systems.
This is well known and extensively documented. I would encourage you to study what has happened in Portugal over the last decade.
Different drugs have different effects. Alcohol is one of the more dangerous yet is legal and a huge business. More dangerous than cocaine, heroin, ecstasy.
See David Nutt's research from the UK.
http://www.businessinsider.com.au/alcohol-more-harmful-heroi...
http://www.sciencemediacentre.co.nz/2010/08/06/professor-dav...
You are kidding, right? Do you know how many people die of opioid overdose every year?
I'm not arguing that criminalization has helped, so let's keep these two lines of thought separate. Is alcohol more dangerous than heroin? Perhaps, and David Nutt's research is very interesting on relative harms, but it doesn't magically make either one totally safe.
I'm not arguing that criminalization has helped, so let's keep these two lines of thought separate. Is alcohol more dangerous than heroin? Perhaps, and David Nutt's research is very interesting on relative harms, but it doesn't magically make either one totally safe.
"You are kidding, right? Do you know how many people die of opioid overdose every year?"
Not of heroin overdose. Often "heroin overdose" is reported in the MSM but it is inaccurate
Not of heroin overdose. Often "heroin overdose" is reported in the MSM but it is inaccurate
How right you are. I have a friend whose been on Suboxone for years. First thing she does when she gets her prescription is sell it or shoot it. I have no idea how to help her anymore (as if I ever did). Her ex was the same way.
Why is a psychiatrist on hackernews, just curious?
During my residency, I did some fMRI research and learned a little bit of programming. The structured thinking involved in programming has been a useful skill that I try to maintain.
Plus there's lots of interesting discourse with smart people, which is a rare thing to find on the internet these days.
Plus there's lots of interesting discourse with smart people, which is a rare thing to find on the internet these days.
This article focuses on a single failed case, the actual worst case scenario. And though it is true cases like this exist, it is a tiny part of the story of Drug Court. It gives no credit to Drug Court's immense success. I have personally met dozens if not hundreds of addicts that came into recovery only through drug court, and have achieved long term recovery, and have become productive members of society.
After touting the worst case scenario and ignoring the success, this article puts a little missive in there about how doctors (those mostly with no personal experience in addiction or recovery) prefer opioid maintenance. This is but another marketing message for Suboxone, in the massive PR campaign underway to create an alternative to drug-free recovery through long term addiction to a pharmaceutical product. In the recovery community, Suboxone is referred to as Drug Replacement Therapy (DRT) because that is what it is, switching street dope for dope that comes from your doctor. It gets you high enough to avoid withdrawal, but not so high that you can't move boxes or burgers in an entry-level job. If you do try to get off the Subs, you will experience withdrawal that makes heroin withdrawal look like a walk in the park on a sunny day with a sno-cone and a puppy. This article also fails to mention the suicide rate of people on Suboxone. While I have no hard data on that (ONLY because it has never been studied), I can tell you it happens. It's happened to people I've known. It happens because so long as they are addicted to dope, doctor prescribed or otherwise, the deeply traumatized individual who is an addict remains traumatized. They will never experience the true freedom, healing and wholeness that comes only through deep self-examination and a conversion process of equal or greater magnitude, that leads to self- and social integration. DRT only treats the most visible symptoms of addiction, and does nothing to treat the underlying cause.
While I know not everyone succeeds as a result of drug court, on balance, it is a net positive. Some people need to be re-arrested 2 or 3 times before it takes. And some die. This is an unfortunate reality of addiction. And opioid maintenance IS addiction. It really is up to the individual to work through their trauma, and find the needed support to exist and find a reason to continue living. That cannot be imposed by law, coercion, or prescription.
Bottom line though, research the history of Heroin in the United States. A hundred or so years ago, heroin was touted as the solution for morphine addicts. It was the Drug Replacement Therapy of that time. We have been down this road before and we know where it leads.
