Monday, April 30, 2012

Who cares about overdose prosecutions?

by Matt Curtis

We’ve had a lot of good news around overdose lately. The U.S. Centers for Disease Control and Prevention recently released a report on community-based overdose prevention programs, and the Food and Drug Administration just held a hearing on making naloxone more available. The Commission on Narcotic Drugs – the annual social mixer for lifer international drug war bureaucrats – endorsed giving more attention and resources to overdose prevention. It seems like every week there’s more great work being done on the front lines.

One other thing you’ll notice if you keep track of overdose-related news in the United States is the number of criminal prosecutions following overdose deaths.

These prosecutions have their origins in the Narcotics Penalties and Enforcement Act of 1986, also known as the “Len Bias Law” after the star University of Maryland forward who died of cocaine poisoning two days after being drafted by the Boston Celtics. This was the first major federal legislation of the ‘war on drugs’ era, which amended the Controlled Substances Act to introduce mandatory minimum sentences and a number of other enhanced criminal drug penalties.  One novel feature of the law was that it significantly increased prison time for anyone convicted of supplying drugs “if death or serious bodily injury results from the use of such substance.” Though federal prosecutions are still common, many states subsequently adopted similar legislation.

So, fine you say, isn’t this just drug dealers and corrupt pill mill doctors getting what they deserve for poisoning people?  A scan of news articles from the past couple years does show the occasional major dealer going down with a second-degree murder charge tacked on for an overdose. More common is a case like that of April Lynn Baker and Ryan Hartley in Maryland.

In 2008, Ms. Baker acquired methadone and morphine from a nursing home staff, which she traded to Mr. Hartley for marijuana. Hartley then sold a single 40 mg methadone wafer and 20 ml of liquid morphine to Brandon Sgaggero, who was found dead from an apparent overdose five days later. In describing Baker and Hartley as drug dealers, prosecutors note that both used drugs themselves, which is what led Sgaggero to seek out Hartley, and that Hartley sold to Sgaggero on only one occasion. In the event, Baker was sentenced to three years in prison and Hartley six.

Other examples abound, in Tennessee, Wisconsin, Washington and elsewhere. We’ve even seen prosecution of people for not adequately responding to a witnessed overdose, as in this case in Virginia.

The way in which criminal liability for overdose deaths is currently handled is very difficult to square with our rhetoric about harm reduction and drug policy. Yet I have rarely have heard colleagues in harm reduction or the broader public health and medical fields even mention the issue. This may be because the issue presents itself infrequently in the context of harm reduction services, and it’s even less often brought to the attention of people working in policy or academia. For those cognizant of overdose prosecutions, I suspect there’s a degree of ambivalence related to the getting-what-they-deserve issue. Among the many people working in harm reduction now who come from a professional rather than activist background, many may feel that the issue lies outside the scope of public health or social work.

So I think it’s time to take a deeper look at this issue, and it’s time for harm reduction and drug policy reform advocates to take it on. What is the best way to do so is a little more complicated, and something I will address in future posts around some of these questions:
  • What is the scope of the problem? Where and how are overdose-related prosecutions happening?
  • Should sellers be responsible for outcomes, and if so then under what circumstances? Should the expectation of potential harm from illegal drug use be a legitimate defense?
  • How or why should we approach this differently than sellers of other (potentially) adulterated products, like produce contaminated with E. coli or counterfeit medication?
  • People who use drugs tend not to keep a log of who they buy from, and medical examiners can’t determine the provenance of a morphine or cocaine metabolite. So is it appropriate to prosecute someone for an act that cannot be forensically linked to the outcome?
  • People in drug policy reform often say something akin to ‘No one should be incarcerated for a petty, nonviolent drug crime.’ Where is the line drawn? Who is a drug dealer? Are there any circumstances under which supplying drugs that lead to “death or serious bodily injury" should result in criminal liability, and if so, in the current system is there any way to fairly determine guilt?
I admit some of these questions are a bit loaded. I don’t have the answers figured out though, and welcome comments, counterarguments, data, and anything else you would like to contribute.

Thursday, April 19, 2012

Pubmed April 2012 Update

Here we go with April 2012 ...