After touting the worst case scenario and ignoring the success, this article puts a little missive in there about how doctors (those mostly with no personal experience in addiction or recovery) prefer opioid maintenance. This is but another marketing message for Suboxone, in the massive PR campaign underway to create an alternative to drug-free recovery through long term addiction to a pharmaceutical product. In the recovery community, Suboxone is referred to as Drug Replacement Therapy (DRT) because that is what it is, switching street dope for dope that comes from your doctor. It gets you high enough to avoid withdrawal, but not so high that you can't move boxes or burgers in an entry-level job. If you do try to get off the Subs, you will experience withdrawal that makes heroin withdrawal look like a walk in the park on a sunny day with a sno-cone and a puppy. This article also fails to mention the suicide rate of people on Suboxone. While I have no hard data on that (ONLY because it has never been studied), I can tell you it happens. It's happened to people I've known. It happens because so long as they are addicted to dope, doctor prescribed or otherwise, the deeply traumatized individual who is an addict remains traumatized. They will never experience the true freedom, healing and wholeness that comes only through deep self-examination and a conversion process of equal or greater magnitude, that leads to self- and social integration. DRT only treats the most visible symptoms of addiction, and does nothing to treat the underlying cause.
While I know not everyone succeeds as a result of drug court, on balance, it is a net positive. Some people need to be re-arrested 2 or 3 times before it takes. And some die. This is an unfortunate reality of addiction. And opioid maintenance IS addiction. It really is up to the individual to work through their trauma, and find the needed support to exist and find a reason to continue living. That cannot be imposed by law, coercion, or prescription.
Bottom line though, research the history of Heroin in the United States. A hundred or so years ago, heroin was touted as the solution for morphine addicts. It was the Drug Replacement Therapy of that time. We have been down this road before and we know where it leads.
There's another problem with drug courts which I think is a bit more serious. Given the amount of judicial and supervision time required for a drug court, the courts tend to be very selective as to who can be diverted into that process. They prefer young people with no prior history and those individuals are put through a very stringent process with the threat of going to jail or prison for noncompliance.
The rub here is that that group of people (young, nonviolent first-time offenders) tend not to reoffend anyway. In that light, these courts take credit for putting someone through this process who would have been just as likely to never see the court again if she or he had just been issued a fine or given a stern talking-to. For this group, just being in jail for a night is enough to stop (or never get caught again).
What makes this sadder, I think, is that there are many other people in the system that would benefit from this kind of specialized attention from judges and probation officers. The success rate for that group would be much lower, but the individual successes would be more impressive. They just get put into prison over and over until all they can do is be a criminal.
The rub here is that that group of people (young, nonviolent first-time offenders) tend not to reoffend anyway. In that light, these courts take credit for putting someone through this process who would have been just as likely to never see the court again if she or he had just been issued a fine or given a stern talking-to. For this group, just being in jail for a night is enough to stop (or never get caught again).
What makes this sadder, I think, is that there are many other people in the system that would benefit from this kind of specialized attention from judges and probation officers. The success rate for that group would be much lower, but the individual successes would be more impressive. They just get put into prison over and over until all they can do is be a criminal.
Prohibition/The War on Drugs is stupid. All it does is put money into the hands of criminals and costs the state money by locking people up who should be leading normal lives and paying taxes.
Why is your comment written with an assumption that one of the great things a person can do is to pay taxes? That same attitude is what got us drug laws in the first place.
This points to a more general problem of the lack of accountability of judges.
To me, it only hints at that (a problem that I agree is substantial). The main issue is that our legal system is simply not very well-equiped to deal with issues that require true expertise from a professional outside of those with law degrees.
So how do we get there? More mandatory minimums? Less judicial discretion?
Since I think the solution is to get rid of the drug courts and move them into the medical system, and not to demand more accountability.
Plus, what of accountability for the politicians who set up the policies in the first place?
Since I think the solution is to get rid of the drug courts and move them into the medical system, and not to demand more accountability.
Plus, what of accountability for the politicians who set up the policies in the first place?
IMO we need to decriminalize drugs, treat addiction as a medical issue, and shift our cultural attitudes away from seeking punishment out of the justice system. But none of those will happen because there are too many people making too much money from the current paradigm.
And politicians have worked long and hard to ensure they have no accountability. As long as the place that they're from is aligned to their party affiliation, they have a job for life regardless of what they do.
And politicians have worked long and hard to ensure they have no accountability. As long as the place that they're from is aligned to their party affiliation, they have a job for life regardless of what they do.
I believe you are agreeing with me. FWIW, I was disagreeing with the previous poster. My "So how do we get there?" was to ask for more details about how to add more accountability to the drug court system to get a more equitable and just system. Your answer, like mine, was to propose removing the drug court system.
As the drug court system was put into place by politicians, it seems that the responsibility lies also with those politicians (and their successors), so if the g'parent poster wants more accountability, then where is their accountability?
As the drug court system was put into place by politicians, it seems that the responsibility lies also with those politicians (and their successors), so if the g'parent poster wants more accountability, then where is their accountability?
"none of those will happen because there are too many people making too much money from the current paradigm"
Portugal
Colorado/Washington/Alaska
In the UK they have returned to prescribing heroin to drug addicts
In New Zealand there is new law around novel drugs that will make them legally available in shops if they can be proved safe
It is happening.
Portugal
Colorado/Washington/Alaska
In the UK they have returned to prescribing heroin to drug addicts
In New Zealand there is new law around novel drugs that will make them legally available in shops if they can be proved safe
It is happening.
> In the UK they have returned to prescribing heroin to drug addicts
Do you have a cite for that please?
Here's the current English guidance for Drug misuse, opioid detoxification.
http://www.nice.org.uk/guidance/cg52
So, there are a few doctors that have the required special licence needed to prescribe heroin as a treatment for addiction. These special licences are not new, they've existed for a long time. I'm not aware of the numbers of licences going up.
https://www.evidence.nhs.uk/formulary/bnf/current/guidance-o...
Most addicts are not going to get heroin, they're going to get oral meds like suboxone.
Do you have a cite for that please?
Here's the current English guidance for Drug misuse, opioid detoxification.
http://www.nice.org.uk/guidance/cg52
So, there are a few doctors that have the required special licence needed to prescribe heroin as a treatment for addiction. These special licences are not new, they've existed for a long time. I'm not aware of the numbers of licences going up.
https://www.evidence.nhs.uk/formulary/bnf/current/guidance-o...
Most addicts are not going to get heroin, they're going to get oral meds like suboxone.
My comment was based on my general knowledge. Most recently by reading the book "Chasing the Scream". Look it up, I forget the author.
But your challenge made me go look, and in about 20 seconds (https://duckduckgo.com/?q=prescribing+heroin+for+addiction+i...) I found: http://pb.rcpsych.org/content/29/4/123 and http://www.recoveryfirst.org/englands-heroin-experiment.html...
This is a process, attitudes are changing, they have not changed.
Interestingly I have never heard of suboxone. I do not think it is widely used in my community, where methadone is prescribed to addicts.
I no longer have direct connections to addicts (I found that ruinous to my lifestyle) but 15 years ago in my country any body who wanted could go on a methadone maintenance programme and heroin use almost dies out completely.
It did not completely die out as there was a residual interest among users who were not addicts (yet?) so had no need of a methadone habit which is as useless to a drug enthusiast as a nicotine habit, but much less harmful and much less socially acceptable.
These days I have connections to the treatment community which is different and a lot of interesting things are happening (look up ibogaine). I also campaign in the political sphere for drug legalisation as I have seen the harm done by police and judges to those I love.
But your challenge made me go look, and in about 20 seconds (https://duckduckgo.com/?q=prescribing+heroin+for+addiction+i...) I found: http://pb.rcpsych.org/content/29/4/123 and http://www.recoveryfirst.org/englands-heroin-experiment.html...
This is a process, attitudes are changing, they have not changed.
Interestingly I have never heard of suboxone. I do not think it is widely used in my community, where methadone is prescribed to addicts.
I no longer have direct connections to addicts (I found that ruinous to my lifestyle) but 15 years ago in my country any body who wanted could go on a methadone maintenance programme and heroin use almost dies out completely.
It did not completely die out as there was a residual interest among users who were not addicts (yet?) so had no need of a methadone habit which is as useless to a drug enthusiast as a nicotine habit, but much less harmful and much less socially acceptable.
These days I have connections to the treatment community which is different and a lot of interesting things are happening (look up ibogaine). I also campaign in the political sphere for drug legalisation as I have seen the harm done by police and judges to those I love.
Your original statement was "In the UK they have returned to prescribing heroin to drug addicts".
The counter-statement was that it doesn't appear to have been a recent change in the numbers. That is, doctors in the UK have been able to prescribe heroin since the 1920s, so long as they had special permission from the Home Office. The first link repeats the baseline that has been present for decades. It does not report a change.