Rosca P, Haklai Z, Goldberger N, Zohar P, Margolis A, Ponizovsky AM.
Drug Alcohol Depend. 2012 Apr 6. [Epub ahead of print]
Comment: Rate of overdose mortality was 0.22/100 person-years (i.e. 0.22%), one-quarter to one-fifth the expected rate in most studies of other cohorts

Yokell MA, Zaller ND, Green TC, McKenzie M, Rich JD.
J Opioid Manag. 2012 Jan-Feb;8(1):63-6.
Comment: Buprenorphine is a partial agonist with a ceiling effect that limits the capacity for overdose among those with a tolerance to opioids. Like naloxone, buprenorphine really likes binding to opioid receptors and kicks most other opioids out. Since buprenorphine out-competes other opioids for receptors and has a ceiling effect, administration in the setting of overdose may result in reversal of opioid overdose. That said, this wouldn't be the approach I would advocate for dissemination since (1) buprenorphine could cause overdose in an opioid user with minimal tolerance and (2) buprenorphine could cause prolonged withdrawal (for over a day) in those with a very high tolerance.

Andrews JY, Kinner SA.
BMC Public Health. 2012 Apr 4;12(1):270. [Epub ahead of print]
Comment: An interesting exploration of circumstances surrounding prisoner death post-release.

Goli V, Webster LR, Lamson MJ, Cleveland JM, Sommerville KW, Carter E.
Harm Reduct J. 2012 Mar 15;9(1):13. [Epub ahead of print]
Comment: An intriguing analysis of whether or not injecting the pre-formulated morphine + naltrexone actually blocks the effects of morphine. It appears to partially, but not completely, block the effect.

Kinner SA, Milloy MJ, Wood E, Qi J, Zhang R, Kerr T.
Addict Behav. 2012 Feb 7. [Epub ahead of print]
Comment: Prior overdose, daily or binge drug use, and public injecting are associated with nonfatal overdose among recently released drug users.

Upadhyay SP, Mallick PN, Elmatite WM, Jagia M, Taqi S.
Indian J Palliat Care. 2011 Sep;17(3):251-4.
Comment: An interesting use of a particular sedative to assist with opioid withdrawal in an intensive care unit.

Wilcher G.
Am J Forensic Med Pathol. 2011 Dec;32(4):314-8.
Comment: Intriguing review of 5 cases of drug-induced death among "body packers" or "body stuffers", including a review of that language. Interestingly, most of the deaths were due to overdose on consumed drugs rather than toxicity from rupture of drug packets.

Saturday, April 14, 2012

FDA Hears Testimony on Naloxone Access and Potential for Over-the-Counter Status

This past Thursday, April 12, the U.S. Food and Drug Administration (FDA) held its first ever workshop on naloxone availability and use in emergency first aid in the United States. The event marks an important first step in the federal government taking greater responsibility for overdose prevention efforts, and by all accounts FDA was looking for ways to be a constructive partner with local peer distribution efforts.  More information on the goals of the meeting, the agenda, and a speakers list may be found on the FDA website

While the goal of rescheduling naloxone to remove prescription requirements faces significant bureaucratic hurdles, FDA may be able to take other measures in the near term, such as approving emergency importation of naloxone from manufacturers in Europe or elsewhere in order to address the stock-outs and price hikes plaguing overdose projects in recent years.

We'll soon have more analysis about the meeting and next steps from several participants. In the meantime, Time magazine's Maia Szalavits continues her quest to make completely OPA redundant with an excellent first-take on the meeting

Tuesday, April 3, 2012

News: FDA will discuss making naloxone over-the-counter

By Maia Szalavitz, The Fix
Posted on March 31, 2012, Printed on April 3, 2012

When I was injecting drugs back in the mid-1980s, several sneaky killers were haunting addicts. We didn’t know it at the time, but half of all New Yorkers who shot drugs were already infected with HIV and many more were carrying the hepatitis C virus. There was no effective treatment for either disease. Thousands died. And unfortunately, many in the recovery community stayed silent.

The risk we knew about—overdose—seemed just as implacable. You could reduce the danger by limiting your doses and not mixing similar drugs, such as heroin, Valium and alcohol, say, or cocaine and amphetamines, and that remains good advice. Back then, we fatalistically assumed that this menace pretty much came with the territory.

In 2012, however, both HIV and hepatitis C are not only treatable but amenable to prevention campaigns. New HIV infections among drug users have been cut in half in the last decade, largely by clean-needle programs, which can also fight hepatitis C (though not as effectively).

But some 15,000 people still die annually from opioid overdoses—even though there’s a cheap, effective and safe remedy that could save most of these lives if it were more widely available. With prescription opioid misuse now the main cause of rising overdose fatalities and with the overwhelming failure of ongoing efforts to cut supply, it’s long past time to focus on the most direct way to prevent death by OD.