If there's no change, then there's no "return". DanBC's comments were to suggest that there hasn't been a recent change in the numbers. I found http://www.jrf.org.uk/sites/files/jrf/1859350836.pdf which says that no more than 50 patients received heroin in 2000, and 9 lived in London. In 2011, http://www.bbc.com/news/uk-england-london-13944209 says that almost 120 addicts in London, over three years, received heroin this way.
While that is an increase, it's hardly enough to be a significant change.
Your second link appears to not be a high-quality source. For one, it cites Wikipedia. For another, its second citation is to a summary of the survey done in 2000; which is the one I mentioned earlier that found fewer than 50 patients receiving heroin. Therefore, it does not indicate any recent change, either to the UK drug laws or change in medical policy.
I therefore concur with DanBC. The UK has not "returned" to prescribing heroin to drug addicts given the information you provided, or the sources that I examined in trying to answer this for myself.
The counter-statement was that it doesn't appear to have been a recent change in the numbers. That is, doctors in the UK have been able to prescribe heroin since the 1920s, so long as they had special permission from the Home Office. The first link repeats the baseline that has been present for decades. It does not report a change.
If there's no change, then there's no "return". DanBC's comments were to suggest that there hasn't been a recent change in the numbers. I found http://www.jrf.org.uk/sites/files/jrf/1859350836.pdf which says that no more than 50 patients received heroin in 2000, and 9 lived in London. In 2011, http://www.bbc.com/news/uk-england-london-13944209 says that almost 120 addicts in London, over three years, received heroin this way.
While that is an increase, it's hardly enough to be a significant change.
Your second link appears to not be a high-quality source. For one, it cites Wikipedia. For another, its second citation is to a summary of the survey done in 2000; which is the one I mentioned earlier that found fewer than 50 patients receiving heroin. Therefore, it does not indicate any recent change, either to the UK drug laws or change in medical policy.
I therefore concur with DanBC. The UK has not "returned" to prescribing heroin to drug addicts given the information you provided, or the sources that I examined in trying to answer this for myself.
Colorado and Washington are already blowing it. They are taking tax revenue from the sale of marijuana and using it as regular tax revenue for programs such as schools. Just look at the insidious relationship government has with the lottery to see that we are just shackling ourselves to a whole other host of compromised interests. Once they get that money regularly, they are never giving it back with out a (corrupt) fight which means any means to use the revenue from drug sales can never be used for appropriate or creative means to further solve the drug problem and we will quickly find ourselves in the absurd situation where our elementary schools will be active drug pushers (see the recent John Oliver piece that highlights a New York Public School ad pushing gambling and the lottery as some noble activity).
It's the one major social issue that can completely fund, to the full extent of current science, the research and treatment of it's ill effects on society...and we are throwing the opportunity away that will be extraordinarily, if not impossible, to get back.
It's the one major social issue that can completely fund, to the full extent of current science, the research and treatment of it's ill effects on society...and we are throwing the opportunity away that will be extraordinarily, if not impossible, to get back.
They are taking tax revenue from the sale of marijuana and using it as regular tax revenue for programs such as schools.
Is that really blowing it though? I have nothing to prove my claim but I'd say a good dose of substance abuse comes from lacking agency as a result of poor education.
It's the one major social issue that can completely fund, to the full extent of current science, the research and treatment of it's ill effects on society
What about alcohol, which you could argue results in more violence and negative health effects than marijuana consumption?
Is that really blowing it though? I have nothing to prove my claim but I'd say a good dose of substance abuse comes from lacking agency as a result of poor education.
It's the one major social issue that can completely fund, to the full extent of current science, the research and treatment of it's ill effects on society
What about alcohol, which you could argue results in more violence and negative health effects than marijuana consumption?
IMO these are two different problems. One problem is how we treat addictive and/or mind-altering substances and their users. The second problem is how we appropriate tax money (which I will agree with you is completely fucked up).
You can't just take tax money from one source and allocate it against a specific area like education, because then the source that previously funded that cause will reduce its funding and distribute it to other areas.
You can't just take tax money from one source and allocate it against a specific area like education, because then the source that previously funded that cause will reduce its funding and distribute it to other areas.
I am a psychiatrist, and I treat many people with addiction problems. This formulation is a gross oversimplification. Opioid agonist therapy (methadone or bupronorhpine) is not trivial or one-size-fits-all. There are many other factors to consider, not the least of which is the person's interest in getting clean.